Audit in Dental Practice
Jackie Brown, Heather Pitt‐Ford, Ellie Heidari and Dominic Flanagan
What Is Clinical Audit?
Audit is essentially a tool whereby we measure the standard of our patient care against prescribed standards. This enables us to assess the quality of care and implement changes if required in order to improve. Unless no improvement is required, an audit project is not complete until the standard has been re‐measured to demonstrate the improvement. Audit should be undertaken regularly in dental practice in order to evaluate standards of care and make any necessary adjustments.
Definition of Clinical Audit
Clinical audit is a central part of Quality Improvement and is defined as ‘a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change’ (National Clinical Audit Advisory Group (NCAAG), 2009).
However NCAAG believes the contribution of clinical audit within the new quality assurance framework within the NHS should be:
- To define what constitutes good quality care (usually described in guidelines, based on scientific evidence and clinical experience).
- To assess the quality of care provided (clinical audit, patient experience surveys, critical incident enquiries, qualitative methods).
- To improve the quality of care provided (education, performance review, incentives, regulation, redesign, legislation).
NCAAG also believes that clinical audit has a very important role to play in the emerging quality assurance framework, as this depends upon the high‐quality data which clinical audit creates.
While recognising what clinical audit is, it is equally important to recognise what it is not. In this regard it is important to distinguish clinical audit from two other activities with which it is frequently confused: research and service reviews.
- Clinical audit aims to assess the extent to which care is consistent with best practice and/or achieves expected outcomes. In contrast, research aims to establish and define what constitutes best practice. Research plays a valuable role in enhancing quality by producing knowledge to inform guidelines of best practice.
- Clinical audit differs from service reviews, which aim to provide a snapshot description of the state of a service, usually in one locality (although it may take a nationwide perspective) and are usually concerned with inputs rather than processes or outcomes. Such reviews are generally one‐off with no attempt to re‐review (NCAAG, 2009).
The Audit Spiral
The audit spiral has been described as an ongoing development and evolution of a clinical audit project as new developments take place (Bucknall et al., 1992). Thus the audit cycle is never complete as healthcare is constantly evolving (Figure 24.1).
The audit spiral:
- Measures performance against prescribed standards. Is change required?
- If so, perform a root cause analysis to ascertain any underlying cause of the problem.
- Draw up an action plan and decide who will implement it.
- Make changes.
- Repeat with any necessary adjustments for new developments.
Audit thus seeks to improve clinical practice.
Planning a Clinical Audit
Choosing an Audit
Audit should only be undertaken if the necessary improvements are achievable. For this reason it is important to involve all stake holders, including staff, who will need to implement the changes, and also budget holders, at an early stage. There must be a commitment to act on the findings.
Audit should address:
- Anything which is not working as well as it should.
- Outcomes of treatment performed regularly.
- Adverse incidents.
- Legal issues.
- Compliance with standards such as National Institute for Health and Care Excellence (NICE) guidelines, guidelines produced by Royal Colleges and specialist societies, local guidelines.
Designing an Audit
Design of a clinical audit is very important. The following features should be considered:
- The title should state the objectives and what you are measuring.
- Decide on a standard against which to measure. This may be a national or local guideline or recommendation. National guidelines are tailored for local use, so that local guidelines may be developed from them.
- Identify sources of data for collection – where the data will be collected from.
- Identify persons involved:
- Lead person for this clinical audit project.
- Other people involved.
- Outside assistance required.
- Identify materials needed, such as access to a computer.
- Decide on any exclusions from the data to be collected.
- Only record data that are going to contribute to achieving the objectives.
- Decide on number of cases and time scale.
- Choose a sample in such a way as to avoid bias.
When the Data Have Been Collected
Analyse the data and decide whether there is a problem. The cause of the problem may not be immediately obvious. It is therefore advisable to carry out a root cause analysis to find any underlying cause.
Root Cause Analysis (RCA)
This is a very important stage. It involves discovering the reason for the problem. RCA provides a retrospective review of an incident or event in order to identify:
- What happened.
- How it happened.
- Why it happened.
- How solutions can be developed and fed back to staff (National Patient Safety Organisation, 2011).
RCA uses a defined critical analysis approach. It can be used with groups of staff as a helpful investigative tool to identify why something keeps happening, or why there is a series of near‐miss incidents. You can also use other methods such as ‘brain storming’ or ‘brain showers’, ‘five whys’ and the ‘fishbone diagram’ to explore and drill down further into the causes of an incident (National Patient Safety Organisation, 2011).
