Dental Quality Improvement in an Integrated Health Care Setting: Pedal Faster

ABSTRACT

Background

Quality measurement is new to dentistry but will become part of dental care within a short period of time due to governmental and public pressure and medicolegal requirements.

Description

This article describes challenges and opportunities for a dental department to: (1) participate in overreaching organizational quality and safety efforts with non-dental colleagues, and (2) establish a discipline-specific continuous quality improvement program. The article will propose advancing both dental and general health care through measures specific to different institutions and their unique environments, such as hospitals and community-based clinics. Steps and strategies leading to success are suggested for beginning a meaningful program, engaging and educating dental staff, and moving the quality needle forward in dentistry.

KEYWORDS:

• Quality assurance
• hospital dentistry
• dental administration

Introduction

Quality measurement, also termed quality assessment or continuous quality improvement (QA/CQI), value-based care (VBC), and patient safety (PS) are closely related terms prominent in contemporary US health care. Medicine preempted the rest of health care in recognizing the need to revitalize the model of US health care and address safety concerns.¹ Dentistry remains about two decades behind medicine in addressing quality² and safety³ and further behind in a thorough assessment of value-based care.⁴ Reasons for dentistry’s slowly evolving response to significant changes in health care are numerous, ranging from a still dominant cottage-industry status of small practices to its low economic footprint in overall health care. Professional resistance, lack of understanding of driving concepts, absence of financial incentives to change, a perception of few adverse events in dentistry, and lack of consumer pressure probably add to the slow pace toward quality measurement, alternatives to fee-for-service, and mandated safety reporting.

Two additional seemingly esoteric, but obfuscating obstacles to meaningful QA in dentistry are (1) lack of agreement on measuring risk of disease at the patient level and (2) lack of a meaningful and agreed upon working definition of oral health. The leap from procedural technical detail to patient health, function, and development is sizable and may be aspirational. There is a lot to be done in between!

While the dental profession feels minimal pressure to change, segments of it – public dental programs within a comprehensive care system, such as federally qualified health centers (FQHCs), hospital dental departments, and institutions within academic health centers – have the expectation to demonstrate quality measurement processes addressing efficacy, value, and safety. Institutional oversight bodies, like the Commission on Dental Accreditation (CODA), the Centers for Medicare and Medicaid Services (CMS), and the Joint Commission require quality and safety monitoring. The private practice dental community has wet its toes with opportunities to use QA/CQI in specialty board certification and with payers offering quality ratings to participating dentists. Quality measurement is now a part of the dental education experience for new dentists.

This report describes challenges to a dental department in a comprehensive hospital system already engaged in and committed to quality improvement. It suggests ways to address those challenges in clinical care, education, and data management processes that can make dentistry fit and excel in a health care environment committed to the improvement of care as part of its mission. The report directs readers to some sources of information to provide direction and additional understanding of this evolving and emerging aspect of dentistry, and those in turn will provide many more directions and facets to this emerging part of dental care.

The Unknowing and Unprepared have Hope

Challenges to a dental department in an integrated, multidisciplinary health system include (1) its limited background in QA/CQI, (2) often isolated dental programs, (3) global and collaborative institutional expectations, and (4) lack of understanding in health care circles about dentistry. Table 1 identifies some of these immediate and ongoing challenges and ways to address them. Dental care has largely escaped systematic evaluative methods, due primarily to its solo-provider-owner character and focus on procedural technical detail rather than health. Like medicine prior to its systemic introspection late in the last century, dentistry still relies on a ‘no news is good news’ approach, rather than a systematic, regular, and periodic evaluative aspect of all patient care. When dentistry enters an environment where regular, organized, and focused QA/CQI is considered integral to care, it is challenged to respond and often has difficulty doing so.

Table 1. Challenges and opportunities for dental departments within an integrated health system.

