Dental Quality Improvement

When teaching Quality Improvement to dental teams, people often ask for examples of work that they can review. Some papers are excellent on one aspect of QI, but if you want to read a paper that has pretty much everything, it’s worth a look at a paper by Aoife Nic Iomhair and Miriam John.

The work was conducted in a Special Care Dentistry service in Wales. The aim was to increase the completeness of records on the patients, and to make the information easier and faster to access. The work was done as part of a training project in Quality Improvement. It’s no surprise that a range of techniques were used, but the project team did it well, and it’s useful to review the range of approaches they applied.

Discussing all the techniques in detail would occupy several thousand words. We will cover some of the approaches in later posts, but it’s valuable to summarise the team’s approach.

1. Clarification of the Purpose of the Work. This sounds obvious. They wouldn’t have started the work if they hadn’t thought there was a problem. Teams often work on first order problems, the immediate issue that causes them a problem – without looking more deeply to see what underpins that problem. If you focus on the last issue, but don’t resolve the factors that caused it to happen, issues tend to recur. Being clear on the root cause is a great idea.
2. Agreement of a Target. Generally, everyone agrees there is a problem with x, but they may have very different views on what causes the issue, and even on the precise nature of the problem. Drilling down into the problem, and agreeing an aim and preferably a numerical target for improvement helps to align the team behind the problem. It also reduces the chance that team members disagree on whether the improvement was effective. This team used a SMART target, which is good practice.
3. Exploration of Causes, and Influencing Factors. The team conducted a Root Cause Analysis (details not provided in the paper) and produced an Ishikawa diagram and a Driver Diagram. A driver diagram shows what contributes to, in this case, a quality aim. An Ishikawa diagram – also known as a Fishbone Diagram, or a Cause and Effect Diagram – shows what contributes to a problem. These are both good techniques for use with a team and help to achieve a shared understanding of a problem.
4. Prioritisation of Change Options. Teams usually identify multiple causes of a problem, and identify several possible improvement strategies. Deciding on what to tackle first is not always easy. Doing it as a team process helps to keep teams engaged, and keeps everyone on the same page. There are several possible methods, but a prioritisation matrix is a good option. In this method, possible improvement approaches are matched against each other on two dimensions, such as ease of implementation, and likely impact.
5. Use of Improvement Cycles. Plan-Do-Study-Act (PDSA) cycles are at the heart of most quality improvement efforts. We will write about their application in dentistry in more detail, but they provide a repeatable way of testing change and knowing if an improvement occurred. They are often linked together in a series of PDSA cycles, sometimes termed a PDSA ramp, that produces incremental change that builds on learning from previous cycles.

The paper by Iomhair and John is a good overview of the integrated application of these techniques in a dental Quality Improvement project.

Photo by Miguel Á. Padriñán: https://www.pexels.com/photo/photo-of-golden-cogwheel-on-black-background-3785929/