Table of Contents

Title Page

Copyright Page

Foreword

Preface

Acknowledgement

Chapter 1 Introduction

Aim

Outcome

Introduction

Challenges

A Changing Landscape

Clinical Aspects

Benefits

References

Chapter 2 The Meaning of Quality

Aims

Outcome

Introduction

Definitions

Terminology

Quality Assurance and Quality Improvement

Continuous Quality Improvement (CQI)

Quality Gurus

Crosby

Peters

Shigeo Shingo

Ishikawa

Feigenbaum

Deming

Juran

Summary

References

Chapter 3 Quality Concepts

Aim

Outcome

Introduction

Structure

Process

Outcome

Linking Structure and Process

Peer Review

Benchmarking

Kaizen

ISO 9000

Investors in People

The People vs. Systems Concept

References

Chapter 4 The Challenge of Measurement

Aims

Outcome

Introduction

Terminology

Reliability

Validity

Example

Quality Indicators

Quality Measures

Quantitative Measures

Binomial Measures

Additive Measures

Ratio Measures

Averages

Statistics

Qualitative Measures

Walk-through (IHI Tool)

Data Gathering

External Evaluation

Licensing

Accreditation

Certification

Revalidation

Useful Tools

Pareto Analysis

Example 1

Example 2

Client Window

Cause and Effect Diagram

Force Field Analysis

Summary

One Cautionary Note

References

Further Reading

Chapter 5 Continuous Quality Improvement

Aim

Outcome

Introduction

Assessment

Topic Selection

Development of Criteria

Sources of data

Misconceptions

Approach to Quality Improvement

The PDCA Cycle

Limitations

Performance Indicators

What Should Indicators Measure?

Performance Improvement

Benchmarking

Critical Incidents

Adverse Events

Significant Event Audit

Using Clinical Records

Summary

Reference

Chapter 6 Clinical Audit

Aims

Outcome

Introduction

The Audit Cycle

Selecting an Audit Project

Undertaking the Audit

Review the Findings

Implementation of Change

Repeating the Cycle

Example

Standards

What Makes an Audit a Useful Audit?

Examples

References

Chapter 7 Clinical Governance

Aims

Outcome

Introduction

Definition

Aims

Government Agencies

National Patient Safety Agency (NPSA)

NICE

The Healthcare Commission

The General Dental Services’ Contractual Requirements

The Healthcare Commission’s Framework

First Domain – Safety

Domain Outcome

Core Standards

C1

C2

C3

C4

Developmental Standard

D1

Second Domain – Clinical and Cost Effectiveness

Domain Outcome

Core Standards

C5

C6

Developmental Standard

D2

Third Domain – Governance

Domain Outcome

Core Standards

C7

C8

C9

C10

C11

C12

Developmental Standards

D3

D4

D5

D6

D7

Fourth Domain – Patient Focus

Domain Outcome

Core Standards

C13

C14

C15

C16

Developmental Standards

D8

D9

D10

Fifth Domain – Accessible and Responsive Care

Domain Outcome

Core Standards

C17

C18

C19

Developmental Standard

D11

Sixth Domain – Care Environment and Amenities

Domain Outcome

Core Standards

C20

C21

Developmental Standard

D12

Seventh Domain – Public Health

Domain Outcome

Core Standards

C22

C23

C24

Developmental Standard

D13

The Themes of Clinical Governance

Additional Resources

References

Further Reading

Chapter 8 Evidence-based Dentistry

Aims

Outcome

Introduction

Definition

Hierarchy of Evidence

Research Design

Experimental Studies

Observational Studies

Randomised Controlled Trials (RCTs)

Case Reports

Sources of Evidence

Colleagues

Journals and Books

The Internet

Electronic Databases

Dedicated Organisations

Clinical Guidelines

PICO

Clinical Decision Making

Variation

Theory of Innovation

Stacey’s Matrix

Summary

References

Chapter 9 Service Quality

Aims

Outcome

Introduction

Definition

Elements of Service Quality

Service Quality Models

Grönroos Model

The Gap Model

SERVQUAL Model

Internal Service Quality

References

Chapter 10 Business Implications

Aims

Outcome

Introduction

Delivering Value

Quality Waste

Productivity

Optimalism and Maximalism

New Technology

Lifestyle and Prevention

Quality Costs

Return on Investment (ROI)

