Part 3:
Quality Assurance
The quality of a champagne is judged by the amount of noise the cork makes when it is popped.
Mencken and Nathan’s Ninth Law of the Average American
The quality of healthcare services is a major social issue. Activities directed toward the assessment and assurance of the quality of dental care are receiving increased attention. Changes in reimbursement and payment plans, heightened competition, and a rise in consumer expectations have all contributed to the increased emphasis on the quality of patient care. Consumers, government, businesses, and insurance companies are scrutinizing the quality of dental care considering the billions of dollars that they spend annually for that care.
QUALITY ASSURANCE TERMINOLOGY
Quality is difficult for most people to define. When asked whether a given good or service is of high quality, people generally have an opinion, but might have difficulty in stating the rationale for providing that opinion. In other words, it may be difficult to answer the question “What makes Burger King higher quality than McDonald’s?” It may be the way they cook the burgers. Or it might be the variety of menu items, the service, or the cleanliness of the restaurants. It might simply reflect a personal preference or taste, or other criteria might be used to judge.
Dentists often equate the quality of care with technical quality – for example, does a restoration have smooth margins, proper dental anatomy, and adequate occlusion? Quality of care encompasses a much larger domain than simply technical quality. It includes issues such as the appropriateness of care provided to patients, the ability of a patient to receive care when needed (access), and the timeliness of the care provided. To include all these aspects when defining quality, healthcare professionals refer to the three dimensions of quality: structure, process, and outcome.
- Structure
Structure addresses the characteristics of the setting in which the dentist provides the care. This includes the infection control and radiation safety procedures followed in an office, the training and certification of dental office staff, the adequacy of office hours, and office cleanliness. For example, if Dr. Smith operates a roach‐infested dental practice, a person would question the quality of her office and, therefore, the care provided in that office based on a structural concern.
- Process
Process describes the activities between the dentist and the patient. This dimension is the one most often thought of when discussing quality. It includes the actual technical quality of care plus issues such as the accuracy and documentation of oral examinations and medical histories, the status of the recall system to ensure continuity of care, and the frequency with which the dentist takes radiographs. For example, a practitioner who never takes radiographs for diagnostic purposes would not offer high‐quality care.
- Outcome
The outcome dimension reflects the effects of dental care on the health and welfare of the patient. This aspect of quality is new and is still evolving. In dentistry there are two components to the outcome dimension. The first is the effect of the care on a person’s health and functioning: do they feel better, look better, or eat better because of the care received? This component is difficult to measure, and researchers are doing significant work to refine approaches to measuring it. The second component is patient satisfaction with the dental care received. This is based on the belief that patients can accurately evaluate the quality of care provided by their dentist. From the consumer’s perspective, if a dentist has met the patient’s needs as a consumer, then the care is of adequate quality.
Several terms are important in any discussion of the quality of care:
- Standard of careA standard of care is a precise statement outlining what constitutes an acceptable level of quality. (OSHA’s definition of acceptable infection control practice is a standard.) There have been efforts to develop standards of care for other aspects of dental practice; however, presently no universally accepted standards govern quality in dentistry. The standard of care is discussed in more detail earlier in this chapter.
- Quality assessmentThis refers to measuring the quality of any good or service compared with a set of standards. An example of quality assessment in dentistry is the comparison of infection control procedures in a dental office with OSHA standards. If it is common practice in an office to reuse saliva ejectors, an assessment of the office will show a deficiency.
- Quality assuranceThis relates to quality assessment, but includes an essential additional idea. Quality assurance activities go beyond measurement and include any necessary changes to bring the quality of care into compliance with standards governing that aspect of care. In the infection control example, any policies, procedures, or actions that bring the office practices in line with OSHA standards (e.g. using a new saliva ejector for each patient) represent a quality assurance activity.
- Total quality managementTotal quality management (TQM) is a system used in business that attempts to involve all producers of the goods or services in identifying and resolving quality assurance activities.
HISTORY OF QUALITY ASSESSMENT AND QUALITY ASSURANCE IN DENTISTRY
The dental profession has always been involved in evaluating and ensuring the quality of dental care rendered to the public. In the late 1700s, the profession encouraged states to develop a system for licensing dentists. By the 1860s, state dental boards became legally responsible for examining and licensing dentists. Today, clinical board examinations and licensure procedures show organized dentistry’s commitment to quality dental care because they help confirm that a dental graduate is adequately prepared to provide that care.