The analysis is used to identify areas for change, recommendations and solutions that aim to minimise the recurrence of the incident in the future.
The Fishbone Diagram
This may be helpful when there is an underlying problem which may not immediately be obvious. It involves drawing a skeleton of a fishbone on which each spine is labelled with a cause of the problem, as follows.
How to Do a Fishbone Diagram (Figure 24.2)
- Draw a fishbone structure. Record in the head of the fish the problem, situation or effect you are analysing. Decide what the primary causes of this problem might be and label the spines on the diagram accordingly. Potential ways to identify primary causes are patients, processes or systems, equipment, environment, resources, staff or communication.
- For each of the primary cause spines, think of ideas of causes that could be attributed to the primary cause. Attach your ideas (which are referred to as secondary causes) to the relevant primary spine as secondary spines. Attach any further explanations of a cause (which are referred to as tertiary causes) to the relevant secondary spine.
- When you have finished thinking up ideas, decide if you want to set priorities among the potential causes or if you feel that you need to investigate any of the causes thought of.
- Use your conclusions to develop an action plan to address causes of the problem or to investigate further.
- You could use ‘asking ‘Why?’ five times’ or ‘process mapping’ (see the next sections) to investigate further.
Asking ‘Why?’ Five Times
Ask ‘Why?’ five times. Why has the problem occurred? Why has this occurred? etc., until the real underlying cause is discovered.
Make a diagram of the stages of a process and analyse each stage. Remember, it may be the system which is at fault and not how it is implemented (Healthcare Quality Quest, 2007).
Implement Change and Re‐audit
An action plan is drawn up, with specific named persons responsible for ensuring that it is implemented.
When changes have been implemented for an appropriate length of time, repeat the measurements in order to show the improvement.
The first audit cycle is then complete.
Repeat this process at regular intervals, adjusting to take account of new developments. This is the audit spiral.
The Audit Template
The template provided here has been drawn up so that you can create your own audit projects by following the different stages which are identified and explained in the template.
In the following sections of this chapter the template has been used to provide ideas for audit projects with ‘recipes’ for how these may be performed. These might be used as laid down, or adapted to make them more relevant to your clinical practice.
|Title of audit||Give a clear indication of what you are measuring in the title, and the objective.|
|Background||Why is this audit worth doing? Is it an issue of local concern, has it been identified as a problem or is it being done in an effort to improve quality?
Consider the objectives of this audit – what would you like to achieve?
|The standard||Decide on what agreed or recognised ‘standard’ this audit is comparing current practice against. This standard ideally would be a national or published recommendation or guideline but may be a locally agreed criterion or policy.|
|Performing the audit|
|Identify and collect the data||
|Number of cases||Decide on how many cases or items you would like to audit, or alternatively decide on a period of time over which to run your audit.|
|Compare with the standard||You have now collected your data. You are now able to calculate the degree to which the agreed ‘standard’ is being met. This should be expressed as a percentage, e.g. 64% of ‘cases’ met the standard.|
|Implement change||At this stage you will know whether there is a problem – is the standard being met? If not:
First try to analyse the reasons why the standard is not being met. Undertake a root cause analysis; for example, use the fish‐bone analysis principle described above.
Then decide on what change needs to be made and put this into action for a reasonable period of time.
|Re‐audit||This is the important part, and is where you complete the ‘audit cycle’. It is not ‘audit’ until you have completed this phase of the project.
Repeat the same audit after change has been implemented. Repeat the same analysis of your results. Hopefully you will find an improvement!
Share the results – others may benefit from your findings.
Audit Ideas and Recipes
The following audits have been provided to give ‘recipes’ and ideas for future audits. They are divided into:
- Patient‐related audits:
- Audit of patient record keeping.
- Audit of patient consent to treatment.
- Audit of quality of periapical films.
- Audit of radiological evaluation recorded in patient notes.
- Audit of unerupted maxillary canine teeth.
- Audit of emergency management of enamel/dentine tooth fractures in permanent teeth.
- An audit of the management of caries in the primary dentition.
- Audit of patient satisfaction by survey.
- Audit of delivery of oral health promotion advice.
- Practice‐related audits:
- Audit of emergency drugs in dental practice.
- Audit on storage and dispensing of drugs held in general dental practice.
- Audit of equipment checks necessary for providing basic conscious sedation techniques in dentistry.
