Quality Measures in Healthcare and its Implementation in an Oral Health Organization

Quality Measures in Healthcare and its Implementation in an Oral Health Organization

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Abstract

This paper discusses how quality measures influence current practices, dimensions, and drivers for quality and safety in healthcare. Their impact on the delivery of healthcare services in health organizations will also be examined in relation to this. Fundamentally, the paper will provide a description of the structure, delivery of care and quality outcomes to demonstrate how organizations apply safety and quality management principles to guarantee overall patient safety.

Key words: Quality Measures, Oral Health, Patient Safety

Contents

TOC o “1-3” h z u HYPERLINK l “_Toc316335771” Introduction PAGEREF _Toc316335771 h 2

HYPERLINK l “_Toc316335772” Structure of the Health Care Organization PAGEREF _Toc316335772 h 3

HYPERLINK l “_Toc316335773” Target Population, Clinics and Dental Staff PAGEREF _Toc316335773 h 3

HYPERLINK l “_Toc316335774” Figure 1: The organization chart (Source: Author’s organization 2011) PAGEREF _Toc316335774 h 4

HYPERLINK l “_Toc316335775” Delivery of Oral Health Care PAGEREF _Toc316335775 h 4

HYPERLINK l “_Toc316335776” Health Education PAGEREF _Toc316335776 h 5

HYPERLINK l “_Toc316335777” Prevention PAGEREF _Toc316335777 h 6

HYPERLINK l “_Toc316335778” Treatment PAGEREF _Toc316335778 h 8

HYPERLINK l “_Toc316335779” Safety Measures in Delivery of Care PAGEREF _Toc316335779 h 10

HYPERLINK l “_Toc316335780” Quality Control and Outcome Measures PAGEREF _Toc316335780 h 12

HYPERLINK l “_Toc316335781” Evaluation of Health Education PAGEREF _Toc316335781 h 13

HYPERLINK l “_Toc316335782” Evaluation of Preventive Procedures PAGEREF _Toc316335782 h 13

HYPERLINK l “_Toc316335783” Figure 3: Organizational prevention procedures between 2003 and 2010 (Source: Author’s organization 2011) PAGEREF _Toc316335783 h 13

HYPERLINK l “_Toc316335784” Evaluation of Treatment Procedures PAGEREF _Toc316335784 h 14

HYPERLINK l “_Toc316335785” Continuing dental education: PAGEREF _Toc316335785 h 15

HYPERLINK l “_Toc316335786” Electronic Health Recoding System (EHRS): PAGEREF _Toc316335786 h 16

HYPERLINK l “_Toc316335787” Conclusion PAGEREF _Toc316335787 h 16

IntroductionIn the last 30 years, various studies have been performed in the field of quality and safety measures in health care with the aim of providing high quality services at affordable cost. These studies have led to an overall change in the understanding of the impact of quality and safety on the outcome of services provided by health care organizations (Groene, O et al. 2010:282). In spite of this change, there is still a debate about how quality can be measured and how it can be improved, given the persistence of quality and safety problems. Consequently, the focus of the debates have centered on the following factors: safety of patients, effectiveness, timeliness, patient-centered care, efficiency and equity. These elements comprise quality and safety aspects in healthcare and determine the delivery of healthcare services in organizations (Institute of Medicine 200:1). This paper critically discusses how quality measures influence current practices, dimensions, and drivers for quality and safety in healthcare, and their impact on the delivery of healthcare services in health organizations. The discussion will focus on the quality and safety of healthcare in the author’s organization. Subsequent pages will therefore describe the structure, delivery of care and quality outcomes to demonstrate how the organization applies safety and quality management principles to guarantee patient safety.

Structure of the Health Care OrganizationThe author’s organization provides oral health care services including oral health education, prevention, and treatment to school-aged children. The national level organization was established based on findings of an oral health survey in 1982 showing the need for oral health services for children. The mission of the organization is to decrease the percentage of dental caries (tooth decay) and try to nurture generations through awareness programs on the importance of good oral health.

Target Population, Clinics and Dental StaffThe target population for the organization around 300,000 school-going children aged between four and sixteen year. The organization provides oral education, prevention and treatment services in three main clinics: (1) Center-based clinics; (2) School-based fixed clinics; and (3) Mobile clinics (covering schools without fixed clinics) to provide access to dental care for all public school children in the country.

Figure SEQ Figure * ARABIC 1: The organization chart (Source: Author’s organization 2011)Services are similar for all the regions and children. Branches in each governorate are managed by a head that is supported by a Clinical Supervisor (for quality control), prevention leader and health education in-charge. This structure streamlines administrative processes for the smooth flow of operations and quality management.