During this time, US dental education underwent significant changes. It progressed from the apprentice system through proprietary schools to university‐based programs. Accreditation activities were founded on the dental profession’s commitment to quality; that is, ensuring that dental schools give students the knowledge, skills, and abilities needed to render high‐quality care to the public. Today, all dental schools are subject to accreditation through the ADA’s Commission of Dental Accreditation (CODA). This accreditation process requires schools to evaluate critically their curricula, facility, and educational practices. It culminates in a multiple‐day site visit by CODA representatives. If a dental school loses its approval by CODA, its graduates will not be eligible for licensure in most states. This, then, is a virtual death penalty for the dental school.
Dental school accreditation and licensure are important components of a quality assurance program. However, simply graduating from an accredited school and getting a dental license do not guarantee that a dentist will continue to provide high‐quality patient care. To ensure that practitioners remain current in knowledge and technique, many states require that dentists participate in continuing education courses as a prerequisite for relicensure. These states often require a certain number of hours per year of participation in scientific coursework by each dentist or hygienist. Although these courses expose practitioners to current materials, they offer no guarantee that participants will learn or use the material presented.
Each state has laws that govern the practice of dentistry in that state. Most have a board of dentistry or a similar oversight committee whose job is to protect the public from incompetent or unscrupulous practitioners. They have several methods to accomplish this end. They intend clinical licensing exams to assess the technical quality of an unknown practitioner, protecting the public from poor‐quality dentists. (In fact, nearly all dentists eventually pass a licensing exam, so these are not particularly effective.) Boards may also revoke or suspend dental licenses for conduct that endangers the public. Examples of this conduct may be alcohol or drug abuse, continually faulty dentistry, or conviction for a crime that shows poor moral qualities, judgment errors, or character deficiencies. There is significant room for interpretation by the individual boards and state laws.
Another form of professionally developed quality assessment activities is peer review, a system that most dental societies operate. In these systems, a dispute between a patient and a dentist can go to a committee composed of dentists trained to evaluate the situation impartially. Disputes handled by peer review committees generally relate to the quality of treatment and the appropriateness of care. The peer review process reflects one basic tenet of a profession: the ability to “police its own” and thereby maintain high standards. It also has a couple of disadvantages that are worth mentioning. First, peer review is a reactive process initiated only after the allegations of poor‐quality work exist. Thus, rather than raising the overall level of quality provided by the profession, the process aims at the few poor‐quality providers. Secondly, most patients who perceive receiving less than optimal care change dental providers. They will not waste the time and effort of filing a complaint with the peer review board. Thus, peer review does not become involved in many situations where the care provided may warrant it.
Malpractice litigation is another form of quality assurance in the profession. A dentist who has several instances of successful malpractice litigation brought against them may have difficulty in finding malpractice insurance and may lose patients as the public becomes aware of their incompetence.
The most recent step in quality assessment and assurance activities stems from third‐party involvement. Insurers primarily became involved with quality‐of‐care issues as they related to efforts to contain costs. They began to review the insured’s claims to detect overutilization patterns, where particular patients or groups of patients consumed “too many” services. Traditional indemnity plans quickly became aware that “overtreatment” was common among their involved providers. Third‐party plans began requiring dentists to obtain a preauthorization from the plan to ensure that the services the dentist has proposed are, in the opinion of the plan, necessary and warrant coverage. Because of this concern with controlling care costs, third‐party plans began to address quality‐of‐care issues, such as the appropriateness of the care provided and patient overtreatment.
CURRENT FOCUS ON QUALITY ASSESSMENT AND ASSURANCE ACTIVITIES
Today’s healthcare arena has an increasing focus on the quality of care provided. One needs only to scan the daily papers to find an article about healthcare reform, with quality‐of‐care issues being a central focus. Four trends in the healthcare system contribute to the public’s concern with quality.
THIRD‐PARTY PLANS
By virtue of the reimbursement structure, many managed care plans (e.g. capitation plans, preferred provider organizations, etc.) provide incentives for a dentist to undertreat patients. For example, suppose Dr. Smith receives less than the usual fee for a crown for a patient covered by the local capitation plan. In that case, she may reduce costs by using lower‐quality materials, providing less than ideal treatment, or not treating the patient at all.
HEALTHCARE COSTS
The costs of healthcare have risen dramatically over the last several years. Though dentistry is only a small component of the healthcare system, the costs have followed those in the medical community on their upward spiral. As patients, insurers, and employers pay more for the care received, they increasingly demand that their purchases be of high quality.
