| Individual Dentist Planning Guide
This guide is targeted towards individual dentists who are planning smaller events.
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Photo courtesy ADA News |
Dear Doctor:
The American Dental Association is pleased to provide you with the Give Kids A Smile® Program Planning Guide. On Friday, February 1, 2008, the nation's dentists will provide free oral health care services to thousands of low-income children across the country. If you participated in Give Kids A Smile in 2007, you were part of an effort that resulted in the delivery of over $72 million in dental education, screening, treatment and products to half a million children around the country by 53,900 dental professionals. Congratulations! If you were not able to be part of that exciting effort, now is the time to gear yourself up for 2008!
Give Kids A Smile is now an annual centerpiece to National Children's Dental Health Month and will be observed every year on the first Friday in February. National Children's Dental Health Month focuses on providing oral health education to all children despite their economic status. Give Kids A Smile was designed to provide education, screening, treatment and preventative care to low-income children who do not have access to care.
In addition to helping needy children, the project's intent is to highlight for law- and policymakers the on-going challenges that disadvantaged children and children with disabilities face in accessing dental care. The overarching message of Give Kids A Smile is that even the high level of charitable care delivered by dentists every year will never solve the problem of untreated dental disease among the nation's children. So a major purpose of the project is to influence government and society at large to work with dentistry to craft common sense, market-based solutions to access disparities.
Give Kids A Smile would not be possible without the generous support of our corporate co-sponsors, who provided more the $4 million in products and services for the 2007 event. Our corporate partners for 2007 include Sullivan-Schein Dental (and 51 of its vendors), DEXIS Digital X-Ray and additional sponsors.
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A Little Background Information…
The Give Kids A Smile® name was first used by the Greater St. Louis Dental Society and a group of dentists who set up a temporary full-service clinic that treated nearly 400 children over two days in February 2002. The ADA's role in the national Give Kids A Smile project is to function as an umbrella for the numerous charitable education, screening, prevention and comprehensive treatment programs already in existence by having as many of them as possible occur on the same day under the same brand. At the same time, the campaign provides a framework for identifying, cataloging and recognizing the many access activities—large and small—that take place throughout the year.
We recognize the need for flexibility and that full-service dentistry is neither feasible nor appropriate in every case. Give Kids A Smile welcomes essentially any activity that addresses the needs of underserved children, from tooth-brushing demonstrations in schools to screenings to comprehensive dental care. The ADA also is working to ensure maximum positive coverage and perception by media, government and opinion leaders and to assist dental societies in those efforts. The ADA is providing this Program Planning Guide to make it as easy as possible for individual dentists to participate.
Some Things to Think about as You Begin to Plan Your Give Kids A Smile Event...
Whether conducting an access event is something you have done in the past, or whether it is a new activity for you, the keys to a successful event are organization, planning, execution, publicity and evaluation. To help you in that effort, this Program Planning Guide is divided into three sections:
- Program Planning Guidelines
- Community Coalition-Building and Identifying Qualified Children
- Legal, Insurance and Risk Management Considerations
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Program Planning Guidelines
Four Steps to a Successful Promotion
Step #1: Involve Your Dental Team
Getting the most mileage for your Give Kids A Smile® event will take advance planning and good organizational skills. One of the keys to your success will be to build a committed, energetic dental team.
To generate enthusiasm for Give Kids A Smile, involve team members in program planning, budgeting, promotion and, in the end, evaluation. They will be a major factor in making your day successful.
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Step #2: Consider Your Options
Programs come in all shapes and sizes, and the first task of your dental team is to consider various options.
First, consider what you have done in the past. Many dentists are already volunteering in access programs that will fit under the Give Kids A Smile umbrella. Call your dental society to see if an event is planned, and join in a group event if that is possible and feasible for you and your dental team.
Second, focus on what you can do now. If you choose to do a Give Kids A Smile event in your own office, don’t be afraid to start small by focusing on a few activities. You can build on small successes in future years. Here are some ideas:
- Offer presentations to schools where the majority of children are eligible for federally funded meal programs. Choose your target audience: preschool, grade school or teens. Contact the school nurse, health or physical education instructor or the school administrator to make arrangements. Or give a talk at a community center that serves low-income families.
- Focus your short presentation on daily oral hygiene and diet and dental health. Set up an educational display. Using mouth models, give demonstrations of brushing and flossing and have a question and answer session. Posters and handouts can help reinforce oral health messages. You can request free National Children's Dental Health posters by visiting the following link: www.ada.org/goto/ncdhm.