- Audit of washing and decontamination of instruments.
- Audit of sterilisers.
- Audit of storage and use of sterilised instruments.
- Audit of laboratory return times.
- Audit of patient waiting times.
- Staff‐related audits:
- Audit of basic life support training.
- Audit of hand hygiene.
- Audit of use of personal protective equipment.
- Audit of training in child protection.
1. Audit of Patient Record Keeping
The following areas of a patient’s clinical notes can be audited for accuracy and completeness according to Faculty of General Dental Practice (UK) recommendations (Faculty of General Dental Practice, 2009):
- Minimum data set of patient details and demographics recorded for all dental examinations.
- Classification of patients according to risk status for:
- Periodontal breakdown.
- Oral mucosal health.
- Likelihood of endodontic failure.
- Currency of medical histories.
- Currency and completeness of dental histories.
- Quality of written reports on radiographs.
- Quality and comprehensiveness of diagnosis and treatment plans.
- Recording of the causes of endodontic problems.
- Proportion of patients according to whether they are new patients, recall patients or patients attending for an unplanned visit.
- Recall intervals for patients with different oral health profiles.
In this audit we suggest that you choose one or several areas from the list above to examine more carefully using audit. An example of an audit template is included here to help in data collection.
|Title of audit||Audit of patient record keeping|
||To improve quality of care of patients by having high standards in record keeping in terms of accuracy, legibility and timeliness.
It is also necessary for medicolegal and clinical governance reasons.
||100% of dental records should contain clear and complete details relating to the section you have chosen to audit, e.g. patient details or patient’s medical history
These should be written clearly, ideally in black ink (for ease of photocopying if necessary), dated and signed (and name printed) by the clinician (Department of Health, 1999; National Institute for Clinical Excellence, 2004; General Dental Council, 2005; Faculty of General Dental Practice (UK), 2009) .
|Performing the audit|
|Identify and collect the data||Examine patients’ records with regard to the sections mentioned above.|
|Number of cases||Look at the relevant details and last entry in all dental records of patients attending the clinic in a 2 week period.|
|Compare with the standard
||Calculate how many records were examined.
Calculate % of records in a chosen section that are complete.
||Analyse areas of discrepancy between records and ideal compliance – where were the notes deficient?
Consult with staff about areas of non‐compliance.
Train staff to enable them to correct errors.
||Repeat audit every 3 months until a score of >90% has been achieved.|
An Example of a Record Keeping Data Template
|Audit number||Dental record number:||Data collection date:|
|The dental record||
2. Audit of Patient Records of Consent to Treatment
|Title of audit||Audit of patient records of consent to treatment|
||Informed consent is required for treatment, to show that a patient understands and agrees to treatment they are to receive. A record of the consent, and any changes to their agreement, should be recorded in the patient’s notes.|
||All patient notes should contain a record of their consent to the treatment proposed, given either by themselves or by a responsible competent adult, and the information they received. This should be either a direct entry in the notes or as a completed consent form within the notes.
The practice should have a local policy on procedures deemed to require consent and in what form that informed consent is normally given and recorded, either implied or written (Care Quality Commission, 2010a).
|Performing the audit|
|Identify and collect the data||Retrospectively review patient notes to identify a record of the presence of information given and type of consent obtained (implied or written) made at the beginning of the most recent course of treatment.|
|Number of cases||50 patient notes from those patients receiving a course of treatment, which may be randomly selected from patients seen within the last year.|
|Compare with the standard
||Analyse failures to comply with the requirement for all notes to show a record of information given and consent obtained to treatment, and identify reasons for failure.
Meet with all staff involved to discuss reasons for failure.
Develop a strategy to ensure consent is obtained and recorded reliably, and implement this.
||Re‐audit in 6 months.|
3. Audit of Periapical Radiographic Film Quality
|Title of audit||Audit of the quality of periapical films|
||To improve quality of periapical films, and to prevent unnecessary repeat radiographs which increase costs and radiation exposure, and waste clinical time.|
||Nationally‐recommended standard for film quality (Royal College of Radiologists and the National Radiation Protection Board, 1994):
Grade 1 = perfect radiograph without errors of technique, positioning, exposure or processing.
Grade 2 = some faults but still diagnostic.
Grade 3 = reject radiographs which are non‐diagnostic.