Challenge	Opportunity
Lack of background in QA/CQI^a	Become familiar with basic principles and theory in quality, safety, and alternative payment mechanisms in health care! Become familiar with extent of dentistry’s activities in the above Engage in organizational efforts in areas of quality measurement, safety, and payment
Lack of infrastructure and technical support	Investigate organizational opportunities for learning and structuring the effort Understand digital opportunities and shortcomings in existing systems Engage available organizational personnel for consultation and advice Investigate intra-organizational capabilities
Lack of available dental-specific resources	Consult Dental Safety Foundation Investigate ADA^b Dental Quality Alliance Search accrediting bodies for relevant QA/CQI and safety information If dental specialty-based, search for organizational information
Lack of educated personnel	Support CE^c in quality and safety areas Coordinate intra-departmental education programs Utilize in-organization educational programs
Inadequate data accumulation and management	Look at internal data systems Investigate successful data management systems in other institutions Pilot data analyses
Poor fit with extra-dental QA/CQI efforts	Develop presence in organizational quality analysis systems Mimic basic applicable organizational quality measures within dental department Seek medical-dental measures with clear patient care applicability
Lack of culture	Provide education to all staff Institute non-threatening quality efforts such as time outs and patient verification Reward quality and safety interventions Make quality and safety integral with all- hands sessions

^aQA/CQI is a commonly used acronym to encompass the wide-ranging quality endeavors in health care.

^bADA is the acronym for the American Dental Association which supports quality measurement through its Dental Quality Alliance or DQA.

^cCE is continuing education.

Ironically, and probably to the chagrin of some readers, the insurance and payer communities have led the way in consolidating care into measurable increments. Their systematic approach is often colored by economic drivers, but it is hard to criticize the basic tenet of wanting to know what care is provided and whether that care works. Harnessing the reality of ‘he who has the data wins,’ the American Dental Association’s Dental Quality Alliance (DQA)⁵ brings together stakeholders – providers, advocates, payers, the dental public health community, and organized dentistry – to move the quality needle forward. Its Dental Experience and Research Exchange (DERE) Project⁶ illustrates a collaborative approach to systematically measuring quality within individual practices. Those individual dental providers reading this report are encouraged to investigate this excellent opportunity to enter the QA/CQI world painlessly and with minimal human and financial expense.

So, you have to Measure Quality, Now What?

Landing in an integrated setting or having a parent institution react to QA/CQI mandates or adopt quality measurement in its mission, a dental department is faced with a choice of lining up with other disciplines or making the case for exclusion. The former offers the duality of hard work, but great reward, while the latter ultimately leads to dentistry’s relegation to a secondary auxiliary health service, or even exclusion, in the experience of this author. With expansion of FQHCs, adoption of dentistry by commercial health care systems, and advanced dental educational programs being funded in institutions and settings previously without dentistry, the reality is that QA/CQI and safety will become inseparable parts of dental care. Federal and state mandates that require health entities to engage in quality measurement have already brought dentistry into the milieu and there is no turning back.⁷

So, how does one begin to develop a quality consciousness? The next section of this report will provide advice about what dental leadership needs to do to catch up and be a full player.

Be a Quick Learner

The amount of information about the three interrelated concepts of quality, value and safety is overwhelming. That being said, the information ranges from simple ‘ABCs’ to more advanced conceptual and ethical treatises for those wanting to go further. Table 2 is a brief list of basic opportunities to learn more about these concepts and how to apply them systematically to clinical practice. Most institutions using these processes have at least a manual or policies and maximally, have educational tools available focused on specific approaches.

Table 2. Educational sources for beginning quality, safety and value-based care programs.