The Cost of Quality

Balanced Scorecard

Summary

Reference

Cover

Quintessentials of Dental Practice – 31
General Dentistry/Practice Management – 4

Quality Matters:
From Clinical Care to Customer Service

Author:

Raj Rattan

Editors:

Nairn H F Wilson
Raj Rattan

cover
Quintessence Publishing Co. Ltd.

London, Berlin, Chicago, Paris, Milan, Barcelona, Istanbul, São Paulo, Tokyo, New Delhi, Moscow, Prague, Warsaw

Foreword

One of the primary concerns of patients is quality of care. Today, quality of care, as considered in this most welcome addition to the now substantial Quintessentials series, is a broad concept, embracing all aspects of the patient experience. In this carefully crafted book, Dr Rattan aims to help colleagues better understand how to satisfy, and wherever possible exceed, patients’ ever increasing expectations of quality of care. The aims and objectives of the book have been surpassed through Dr Rattan’s skilful consideration of the relevant theory and his authoritative approach to the necessary attitudes towards quality and quality improvement to optimise the delivery of care in the clinical practice of dentistry. Quality Matters: From Clinical Care to Customer Service is an engaging, easy-to-read text, peppered with advice and guidance of immediate practical relevance. Understanding and applying the many interrelated aspects of quality of care should be considered an integral element of professional ethics and professionalism, as viewed in our changing society. As such, Quality Matters: From Clinical Care to Customer Service should be essential reading for all those with limited knowledge of quality issues in oral healthcare provision. Moreover, and in common with Dr Rattan’s other books in the Quintessentials series, this book includes numerous pearls of wisdom for even the most experienced of practitioners. The few hours necessary to read and digest this concise, thought-provoking book, will be time well spent. What good is care that lacks quality?

Nairn Wilson
Editor-in-Chief

This book is for Ella, Alex and Anna

Preface

The challenge of writing this book was a challenge of interpretation.

How should I interpret the term “quality”? Narrowly defined, quality refers to clinical outputs – periodontal treatment, crowns and bridges, simple and complex restorations, and so on. A broader interpretation would include the quality of the process of care, the quality of the service, the quality of the people delivering the care, and the quality of the environment in which the care was provided. Each of these facets is in itself an aggregate of smaller components, so how far do we need to explore each individual component?

I have chosen to take the broadest view on quality and thus include elements that I believe to be relevant to general dental practice. There is more to quality than implementing a system or working towards a given standard; it is about an attitude of mind that makes us want to improve the way we work and live. Attitude is the fuel of ambition.

Throughout this book, I have referred to users of our services as “patients”. It has become fashionable to talk about “customers” and “clients” in dentistry, but the use of these terms has been used only where they appear in verbatim citations from other texts. To serve a patient is a privilege bestowed only to healthcare workers; it embraces all the desirable elements important to clients and customers but also includes the unique ethical attributes associated with healthcare.

The reader should be aware of one omission from this text. It relates to an important element of quality and that is risk management and patient safety. This subject has been covered in depth in a previous book in this series, Risk Management in General Dental Practice.

Professor John Øvretveit, Director of Research at the Medical Management Centre, Karolinska Institutet, Stockholm, is a respected authority on quality in healthcare. His view that “a quality system is based on underlying theory about what needs to be done to provide a quality service” has influenced the structure of this text. The theory is important – it drives the implementation of quality initiatives in the context of our own working environment.

If we wanted to build a car engine, we would need to know and understand the theory behind the design. We would welcome information on how others have approached engine design and we would ask for guidance on how and where to begin. That is what I have aimed to do in this book.

The value of the theory, ideas and examples is only realised when the rubber hits the road. That remains the driver’s responsibility.

