Quality Assessment,

Quality Assurance and

Quality Improvement in Dentistry

	November 18, 2003
	With thanks to Drs. Georgina Zabos and James Crall

Objectives

	Become familiar with the social, economic and political forces underlying efforts to assess and improve the quality of health care
	Become familiar with general elements and dimensions of quality health care
	Understand the basic features and goals of quality assessment, quality assurance and quality improvement programs
	Become familiar with “real-world” examples of dental quality assessment and quality improvement programs

Preventing Medical Errors :        A Call to Action

	In U. S. hospitals , Between 44,000 and 98,000 people die each year due to medical errors. (Institute of Medicine report , Dec. 1999)
	To Err is Human: Building a Safer Health System - Medication errors are estimated to account for 7,000 death annually.
	“Most people view medical mistakes as an `individual provider issue` rather than a failure in the process of delivering care in a complex delivery system.”

Definitions of Quality

	Transcendent definition: excellence
	Product-based definition: quantities of product attributes
	User-based definition: fitness for intended use
	Value-based definition: quality vs. price
	Manufacturing-based definition: conformance to specifications

Quality of Care

	Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes.                                                          ( Lohr , 1990 )

Background of the

Quality Movement

	Self-regulation by professions
	Cost Containment
	Protection of the public / Safety
	Emphasis on value

Fundamental Issues Concerning Health Care Quality

	How would you know quality health care if you saw it?   Or experienced it?
	Can the quality of health care be measured?  Differentiated?
	What are the most important attributes of health care quality from the perspective of professionals and consumers?

“Essential Elements of Quality*

	Produces optimal improvement in a patient’s physiological status, physical function, emotional and intellectual performance, and comfort at the earliest time possible consistent with the best interests of the patient
	Emphasizes the promotion of health, the prevention of disease or disability, and the early detection and treatment of such conditions
	Provided in a timely manner, without undue delay in initiation of care, inappropriate curtailment or discontinuity, or unnecessary prolongation of such care
	* AMA Council on Medical Service

“Essential Elements of Quality (Cont’d)

	Seeks to achieve informed cooperation and participation of the patient in the care process and decisions concerning that process
	Based on accepted principles of science and the proficient use of appropriate technological and professional resources
	Provided with sensitivity to the stress and anxiety that illness can generate and with concern for the patient’s overall welfare
	Makes efficient use of technology and other health care system resources to achieve desired treatment goals
	Sufficiently documented in the patient’s record to enable continuity of care and peer evaluation

Dimensions of Quality

	Effectiveness:  the power of a particular practice to improve health status
	Efficiency:  the delivery of a maximum of comparable units of health benefit for a given unit of health resources used
	Accessibility:  the ease with which health care can be reached in the face of financial, organizational, cultural and emotional barriers
	Acceptability:  the degree to which health care satisfies patients
	Provider Competence:  the provider’s ability to use the best available knowledge and judgment to improve the health and satisfaction of consumers

Quality Assessment

	Definition:  Measurements of or judgment about the quality of care provided
	Dimensions of care commonly assessed:
	Structure:  resources used for health care
		(e.g., facilities, equipment, personnel, qualifications and experience, organizations)
	Process:  the content of care
		(e.g., how patients move into, through and out of the health care system; services provided)
	Outcomes:  results of care
		(changes in health status, comfort, function, satisfaction)

Quality Assurance

	Definition:  the assessment or measurement of, or judgment about, the quality of care and the implementation of any necessary changes to either maintain or improve the quality  of care rendered
	Attempts to assure quality in dentistry:
		Licensing / accreditation / certification
		Peer review
		Review by third parties (UR, profiles, audits)
		Malpractice litigation
		Formal office assessments

Quality Improvement

	Majority of “sub-optimal” performance is due to system problems (design, operations)
	Improving systems reduces variation and increases desired outcomes
	“Special” (individual) problems dealt with separately after system is optimized
	Focus is on improving performance of all participants, thereby “shifting the curve”, rather than on search for “bad apples”
	Team approach involving “line personnel” to understand and re-design processes

Major Aspects of Dental Practice Examined in in Professionally Administered Office Assessment Instruments

			Structure Process Outcomes
			Facilities Practice mgt.         Pt. satisfaction
			Equipment Radiograph Q       Pt. oral hygiene
			Personnel / Staff Data collection Pt. education
			Administration Diagnosis Pt. disability
			Access Tx. planning            Perio. disease
			Record system Tx. (service Q)          Completion of tx.
			Sterilization / I.C.    Maintenance care
			Emerg. readiness Pt. care mgt.
			Radiological safety Service outputs
			Mercury hygiene Dentist/Staff Demeanor
			Office policies Appropriateness
			of tx. & prevention

What do patients value most?

