A R T IC L E
Im p licit and explicit reviews are used for the evaluation of the quality of dental care in tw o neighborhood health centers. Dentists and patients can benefit from a n o nthreatening appraisal of dental care.
Quality assurance in a neighborhood health center: dental services Neal A. Demby, DMD, MPH Murray Rosenthal, DDS, New York City
In the past decade, m uch attention has been fo cused on developing a formal m echanism for the assessm ent of care throughout the health field. T he passage of the Professional S tandards R e view A ct (Public Law 92-903) establishing P ro fessional Standards R eview O rganizations (PSR O s) put pressure on the providers to d e velop and im plem ent such m echanism s. Ini tially, the em phasis for establishm ent o f stan dards was placed on the m edical profession, particularly for inpatient care. H ow ever, inter est in m echanism s for assessing the quality of dental care has increased recently, especially in relation to anticipated expansion o f P SR O ac tivities. In the past ten years, Bailet and o th e rs,1 A bram ow itz and M ecklenburg,2 F riedm an,3 M o rehead,4 Soricelli,5 and Schoenfeld6 have created objective tools for the assessm ent o f the dental care process. This paper describes the developm ent and outcom e o f a dental quality assurance program in tw o neighborhood health centers in N ew Y ork City. 1008 ■ JADA, Vol. 96, June 1978
M ethodology C ertain term s will be used in this paper that re quire defining.7 “ S tructural m easurem ents” are concerned with the input resources of the health delivery system . T hese include the characteris tics o f the facility and providers and the organi zational structure o f the program . “ Process m easures” evaluate both w hat the provider does for the patient and how well the patient m oves through the health system . “ O u tco m e'’ evalu ates the results o f care and is usually m easured by health status indicators to analyze changes in the p atien t’s state o f health. T w o m ethods w ere used for assessing the process o f c a re.8 “ Im plicit review ” relies on the subjective evaluation of the auditor. This m ethod o f review is based on criteria that w ere inter nalized by the individual and may differ accord ing to the individual’s knowledge, training, and experience. “ Explicit review ” is based on
A R T IC L E
criteria th at w ere set or predeterm ined by group consensus o f recognized authorities in the field. In 1972, concern by the dentists o f tw o neigh borhood health centers about the technical qual ity o f dental services and the judgm ent used in developing treatm ent plans prom pted the devel opm ent o f a dental assessm ent m echanism focusing on the process o f care. T he dentists de term ined th at answ ers w ere needed to the fol lowing questions: — W ho should do the review? — Should the review be a review o f charts, or a direct exam ination o f patients, or both? — By w hat m ethod should the charts or the patients be selected? — Should the review be explicit, implicit, or both? — W hat should be the frequency of the re view? — W hat approach should be used w hen in adequate care is found? T hese questions caused considerable discus sion that resulted in a general consensus on each issue. It w as decided that the review er should be a dentist, em ployed outside the center, who was fam iliar with the goals o f dental services in neighborhood health centers. In addition, this person w ould have to be respected for his abili ties as a dentist. It was agreed that the m ost ap propriate individual would be an esteem ed den tist from an o th er neighborhood health center. T he audit w as to include both a review o f the chart and a clinical assessm ent o f the patient. Patients w ere to be selected who had com pleted treatm ent th ree to six m onths before the review. F ive patients of each dentist would be chosen. C harts would be selected random ly by clerical personnel. L etters would be sent to these pa tients explaining the intent o f the study and re questing their cooperation. T he audit would be explicit for evaluations of the technical com ponent and review o f the chart and would be implicit for evaluations o f the treatm ent plan and overall process o f care. The assessm ent would be sem iannual. All patients requiring corrections o r further treatm ent would be given an appointm ent at the tim e o f the audit. ■ T he quality assessm ent fo rm a t: T he audit, as originally conceived, consists o f tw o parts, a di rect clinical evaluation (Fig 1) and an evaluation o f the chart (Fig 2). T he clinical evaluation form is categorized into four parts. T he “ technical” area m easures the process of dental care using