- Reach out to children's and youth groups. Head Start programs, Boys & Girls Clubs, YMCA/YWCA, faith-based youth organizations and other groups have young members who can benefit from screenings, dental care and educational activities. Some kids may be interested in a dental career. Additional information on dental career resources may be found at www.ada.org/goto/careers.
Set aside a day in your practice and offer screening and treatment to needy children. Although Give Kids A Smile will be observed nationally on February 1, 2008, choose another day if that date does not work for you.
In 2005, the ADA produced Smile Smarts!, An Oral Health Curriculum For Pre-school-Grade 8. As you develop your Give Kids A Smile event, we suggest you refer to the Smile Smarts! curriculum to help you develop presentations for the children and their families. There are lesson plans, support materials, hands-on classroom style demonstrations, student activity sheets and much more.
Smile Smarts! is available for immediate download at the following link:
http://www.ada.org/goto/smilesmarts
You can also purchase a bound copy of Smile Smarts! through the ADA Product Catalog. Please call 1-800-947-4746 and ask for item# W569. You can also visit ADA Catalog and order the curriculum online.
The ADA has secured a limited number of dental supplies and materials from our sponsors. There is a selection process for these supplies and every program will not receive product. If you are selected to receive product, you may need to supplement these products with other supplies, and those commitments should be solicited early in your planning process. Dental supplies must be requested online by November 15, 2007.
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Step #3: Plan Your Event
How will you identify children for your event?
If you will be giving oral health presentations in a school, the task is a straightforward one of identifying a school in which children are eligible for school lunch programs, for example. But for screening events and those during which restorative care will be given, the question is more complex.
One of your most important decisions is whether to pre-identify children for your event (either by screening children prior to the day or by seeking referrals from school or community service groups), or to open your event on a first come, first served basis. All of your planning and promotion, as well as the practical logistics, hinge on the answer to this question.
Pre-identifying children
Advantages:
- You can ensure that your physical facility can accommodate the children.
- You can identify enough staff and volunteers (if needed).
- You will be able to plan for having supplies and equipment to meet the dental needs of the children.
Challenges:
- It requires more administrative work ahead of time to identify the children.
- Even when children are scheduled ahead of time, they may or may not show up at their appointment time.
First come, first served
Advantages:
- It allows you to triage on site, thereby affording the dental team more flexibility in treating the children.
- Patient expectations regarding how quickly they will be served may be more flexible.
Challenges:
- To alert the public about your event, this method requires pre-event publicity efforts such as advertising in local newspapers and reaching out to local media.
- There may be more people lined up than you have the capacity to serve that day, resulting in disappointment for the children.
- You may not know whether the children arriving for care are truly underserved.
- While in either approach you may have dental team members standing around with nothing to do if enough people do not show up, usually this is more of a problem with the first come, first served approach.
In the vast majority of cases, pre-identifying children is the more manageable approach.
Following this overview of the planning process is a section entitled Community Coalition-Building and Identifying Qualified Children for Give Kids A Smile, which will give you more ideas about how to collaborate with other organizations to identify children for your event.
After you have decided on the type of event, assess your budget. Your budget may include postage, stationery, printing, gas or other transportation, dental products, brochures or other handouts. Good record keeping will help you to plan and budget realistically.
Dental products must be requested online by November 15, 2007.
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Step #4: Promote GKAS to your member dentists
- Ask the editors of your state dental journal, local newsletters and bulletins to promote Give Kids A Smile through editorials, feature articles, advertisements and follow-up reminders. The ADA also will work with dental editors nationally to publicize the campaign.
- ADA publications and ADA.org will publicize the campaign heavily. Societies, members and non-members should sign up to participate on the Web site after October 1. This will assist the ADA in publicizing the number of children served and the number of participating dentists. That database will be shared with dental societies and used to update participants about Give Kids A Smile news. The ADA also will use its e-mail database of 75,000 dentists to promote the campaign periodically.
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Step #5: Conduct Your Event
Sound planning will help ensure that your event runs smoothly. While some logistical issues may be familiar to you, the nature of a screening or direct care presents some particular challenges. Here are a few tips:
- To avoid no-shows and dental staff standing around with nothing to do, consider over-booking. It can be very discouraging for staff to be ready to help and have no opportunity to do so.
- If you are providing prophylaxes and restorative care, have a layperson assigned to each child for the entire time the child is in your facility. Many low-income children have very limited experience with dental care, and having a caring, attentive adult nearby can help put them at ease.
