Do you need the penetration test?

Don’t worry, I’m not about to delve into the wet fingers stuff – this is a different penetration test (no smirking at the back). The idea came to me after hearing a radio programme about cyber crime. They interviewed someone who had been employed as a Penetration Tester. A penetration test (a.k.a. pentest, intrusion detection and red teaming) is, it seems, a well-known and recognised process in the worlds of cyber security and IT governance. Essentially, it is an evaluation of the security of IT systems by trying to exploit vulnerabilities before hackers and criminals can. It goes beyond looking at operating systems and software to include improper configurations and risky operator or end-user actions.

A dentest?

My idea is that dental practices should evaluate their governance vulnerabilities by what I’m calling a ‘dentest’. In other words, before CQC inspectors mark you down, the GDC writes a disapproving letter or a patient uses your complaints procedure you should check whether your systems or staff can be faulted. There might be several ways to do this. In the wider world reformed hackers and fraudsters are often employed for such tasks. However, I don’t recommend scouring the GDC’s list of erased dentists. Much more sensible to keep it in-practice.

This is where that irritating team member who is always finding fault and asking endless questions comes into their own. Divide activities in the practice into manageable chunks and set them the task of ‘penetrating’ them one at a time. In theory, they need expertise in an area to be able to exploit any vulnerabilities. Otherwise, how will they know whether, for example, decontamination procedures are being followed correctly?

A journalistic trick

Fortunately, such in-depth knowledge is not required. How do you think Jeremy Paxman managed to get politicians to squirm night after night? How does the team on Channel Four News report on a variety of different topics with apparent authority? The answer lies in what journalists and reporters learn on their first day at university – the ‘5 W’s’ – Who? What? When? Where? Why? and How? (yes, I know there’s also an ‘H’). Ask these questions persistently enough and you’re bound to get the answers (or not) on virtually every topic.

For example

Take decontamination procedures. Your ‘dentester’ needs to be given half an hour during which they ask the 5 W (and 1 H) questions of, initially, virtually anyone in the practice. Anyone? Yes, because they might start by asking the practice manager: “Who is responsible for decontamination?” With that answer, they could ask the person or persons named: “What is the decontamination procedure?” Then follow up with: “Where is it done? Why? How?”

Any “I don’t know”, “I’m not sure”, “I’d have to ask”, “I can’t remember”, replies suggest a vulnerability.

If they began with a receptionist, they might get the answer: “I don’t know”, which they can follow up by asking: “Who will know?”. If the receptionist says the practice manager, the dentester is off and running. If the receptionist doesn’t know, that suggests a vulnerability – each member of the team should know what roles and responsibilities other members, especially senior staff, have.

Another example

Now the dentester, or another member of staff with an equally enquiring mind, could play at being a patient. They could ask any team member: “How do I make an appointment?”, “How do I make a complaint?”, “When is the hygienist available?”, “Where is the nearest car park”, “How much do implants cost?” Depending on whether they questioned the part-time Associate or a receptionist, they should be given either the name of the person who will know or the actual answer. The dentester proceeds to ask more questions, as before.

The learning points

The dentester’s work is, of course, wasted unless you ensure the vulnerabilities he or she uncovers are shared with the team and corrections discussed and implemented. Also, a dentest is neither a one-off exercise or a standalone one. With new compliance requirements coming on stream all the time, new systems being introduced and new staff joining the team, vulnerabilities may surface again – so regular dentesting is required.

Also, you may wish to enlist a ‘secret shopper’ to check for vulnerabilities. Obviously it needs to be a person your can trust and who will respect confidentiality. Perhaps someone from your plan provider or the dental lab you use or, better still, your favourite dental business management consultant…

Image credit -Andy Maguire under CC licence -  modified.

Walk down any high street and you’ll likely witness a cornucopia of contrasts and contradictions. Overweight people, painfully thin people. Healthy looking pensioners, teenagers who couldn’t run for a bus. Naturally wrinkly old people, unnaturally smooth-skinned middle-aged people. Adults with bright shining teeth, children with a mouth full of decay.