Raj Rattan

Acknowledgement

My sincere thanks to all those who willingly and unselfishly gave their permission to quote and reference their work in the preparation of this book. Their responses to my requests for information and advice were always positive and immediate; their individual contributions are cited in the text.

Chapter 1

Introduction

Aim

The aim of this chapter is to provide an overview of the meaning and interpretation of quality in the broadest sense and to highlight some of the key benefits of a commitment to quality.

Outcome

The reader will have an understanding of how the meaning of quality can vary in relation to its context and the relevance of the various interpretations in everyday dental practice.

Introduction

Healthcare quality has been on the agenda of scholars, policy analysts, providers and patients for many decades. By the 1970s, Avedis Donabedian had established his model for assessing quality on the basis of structure, process and outcome. A decade later, patient safety, risk management and appropriateness of care were added to the common list of measurement variables.

Many practice websites, leaflets and marketing materials make references to quality, but few are explicit about its meaning and interpretation.

“Quality … you know what it is, yet you don’t know what it is. But that’s self-contradictory. But some things are better than others, that is, they have more quality. But when you try to say what the quality is, apart from the things that have it, it all goes poof! There’s nothing to talk about ...” So wrote Robert M. Pirsig in his book, Zen and the Art of Motorcycle Maintenance (p.163). In his PhD thesis “On Quality of Dental Care”, Poorterman makes a similar point that: “A person generally is able to make an image of the meaning of that particular word and recognises it when in contact, but it is difficult to give the exclusive right description.”

The meaning of quality is explored further in Chapter 2.

In general dental practice, quality is the measure of how good dental health outcomes are, and can be evaluated for at least two components. The technical element of quality care looks at the components of clinically appropriate diagnostic decision-making, treatment planning and execution and any required follow-up.

The personal element includes the degree to which the patient perceives being cared for – confidence, compassion, trust – and an overall sense of satisfaction from the practice as a whole. While the technical element of quality is relatively objective, and the personal relatively subjective, both are measurable.

Writing in the British Dental Journal in 1996, Mindak points out that: “Patients judge the dental service they receive by the interaction with the service providers – the dentist and his or her staff – as they are unable to judge the technical quality of the service.”

The interactive and organisational elements make us unique; we may know the recipe for quality in general practice but the way we choose to apply it results in a blend that is unique to each and every practice.

The Dutch National Council for Public Health has developed a framework that describes quality in clinical practice (Fig 1-1).

QE31_Rattan_fig002.jpg

Fig 1-1 The Dutch National Council for Public Health framework for quality in clinical practice.

A quality clinical outcome will result from a combination of the aspects under each of the three domains, some of which will be more important than others for each patient experience (Fig 1-2).

QE31_Rattan_fig003.jpg

Fig 1-2 Quality outcome (a–e) Teeth suitable for direct build-up with resin composite featuring caries and tooth wear. (b) Unaesthetic anterior view due to tooth wear, resulting in translucent incisal edges. (c) Split rubber-dam isolation. (d) Completed treatment (anterior view). (e) Completed treatment (palatal view).

Challenges

We live in the age of the mixed economy and there are challenges in managing quality in this context. Many practices choose to provide care and services through private and public sector funding. These practices must satisfy the meaning of quality as defined by the stakeholders of all the parties. Who is the customer in the public sector – the commissioner or the patient? Is there shared status? Equity is the priority in many public sector services. The requirement to maintain a balance between the needs of the individual and the needs of the community means that a particular person cannot always have everything. Is it then possible for the provider to satisfy both the patient and the commissioner? A patient who is denied a service because it is not available through the public sector is unlikely to consider the public service in terms of quality, but another patient who is able to access the service at a time of acute need will have the opposite view.

The definition of quality in a public service is based upon the values and expectations of key stakeholders. There is a requirement on the part of the commissioners to deliver value and the need to use public funds in a clinically and cost-effective way. All members of a caring profession would be willing to jump the hurdles of quality, patient safety and clinical efficacy, but not all feel able to accept the funding provided to tackle these challenges. It is the fourth hurdle of health economics that presents the real challenge for many dentists (Fig 1-3).

QE31_Rattan_fig004.jpg

Fig 1-3 The challenge of the fourth hurdle.