- If space permits, have a craft and coloring table with materials related to dental health. It will help keep children occupied while they are waiting to be screened or treated. Visit the Resources Section to view activity and coloring sheets.
- If the facility in which you are delivering care is large, be sure that your volunteers who are coordinating care have cell phones with them or rent a walkie-talkie system to avoid wasting time looking for someone.
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Step #6: Evaluate Your Event
Knowing how well you met your program goals and objectives this year will be of great help for future planning. Unfortunately, this important step often is overlooked.
Try to answer the following questions:
- What was the total dollar value of services and products delivered?
- What was the total dollar amount spent on this event? Itemize these expenditures if you can.
- Did you receive any donations? What goods were received, and what was their dollar value?
- Who were your target groups? How many children did you reach?
- What materials were distributed and in what quantities?
- What types of publicity did you receive?
- How many volunteers did you recruit? How many hours did they contribute? Which oral health services were delivered and in what quantity? Did you have enough support?
- How many dental team members did you involve? What were their roles? How many hours did each person contribute?
- What would make your program more successful next year?
- Please share this information with the ADA. The Association will compile information about Give Kids A Smile results, publicize it and share it with appropriate law- and policymakers. This step is essential if dentistry is to be able to call attention to its charitable efforts.
Reminder! Be sure to go back to www.ada.org/goto/gkasignup  and report your results! You can pull up your original sign-up form to report your results.
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Step #7: Last, But Not Least
Remember to THANK all who contributed their time and/or resources toward your event. Recognizing those special people will not only make them feel appreciated but will encourage them to participate again next year. There is a certificate of appreciation on our website that you can download and duplicate. Visit the Resources section of the Group Program Planning Kit.
Out-of-pocket expenses incurred in connection with a dentist's volunteer work may be tax-deductible. A tax advisor should be contacted for further information.
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Program Planning Timetable
Getting the most mileage from your Give Kids A Smile event takes planning and good organizational skills. This program planning checklist and timetable will help you to effectively budget time and resources. Be sure to visit the Give Kids A Smile home page frequently at www.ada.org/goto/gkas for the latest updates on the program!
October
- Involve your dental team in the planning for your Give Kids A Smile event.
- Consider your options and select one or more activities that are suitable for your dental office.
- Decide whether you will pre-identify children for your event or whether it will be first come, first served.
- Sign-up your program. This is the only way to receive e-grams with the latest information on the program. Sign-up begins October 1, 2007.
- Request dental products via the sign-up form. NOTE THE DEADLINE: November 15, 2007.
November
- Review your financial resources and determine your budget. Solicit funding/donations if applicable
- Supplement the supplies you requested by contacting dental companies, local businesses, etc., for donations.
December
- Finalize the budget and timetables
- Recruit volunteers, if needed.
- If you are pre-identifying children for your event, contact local organizations or schools for assistance in locating low-income children.
- Finalize details for each activity and event.
January
- Consider distributing posters on children's oral health and/or brochures in your area. You can also request National Children's Dental Health Month posters by visiting the following link: www.ada.org/goto/ncdhm.
- Secure any other supplies you may need for the event, such as brochures and handouts for children. You can purchase these at ADA Catalog or by calling 1-800-947-4746.
February
- Conduct your Give Kids A Smile event.
- Acknowledge everyone who assisted with your event with a letter of thanks or certificate of appreciation. There is a certificate of appreciation on our website that you can download and duplicate. Visit the following link and refer to the Resources section to download the certificate
- Review your event and related activities. Prepare a summary report of activities, expenses and other meaningful data including recommendations for next year.
- Report your results by updating your event information.
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Community Coalition-Building and Identifying Qualified Children for Give Kids A Smile®
Partnering with Others in Your Community
Momentum for Give Kids A Smile® can be generated by state and local dental societies, dentists in private and public practice, dental schools, dental health insurance companies, and industry partners working in local coalitions. Such partnerships can:
- Identify key access barriers in the provision of oral health care to target populations
- Explore alternative ways to address these barriers
- Create opportunities for community members to join together in expanding access
- Develop a sustainable action plan for implementing local oral health care access programs for the target populations
This program aims to encourage a variety of innovative strategies for the provision of dental services to children, build on these innovations, create visionary approaches to care, and diversify collaborations to meet local goals for expanding prevention and/or treatment services. The first year of Give Kids A Smile resulted in successful, collaborative programs that included oral health education, screening and provision of restorative and other types of care.