It’s deeply ironic that in an age when many of us could live to a 100 and all but the most serious diseases can be treated, some people are clearly missing out. As a mother of two and former practice manager it particularly disturbs me to see children with bad teeth. The numbers are staggering. According to the Health & Social Care Information Centre recent report NHS Outcomes Framework for England, tooth extractions due to decay in children admitted as inpatients to hospital, aged 10 years and under were at the rate of 462.2 per 100,000 population in 2014/15. That’s about one in every 216 children.

That’s an average for England, in Yorkshire and The Humber the figure was about one in every 112. The report also showed that: ‘Nationally, there is a strong correlation between area deprivation and the rate of tooth extraction. As deprivation increases so does the rate of tooth extraction. The rate of tooth extraction in the most deprived decile is almost 5 times that in the least deprived decile (808.7 compared to 167.5 per 100,000 population).’

What does Google say?

To attempt to answer the question posed in the title of this blog I decided to post it into Google. The result was many references to information on children’s oral health and an article in the Daily Mail with the headline: ‘The lazy middle-class parents who don’t teach children to brush their teeth: By a teacher who’s seen the horrific consequences’.

The article claimed that parents were too busy to show the children how to brush their teeth and when the teacher opened a pack of tiny toothbrushes and tubes of toothpaste in her class of four-year-olds ‘the children were saucer-eyed with curiosity.’

An article on parents.com claims: ‘Many parents are surprised to learn that kids need help brushing their teeth until at least age 6. Young children simply don't have the manual dexterity to do the job well.’

In October 2014, in guidance aimed at local authorities, NICE said: “Schools and nurseries should run tooth brushing schemes to help standardise the oral health of younger children.”

In an article about this guidance in The Telegraph, Joyce Robins from Patient Concern was quoted as saying: “Nice has often been accused of pushing nanny state measures but this is more like a ‘supernanny state’.

“What will they suggest next, that parents can drop their children off at school naked and unwashed, and leave the state to step in and do the rest?”

Oh dear.

There is an answer

So if parents are too lazy, too ignorant, too impoverished, living in area of deprivation or are combination of some of these factors, what is to be done? The answer comes from the USA. Tegwyn H Brickhouse D.D.S., Ph.D. Department chair, research director and associate professor in Pediatric Dentistry at the Virginia Commonwealth University was the lead author of a paper presented to the IADR/AADR/CADR conference in March 2013. In it she wrote about a study into a scheme to decrease the number of low-income children in the Roanoke Valley with long term dental disease. The Child Health Investment Partnership of Roanoke Valley (CHIP) provides in-home preventive oral health services designated as the Begin with a Grin Program. The paper states: ‘In the context of a home visit, Community Health Nurses (CHNs) and Pediatric Nurse Practitioner (PNP) apply fluoride dental varnish (FV) to the teeth of CHIP-enrolled children from tooth eruption to 36 months. They educate the caregiver in preventing tooth decay and the importance of a dental home.’

The study found that: ‘Two applications of FV to the child’s teeth significantly reduced the likelihood of having any decay.’ The conclusions were: ‘Home visiting programs such as CHIP’s Begin with a Grin serves as a model to improve the oral health of high-risk children. The CHIP program provides an innovative solution for providing oral health care to the nation’s medically underserved populations.’

NHS Choices states: ‘From the age of three, children should be offered fluoride varnish application at least twice a year. Younger children may also be offered this treatment if your dentist thinks they need it.’

That presupposes a parent takes their child to a dentist. The CHIP Begin with a Grin programme avoids that requirement. However, dental practices would need to be informed when children are born in their area.

Is this something the GDC and NMC (Nursing & Midwifery Council) should be liaising about? Another question seeking an answer…

Image credit -Tiffany Terry under CC licence - not modified.