Area of Quality Movement	Suggested Beginning Reading^a
Quality Assurance and Continuous Quality Improvement	McCarthy D, Klein S. The triple aim journey: Improving population health and patients’ experience of care, while reducing costs. Commonwealth Fund, Pub. 1421, 2010; 48 (Pub 1421): 1–11. On the Quintuple Aim: Why Expand Beyond the Triple Aim? Kedar Mate, September 2022 https://www.ihi.org/communities/blogs/on-the-quintuple-aim-why-expand-beyond-the=triple-aim Measures Development and Maintenance Committee (MDMC), Dental Quality Alliance. Procedure manual for performance measure development and maintenance. Chicago, IL: American Dental Association, 2022. Institute for Healthcare Improvement. Quality Improvement Essentials Toolkit, Boston, MA.
Safety Measurement	Ramoni RB, Walji MF, White J et al. From good to better. JADA 2012;143(9):956–60. Institute of Medicine. Committee on Quality of Health Care in the US. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press, 2000. Papadakis, M., Meiwandi, A., & Grzybowski, A. (2019). The WHO safer surgery checklist time out procedure revisited: Strategies to optimise compliance and safety. International Journal of Surgery, 69, 19–22. Szekendi, M. K., Barnard, C., Creamer, J., & Noskin, G. A. (2010). Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety. The Joint Commission Journal on Quality and Patient Safety, 36(1), 3-AP2. Gildon, B. L., Condren, M., & Hughes, C. C. (2019, April). Impact of electronic health record systems on prescribing errors in pediatric clinics. In Healthcare (Vol. 7, No. 2, p. 57). MDPI.
Value-based Care	Perrin JM, Flanagan P, Katkin J, et al.; AAP Committee on Child Health Financing. The Unique Value Proposition of Pediatric Health Care. Pediatrics. 2023;151(2):e2022060681. DentaQuest Partnership for Oral Health Advancement. Glossary of value-based care terminology. April, 2020. Apostolon D, McLeod C, Tranby E, Mathews R. Alternative Payment Models in Dentistry: A Provider Perspective. Boston, MA: CareQuest Institute for Oral Health; December 2020. DOI: 10.35565/CQI.2020.2021

^aThese respective literatures are voluminous and the above are simply primers that would lead to other sources of information for beginners.

Immersion is Conversion

The very best advice to a dental department is to become a part of the whole by engaging in overall management of safety and quality in the organization, side by side with other health professionals. Often, this is not a choice. Rather than see it as a burden, dental personnel should see it as an opportunity to learn, establish trust and respect within the greater institution, and share information about what dentistry is. One benefit in a hospital setting, by engagement in these processes, is to share information about medical–dental relationships. This patient-centered care approach benefits patients as well as establishes a core role for dentistry in the institution’s patient care and educates non-dentists on the essential role of oral health in systemic health.

Assess Record Systems and Choose the Mercedes

The dental digital revolution still uses the musket, while medicine uses the stealth fighter. Dental software already in the marketplace is familiar and thus attractive to dentists, so it is often adopted in a comprehensive care environment. Unfortunately, its ability to interface with medical record-keeping software is often limited or non-existent, forcing two parallel data entry burdens, limited communication, and clumsy patching programming.⁸ Some comprehensive software has a dental component, such as Epic, and offers a broad palette of service-orientated functions germane to dentistry as well as general health. In a comprehensive health care environment, it may be more costly to choose an integrated model, but the benefits and significance of doing so can not be overstated.

Start Small but be Meaningful

The leap to a systematic accountability culture from a tooth-oriented one is huge. A dental department would be well served to act in two parallel tracks – the first is mentioned in 1., above, by integrating into the organization’s overall processes, and the second is to institute meaningful markers within the dental department. These should be (1) easily obtainable and retrievable, (2) meaningful to care/safety, and (3) amenable to all-hands reporting in vehicles like department meetings and morbidity and mortality (M&M) conferences. Table 3 lists some areas and measures that are easily obtainable, often with national comparable data sources, and amenable to address with policy and protocol changes if required.

Table 3. Basic measures for initiating quality and safety measurement.

Access	Appointment availability (days to appointment) Soonest re-appointment available Emergency access
Safety	Patient verification Time out Medical history review Handwashing Waterline testing Biological marker schedule
Care quality, dental control	Days to treatment plan completion Re-treatment of teeth Return for re-care, individualized to risk and compliance Chart completion (within time period)
Care quality, patient assessment	Satisfaction survey, overall and per visit Staff specific feedback Environmental (cleanliness, physical safety) assessment Internal staff feedback

Engage Dental Staff in the Cultural Shift

A hallmark of viable quality and safety culture is the horizontal function of all team members. Medical and surgical hierarchies historically presented huge obstacles to the quality and safety culture shift in hospitals and other facilities where vertical power structures had been in place for decades. Dentistry is no different in that challenge, but if it is to succeed like medicine, the challenges of: (1) fear of retribution, (2) assumption of ownership, (3) recognition of value in individual contributions, and (4) the ultimate sharing of the responsibility for patient safety and health need to be overcome. Appointment of a non-dentist as quality officer is one way to align all levels of personnel. The ‘time out’ procedure is an excellent example of how this can be started as it engages reception (identification of patient), assisting staff (verification of patient identity), operator (confirmation of patient identity), and the patient.