Since a community's ability to significantly impact local oral health access issues will depend on activating and strengthening existing networks, it is important to invite significant stakeholders to participate in Give Kids A Smile. These may include members of the dental community, and other key institutions such as public health departments, the state Medicaid office, hospitals, academic institutions, schools or early childhood programs, consumer groups, social service agencies and community foundations. Through the participation and endorsement of a broad array of institutions, partnerships will stand a better chance of securing the support of potential contributors. Finding meaningful roles for partners, to optimize their buy-in and create avenues for expanded care, should be an important part of your planning process.
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Identifying Children for Your Event
A number of organizations and groups can help identify children in need of dental services and connect them with Give Kids A Smile group activities or volunteers, including:
- Boys & Girls Club
- Head Start centers
- Social service agencies
- United Way chapters
- Faith-based groups in the community
- Public health agencies
- School nurses
- Hospitals
In addition to local agencies, some national groups can help you connect to chapters in your area that can help identify children.
Boys & Girls Clubs: B&GCA has identified improving oral health as one of their most important priorities. Many of the 3,700 Boys & Girls Clubs nationwide may be interested in participating in Give Kids A Smile. More than 1,000 Clubs have already conducted some level of oral health education, screening or treatment. Some Clubs also have on-site dental clinics.
To locate a Boys & Girls Club in your area to discuss joint activities on February 2, visit www.bgca.org . You can also call 1-800-854-CLUB to locate a local Club.
- Select "Find a Club".
- Type in your zip code or another nearby zip code.
A list of Clubs and contact information will appear for the zip code requested.
Tips for contacting a Boys & Girls Club:
- When calling the Club, the best time to reach the programming staff is late morning or early afternoon before school ends.
- Ask to speak with the Health & Life Skills program director, or if not available, the person in charge of educational programming.
- Explain your event to the programming director. Ask if they are interested in bringing their members to your event or practice or holding an event at their Club.
National Head Start Association: Head Start is a federally funded and administered early childhood development program, which serves low-income children (from birth to age five), pregnant women, and their families. There are currently more than 2,400 Head Start grantee agencies across the nation that strive to provide comprehensive child development services, including early childhood education, health, dental health and nutrition services with a focus on family support and parent involvement. Head Start programs can be administered by local public agencies, private organizations, Indian Tribes or school systems. You can find a Head Start program in your area by using the Head Start Bureau’s Web site at
http://www.acf.hhs.gov/programs/hsb .
For more information, visit www.nhsa.org , the Web site for the National Head Start Association, the membership organization representing Head Start directors, staff, parents, children and friends.
United Way of America: The United Way system has offered its support of Give Kids A Smile in several ways, and while the level and type of support may vary among local United Ways, the organization’s resources can play an important role in the campaign's success. Each United Way has a network of relationships with social and health service agencies, local government and business through which children with unmet oral health needs can be identified. United Way may play a role in transporting children to points of treatment or assisting with other volunteer capacities. To contact your local United Way, visit http://national.unitedway.org/myuw/ and enter your zip code.
School Sealant Programs: Several health department dental divisions operate dental sealant programs that serve schools in which the majority of children are from low-income families (eligible for federal school meals). Many sealant programs use portable or mobile equipment on the school grounds or refer children to local dental Medicaid providers. Go to www.astdd.org to find contact information for state public health dental programs. A guide was developed by the National Maternal and Child Resource Center (www.mchoralhealth.org ) as a resource for community dental sealant programs. A Dental Sealant Resource Guide can be accessed at http://www.mchoralhealth.org/PDFs/DntSlntGd.pdf .
State and Local Dental Access Programs: Numerous dental access programs serve low-income families and persons with disabilities on the state and local level. These programs vary in size and operation. For Give Kids A Smile day, it may be practical to join forces and volunteer with an existing program. The ADA has general information on existing access programs sponsored by dental societies, health departments, dental schools and community services groups. To inquire whether there are existing dental access programs in your area, e-mail gkas@ada.org or call 312-440-2868.
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Additional resources for your program…
Delta Dental: In several areas of the country, local Delta Dental offices have been part of Give Kids A Smile events. Consider contacting a local office to solicit support. You can access your local office’s contact information at this link: http://www.deltadental.com/Public/index.jsp .
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Complementary Initiatives
Dental Career Mentoring: Give Kids A Smile® events draw children who are at an impressionable age. A positive dental experience in a GKAS event could go a long way toward instilling in a child the dream of a dental career; they are never too young to reach or teach. A particular focus would be to spark dental career interest among children in ethnic groups underrepresented in dentistry. Mentoring is the most important factor in influencing a child to pursue a career in the dental profession. Consider having ADA Something to Smile About-Careers in the Dental Profession career guidance materials and posters available at your GKAS event, go to http://www.ada.org/goto/careers for more information. You can also e-mail Ms. Beverly Skoog at skoogb@ada.org or call 312-440-2390.