My previous post about stress was posted here on 28 January. This time, I’m attacking (more accurately, sneaking up on) stress from a different angle. And I’m starting by going back in time. Way, way back to pre-CQC. It seems prehistoric man suffered stress, would you believe? And guess what – we know it from their teeth! In 2010, George Armelagos, an anthropologist from Emory University in the USA, discovered enamel defects in teeth dating back one million years indicating that, ‘During prehistory, the stresses of infectious disease, poor nutrition and psychological trauma were likely extreme.’ This stress reduced life expectancy – remains from Dickson Mounds, Illinois, showed that individuals with teeth marked by early life stress lived 15.4 years less than those without the defects.

So is stress bad then?

Not necessarily; read on. According to the Mental Health Foundation: ‘Some stress can be positive. Research shows that a moderate level of stress makes us perform better. It also makes us more alert and can help us perform better in situations such as job interviews or public speaking. Stressful situations can also be exhilarating and some people actually thrive on the excitement that comes with dangerous sports or other high-risk activities.’ The Foundation does point out that stress is only healthy if it is short-lived.

Stress causes a surge of hormones to better help you deal with ‘fight or flight’ situations. According to NHS Choices: ‘Once the pressure or threat has passed, your stress hormone levels will usually return to normal. However, if you're constantly under stress, these hormones will remain in your body, leading to the symptoms of stress.’

How much stress is normal?

Now we come to the science – specifically the Depression, Anxiety and Stress Scale (DASS). This is a self-report questionnaire whereby you answer questions, add up the score and convert these to severity ratings for depression, anxiety and stress. There are two versions – DASS and DASS 21. The former has 42 questions, the latter 21 (so you multiply the scores by two). Ignoring depression and anxiety for the purposes of this article, the severity scores for stress are:

·        Normal 0-14

·        Mild 15-18

·        Moderate 19-25

·        Severe 26-33

·        Extremely severe 34+

DASS is not a diagnostic tool. If you are feeling anxious, depressed or stressed, you should see your GP – even if you get low DASS scores. However, if you wish to get some idea of how stressed you are and so gauge whether it could be considered healthy, go to https://www.cesphn.org.au/images/mental_health/Frequently_Used/Outcome_Tools/Dass21.pdf for DASS 21 (remember to double your scores for the full DASS severity ratings.

No added stress

In my previous post, I urged you to stop putting stress on others – particularly colleagues and staff in your practice. Now we see that some stress is normal and may well be beneficial. So does that contradict what I wrote before? Not at all. Yes, some stress is normal and healthy but so very few of us lead completely stress-free lives that we need added stress at work. Relationships, health, family obligations, household maintenance, cars, money worries all cause stress. Many of us are also good at getting stressed about things that haven’t even happened yet! So who are you to add to the stress of your colleagues or staff and maybe move them from normal to mild, moderate or severe on DASS?

Stress as a management tool?

Excuse me? Think twice (or more) before you decided to ‘push’ members of your team to make a greater effort. It is far more effective to motivate people to work more effectively or efficiently. People work best through their lunch hour when they don’t hold a grudge at you demanding it but because they genuinely want to get the patient records up to date.

As a manager you should be familiar with the theory of psychological type as introduced by Jung and the Myers-Briggs Type Indicator – so you know how to get the best out of each member of your staff.

This is a topic covered on my courses – come and find out.

Image credit -Bottled_Void under CC licence - not modified.

What a day! Traffic jams, a flat battery in my mobile, a parents’ meeting tonight and I’ve still got to write this blog about being stressed.

Ah, that’s better. It’s another day and instead of writing the blog when I was tired and grumpy, I wisely left it until now. If only all stress would dissipate so easily.

This is not an examination of stress in dental practice. For that, I recommend an excellent study on the Yorks and Humber Deanery website.

And this is not about managing stress because I agree with dentist and communication coach, Brid Hendron, who says we need to be eliminating stress.

This is also not a guide to stress relief. There are plenty of those available and the Stress Management How to Reduce, Prevent, and Cope with Stress article here is better than many.

So what is this blog about?

Oh dear, I can sense you’re become a bit stressed reading this, so I need to get to the point. Which is to ask: are you the source of stress in your practice?

Can you honestly say you don’t ever put stress on your subordinates/superiors/equals? Think carefully, do you bang on endlessly about problems that cannot be solved within the practice (government policy, for example)? Do you set your staff unnecessarily tight deadlines to complete work? Are you careless about returning equipment so that colleagues can’t find it? Do you leave an empty loo roll in the toilet and a dirty mug in the sink?