(Source: Author’s organization 2011) Figure SEQ Figure * ARABIC 2: Structure at branch level

Delivery of Oral Health CareThere are many opportunities for improving the quality of health care in many hospitals. According to Weiner, Alexander, Shortell, Baker, Becker and Geppert (2006:308), injuries in healthcare organizations are caused by patient exposure to safety risks, issuing wrong prescriptions and lack of follow-up by clinicians in abnormal test results. Consequently, they propose that healthcare organizations implement quality improvement strategies that emphasize continuous improvement of current practices and processes of quality performance. Quality improvement (QI) strategies focus on the practices and processes for quality of healthcare (Bates 2006; Institute of Medicine 200:1). Market concentration and competition from other hospitals, affiliation to system or network, ownership, profitability, inpatient/outpatient ration, hospital size and clinical integration is also important QI strategy (Weiner et al. 2006:310). The QI strategies for the author’s organization are divided into education, prevention and treatment.

Health EducationQI strategies on education focus on patient education and practitioner training. Patient education is very important. According to Groene et al. (2010:282), it is the responsibility of healthcare providers to educate the population at a very early stage before the onset of a disease. They claim that it is good practice to collaborate with patients to improve their wellbeing and change their lifestyle from illness to health. An informed patient is an asset to the organization because it reduces cost of treatment and improves the success of the organization’s prevention outcomes. To address patient education issue, the organization implemented an oral health education (OHE) program for children and parents.

OHE is an annual plan that is integrated into school-based education activities and partners with teachers to provide oral education to schoolchildren. The topics should be carefully chosen to meet the needs of children and are managed by education teams who communicate with the students in simple language to make the instructions given more acceptable. Moreover, dentists, dental hygienists or dental assistants use innovative techniques for OHE. Care is taken not to break the local cultural and traditional rules or exceed the limit of understanding of the children. Each centre has specific space for education of children and parents by audio and video means with instructions given mainly by a dental hygienist before the child receives treatment in the clinic. The education teams also reach the families by participating in the social activities to give the instructions about the oral hygiene.

PreventionThe reduction in dental caries had a remarkable progress in the last 30 years because of fluoride use in public water supply, toothpaste and professional dental products; increased access to dental care; and improved oral hygiene (Carounanidy & Sathyanarayanan 2010:209). Studies show that nearly 20 percent of children between 2 and 4 years have detectable dental caries, which increase to 80 percent by 17 years when most of them will have had a cavity manifestation. Moreover, more than 2/3 of adults between 35 to 44 years old will have lost at least one permanent tooth due to dental caries (Carounanidy & Sathyanarayanan 2010:210).

Carounanidy & Sathyanarayanan (2010:210) observe that safety through prevention has been the main changeover of healthcare management. They note that healthcare providers now focus on preventive strategies and non-invasive illness management. Preventive strategies may be primary, secondary or tertiary. Primary prevention strategies focus on preventing onset of an illness, such as new lesions in dental care, while secondary prevention strategies focus on arresting or controlling the progress of a disease through treatment and lesion management. Tertiary prevention strategies are implemented when the disease has already progressed and focus on administering effective treatment (Carounanidy & Sathyanarayanan 2010:211-12). The author’s organization QI objective is primary and secondary prevention through minimal invasive treatments. The organization has also implemented the following preventive strategies:

Primary prevention to all children between 4 and 16 years

Evolving the type and mode of delivery of preventive care

Performing bi-annual application of FV and FS on newly erupted permanent molars and pre-molars for primary prevention

Replacing fluoride gel with FV

Efficient use of portable units to increase prevention productivity

Increasing mobile clinics to 43 for Sealants and 30 teams for FV application

Carounanidy & Sathyanarayanan (2010:211-212) propose that the organization should use a treatment decision tree to achieve its QI objectives. The decision tree would help dentist determine the suitability of a preventive treatment for each patient. It would also help them determine the need for intervention, type of treatment (non-operative or operative), treatment regime, minimal restoration, risk status for patients and the dominant causal factors. The decision tree helps practitioners determine whether to progress with application fluoride vanish (FV) or placement of fissure sealants (FS). FS and FV are used because it reduces dental caries. Adair (2006:134) agrees, ‘FV is a safe material because it helps the teeth to get high concentration of fluoride when applied due to the adhesiveness property and the rate of quality of evidence for the effect of fluoride varnish in preventing and controlling dental caries’. FS uses resin material on teeth to reduce dental carriers. These two measures are useful in reducing dental caries especially in the absence of public water fluoridation (Beauchamp et al. 2008:260; Muller-Bolla, Lupi-Pequrier, Tardieu, Velly and Antomarchi 2006: 323).