Community Water Fluoridation Coalition Building: Are the community water sources in your area fluoridated? If not, a Give Kids A Smile event is an opportunity to build a supportive coalition. GKAS can rally parents, caregivers, educators, other health professionals and community leaders to partner and pursue/preserve community water fluoridation—the cornerstone of decay prevention in the United States. As former U.S. Surgeon General David Satcher said in 2001, "Water fluoridation is a powerful strategy in our efforts to eliminate health disparities among populations. Fluoridation is the single most effective public health measure to prevent tooth decay and improve oral health over a lifetime, for both children and adults." Go to http://www.ada.org/goto/fluoride for more information. You can also e-mail Ms. Nicole Stoufflet at stouffletn@ada.org or call 312-440-2858.
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Legal, Insurance and Risk Management Considerations
As with any access program, Give Kids A Smile® may raise legal, insurance and risk management considerations. The good news is that, particularly with some advanced planning, these issues can be effectively managed. Here is a summary of the key issues, along with some ways you might wish to address them.
Overview
With most access programs, the key risk is the same as in any practice setting: someone getting hurt. This could be a patient being injured as a result of receiving care; it could also be a patient, family member, treatment team, access staff or volunteers sustaining an injury in connection with the program, such as a "slip and fall" incident on the way to or from treatment. Abandonment issues may also arise, particularly if there is any need for follow-up care after an "access day" visit. In addition, access programs and participating volunteers need to adhere to all applicable laws, such as those regarding anti-discrimination, record keeping, privacy, security, and fraud and abuse.
The potential malpractice risks associated with a dentist's participation in an access program, including Give Kids A Smile, are generally insurable under professional liability insurance policies. Allied dental employees or volunteer staff members working at the direction of the dentist are also typically insured. For specific information about your personal coverage, including any limitations or requirements, it is advisable to discuss your plans with your insurance agent or company representative. We trust you’ll find that your policy affords protection for you and your team members—so the opportunity is yours to simply volunteer!
Beyond insurance, it is worth noting the following with respect to managing risks associated with access programs:
- Dentists routinely manage all of these risks in their daily practices.
- If an access program is properly structured, charitable immunity laws may afford liability protection to dental team volunteers.
- Dental access programs report they have effectively managed their risks (see below!)
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Safely Navigating the Dental Society's Role
What may be new with an access program is the dental society's role and potential liability exposure. In addition, the society's involvement may trigger additional legal and/or tax considerations, especially if the society wishes to incorporate its program as a non-profit organization. With the right help and planning, this situation also is readily manageable
A dental society wishing to develop, promote and/or operate an access program can be well served by seeking legal counsel and insurance advice for its program from the very beginning of the planning stages. This can help the society avoid future challenges with respect to legal exposure, insurance and indemnity considerations, incorporating as a nonprofit organization and other issues. The extent of the society's involvement may affect its legal exposure. Then again, state law may provide some protection for access activities (see below), or the society may simply decide that the benefits of a well-run access program outweigh any legal risks.
Although liability considerations regarding access programs cannot be absolutely extinguished, a lawyer can help a dental society structure its access program to minimize potential risks, and an insurance advisor can help identify the appropriate coverage. For example, a lawyer might suggest ways to structure the program to minimize the society's liability exposure and the likelihood of being sued for a dentist's malpractice. This would include, for example, participation agreements, and consent and release forms. Similarly, an insurance agent could best define the proper coverage to be held by the society and any additional insured requirements. An agent is likely to advise that participating volunteer dentists should be asked to submit evidence of their own malpractice insurance.
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HIPAA
Just as the Health Insurance Portability and Accountability Act (HIPAA) was the new legal wrinkle for GKAS in 2004, so it is again in 2007—but this time it's yet another, different part of HIPAA that's been added to the equation. In 2004, the focus was on the then relatively new HIPAA Privacy regulations, which became effective after the inaugural (2003) national GKAS event; this year, an additional regulation is in effect under the rubric of HIPAA Security. In many respects, for GKAS purposes HIPAA compliance with each regulation, Privacy and Security, should be straightforward to address.