#LoveYourImperfections (not)

Such behavior may, according to the online dating service TV advertisement, result in you finding true love but that won’t be in your practice. Instead, it will result in stress, which will have consequences. According to the HSE, 9.9 million working days were lost to work-related stress, depression or anxiety in Great Britain in 2014/15.

Just stop

Like ceasing smoking or the consumption of alcohol in too large quantities or (as in my case) pigging out on cream buns, stopping causing stress is easier written than acted upon. Here’s what you should do. Suffers of stress are advised to keep a stress journal. Do likewise but instead of recording stressors on a daily basis, you should identify ‘stressees’ (the colleagues to whom you’ve caused stress). This won’t be easy. Not everybody reacts to stress by pigging out on cream buns or bursting into tears. Quite probably, you won’t witness the effects of your stressful action within the practice. So here comes the clever bit.

Stress balls

At a team meeting, explain you’ve read an article about stress in the workplace and want to learn how many people in the practice feel it. Now place a bowl of marbles, walnuts or (if you are in an upmarket practice) Ferro Rocher chocolates in the tea room (staff lounge) with a mug (porcelain cup) beside them. Ask your staff to place one of the items in the mug (cup) at the end of each week if they’ve felt stressed.

Self-regulating stress reduction

Once this has been done for a few weeks (so that staff have become comfortable with it), explain that you’re keeping a stress journal and would like others to do likewise (anonymously, of course). While there is no direct correlation between what people note in their stress journals and the weekly marbles/walnuts/chocolates ‘score’, it is in everybody’s interest to reduce the stress they place on colleagues in order to decrease how many ‘stress balls’ are in the mug (cup) at the end of the week.

Let me know how you get on with this exercise (and perhaps you can come up with a name for it).

‘Hope got me through…..’ Terry Waite CBE

A warming Xmas story to boost practice manager’s morale

I have been to many a Christmas carol concert over the years but this festive season I attended one that I will never forget! The concert was held in aid of Emmaus, a UK charity that helps homeless people off the streets and of which Terry Waite CBE is president. For those young readers who may not know, Terry was an envoy for the Church of England in the late 1980’s. He travelled to Lebanon to try to secure the release of four hostages but was kidnapped himself and held captive from 1987 to 1991. Terry spent almost five years, including four Christmases, in solitary confinement without any news of his family, his friends or the outside world. Torture and mock executions were a regular occurrence.

Terry was invited to be a guest reader at the concert and he relayed a story to us of his fourth Christmas in solitary confinement……the room was dark, damp and cold. There was no source of heating and only a single blanket to keep him warm. Terry was forced to sit on the floor in the tailor’s position whilst shackled to a radiator which for a very tall man must have been torture in itself. His only source of light was a single candle; his only company, a bible. One day, after many attempts, Terry managed to encourage his guard to tell him the time and date. He was surprised to find that it was late afternoon on Christmas Eve. Terry decided to celebrate Christmas by holding his own, personal Holy Communion so saved a small piece of bread and drop of water from his meagre rations. His candle was burning low but he wanted to wait as long as possible to be sure that his celebration was as near to Christmas Day as possible. In the dying light of his candle, Terry took the morsel of bread and water, blessed it and savoured it whilst reading a passage from his bible. The moment passed as the light finally died.

When asked how he survived these lonely, unbearable years, Terry’s answer was ‘hope’!

I think in the world of the practice manager there is much hope that can be taken from this message and many synergies too. I work with many practice managers who feel lonely and isolated incarcerated in their cold offices in the rafters of their practices. Communication with busy staff can be scarce increasing the sense of segregation. On the rare occasion that a staff meeting is held, everyone wants a ‘piece of flesh’ or demands answers about something. The practice principal is generally focused on the clinical workload leaving the burden of renewed CQC inspections, financial management and human resource issues to the overloaded practice manager. The pressure to perform is sometimes torturous. On top of the internal workload scrutiny is increasing from the outside world. A week rarely goes by without dentistry featuring in media headlines and public observation of the dental profession being heavily influenced by this bad press. The weight of complaints handling and demands from patients also falls on a practice manager’s shoulders and sometimes ‘giving blood’ is still not enough in some cases!

