Tasks and Tools of Safety
As far as I can tell, the definitive book on acupuncture safety (beyond Clean Needle Technique) is Acupuncture Risk Management: the Essential Practice Standards & Regulatory Compliance Reference, by David C. Kailin. It was published in 1997 and it does not appear to have been updated. Somebody kindly donated a copy to POCA Tech’s library, so I read it, and I had lots of thoughts, mostly about the difference between what David Kailin is trying to do there and what we’re trying to do here.
The introduction starts out, “This book is primarily intended to train acupuncturists to assess many dimensions of risk, and to implement practical strategies for the prevention of harm...You have selected this wake up call to help you examine -- and possibly transform -- every aspect of your practice. While your livelihood certainly depends upon it, so might your life...Risk management extends well beyond technical safety.”
Is that ominous first paragraph intended to make people care about an excruciatingly detailed list of acupuncture safety topics which they would otherwise gladly ignore? I sympathize with the difficulties of getting people to pay attention to these topics; I’m pretty confident that the readership of this blog consists almost entirely of POCA Tech students and staff who don’t have much choice about it. Nonetheless, I don’t think that presenting risk as BIG AND SCARY is the right way to introduce it to anybody. And even if you skip the introduction, Acupuncture Risk Management comes across as technical and intimidating.
There’s something else that’s subtle but important -- the orientation of the book. Acupuncture Risk Management seems mostly to be concerned with the questions: what could go wrong in my practice and how can I as an individual limit my personal/business liability? Which are fine questions (from a capitalist perspective) but they’re not adequate for the praxis of community acupuncture. And so our approach is more like: what elements of safety need to be cultivated all the time, whether things are going right or going wrong or a mixture of both (which is closer to what life in small business is actually like) and how can we collectively create more safety for each other?
It was good for me to read the list of risk/safety topics in Acupuncture Risk Management and note that there’s substantial overlap with our list. But the most important thing it’s missing is a sense that risk management is an aspect of safety, and safety isn’t just a matter of avoiding bad things. Safety is an active, collective, creative and imperfect enterprise that requires certain tasks and tools.
Acupuncture Risk Management alludes to those tasks and tools, but doesn’t spell them out. Which is what I want to do in this post.(I feel like not spelling things like this out is a classism issue; it assumes that everybody has a professional/managerial/upper middle class background and bureaucracy requires no explanation.) Because you can manage risk without spending most of your time and energy worrying about what could go wrong -- and the way you do it is by focusing on building something positive. It's like the acupuncture business version of Things to Make and Do.
Here’s a list of what I think of as the concrete tools of safety, from less complex to more complex:
- Patient Chart
The patient chart is one of the most basic forms of communication in any acupuncture practice, even when it’s primarily just a communication between the practitioner’s past and future self. Creating safety by means of the patient chart means making simple, clear, understandable notes that portray as accurately as possible the clinical interactions between the patient and the practitioner(s).
The chart includes intake paperwork which, as part of the intake, goes a long way to set a tone of social safety (or, unfortunately, the opposite). Having the right forms, which elicit only the information that the acupuncturist really needs and give enough information to the patient to help them use the clinic on their own terms, is a foundational safety-positive choice.
And of course no patient chart would be complete without informed consent.
Train yourself to have good, timely charting habits -- it’s a major stress-reduction strategy. Charting is only a big deal when you don’t do it.
Incident reports are exactly what they sound like: descriptions of incidents that involve safety issues. (For a cautionary tale about the importance of incident reports, check out Anatomy of a Safety Incident #4.) Incident reports often go into a patient’s chart, but if they’re not about a specific patient, they can go into a more general clinic log.
And of course, AERD reports are a great way to create safety!
Train yourself to write incident reports and AERD reports; like charting, they’re only a big deal if you don’t do them.
- Regular Meetings
Safety meetings at WCA are pretty simple: once a month, our regular governance meetings include an agenda item titled “safety check in”. When we get to that part of the meeting, the facilitator says, “does anybody have any safety issues or safety concerns that have come up over the last month?” Since our clinics re-opened after lockdown, there have always been COVID-related policy updates to discuss because events were continually unfolding; it’ll be interesting to see what happens post-pandemic. Regardless, though, safety meetings are a vital part of OSHA compliance, and they can be as simple as training everybody to expect a brief safety check-in as part of other regularly scheduled meetings. The consistency is what’s important. And of course, remember to take minutes!
If you have a solo practice, you can still have safety meetings with yourself.
And always practice good meeting hygiene -- more about that here, under the heading of "Meetings and How Not to Hate Them".
- Scripts for Conversations
Especially difficult ones; one major purpose of scripts is to make certain inevitable conversations less stressful for you, the practitioner. (Even intake scripts fall into this category: there are lots of different ways to do intakes but having your own version memorized make them much easier to navigate.) For example, here’s a script for patients who feel worse after a treatment.
Patient Safety Handouts are a useful resource for these conversations as well.
For the basic ingredients of a safety manual, please see the POCA Tech Clinic Handbook, pages 56 to 83. Feel free to copy and adapt.
If you have employees, you also need an OSHA manual. Here's an example.
A profoundly unglamorous and profoundly important safety-making skill is the ability to write policies, something that COVID-19 demonstrated over and over. Confidentiality policies are a tool for both physical and social safety; for more details (as well as an example of another manual) please see the POCA Tech Privacy Manual.
Anyone who has an acupuncture practice should have the following kinds of insurance: professional liability (malpractice) and a general business operating policy (or BOP). Sometimes professional liability folds in what they call “slip and fall”, meaning a limited general liability for exactly what it sounds like, patients slipping and falling. (No matter how careful you are, this can happen; WCA once had a patient decide to not put on her shoes because she thought they were too noisy and she was afraid she’d wake people up; she started to tiptoe out in her socks, fell down and broke her wrist, and of course woke everyone else up. She didn’t ask us to pay for anything, and we didn’t use our insurance -- though we did talk to them -- but it’s a good example of how things can happen.) BOP policies cover more than basic liability -- there’s a broad range of other possible unfortunate events when you have a small business, like burglaries. (Yes, we’ve had those too.)
Can you get by without insurance policies? In theory, but don’t ask me (the person who lost an entire clinic to a two alarm fire) about that. Just get the insurance, okay? Like charting and incident reports, it’s only a big deal if it’s not there.
So those are the basic tools. It’s not an endless list! Maintaining safety tools requires some organization and self-discipline, but it’s definitely not rocket science.
One other note: in order to maintain your safety tools in good working order, you need to keep up with regulations from your licensing board (because sometimes they change). The Oregon Medical Board has an excellent example of a “licensee handbook” here that details licensees' responsibilities and the regulations they need to follow. The nice things about licensing boards is that they’re not trying to be secretive about what they want -- in general, they’ll just tell you.
What I think of as the “tasks” of safety are actually more like meta-tasks: organization, communication, boundaries and self-care. I recognize that they represent work that I just have to keep plugging away at, all the time. They overlap with the basic tools -- for example, most of the tools on the list reflect some aspect of communication and organization. But they’re all something to do, not something to fear or worry about.
Maybe, as David Kailin writes, your life really does depend on how you manage the risks in your acupuncture practice. But think of it this way, your life also depends on breathing. And you’re already doing that; you’re doing a good job! Risk management can have the same matter-of-fact, routine quality. It doesn’t have to be scary.