Standard: >70% Grade 1, <20% Grade 2, <10% Grade 3.
|Performing the audit|
|Identify and collect the data||Create a log of all films taken over a 3 month period. This should include:
Perform film reject analysis – reason for film faults for both Grade 2 and 3 films.
|Number of cases||All films taken in a 3‐month period.|
|Compare with the standard
||Identify the most common cause for Grade 2 and 3 films.
Train staff to enable them to recognise and correct errors.
||Repeat audit every 6 months.|
4. Audit of Radiological Evaluation Recorded in Patient Notes
|Title of audit||An audit of the recording of a radiological evaluation of radiographs within patient notes|
||The IRMER 2000 legislation requires that all radiographs are evaluated and a report recorded in the patient’s notes. Dental radiographs are frequently taken in dental practice and an appropriate report of radiographic findings should be entered in the patient’s notes.|
||100% of all radiographs taken should have a short, relevant radiological report recorded in the patient’s notes for that radiographic examination, entered within a reasonable time after the radiograph has been taken, e.g. before, or by, the patient’s next appointment (Department of Health, 2000).|
|Performing the audit|
|Identify and collect the data||Retrospectively review patient notes for:
|Number of cases||50 patient case notes/dental records.|
|Compare with the standard
||Calculate the number of notes with radiographs and a radiological report recorded before or by the next patient appointment.
Calculate % compliance with the standard.
||Investigate and analyse reasons for failure to record a radiological report in patient notes, e.g. Were case notes unavailable when radiographs were reviewed? How might that be overcome?
Address issues and introduce new strategies as appropriate at a staff meeting.
||Re‐audit in 12 months.|
5. Audit of Unerupted Maxillary Canine Teeth
|Title of audit||Audit of impacted maxillary canine teeth|
||The aim of this audit is to improve the management of ectopic maxillary canines through timely diagnosis in children. Permanent maxillary canines should normally be palpable buccally by 8–10 years of age and should erupt at approximately age 11–13 years. If the canine is palpable buccally at age 8–10 years then no further action is required.
If this is not the case or if the position of the canines appears to be asymmetrical on clinical examination, radiographs should be taken at approximately 10–11 years to identify the presence and position of the unerupted canine tooth. This is particularly important as a malpositioned unerupted tooth may cause damage to other teeth. If an abnormality is detected, the appropriate referral should be made (British Orthodontic Society, 2008).
||If the canine cannot be detected clinically, then all affected children (100%) should undergo a radiographic examination such as a panoramic, periapical or maxillary occlusal radiograph at approximately 10–11 years, and an appropriate referral made if necessary.
An exception would be made in the presence of dental anomalies and syndromes associated with delayed eruption (Husain, Burden and McSherry, 2016).
|Performing the audit|
|Identify and collect the data||Create a log of all paediatric dental patients aged 10 or over, with maxillary canines unerupted, seen during a 3‐month period, but exclude patients with syndromes which may delay eruption. The log should include:
|Number of cases||All young patients (aged 10–11 years) with unerupted canines seen in a 3‐month period.|
|Compare with the standard
||Calculate the number of children aged 8–11 years seen in this period.
Calculate the number of these children examined who show undetectable canines on clinical examination.
Calculate the number of these patients who have been investigated, diagnosed, the diagnosis recorded correctly and the appropriate referral made.
||Analyse the results for deficiencies in the examination and investigation of unerupted canines.
Discuss with staff and develop strategies to ensure that all patients are appropriately examined for presence and position of unerupted canines, and that examination of patients with unerupted canines is correctly recorded.
Ensure that all patients with displaced canines are referred to an orthodontist at the appropriate time.
||Repeat audit every 2 years to create an audit spiral.|
6. Audit of Emergency Treatment of Enamel/Dentine Tooth Fractures in Permanent Teeth
|Title of audit||Audit of emergency treatment of enamel/dentine fractures in permanent teeth|
||The urgent care option (for teeth with an enamel/dentine fracture) is to cover the exposed dentine. If the tooth fragment is available, it can be bonded to the tooth (Flores et al., 2007).
Inflammatory changes are transient as long as the pulpal vascular supply remains intact and bacterial invasion is prevented. This may be achieved by an efficient sealing of the dentine; only in the case of improper sealing will further irreversible pulpal lesions occur. Prognosis of the pulp is very good. Long‐term clinical studies show very little response to enamel/dentin fractures and subsequent restorative procedures, as long as there is no concomitant periodontal injury and the restoration is efficiently sealed (Maguire, Murray and al‐Majed, 2000; Olsburgh, Jacoby and Krejci, 2002).