So, where can a practice manager find ‘hope’ in such difficult circumstances? How can they release the burden, shake off the shackles and find freedom and enlightenment as Terry did? One definition of hope is ‘a feeling of expectation and desire for a particular thing to happen’. This is all well and good, but in business, hope sometimes needs to be accompanied by a ‘mental shift’ to allow change and escapism to happen.

Here are my ten top tips for seeing your hopes come to fruition:-

1.      Define your purpose – be clear as to what kind of manager you wish to be. Take responsibility for shaping the future.

2.      Embrace change – be proud of what you have achieved to date but embrace change and make improvements.

3.      Keep moving forward – view failures and disappointments as an opportunity to improve, evolve and succeed.

4.      Communicate – plan, organise and review communications with your team and patients to be effective.

5.      Lead authentically - be sensitive, open, firm and fair. Learn to listen. Be you!

6.      Believe in yourself – be prepared, have faith in yourself and be true to your inner beliefs.

7.      Make everyday count – give 100% to everything you do.

8.      Act now – deal with situations as they arise. Don’t leave things to fester.

9.      Keep a positive attitude – do not tolerate negativity or poor attitudes. Stay focused on steering a buoyant ship!

10.  Stay healthy – sleep, eat and exercise well. It has a direct impact on your mental wellbeing as well as your body.

Happy Christmas everyone and here’s to a New Year full of hope!

Image credit Mararie under CC licence - not modified.

Are you giving your patients what they want this Mouth Cancer Action Month?

A recent survey highlighted by the British Dental Health Foundation (www.dentalhealth.org) found that 9 out of 10 dental patients want to be screened for oral cancer but only 14% of those surveyed were aware that they had been whilst visiting the dentist. An estimated 90% of dentists are screening for oral cancer during a dental examination but do not talk to the patient about what they are doing!

Why is the dental profession so reluctant to talk about the ‘C’ word when patients want to hear it? Is this due to our fear of litigious activity if patients know too much or is it because dentists lack knowledge, confidence and experience in dealing with oral cancer management? It seems irrational when we hear about skin, cervical, breast and testicular cancer all the time. The public is exposed to messages about these types of cancer on the television, through other media and even in GP’s waiting rooms. At certain ages we are invited to be screened for a variety of cancers and given advice about screening ourselves regularly too. People are generally well informed about prevalent cancers and aware of Government initiatives to tackle the problems.

Why is oral cancer any different? Why is our profession so fearful of talking to our public about this developing epidemic? Why is there no Government initiative to combat this hidden killer? Why are girls not informed that the HPV vaccine will safeguard them against oral cancer as well as cervical cancer? Oral cancer is not just a hidden killer but also a silent one as nobody seems to be talking about it!

So, this Mouth Cancer Action Month (https://www.dentalhealth.org/our-work/mouth-cancer-action-month) give your patients what they want! Train your team to talk to patients in a confident, knowledgeable and appropriate way particularly during screening. Teach patients to self-screen on a monthly basis and arm them with the information that they need to look out for the early signs of the disease. Self-screening is particularly important as NHS recall intervals continue to be unreasonably stretched. The way I see it, if patients are given joint responsibility to screen themselves for oral cancer, this may help to counteract the barrage of litigation we are experiencing. As a profession, if we screen for, talk to and educate our patients about oral cancer, we will be meeting our professional obligation to do so as well as keeping the CQC happy when they come knocking at our door.

Talking to patients about oral cancer not only raises their awareness but it also helps to spread the word about the disease. Give people what they want and they will also tell their friends and family about the fantastic job that you are doing. ‘Word of mouth’ is the most effective marketing tool at your fingertips, so go ahead and use it!

"Squamous papilloma -- very low mag" by Nephron - Own work. Licensed under CC BY-SA 3.0 via Commons.