explicit criteria relevant to the practice o f good dentistry. T hese criteria are scored on a twopoint scale, adequate and inadequate. T he “ prevention” area m easures the outcom e o f the patient’s oral hygiene, using a m odification of the Plaque Index developed by L o e.9 T he “ treatm ent plan” area evaluates the judgm ent of the dentist in logically developing a plan on the basis of the needs of the patient and taking into consideration all pertinent variables. B ecause of the difficulty in establishing explicit criteria in this area, an implicit approach is used. If the re view er finds fault with the treatm ent plan, a brief discussion of alternative approaches and their rationale is expected. T he “ Sum m ary” al lows the review er to integrate all the findings into a general statem ent and provides an oppor tunity for making recom m endations. In the sec tion entitled “ R ecom m endations to professional supervisor,” corrections can be suggested in those aspects of treatm ent that, either by their presence or their absence, may have im paired the p atien t’s oral condition and need im m ediate rectification. T hese conditions may include se vere caries, either uncharted or recurrent; an ill-fitting prosthesis that causes discom fort to the patient and injury to the tissue; o r periodon tal and orthodontic problem s that w ere over looked. D entists receiving these recom m enda tions are expected to rem edy the problem s as soon as possible. Patients will be recalled at the time o f the next audit to determ ine w hether the indicated corrections w ere m ade. T he evaluation o f the chart m akes certain that adequate records are kept to facilitate care and to prevent legal com plications. It consists o f ex plicit criteria widely accepted in dental practice. T he com pleted evaluation is placed on the p a tien t’s chart and becom es a part o f his or her perm anent record. All recom m endations m ade by the review er and deem ed applicable by the professional supervisor are expected to be com plied with by the dentist, who m ust subm it a follow-up report to the professional supervisor, thereby assuring com pliance and im proved care. ■ Clinical evaluation: Tw o audits w ere p er form ed in each of the tw o health centers during 1973 and 1974. Both authors served as the re view ers of each o th er’s dental departm ent. Five patients w ere selected for each staff dentist; how ever, only half o f these patients appeared for the audits, resulting in a m ore extensive evaluation o f some dentists than o f others. T he Demby— Rosenthal: QUALITY ASSURANCE IN DENTAL SERVICES ■ 1009
~
~
CD
"'
c.... c:
!"
•
.... 0 .... 0
3.---------------
2. ______________
Auditors 1. ________________
Radiographic evaluation--4 bitewings
Open margins on crowns
A.
Marginal percolation of
5. Open contact areas excluding diastema
4. Uneven marginal ridges or no marginal ridges (irregular tooth position will be taken into consideration)
3. Premature occlusion with gross facets--can be checked by testing active mobility on tapping
2. Overhangs or poor contour of fillings at the gingival margin
1.
Operative and crown and bridge
Clinical evaluation
fillings
2.
C. Caries not removed unless chart indicates an indirect pulp cap
B.
A. Overhangs of 1 mm or more on amalgam restorations
1. Adequate Inadequate
I. Treatment area--Using the following explicit criteria as a guide for inadequate treatment, indicate by either a check if work is adequate or by location (tooth/quadrant) if work is inadequate.
Guidelines for evaluation of clinical work three to six months after treatment is completed.
Practitioners. _____________________________
Name. _____________________________________
Clinical Evaluation Overcontouring of crowns in
Open margins on crowns
Prosthetics
Pedodontics
Impingement on rest position
Fabricated but inadequate
Not fabricated when indicated
Fabricated when indicated
1. Deciduous molars extracted without space maintenance is unacceptable unless orthodontics is considered or permanent tooth expected to erupt within six months of the extraction.
c.
7.
6. Retromolar pad not covered by lower denture
5. Flabby or irritated tissue underlying denture
4. Poor occlusion causing skiding on denture base
3. Borders grossly overextended or underextended
2. Abutments for the partial denture in poor periodontal condition (tooth in excessive 2-3 mm mobility, with less than half of root in bone)
1. The partial frame does not seat properly--check patient's history as he may have distorted the partial denture or not worn it.
B.
a) Improper embrasures b) Concavities on gingival surface of pontic, resulting in inability to remove plaque
8. Poor hygiene qualities on bridges which includes:
cervical area
7.
6.
Demby— Rosenthal: QUALITY
ASSURANCE
IN DENTAL SERVICES
■ 1011
Prevention area
____________________ _
____________________ __
______________________
______________________
______________________
______________________
Discuss:
Treatment plan
IV.
3.
2.
1.
Recommendations to professional supervisor
Recommendations to dentist
General assessment
Summary
Whether treatment plan is logical and demonstrates a concept of total care
Whether medical problems were integrated into treatment plan____
Whether all oral problems were treated or mentioned in treatment plan (uncharted caries and overlooked periodontal problems)
III.
Fig 1 ■ Clinical evaluation form.
Evaluate each tooth above; if the tooth is missing, do not evaluate another tooth. Figure the average plaque index for the patient: add each score and divide by the number of teeth evaluated for the total plaque index_______________
Lingual surface of mandibular left first molar or deciduous left second molar Labial surface of mandibular left central incisor or deciduous left central incisor Buccal surface of mandibular right second bicuspid or deciduous right first molar
Buccal surface of maxillary right first molar or deciduous second molar Labial surface of maxillary right central incisor or deciduous right central incisor Buccal surface of maxillary left second bicuspid or deciduous left first molar
Plaque score per tooth
up to 1, good; 1.1 to 2.0, fair; 2.1 to 3.0, poor.