In contrast, the private sector is able to address needs, aspirations and demands at an individual patient level which may be consistent with those at population level. The private sector service can be totally patient-focused because “the customer is king”, although there may be a shared status where third party payers are involved.

The context of care delivery is further complicated by the fact that patients receive some types of care funded through the public sector and other services funded by private contract. The provider of these services now faces a further challenge – meeting and satisfying the varying regulatory requirements and satisfying the interpretation of quality imposed by all parties.

In the UK, this scenario is common where many practices provide services under the terms of the National Health Service (NHS) and private contract – so-called “mixing” of treatment.

A Changing Landscape

The approach to quality has changed over the years. Today’s approach focuses on continuous quality improvement (CQI) and recognises evolving standards and the need for patient empowerment and involvement (Table 1-1).

 

Table 1-1 Past and present approaches to quality
Level of commitment Yesterday’s approach Today’s approach
Leadership commitment Occasional review Total quality management involving the entire practice
Emphasis of effort Retrospective analysis Proactive approach.
Continuous quality improvement
Focus of effort Retrospective inspection to catch error Ongoing identification and improvement of faulty processes
Timing of effort Retrospective analysis of quality indicators Concurrent management of processes of care with built-in measures
Outcomes Measure to acceptable standard Measure against evolving standards

 

The aim of today’s approach is to shift the mean standard of care over a period of time by a process of CQI (Fig 1-4 and Chapter 5).

QE31_Rattan_fig006.jpg

Fig 1-4 Shifting the mean standard of care.

Clinical Aspects

The meaning of quality is not only dependent on the observer’s perspective, but also influenced by evolving standards, scientific advancements and changing societal values. Quality markers and indicators are time-sensitive. Today’s guidance inspires and informs tomorrow’s standards. Infection control standards in general dental practice are a prime example.

We are presented with research findings, clinical guidance and protocols and asked to adhere to certain standards. All the requirements have subtle differences in meaning and we should be aware of these if we are to implement them in a practical and relevant way.

Table 1-2 summarises the terminology used in clinical quality and gives a description of what it means.

 

Table 1-2 Clinical quality vocabulary
Clinical quality terms Description
Standards Standards are instruction documents that detail how a particular aspect of the project must be undertaken. The standard is absolute; there should be no variation.
Guidelines Unlike Standards, Guidelines are not compulsory. They are intended to guide a project rather than dictate how it must be undertaken. Variations in your practice do not require formal approval.
Checklists Checklists are useful as prompts and serve as a useful aide-memoire. They are particularly suitable for checking for compliance. A list of Health and Safety legislation is one example.
Templates Templates are blank documents to be used in particular situations. They facilitate the recording of essential information that may be required for legislative or regulatory purposes. Templates for recording adverse incidents or complaints are two examples. Sample completed templates can serve as guides to what is required for satisfactory completion.
Procedures Procedures outline the steps that should be undertaken in a particular activity. For example, a practice will have a procedure for welcoming a new patient to the practice.
Process A Process is a description of how something works. It is often described graphically by means of a process map – commonly called a flow chart. A process also contains explanations of “why and how”. In contrast a procedure is a list of steps – the “and when”.
User guides User guides provide the theory, principles and detailed instructions about how equipment should be used. They include technical information, definitions and the rationale for correct usage. Examples include user guides accompanying machines for dental radiography and film processing.
Methodology A Methodology is a collection of processes, procedures, templates and other tools to guide the practice team through a particular activity. The clinical method for proving a full coverage metal-ceramic crown would involve the procedure of tooth preparation, the process of impression-taking and the fabrication of a provisional crown.

 

This is the content of everyday clinical care and it requires the process of care to deliver quality (Fig 1-5). This process is outlined in Fig 1-6.

QE31_Rattan_fig008a.jpg

Fig 1-5 The Framework for Clinical Quality Improvement.
Adapted from: Batalden P, Stoltz P. A Framework for Continual Improvement in Healthcare. Joint Commission Journal on Quality Improvement. October 1997.

