WHY PLAN?

As part of our role as health professionals, we are called on to assist health agencies and organizations in developing plans for obtaining dental care. We need to develop our own abilities to take our dental expertise and channel it into the areas of policy development, decision making, and program planning in a system more complex than the one with which we are familiar in the private dental office. This complex system may take the form of a community, an organization, a corporation, or an institution. The system can be better understood if we look on it as a patient, possessing certain needs and characteristics. Because we are dealing with more than one individual, planning a program for a community or institution requires a deep understanding and analysis of the system as a whole and of the individual members that make up the system.

Planning Dental Care for the Patient

The steps the dentist takes when seeing a patient for the first time can be compared with the steps a planner takes when viewing a system for the first time. A new patient who walks into the dental office is given a medical and dental history form to complete. This record provides background information on the patient’s health, history of diseases, and drug reactions, as well as the patient’s history of dental care. Information on the patient’s ethnic background, degree of education, and financial status may indicate the patient’s attitude about dental care, the type of dental care wanted, and how that care will be financed. A clinical examination with the use of radiographs further reveals the type and quality of dental care received and identifies any existing conditions or disease requiring treatment. For the dentist these steps assess the needs of the patient.

The next step is to identify and diagnose the problem or problems. Perhaps the patient requires full mouth reconstruction to restore the mouth to optimum functioning. The dentist reviews with the patient the ideal plan and acceptable alternatives based on the patient’s wants and financial limitations. Once the patient accepts the treatment plan and the method of payment, the plan is ready to be implemented.

The dentist selects the appropriate person to perform the necessary services from a staff of specialists and designs a realistic timetable to coordinate who will do what first, second, and so on until treatment has been completed.

When treatment has been completed, the patient is placed on an appropriate recall schedule and returns to have an evaluation of the care that was rendered. Any modifications or adjustments are done at this time. The patient is then placed on a maintenance plan and returns periodically for a routine examination. This becomes an ongoing process for the patient and the dentist. The difference between the planning steps for an individual patient and the planning steps for a community is that dealing with more than one individual at a time requires more complex steps. Box 12-1 compares the provision of dental care for a private patient with that for a community.

BOX 12-1 A Comparison of the Provision of Dental Care for a Private Patient and a Community

Modified from Young W, Striffier D: The dentist, his practice, and the community, Philadelphia, 1969, WB Saunders.

Private Patient

1. The dentist conducts a dental and medical history and a clinical examination of the patient.

2. The dentist diagnoses the oral health of the patient.

3. The dentist develops a treatment plan based on the diagnosis, the priorities, the patient’s attitude, and the method of payment for the services.

4. The dentist obtains patient consent for treatment.

5. The dentist selects the appropriate personnel to provide the care: dentist, specialist, laboratory technician, dental hygienist, and dental assistant.

6. The dentist selects the appropriate dental service for the patient: preventive services, restorative services, endodontic services, and so on.

7. The dentist evaluates the treatment rendered to the patient: clinical examination, radiographs, patient oral hygiene, and patient satisfaction.

Community

1. The planner conducts a survey of the community’s structure and dental status.

2. The planner analyzes the survey data of the community.

3. The planner develops a program plan based on the analysis of the survey data, the priorities and alternatives, the community’s attitudes, and the resources available.

4. The planner obtains community approval of the plan.

5. The planner selects the appropriate labor to implement the program: dentist, dental hygienist, dental assistant, dental technician, nutritionist, health educator, school-teacher, social worker, health aides, and public health nurses.

6. The planner selects the appropriate activities for the community: community water fluoridation and school-based fluoride rinse programs.

7. The planner evaluates the community program: comparison of baseline survey with subsequent survey, attainment of goals and objective, cost-effectiveness of activities, appropriateness of activities, and community satisfaction.

Planning Dental Care for the Community

Usually a planner is contacted because a problem has been identified within the community, for example, a high incidence of early childhood caries (ECC) among children. The planner, like the dentist, begins by conducting a needs assessment of the affected children and their families. Included in the needs assessment are the population’s health problems and beliefs, ethnic makeup, diet, education and socioeconomic status, number of children with ECC, and the severity of the disease.² Again, this information will help the planner in determining an appropriate plan.

Once the information has been gathered and analyzed, the planner, along with the community, sets priorities for dealing with the problem. The planner may decide that the first priority is to treat all existing cases of nursing bottle caries within the community, followed by reeducating the parents of these children and those individuals who recommended sweetening the contents of the children’s bottles. The planner then sets a reasonable goal to reduce the incidence of ECC within that community within a specified time and proposes methods or objectives to accomplish the goal.

Next, the planner identifies resources available to the community, such as who will provide the treatment, how the care will be financed, and where the care will be provided. If constraints exist (e.g., no transportation available to bring the children to the dental office or a lack of funds necessary to provide the treatment), the planner needs to consider alternative strategies to accomplish the intended goal. The planner might identify and recruit volunteer dentists or dental students to treat the children at no cost to the community.

