In the chair
Out-of-control dental waiting lists and struggling NHS practices are well documented. Peter Thomson offers an insight into one UK health authority’s practices and how clinical governance guidelines can help – with the assistance of a third party audit
In February 2002, health care consultancy HQHQ was invited to undertake a benchmarking project of dental practices for a UK health authority. The remit was to discover the level of conformance to clinical governance requirements established by the UK 1999 Health Act which are:
- clear lines of responsibility and accountability for the overall quality of care
- a comprehensive programme of quality improvement activities
- clear policies aimed at managing risks
- procedures for all professional groups to identify and remedy poor performance
The process was repeated a year later to establish the impact of the audit on conformance. Fifty-six out of 110 subcontracting dental practices were selected by the health authority for the first year of the project. The second year was a mixture of new and repeat visits. Prior to this project, the practices’ conformance had been by a self-assessment questionnaire and spot checks by the health authority’s dental practice advisers in line with the current NHS procedures.
As far as the consultancy was aware this was the first formal approach using third party audit on this scale, given the small number of dental practices which have ISO 9001.
The key points
In 2003, 13 per cent of practices sampled were fully conforming, compared to none in 2002. A further 16 per cent of practices were within ten per cent of conforming. Furthermore:
- only 2.5 per cent of the practices sampled were below the 60 per cent conformance level compared with 51 per cent in the previous year (2002)
- the largest improvement in an individual practice was 53.5 per cent - from 38.5 per cent in 2002 to a 92 per cent conformance level in 2003
- practices which were failing in 2002 increased conformance by an average of 50 per cent between visits
The health authority agreed that the report should remain confidential between the auditors and the subcontracting practice. The health authority then received a copy of the action plan drawn up to address any deficiencies at each practice, a weekly report on overall findings and an overarching report on completion of each year’s work. As all of the auditors were covered by the legal requirements of the UK Dentists Act they had to inform the health authority if standards of care were ever threatened.
Teething trouble
Most dental practices are micro-businesses. The majority of failings were down to a combination of ignorance, poor morale, lack of clear information on what was required and a culture that considers a dentist’s job is to treat patients and not to fill in government tick boxes.
But weaknesses were still apparent in performance reviews, which meant that opportunities for improvement were being missed. Practice leaders often thought themselves to be great communicators, and working in a tight-knit team with a common aim, but in fact they had never asked the rest of the team if they knew what the aim was.
Many dental surgeries in the UK are desperate for help. They know they are not getting it right but do not have time in their busy clinical day to sit down and sort the problems out. This is why creating a formal action plan helps to facilitate solutions in a sensible and logical manner.
Creating an action plan to establish a health and safety policy enabled the dentist and their team to see it as a series of steps. Using a team approach meant the health and safety policy was properly communicated and understood by all the team.
The impact of action planning was that dentists and their staff could communicate in an arena which was not threatening, and ended up with solutions to implement rather than creating more problems.
Following the initial audit, the health authority was surprised to discover that morale amongst dentists had received a boost rather than a decline. The process helped the dentists to feel their concerns could actually be voiced. Even more importantly, the audit meant there was practical guidance available. Within two weeks of commencing our initial audits, suspicion was replaced with openness. As dentists were assured that their would be presented to the health board confidentially.
Evidence indicates that the third party audit approach has had a positive impact on dental practices’ ability to conform to clinical governance requirements. It has given the health authority a good return on its investment, through the preparation of a report that stands close scrutiny and an in-depth overview, explanation and discussion of the audit team’s findings.
The audit report could be sent to the Department of Health as evidence of clinical governance conformance within dentists in the health authority area, saving the health board costs and time in drawing up its report. More importantly, the audit process has given the health authority an established baseline in terms of meeting its own clinical governance commitments for dentists to encourage best practice.
The widely differing approach to the provision of a treatment plan and estimate to patients was cause for concern. In practices that were computer-based there was a higher level of conformance but there was often no agreement between practitioners in the same practice as to when estimates and treatment plans were issued. ‘Maintaining standards’ (2001) makes it clear that informed consent must be obtained prior to treatment which includes the provision of a written treatment plan, estimate and contract as best practice.
The General Dental Council does not expect a written estimate or treatment plan for every case but some clearer guidance on the health authority’s position with respect to NHS patients would be a help to practitioners. The impact of the lack of an estimate was observed when a patient was clearly unhappy with what they perceived as an open-ended bill. The patient’s response was to pay for treatment carried out to date and then leave the practice vowing never to return.
As a result of discussion between the health authority’s dental advisers and practitioners it was felt to be logical to provide all new patients with a treatment plan and estimate (where applicable) and any existing patient where the course of treatment involved advanced conservation such as root canal therapy, prosthesis, cosmetic dentistry, when mixing NHS and private treatment or when a patient requested a treatment plan and estimate.
The results speak for themselves: in 2003 the use of treatment plans and estimates was significantly more consistent than the year before, and only 2.6 per cent of practices could be deemed to be failing in 2003 compared with 30 per cent in 2002.
Looking ahead
All the practices that managed to demonstrate 80 per cent conformance, but not full compliance, indicated plans to be fully compliant by 2004. Practices which made the biggest jump in compliance appeared to be the most enthusiastic to complete the process, whereas those which scored quite high in 2002 appear to have been less driven to meet full compliance.
It was also noticeable that some of the practices failing in 2002 were under new ownership and demonstrated major improvements in compliance, while other failing practices have closed. Clinical audits and peer reviews have been accepted with varying levels of enthusiasm. Responses have ranged from complete refurbishment of some clinics to the less enthusiastic ‘tick-the-box’ approach. Luckily the latter response was very much in the minority.
Overall, most practices found the audit beneficial in giving them a clear guide as to what is expected with respect to clinical governance. Even single-handed practitioners who thought they were good at listening to their staff have found that the formal review process has improved the service to patients. At one practice, just by reorganising the appointment book and the way emergencies were dealt with, the number of complaints about late running, as well as stress on the receptionist, nurse and dentist were reduced.
The decrease of these negative impacts has improved the quality of service and work environment. This study shows that one effective way to change the culture of professional thinking and resistance to change is to offer supportive guidance and encouragement through the application of third party audit. Dentists are clearly overworked and have little time, enthusiasm or energy for non-clinical activity. Guidance manuals alone are not enough. Busy practitioners need simple, practical solutions to work towards which the third party audit approach can bring
About the author: Peter Thomson is an ex-dentist who has spent the last nine years working with health authorities, medical and dental practices and related health organizations and suppliers helping them make sense of clinical governance (QA) in a pragmatic and useful way. Currently he is working on a project to seek a solution to the problems in providing dental care to remote and rural communities in Scotland.
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