			Structure Process Outcomes
			Facilities Practice mgt.
			Equipment Radiograph Q       Pt. oral hygiene
			Personnel / Staff Data collection Pt. education
			Administration Diagnosis Pt. disability
			Access Tx. planning            Perio. disease
			Record system Tx. (service Q)          Completion of tx.
			Sterilization / I.C.    Maintenance care
			Emerg. readiness Pt. care mgt.
			Radiological safety Service outputs
			Mercury hygiene Dentist/Staff Demeanor
			Office policies Appropriateness
			of tx. & prevention

What do patients value most?

			Structure Process Outcomes
			Facilities Practice mgt.         Pt. satisfaction
			Equipment Radiograph Q       Pt. oral hygiene
			Personnel / Staff Data collection Pt. education
			Administration Diagnosis Pt. disability
			Access Tx. planning            Perio. disease
			Record system Tx. (service Q)          Completion of tx.
			Sterilization / I.C.    Maintenance care
			Emerg. readiness Pt. care mgt.
			Radiological safety Service outputs
			Mercury hygiene Dentist/Staff Demeanor
			Office policies Appropriateness
			of tx. & prevention

A Comprehensive Q.A. System for Practicing Dentists

	Clinical Outcomes Management Approach

Dental Q. A. Criteria Synopsis
 Example

	Restoration acceptable:                                    serviceable, caries free                          healthy gingiva
	Not acceptable:                               deficiency-1mm or > overhang, plaque retention

Dental Office Assessments

	Facilities
	Equipment
	Personnel
	Administration
	Practice Mgt.
	Sterilization/Inf. Control
	Radiographic Evaluation
	Data Collection
	Diagnosis
	Treatment Plan
	Treatment

Quality Resource Guides

	Radiographic techniques
	Blood pressure
	Documentation (record keeping)
	Informed consent
	Chronic adult periodontitis
	Oral Cancer

Consumer Assessments of Health Plans

	Dental office / clinic
		Finding a provider
		Explanations of care
		Continuity of care
	Getting care from dental specialists
		Getting a referral
		Provider rating
	Calling dentists’ offices
		Questions answered
	Dental care in the last 12 months
		Able to get appointments
		Timely care
		Waiting times
		Staff helpful and courteous
		Dentist helpful,  courteous & thorough
	Experience with the dental plan
		Information, paperwork & customer service

Summary

	Efforts to monitor, assure and improve the quality of health care have been sporadic, but remain important to policy makers, payers and the public
	Methods for assessing the quality of dental care have been limited by data collection technologies and costs
	Emerging technologies and information systems have the potential to provide useful data for internal and external assessments of dental practice

Donabedian`s Definition of the Ideal Physician

	Selects and implements the strategy of care that maximizes health status improvement without wasting resources.
		Efficiency of the strategy of care is termed clinical efficiency (Example: Order of care, exam, radiographs, hygiene visit, periodontal re-evaluation, restorative treatment, prosthetic treatment)
			Production efficiency - The manner in which the services are produced

Definition of Quality

	Individual Optimum
	Social Optimum

Donabedian`s Conclusions

	Considering social costs and individual costs society will allocate less resources to health care then what individuals would want

Continuous Quality Improvement

	Edward Deming and Joseph Juran 1930-s Western Electric Laboratories
	( AT&T )

Problems

	Built into a complex production process
	Poor job design
	Failure of leadership
	Unclear purpose

Improving Quality

	Understand process
	Revise
	Monitor
	Feedback
	Measurable data

Kaizen

	Continuous search for making things better
		“ Every defect is a treasure. “

Teamwork

	Applicability of Theory of Continuous Quality Improvement to clinical practice: Teamwork is a must

The Basics of Quality Improvement

	Mr Deming`s teachings:
		Process : a series of interrelated tasks
		System : a group of related processes
		Project team : people working on a process

Organization

	Systems designed to serve customers - Systems to be improved continuously

Deming’s 14 Points of Quality Management

	1. Create a statement of aims and purposes of the company
	2.  Learn the new philosophy
	3.  Understand the purpose of inspection, for improvement of processes and reduction of cost
	4.  End the practice of awarding business on the basis of price tag alone
	5.  Improve constantly and forever the system of production and service
	6.  Institute training
	7.  Teach and institute leadership

Deming’s 14 Points of Quality Management

	8.  Drive out fear
	9.  Optimize towards the aims and purposes of the company
	10. Eliminate exhortations for the work force
	11. Eliminate numerical quotas
	12.  Remove barriers that rob people of pride of workmanship
	13.  Encourage education and self-improvement for everyone
	14.  Take action to accomplish the transformation

Deming’s View of a Production System

Criteria :

	Medical Care criteria are predetermined elements against which aspects of medical service may be compared.
	They are developed by professional expertise and based on the professional literature.
	They are based on attributes of  PROCESS & OUTCOME
	They often include “ STANDARDS “

Explicit Criteria :

	Were set , developed, or predetermined by Group Consensus of recognized authorities in the field.

Implicit Criteria :

	Rely on the Subjective Evaluation of the auditor. They have been internalized by the individual and may differ according to knowledge, training, and experience.