Once the decision is made and approved by the community, it is ready for implementation. An implementation timetable is developed to provide a schedule for putting the plan into action.

After the children have been treated, a 6-month follow-up examination is instituted to evaluate the effectiveness of the plan. At that time the planner addresses questions such as the following: How many children identified as having ECC were treated? How many dropped out of treatment, and why? How many developed new ECC? The answers to these questions will help the planner to modify and adjust the program according to the needs of the community.³

Many kinds of planners exist. Some have been professionally trained or educated, whereas others have received on-the-job experience within their organization. There are two distinct approaches to planning: internal, planning by individuals within the system or organization; and external, planning by those brought in from outside.⁴ A planner hired from within the system is usually an individual whose work responsibility is to plan for the system on a full-time basis. The advantage of hiring from within is that the planner already has a true understanding of the issues and operation of the system, including the subtleties of that system. This knowledge enables the planner to begin making decisions more quickly regarding appropriate action. The disadvantage, however, is that the planner may already have acquired certain biases about the system that could influence his or her objectivity.

The planner brought in from outside is usually an individual who contracts to work for the company or agency on a consulting basis for a short period. The planner’s job is to assist the organization in its planning by formulating a new proposal or making recommendations for changing an existing plan. The advantage of an outside planner is that the organization may receive a fresher outlook, less bias, and a greater sense of objectivity. The drawback is that the outside planner requires more time to reach a sufficient level of understanding for effective action to take place.

One of the most important concerns for any planner is to take into consideration the human element. Statistics alone do not tell the whole story. For example, a planner who reviews the health labor statistics on a multiethnic community and who sees that, overall, sufficient numbers of practitioners work within the community may think that the community does not need any new practitioners. A closer examination of the practitioner and patient populations may reveal that the practitioners are primarily of a certain ethnic background and do not like treating patients of different ethnic backgrounds, of which there are a great number in the community. Thus large subgroups of the population may not have access to dental care, even though statistically enough dentists are available in the community.⁵ Although statistics can be most useful in analyzing data, a planner must be aware of their limitations.

PLANNING: A DEFINITION

Banfield presents a basic definition of the term planning: “A plan is a decision about a course of action.”⁶ In other words, a plan is a systematic approach to defining the problem, setting priorities, developing specific goals and objectives, and determining alternative strategies and a method of implementation.

Many types of health planning exist. Each varies according to the factors affecting the health system, such as the geography of a region, the sociocultural background of the population, economic considerations, and the political situation. Some types of health planning, as outlined by Spiegel and associates,⁷ include the following:

1. Problem-solving planning involves the identification and resolution of a problem. An example of problem solving was the appearance of dental fluorosis among residents of a community in Colorado. This enamel disorder was identified through a scientific study of possible causative factors.

2. Program planning entails designing a course of action for a circumscribed health problem. School-based fluoride rinse programs are an example of designing a course of action for the problem of dental caries within a community setting.

3. Coordination of efforts and activities aims to increase the availability, efficiency, productivity, effectiveness, and other aspects of activities and programs. This stage often involves an adjustment process, such as a merger or a closing of services and facilities. An example is the closing of obstetric and pediatric wards in hospitals located in areas with a declining birth rate.

4. Planning for the allocation of resources involves selecting the best alternative to achieve a desired goal when the amount of resources is limited. Planners are called on to allocate the budget, the labor, and the facilities in a system so that it may meet existing needs and demands. An example is the decision by a state government with limited financial resources for the provision of dental services to cut services to medically indigent adults based on the cost-effectiveness of providing preventive dental care to a younger population.

5. Creation of a plan involves the development of a blueprint or proposal for action containing recommendations and supporting data. It is common for a commission or special task force to be created to prepare the plan. A state health plan that describes the health status and the distribution of health services for the population in that state is a good example of such planning.

6. Design of standard operating procedures requires planners to come forth with a set of standards of practice or criteria for operation and evaluation. This can be a result of legislation, or it can be created voluntarily by the parties concerned. Guidelines for evaluating the quality of dental care as part of a continuous quality improvement program for an insurance company is one example.

This chapter describes various types of health planning but concentrates specifically on the program-planning process. This process of program planning uses a systematic approach, as seen in Fig. 12-1, and should be used as a guide to solving a particular problem. The process can be compared with the ability of a jazz musician to take the notes of a standard musical scale and use them to create a unique melody. In a similar fashion, a planner uses the program-planning steps to create a plan that is unique for the specific situation or system. The process of planning is dynamic. Within a fluctuating and ever-changing system, the process itself must remain fluid and flexible, responsive to the presentation of new factors and issues. This chapter discusses the components of program planning and focuses on the various options available to the planner. The initial step in the planning process is to conduct a needs assessment.