Reinforce Behaviors of all Dental Staff

Organizations institute recognition and reinforcement programs to keep staff engaged in quality and safety efforts. Ways to acknowledge positive and contributory behaviors can range from public recognition to tangible rewards. Many institutions focus on the smaller but obvious reinforcement in ways that are preferred by staff. Dental departments would be well served to integrate staff into existing programs as well as instigating dentistry-focused motivational efforts to jump start and make internal programs more likely to succeed.

Review, Repeat, Reevaluate

Quality and safety programs aim to assess function and change behaviors if necessary, so in the best of worlds, many quality and safety markers become standard operating procedure if care patterns change for the better. Others may become institutionalized if they are significant or address frequent events. In many dental departments, turnover of staff and trainees requires continuation of procedures to engage new participants into the culture.

Strategic Directions – Aim High

Once a solid presence of quality and safety procedures is established, the opportunity exists to move the care needle forward. Much of quality assessment is structured to improve a numerator against a denominator, such as patient visits or types of procedures done, which remains stable. That percentage incremental improvement is often necessary in a care environment to catch up with other health disciplines or achieve performance commensurate with the standard of care. However, at some point, QA/CQI and safety measures need to mesh with missions beyond those typically associated with dental care. For example:

Equity

Much is made today about achieving health equity among populations previously denied that opportunity. Data analysis in quality assessment can be partnered with social and economic characteristics to evaluate equitable and non-biased application of care within an organization, particularly one disproportionately caring for the underserved. That is the next generation of quality.

Population Health

The deeper dive in data analysis relative to quality and safety would investigate population health. This might include measurement of things not traditionally considered dental in nature, such as obesity, hypertension, substance abuse, and mental health, or closer looks at nutrition and trauma risk for a community. The QA/CQI opportunities to link oral to systemic health are an excellent way to identify oral–systemic relationships, cement dentistry in overall care, and improve systemic care of hospital-based patients.

Interdisciplinary Measures

As dentistry and medicine continue to merge in an oft-time awkward relationship, teams form around health condition management, dealing with variants of the same quality measures. Intellectual and developmental disabilities (IDD), diabetes, and cancer are examples of conditions with shared impacts. Developing and assessing markers that affect both systemic and dental health (such as oral mucositis in cancer therapy) are not the same as being participant in, for example, organization-wide activities like measuring falls or handwashing within the dental department alongside other departments. Interdisciplinary measures move into new quality territory.

Advancing Evidence-based Dentistry (EBD)

For most readers, EBD is about randomized clinical trials (RCTs) and information derived from well-planned and controlled studies. For dentistry, which as stated earlier, is a small piece of the economic health care pie, the likelihood of RCTs addressing dentistry’s EB deficit is slim. Claims data present an opportunity to assess what works and what doesn’t, but such data are often proprietary. An untouched source of evidence for treatment efficacy and safety is a well-structured collection of clinical care data in a system with established policies and protocols for procedures that serve to control variables. At some point, these types of data will help shape clinical care in the absence of RCTs and likely already do in some organizations. Artificial intelligence (AI) will use these types of data rather than rely on RCTs.

Value-based care in dentistry remains the poor stepchild in this article’s triad, but the above efforts will likely move dentistry forward in this area as well.

Summary

Embarking on a QA/CQI process in an integrated health care organization can seem like an Everest climb for the inexperienced. A little preparation as suggested above, engagement in ongoing non-dental QA/CQI organizational processes and then baby steps in developing parallel and then dental-specific measures offer a door to meaningful quality and safety monitoring.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Paul S. Casamassimo

Dr. Paul S. Casamassimo is Professor Emeritus at the Ohio State University and past Department of Dentistry Chief and Medical Staff President at Nationwide Children’s Hospital, Columbus, OH. He is past chair of the Dental Quality Alliance of the American Dental Association.