Although a preventive decision tree is effective for QI, practitioners find it challenging to implement patient safety strategies for all children through school-based, mobile or centre clinics. Weiner et al. (2007) believes that this problem is due to dilution of focus between the clinics and the hospital, which cause management to engage in diverse and unrelated QI projects. Moreover, separating QI between the hospitals and clinics means that management and staff have to split resources and attention among each QI project and spread the resources too thinly. Therefore, it is paramount that the organization integrates clinic and hospital quality strategies to ensure equity, timeliness, acceptability, effectiveness, and patient-centered care (Maxwell 1992:171).

TreatmentThere is a high percentage of dental caries incidences especially among young population in the Middle East, which has affected the quality and delivery of treatment in the organization. Moreover, the high treatment costs and government sponsoring which make it a right for all children to access free dental care has affected the organization’s service quality. Presently, the organization offers five key treatments including restoration of decayed/broken down teeth; pulpotomy and stainless steel crowns for primary teeth; pulpotomy and pulpectomy for permanent teeth; extraction for badly decade teeth and patient referrals. To ensure patient safety, treatment is given only in centre- and fixed school-based clinics, as the procedures are critical and need to be done in a specific environment with strict infection control measures. The Institute of Medicine (2001:2) posits that reinventing the system at treatment level could improve the quality and delivery of health care. This reinvention can be implemented by reengineering care processes, using information technologies effectively, managing knowledge and talent, developing effective teams and coordinating care across patients, services and location of clinics. It proposes the following ten principles to support the redesign:

Ensuring that care focuses on establishing healing relationships with patients by being responsive at all times via telephone, Internet, mobile clinics and school visits.

Customizing care according to the needs and values of the patient

Giving patients the necessary information and opportunity to control their healthcare decisions through shared decision-making with the caregiver

Sharing information with patients and encouraging open communication between patients and clinicians.

Ensuring that decisions are evidence-based so that care from clinicians relies on scientific knowledge

Implementing patient safety to keep patients safe from injury, reduce risks and mitigate practitioner errors.

Ensuring transparency by making the system available to patients, their families and clinicians so that the safety and satisfaction of patients is achieved.

Anticipating the needs of the patients instead of reacting to events

Decreasing the waste of resources or patient time

Facilitating clinician and institutional cooperation through information exchange, collaboration and care coordination (Institute of Medicine 2001:4).

Safety Measures in Delivery of CareNumerous safety controls have been introduced in author’s oral health care organization to ensure the safety of the child, operator, and the procedures performed. Some of them are listed below:

Consent – Requires the organization to create separate consent forms for prevention and treatment procedures in local language and signed by parents.

Insurance policies – To protect the child and staff from malpractice, liabilities, workman compensation among other patient-related risks.

Referral centers – To establish networks with adequate referral centers that can take over any complications or emergencies

Infection control procedures – To implement infection control measures to ensure the safety of patients and staff.

Post-operative care- To specify strategies for post-operative care and ensure patient satisfaction

Emergency clinics – The organization should have an emergency clinic offering emergency services that extend to the holidays.

Digital radiography – Proposes the use digital radiographs that limit child exposure to about 70 percent compared to conventional radiographs

Practitioner training is an important safety measure. The author’s organization training ensures that the dentists diagnose dental caries properly and make the right decision on the most appropriate treatment. Dentists should be trained on the treatment decision tree to help them determine whether intervention is needed, what type of treatment to use (non-operative or operative), the regimen, minimal restoration, patient’s risk status, and the dominant causal factors (Carounanidy & Sathyanarayanan 2010:211-212). Employee safety is also important. This is because health care providers are exposed infections like Hepatitis BV (HBV) or Human Immuno deficiency Virus (HIV) and many other micro organisms which can be fatal or destroy the career of the health care worker if the patient got an infection in the clinic (Suñol et al. 2009:i59). Therefore, all the procedures in the organization should follow the guidelines given by Center for Disease Control (CDC).

Groene et al. (2010) posit that standardization of processes a key factor influencing QI. They suggest that all of the treatment procedures should be standardized in a clinical protocol, which is regularly updated to meet technological and evidence-based demands. The standards emphasize early diagnosis and treatment, and the use of minimally invasive techniques. Moreover, treatment procedures should be performed on quadrant basis in order to finish as much treatment in single appointment and high patient to practitioner ratios. Accreditation is another safety measure (Legido-Quigley et al. 2008). And it is planned to be for the author’s organization in order to improve service delivery. All employees have to wear protective masks, face shields, eyeglasses and protective clothing while working in clinics or sterilization room. Gloves are changed for every patient and used only once. The surfaces of the dental units and clinics are disinfected after finishing the procedure, and hand wash is mandatory before and after working on patients. Instruments and hand pieces used during each procedure should be washed and cleaned thoroughly to remove all residual materials,

The oral health organization sterilization room is divided into three areas:

Area of Receiving and washing the contaminated instruments

Area of Packing and sterilizing by autoclaves

Area of production clean sterilized instruments.

