Dental Quality Improvement

Quality Improvement and dentistry should be an obvious fit. Dental teams want to deliver the best care they can. As well as the ethical and humanitarian reasons for this, most dental patients are free to move to different providers if they do not like their treatment, often taking friends and family members with them. In urban areas practices compete for patients, and perceptions of quality and value are important. Many dentists are self-employed or own a stake in the practice in which they work. Avoiding unnecessary delays in treatment, mistakes and re-work all contribute to keeping costs competitive, and earnings up. So why then is there so little focus on Quality Improvement in dentistry?

A recent paper included discussion of reasons why patient safety work has had less prominence in dentistry than we might expect. Some of the factors they suggest also help to explain the slowness of uptake of other dental Quality Improvement activities. Combined with information from papers and reports, we can come up with a tentative list of the barriers.

A few of the candidate issues are:

Focusing only on individual technical proficiency: Dentists spend most of their time working only with a dental nurse, and in the presence of their patient. Dental training, and most post-graduate courses, are about skills acquisition for the dentist or other members of their team. This can make the root of quality feel obvious – it all comes down to the individual dentist, and if things don’t go they way they hope, it must be their fault. This probably is not helped by perfectionism in dentists (although it’s worth noting that there is mixed evidence on perfectionism rates).

If you feel that any problem is related to individual performance, then that is what you focus on. More training, more self-applied pressure, more stress.

This disregards the point that dentists work within a clinical system. Case mix; booking arrangements; appointment lengths; the experience of the dentist and the nurse, materials and equipment, all make a difference. If things go wrong elsewhere – the information available on the patient is difficult to access; a water line leaks; a clinic room is not ready; a colleague is off ill; appointment lengths are too short; there is no good system for emergencies, and you end up trying to fit in three additional patients who are in pain while also seeing your own scheduled list – then things are more likely to go wrong.

Even if no problem arises, the experience for both the patient and the dental team degrades. These are system problems, and no matter how hard the individual dentist works, how much they learn, or how conscientious they are, they are not resolved by individual technical excellence. Reducing these problems requires a focus on the process that surrounds and supports the clinician.

Structural blame: Dentists tend to blame themselves even when problems are out with their control, but other people blame them as well. NHS work is randomly selected for review and grading with potentially serious consequences if quality defects are identified. Patients who want to take legal action for treatment with which they are unhappy have to show negligence: a known adverse effect of a treatment will not get them over the line. The dentist has to be to blame. (We tried to find a link to the criteria, but all the links we could find were created by law firms!)

Accountability is important in any profession, but there are incentives for dental teams to not talk about problems once they are settled for fear of adverse publicity, and combined with the feeling that problems relate only to individual clinical practice, sharing information and learning across practices becomes difficult.

Knowledge and experience of Quality Improvement: A non-scientific straw poll of dentists we had available confirmed our expectations: no one remembered any organised training on Quality Improvement as an undergraduate. People remembered training on standards, and some on clinical audit, but none at all on Quality Improvement methods.

The dental curriculum is crowded and everyone wants their topic highlighted, but no training at all is as minimal as you can get. The group of clinicians we consulted had a preponderance of UK trained dentists, but included dentists who completed their undergraduate training in five other countries, and they also drew a blank. This feels like a clear message to dentists that Quality Improvement is not seen as a serious issue, or at least not one on which valuable training time is required or deserved.

In the UK, dentists who are employed by the NHS will have access to quality improvement staff in hospitals and community groups, and some areas include Quality Improvement as a topic during Vocational Training sessions. In Scotland, there are central NHS staff who can support Quality Improvement work, but they are a small group of people spread across many practices. And if the practices don’t see the need in the first place, they are unlikely to ask for help.

Postgraduate training on healthcare Quality Improvement is available like this course on which one of us teaches (other courses are available!), but before committing to a University course, you need to feel that there is a reason to do so, and that the subject is worth pursuing. Without a ringing endorsement during undergraduate training, further training in Quality Improvement is always going to be accessed by a limited number of people.

Improvements in Quality Improvement

So what are the solutions?

Experience of Quality Improvement: Nothing succeeds like success. In our experience, the thing that gets clinicians engaged and interested in Quality Improvement is seeing that it works; that it makes their lives easier and improves care for their patients, and that the methods are sufficiently straightforward that they can apply them in their own practice. For people outside structured NHS training programmes, or who do not have a local mentor, this depends on training programmes at undergraduate and postgraduate level.

Training in Quality Improvement methods: A decision to include an introduction to Quality Improvement during undergraduate training would certainly help, as would supporting Vocational Trainees to complete a small Quality Improvement project during their VT year. This would have the advantage of letting other clinicians in the practice see the methods in action.

Aligning contracts and professional registration: In Scotland, using the next contract cycle to support Quality Improvement would be valuable. The Quality Improvement requirement in the current contract cycle has very little on QI, although the encouragement of team reflective practice and consideration of equity, is a start. In the UK as a whole, a GMC requirement for at least a basic undergraduate training on Quality Improvement could make a big difference in introducing the concepts.

Quality Improvement materials focused on dentistry: Worldwide, having more access to Quality Improvement material tailored to dental teams would make a difference. Making more explicit links between Quality Improvement and Patient Safety in dentistry may also help to make the value of the techniques and approaches clear. And we will post links to useful materials as we locate them.

Taken together these three steps – training, more exposure to QI, and access to dedicated dental examples and materials – can make a difference.

Photo by DS stories at pexels.com.