HIPAA requirements in GKAS will likely vary depending on if the dentist is already a "covered entity" who must comply with HIPAA, and also the setting of the GKAS event. A "covered entity" is defined as a health care provider who transmits health information using an electronic transaction for which a standard has been established by the HIPAA regulations. Some organizations believe this does not extend to covered entity dentists volunteering outside of their private practice. However, unless and until the enforcement agencies clarify otherwise, a straightforward reading of HIPAA suggests that covered entity status follows the dentist in whatever setting s/he practices.
Let's look at the most likely scenarios, assuming for the moment that HIPAA follows covered entities from private practice to volunteer activities outside their dental office. Keep in mind that if HIPAA applies, the dentist must comply with all of HIPAA, including both Privacy and Security.
Covered entity dentists (already subject to HIPAA):
- Providing care in own private office. The dentist should extend HIPAA compliance to GKAS patients.
- For example, HIPAA Privacy calls for the protection of protected (individually identifiable) health information (PHI), using vehicles such as a Notice of Privacy Practices, which can be reproduced or modified for access program use;
- HIPAA Security focuses on the protection of electronic PHI through the use of administrative, physical and technical safeguards, which also can be incorporated in access programs.
- Volunteering at another facility.
- At a facility operated by another covered entity. If the facility is HIPAA compliant, following that facility's HIPAA policies and procedures is the simplest approach. Doing so can promote consistency in patient HIPAA treatment and ward off inconsistent messages about privacy or security that might lead to complaints. The facility can inform you of its requirements.
- At a facility operated by a non-covered entity. The safest bet based on the regulation is for the dentist to extend his or her HIPAA compliance efforts to GKAS patients in these scenarios. For example, the dentist can bring copies of his or her Notice of Privacy Practices to the event, and try to keep patient information as private as reasonably possible under the circumstances. The dentist should also apply safeguards to electronic communications tools (e.g. laptop computers) brought from the office to the outside facility, in accordance with the office's Security policy. Appropriate security precautions should be taken if those tools will be used to send or otherwise share electronic protected healthcare information from a GKAS program.
Non-covered entity dentists:
- Providing care in own private office or at a facility operated by a non-covered entity. The dentist remains immune from government prosecution of a HIPAA complaint.
- At a facility operated by a covered entity (e.g., a colleague's office). The dentist will probably be asked, and should be ready to follow, the facility's HIPAA policies and procedures. The facility can advise you of its requirements.
HIPAA summary:
Much of HIPAA compliance in GKAS should be simple. In the case of a covered entity dentist volunteering at a facility operated by a non-covered entity, you should exercise common sense. And dental societies promoting GKAS can facilitate HIPAA compliance, including by asking participating dentists to secure simple HIPAA authorizations permitting the use of children’s pictures for their programs, and developing sample compliance materials including the ones attached.
Further developments will be posted on ADA.org, where you can learn more about HIPAA and many of the HIPAA defined terms used in this discussion. The Give Kids A Smile Notice of Privacy Practices form and the Separate Acknowledgement form can be customized for use by your program.
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Charitable Immunity Protection
One piece of particularly good news is that dentists who volunteer their services may have some liability protection under federal and state laws. According to a 2004 summary and analysis of those statutes prepared by Volunteers in Health Care (VIH), "Understanding Charitable Immunity Legislation: A Volunteers in Health Care Guide," charitable immunity laws in 43 states and the District of Columbia afford some protection for routine care provided by "clinician volunteers." It is important to note that the manual provides only general information and is not targeted to dentistry. However, 21 states have legislation with specific reference to "dentists or dental care," and laws in other states may also apply depending on their wording.
According to the VIH analysis, most states choose one of two routes to provide protection: Some change the negligence standard of care—that is, they raise the standard from simple negligence to gross negligence. Often called a "willful or wanton" or "reckless" standard, this approach makes it more difficult to prove negligence. It is the approach also used in the federal statute. Other states indemnify the volunteer clinician as if he or she were a government employee. Under this model, referred to as the "state tort claims act," the state establishes a legal defense fund to cover monetary damages as well as legal defense costs. Often these statutes cap the total compensation that can be paid for claims. Certain conditions may be specified, such as the setting in which the care is delivered or the existence of a formal agreement between the clinician provider and the state (see below).
VIH recognizes that neither of these approaches limits a patient's right to initiate a liability action against a volunteer or ensures that a lawsuit will be easily dismissed. But changing the negligence standard raises the bar for plaintiffs, and indemnity under a state tort claims act can protect against financial loss. Several states combine aspects of both models. Other approaches are summarized in the VIH manual: for example, rather than enacting legislation that extends immunity to volunteer clinicians, a few states provide a mechanism for purchasing malpractice insurance. Eleven states have passed legislation specifically to encourage retirees to volunteer. A dental society's lawyer can help assess the true value of such protections for any particular access program in a given state.