CONSUMER INVOLVEMENT
Forty years ago, patients accepted the advice of healthcare practitioners with no questions asked. After all, the doctor knows best. Today, however, patients are taking a more active interest in their own health and in the care they receive. Most want an understanding of the problem, explanations of treatment, a discussion of the options available to them, and a perception that the care they receive will be of high quality, before ever consenting to care.
PROFESSIONAL LITIGATION
People sue others for anything (or for nothing) because we live in a litigious society. This results in malpractice suits costing the system millions of dollars. To avoid or decrease the costs of a liability suit, dentists and their liability insurers are focusing efforts on monitoring quality to reduce risk. Many insurers conduct courses for students and practicing dentists, which address the methods to monitor and document the care provided in their offices.
IMPLICATIONS FOR PRACTICING DENTISTS
The current focus on the quality of care has several implications for practicing dentists. First, if a dentist participates in a managed care plan, they will likely go through a quality assessment review of the office. To counter the allegations of undertreatment discussed previously, most managed care plans have written standards for their participating providers and conduct formal annual quality assessment reviews. The format of these reviews is discussed later in the chapter. Secondly, because of the increased focus on quality and consumers’ concern with quality, even traditional indemnity plans are becoming more involved in quality assessment. That means that if a dentist participates with any third‐party insurer, the chances are that the insurer will review the dentist’s office at some point.
Dentists generally have one of two responses to these reviews: either they are highly insulted that anyone would question their professional capabilities and resent the intrusion of the reviewer into the practice, or they view the review as an opportunity to learn something about their practice, welcoming the reviewer’s comments and opinions. A word of advice: the second response may be the one to strive for. Usually, if an insurance plan has reached the point of reviewing a dental office, that plan wants to have the dentist work with it. In other words, the plan wants the review to go well. The practice owner should remember that the reviewers are usually dentists who have reviewed hundreds if not thousands of offices and thus have a wealth of experience in what works and what does not. The practice owner might learn something from the reviewer and should be open to suggestions for change!
The benefits of quality‐of‐care reviews for practitioners relate to professional liability premiums and practice marketing. The quality of care provided in an office, and the documentation of that care, is of obvious concern to liability insurance carriers. Like reduced health or life insurance premiums for non‐smokers, the day may come when liability insurance carriers will offer a decrease in the premium to practitioners who have participated in a quality assessment review and provide care according to professional standards. Participating in a quality assessment program and receiving the “seal of approval” from a recognized entity can also have implications for marketing a dental practice. Any patient who chooses a dentist would likely be drawn to a practitioner who has evidence from an independent reviewer that the care provided in the office meets high professional standards.
QUALITY ASSESSMENT REVIEWS IN DENTISTRY
Third‐party (especially managed care) plans conduct most quality assessment reviews in dentistry. Large group practices and networks also conduct quality assessments on many aspects of their business, including the delivery of care. Most of the quality assessment programs operated by those plans are similar in design. Quality assessment reviews generally contain five components: facility reviews, records reviews, laboratory work reviews, patient examinations, and patient satisfaction surveys.
FACILITY REVIEW
A review of a physical practice facility addresses the structural aspects of quality (Box 28.4). It entails an on‐site visit by the quality assessment reviewer. The reviewer will tour the office and ask a series of questions of the dentist or of the office staff. This portion of the review looks at several structural aspects of the practice to find out whether these comply with professional standards. The reviewer looks for specific facility issues. For example, third‐party payers are usually interested in contracting with offices with enough operatories to efficiently see the plan’s patients. They will, therefore, examine the number and condition of the operatories compared with patient volume. If the dentist delegates clinical work to auxiliaries, those staff members must be duly licensed or trained to carry out the work legally and safely. Written policy manuals, regular staff meetings, and such suggest to the reviewer that the dentist is attentive to personnel issues. Constant staff turnover hinders the continuity of care and decreases the satisfaction of patients and plan members. Are the dentist’s office hours sufficient to handle the patient load, or is the waiting time for appointments prohibitive for patients? The practitioner should be accessible to patients during hours when the office is closed. If not, the dentist needs to arrange for someone to cover emergencies. Does the office have a recall system with a follow‐up mechanism to ensure that patients do not get “lost”? Is there equal access to care for patients with different payment sources? This question is critical to alternative care plans to ensure that their plan members are not treated differently in their access. The reviewer may want to observe infection control procedures and question the staff about their knowledge of proper procedures. The reviewer may also check to be sure that the office follows standard emergency procedures, OSHA guidelines, worker safety, and radiation hygiene practices.
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