QE31_Rattan_fig008b.jpg

Fig 1-6 Quality in practice – the key processes.

Benefits

The benefits of implementing a quality programme are numerous. These are summarised in Fig 1-7.

QE31_Rattan_fig009.jpg

Fig 1-7 Benefits of quality initiatives in general dental practice.

References

Dutch National Council for Public Health. Nationale Raad voor de Volksgezondheid. Discussienota Begrippenkader Kwaliteit Beroepsuitoefening. Sept 1986;2.

Mindak MT. Service quality in dentistry: the role of the dental nurse. Br Dent J 1996;181:363–368.

Poorterman JHG. On quality of dental care: the development, validation and standardization of an index for the assessment of restorative care. PhD thesis, 1997.

Chapter 2

The Meaning of Quality

Aims

This chapter aims to explore the various definitions of quality and to define commonly used words and phrases. It also aims to summarise the valuable contributions made by some of the leading gurus of the quality movement.

Outcome

The reader should be familiar with a number of approaches to quality and the impact of some of the leading proponents in this field and how their views relate to general dental practice.

Introduction

Society has always been concerned about the quality of goods and services provided. Over the ages quality has developed as a discipline; the earliest paradigm of quality relying on the principle of caveat emptor (let the buyer beware) – an approach that placed the responsibility of appraising goods and services firmly with the user. The principles of quality control and total quality management came later with the industrial age, although there is evidence of conformance and control in ancient Rome. However, it was the post-industrial age that saw the development of the modern paradigm which impacts on the world as we see it today.

The American Society for Quality (ASQ) suggests that the term “quality” should not be used as a single term to express a degree of excellence in a comparative sense, nor should it be used in a quantitative sense for technical evaluations. These meanings, it suggests, should be communicated by a qualifying adjective.

A review of the literature suggests that there are numerous definitions of quality – almost as many as there are quality consultants. Hoyer and Hoyer (2001) surmised that these expert definitions of quality fall into two broad categories:

This approach is well suited to general dental practice where success is dependent on the delivery of quality care at both these levels.

The meaning and interpretation of quality is contextual; it depends on the nature of the service or product on offer and domain within which it is available. Some examples are listed in Table 2-1 and have certain themes in common, which are:

 

Table 2-1 The contextualisation of quality
Domain The consumer view on quality indicators
Airlines Safety, on-time, comfort, low-cost, good on-board food and drink
Healthcare Correct diagnosis, minimum waiting time, safety, security, low cost
Restaurant food Good food, fast delivery, comfortable environment, good atmosphere, polite service
Postal services Fast delivery, reliable, low cost
Consumer products Well made, fit for purpose, defect-free, good value
Mobile phone communication Clear, fast, good coverage, low cost, design
Cars Reliable, defect-free, faster, inclusion of extras, image and reputation of brand

 

Definitions

According to the American Institute of Medicine, quality is constituted by: “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” It suggests that:

  1. Quality performance and outcomes occur on a continuum, theoretically ranging from unacceptable to excellent.

  2. The scope of inquiry is limited to the structure, process, and outcomes of care provided by the healthcare delivery system.

  3. Quality may be assessed at multiple different levels.

  4. The link between process and outcomes should be established.

  5. Research evidence must be used to identify the services that improve health outcomes and in the absence of scientific evidence regarding effectiveness, professional consensus can be used to develop criteria.

In the UK, Donaldson and Muir Gray defined quality in healthcare as: “Doing the right thing, for the right person at the right time and getting it right first time.” It is a definition that suits the practice of dentistry because it emphasises that there is more to quality than the quality of the technical outcome. For example, the quality of the outcome of root canal therapy on an upper molar may be undisputed, but if the root canal therapy has been the result of an incorrect or delayed diagnosis, then the patient has not received the “right thing at the right time”. The root canal therapy may be excellent, but the quality of care may be less than satisfactory.

Another, more generally stated definition (European Committee for Standardization, 1994) holds that: “Quality is the totality of characteristics of an entity that bears on its ability to satisfy stated or implied needs.” This allows both provider and patient expectations to be taken into account.