After sterilization, instruments should be bagged until the next use or expiry of sterilization period (month from the date of sterilization). The packages are then stamped to show the sterilization date on the package. If package is opened for any reason, instruments are cleaned and sterilized again. The clinical supervisor or infection control personnel monitor these safety policies to guarantee the quality of safety and infection control measures. Employees working in the sterilization room should be well trained in washing the instruments, using autoclaves, signing the checklist of sterilization circles and the checklist of the received and delivered instruments. The employees in the sterilization area are reworded for their work in a critical area in the author’s organization.

Quality Control and Outcome MeasuresQuality control through supervision is very important in an organization because it monitors the implementation of quality and safety strategies (Legido-Quigley et al. 2008; Stockmeier & Clapper 2011). Senior staff should perform the supervision to evaluate the quality of procedures. Some of the evaluation procedures in the author’s organization are:

Evaluation of Health Education

The performance of education teams is monitored and evaluated by a monthly reporting to the team leaders and program administration, which gives an idea about who, what was done and where. The information given is followed up and evaluated by health education department in order to assure the quality of procedures. In addition, the outcome of educational programs is measured on regular basis by conducting Knowledge, Attitude and Practice surveys on the selected population.

Evaluation of Preventive ProceduresQuantitatively, the productivities of the work done measured on daily basis which are later summarized on weekly, monthly, semi-annual and annual basis. Quality measurements of the preventive fillings (Sealants) placed is done on monthly and annual basis. Outcome of the fluoride program is evaluated by measuring the disease levels in a selected sample of children and comparing the results with controls. Some of the quantitative and qualitative measures for prevention performed under this organization are depicted in the graphs below:

Figure SEQ Figure * ARABIC 3: Organizational prevention procedures between 2003 and 2010 (Source: Author’s organization 2011)

Figure SEQ Figure * ARABIC 4. Increase in fluoride applications and consents in primary schools between 2007 and 2011 (Source: Author’s organization 2011)

. figure 5:Trends in sealant retention in mobile and fixed clinics for the last 3 years (Source: Author’s organization 2011)

Evaluation of Treatment ProceduresQuality of the procedures performed should be performed on a regular basis (Adair 2006:137) while staff should be evaluated on an annual basis. proposes that overall outcome measures in terms of disease levels be measured once in 5 years in patients.

Figure SEQ Figure * ARABIC 6: Five-year measures of caries trend in schoolchildren (Source: Author’s organization2011)

Two important measures employed by this organization for improving the quality of care provided are:

Continuing dental education:Continuous dental education has a great role in the author’s organization for all the staff, covering wide range of topics. Poortermaan, & Eijkman (1998:346) concur that it is responsibility of the practitioner to update his knowledge and skill level to practice dentistry properly. This explains why it is mandatory for the concerned staff to attend continuous education for professional growth. Dutch National Council for Public Health has established ‘aspect approach’ dividing quality into various aspects: quality of treatment; quality of professional attitude; and quality of the professional organization (National Institutes of Health 2001). These three divisions can be fulfilled by continuous education, training, and planning based on community needs with clinics can be accessed by most of the target population with putting into consideration the culture of society and the life style.

Electronic Health Recoding System (EHRS):Electronic Health Recording System (EHRS) is part of the structure and process of care as it improves the collection and storage of data. The outcome of EHRS depends on the level of security can be given on the aspect of accessing the data and the benefits that can be gained from facilitating communication among health care providers and between health care providers and patients (Int J Med Inform. 2006; Aspeder, Corrigan, Cot 2004). This system makes data entry and analysis efficient, and less time consuming. However, the main challenge for most organizations is profiling dental providers through electronic records (Hassan 2005). Training users on the system functions can solve this challenge. EHRS has gone a long way in improving the quality of care and making organizations more patient-centered.

ConclusionThis paper has discussed quality measures in health care. It has also discussed the practices, drivers and procedures to guarantee the quality and safety of the author’s organization. The organizational structure shows delivery of care centered on leadership, commitment and teamwork. The author’s organization has established strategies for quality improvement through networking between centers and clinics (fixed and mobile), affiliation to system or leadership and clinical integration The quality improvement strategies are divided into education, prevention and treatment. Overall safety measures for quality delivery in the organization include consent, insurance policies, referral centers, infection control procedures, post-operative care and emergency clinics. Quality control and evaluation measures are also performed to ensure quality care. Further research on quality and safety management in dental practice is needed to improve service delivery for the children.

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