The VIH manual also notes the federal Volunteer Protection Act (VPA) passed by Congress in 1997, which protects a volunteer clinician acting within his or her scope of duties in a nonprofit organization from liability for simple negligence. (There are exceptions for misconduct related to crimes of violence, sexual offenses, civil rights violation and other offenses.) Even when the volunteer is held liable for gross negligence, the VPA limits the award of punitive damages to those cases in which there is clear and convincing evidence of willful or criminal misconduct or conscious, flagrant indifference to the rights or safety of the individual harmed. The VPA also limits awards for non-economic damages (pain and suffering) to the proportion of harm caused by the volunteer. The VPA preempts state laws that are inconsistent with the federal statute but does not preempt any state law that provides additional protection. Like most state statutes, it does not limit the liability of the nonprofit organization through which the volunteer provides services. Also, like state laws, the VPA does not limit a plaintiff's right to bring suit.
The VIH Charitable Immunity Manual has been posted at www.ada.org/goto/vih. The 2004 manual includes a table that lists citations for the applicable state statutes. Though a useful tool, the manual contains only general legal information and stipulates it "does not constitute legal advice or opinions as to the current operative laws of any jurisdiction" and is not targeted to dentistry. Dentists need to rely on their counsel for legal advice on charitable immunity laws that may apply in their states.
It should be noted that charitable immunity protections typically protect only volunteers acting within the scope of their responsibilities of the nonprofit organization (or governmental entity) at the time of their alleged acts or omissions, although some may extend protection for volunteers who are not part of an organized effort. For this reason, state or local dental societies sponsoring access programs may wish to register dental team participants and define their scope of responsibility. It addition, state statutes have various conditions that must be met to trigger immunity. For example, most do not provide protection for in-office care. Some may restrict the type of care. Some impose patient notification of liability limitations, with state variations requiring: written notice, specific language in the notice, language easily understood by individuals with limited education (e.g., 6th grade level in Michigan), or even a posting of a notice.
Also noteworthy is that statutory charitable immunity protections may not necessarily extend to a claim of abandonment. Consider, for example, the provision of preliminary care on an access day that specifically contemplates follow-up care to complete a procedure, or care with unexpected outcomes that require correction. The most prudent course is to make such care available to those who need it, even if that means providing care at the dentist's private practice, for free, and relying on malpractice coverage for protection. Situations like these can be anticipated in advance in consent and release forms that patients in access programs may be asked to sign; such forms should be shaped to protect the dental team to the extent possible by taking advantage of any charitable immunity protections afforded in the state where care is being provided.
Finally, before turning to how to invoke these legal immunity protections, a note about ethics: as with all patient care, participants in access programs need to keep in mind their ethical responsibilities. By their very nature, access programs that serve vulnerable populations work to fulfill ethical responsibilities. That said, dentists participating in access programs must keep in mind the ADA Principles of Ethics and Code of Professional Conduct (the ADA Code). Among other things, the ADA Code calls on dentists to promote patient welfare and embodies the concept of a single ethical standard, as reflected in Section 3. Beneficence:
. . .The dentist has a duty to promote the patient's welfare. This principle expresses the concept that professionals have a duty to act for the benefit of others. Under this principle, the dentist's primary obligation is service to the patient and the public-at-large. The most important aspect of this obligation is the competent and timely delivery of dental care within the bounds of clinical circumstances presented by the patient, with due consideration being given to the needs, desires and values of the patient. The same ethical considerations apply whether the dentist engages in fee-for-service, managed care or some other practice arrangement. Dentists may choose to enter into contracts governing the provision of care to a group of patients; however, contract obligations do not excuse dentists from their ethical duty to put the patient's welfare first.
Without a doubt, access programs serve to promote patient and public welfare. Access participants utilize their professional knowledge, skills and experience to improve the dental health of the public and elevate esteem for the profession. This fulfills the ethical obligation of community service as expressed in Section 3A of the ADA Code. Moreover, access programs advance the ethical principle of justice, which in its broadest sense calls on the profession to seek allies throughout society on specific activities that will help improve access to care for all (Section 4 of the ADA Code). Dentists must simply keep in mind the need to satisfy the "single ethical standard" contemplated in the Code even if they wish to rely on charitable immunity law protections.
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Forms
Exactly what forms should be used to obtain consent and, to the extent possible, release from liability? Due to differences in state law, there are no one-size-fits-all forms that can in good faith be suggested for national use. There are, however, some things that can be kept in mind by access programs seeking to develop forms, including state-specific information on:
- Informed consent—whatever typically may be required as a matter of state law for paying patients, unless your state requires less for access programs.
Note: be cautious about requiring written consent if it would not be required of the typical paying patient.
- Malpractice—release in accordance with any state charitable immunity protection, typically advising patients about how their rights and remedies may be limited in comparison to a typical malpractice case.
Note: think through whether unintended consequences of a release form effectively saying "Dear Patient, by getting care here you’re waiving many of your rights..." is worth any protections your state charitable immunity law may provide, especially if the risk can be managed in other ways, e.g., insurance.
- Abandonment—same as malpractice, plus any information about how any follow-up care will be provided.
Note: it may be prudent to establish in the form that the provision of limited care at an access program does not establish a continuing doctor-patient relationship for other purposes
Sample forms used by well-known access programs across the country are attached to facilitate the development of forms for your access program. Of course, you will need to tailor your forms to your program design and needs and to satisfy the laws of your state.
Forms used in an access program, along with records reflecting patient care, should be completed and maintained in accordance with applicable laws. At a minimum, generally accepted record-keeping practices should be followed, unless state law allows for a lesser requirement for access programs; even then, good risk management may dictate following generally accepted practices.
Resources
Insurance: E-mail Rita Tiernan at tiernanr@ada.org or call 312-440-2491.
Legal: E-mail gkas@ada.org or call 312-440-2851.
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Case studies
As noted above, each access program is different, will raise its own set of legal and insurance issues, and is likely to be governed in certain respects by its own state law. There is thus no one-size-fits-all legal approach to managing those issues. Rather, each access program should be tailored to meet its own needs and objectives and to invoke legal and insurance protections as appropriate. With that in mind, let's take a look at how some highly visible access programs have reportedly managed their risks.
St. Louis, Missouri Give Kids A Smile Program: All dentist volunteers had their own malpractice insurance. Delta Dental of Missouri was a corporate sponsor for Give Kids A Smile and provided facility liability protection for the Clinic. As they were exiting the facility, parents and caregivers were given an emergency telephone number that could be accessed for one week at the Greater St. Louis Dental Society Central Office. They were also given a treatment plan for work that still needed to be completed and were encouraged to call a dentist on a list of low-cost clinics and active dental Medicaid providers, which was assembled by dental society staff. The St. Louis Give Kids A Smile Clinic is working very closely with a newly formed dental clinic called Dentistry For Kids, which will care for the future dental needs of these children.
Virginia, Missions of Mercy (MOM Project): The Virginia Dental Association (VDA) advises its members to contact their malpractice providers to notify them that they are providing care in a different setting and under different circumstances. In addition, all patients/guardians sign a consent and waiver release prior to treatment. Local dentists in the MOM Project geographic area are asked to provide follow up care for a period of one week. In November of 2000, the VDA received an Attorney General's opinion from Mark Earley, then Attorney General of the Commonwealth of Virginia: "Therefore, it is my opinion that dentists who provide free dental services for the Mission of Mercy project are only liable for civil damages when their acts or omissions result from gross negligence or willful misconduct." In addition, the VDA sought an opinion from its personal attorney who agreed that the statute’s meaning (54.1-106(A)) was clear in its intent and that under the MOM Project, licensed providers would be covered. Finally, the Missions of Mercy clinic takes advantage of a voluntary liability plan available to Virginia's free clinics as defined in § 2.2-1839 of the Code of Virginia. This program offers coverage for a variety of exposures including general liability, errors and omissions and medical malpractice. VDA submits the names of licensed volunteers to the state office of risk management, which oversees the liability plan program.
Oregon, Assistance League of Portland Children's Dental Center: This is a free clinic located in low-income schools in Portland. The program has operated since 1962, and has one full-time staff dentist. Dental society members volunteer a few days a year, and have their own liability insurance. Last year the Oregon legislature provided one-time-only funding to purchase liability insurance for those volunteer dentists.
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Conclusion
Potential risks associated with access programs are real but can be effectively managed. Securing sound professional advice including from your attorney or malpractice carrier as appropriate, can help shape a successful program for all concerned. State law will play a key role. Among the factors to consider are whether the program sponsor wishes to invoke the protections of charitable immunity laws and, if so, whether the benefits and requirements of state law make doing so worthwhile, particularly if the potential liability risk can be insured.
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Supporting Documents
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are registered service marks of the American Dental Association.
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