Evaluate the following teeth
Key for index:
0— No stainable material observed after application of disclosing solution to tooth surface. 1— Discreet, discontinuous areas of stainable material observed on the tooth surface. 2— A continuous layer of thin stainable material at the area of the gingival margin. 3— A thick, continuous layer of material at the gingival margin, often covering half or more of the clinical crown.
Use modified plaque index to determine efficacy of plaque removal:
II.
2.
Auditors 1.
Easily located
Treatment plan
Yes________
No________
Check the following for the initial charting Complete____________________ Incomplete__________________ Not done____________________ Comments:
Quality
Fig 2 ■ Chart evaluation form.
Logical services planned and outlined by more than one treatment phase
(periodontal, operative)______________________________________
No full-mouth survey
Incomplete full-mouth survey
Complete (minimum of 16 radiographs or 1 panoramic radiograph and 4 bitewings)
Radiographs
( ) ( )
( ) ( )
Charting
( )
( )
C o m p l e t e ______________ Incomplete__________________ Not taken___________________ Consent signed when indicated_________________________ Plaque control Fluoride for children 12 and under Scaling for adults
No
Yes
7.
( ) ( )
( ) ( )
( ) ( )
( ) ( ) ( )
( ) ( ) ( )
( ) ( )
Check if following information included if indicated
Prevention
Date of each visit Progress notes complete Progress notes legible Work to be done next at following appointment Name of therapist
Never
Sometimes
Always
Check if following information included:
Continuation sheet
Medical history
Logical services planned and outlined by treatment phase only
4.
3.
2.
Complete____________________ Incomplete__________________
1. Top of chart— to include: name, address, household numbers, third party coverage, phone number, birth date.
Practitioners
Name_________________________________
CHART EVALUATION
A R TIC L E
process established for the audit proceeded sm oothly at both centers. F irst, the patient had bitewing radiographs taken. W hile these w ere being developed, a hygienist or oral health edu cato r calculated the Plaque Index and, if neces sary, reem phasized appropriate oral hygiene techniques. Finally, the review er com pleted both parts o f the audit.
Results T h ere w as little difference in the results o f the audit at both centers. T he m ost com m on prob lem s in all four audits w ere lack o f a logical se quential treatm ent plan; incom plete charting of caries; radiographs that w ere inadequate for diagnostic purposes; and a lack o f adequate evaluation and treatm ent o f both periodontal and orthodontic problem s. H ow ever, the tech nical proficiency o f the dental w ork w as, in m ost cases, at least adequate and often excel lent. T h e one distinct difference betw een the centers was th at one program show ed a signifi cantly low er m ean on the P laque Index than did the other. T his was directly attributed to the greater em phasis on prevention in th at program . T h e results o f the second audit at both centers show ed an im provem ent in the quality o f care, with the exception o f the Plaque Index, which actually increased in one center. A lthough the frequency o f problem s decreased, the problem s listed previously rem ained the m ost prevalent.
Discussion M ethods for the assessm ent o f the quality of health care are a source o f increasing con troversy. M ost m ethods developed have evalu ated the process o f care in the hope th at the ac tual health status o f the patient is im proved. Brook and A ppel8 found th at judgm ent o f the process used correlated w eakly with outcom e. T o com plicate m atters further, m ost process evaluations have used an explicit approach, re flecting a need to quantify standards and im prove the reliability o f the evaluation. H ow ever, several problem s are inherent in the explicit ap proach. F irst, to ensure m axim um adherence to standards, several expensive and, perhaps, inef fective item s are included.10,11 F o r exam ple, is it necessary to do routine culturing in endodon-
tics? Second, criteria for decision m aking are not com m only “ b ra n ch ed ,” m aking each step in the process not conditional on the previous ste p .12 T hird, explicit criteria m ake assum ptions that reflect a certain universality that m ay not be correct when the m ost recent research and the social, econom ic, and psychological needs of the individual patient are co n sid ered .11 F o r exam ple, how would one construct explicit criteria for the treatm ent o f periodontal disease? C onversely, the im plicit approach is only as good as the knowledge and skills o f the review er and does not provide any m easure o f reliability in the evaluation process. T hese problem s do not invalidate the use of the quality assessm ent m echanism s as an indicator for the quality of dental services. T he audit presented here was developed to provide the m ost effective, effi cient, and flexible approach for use in a nonacadem ic, public health setting. ■ E fficiency: T en to 15 m inutes was the aver age time taken for the review er’s evaluation. As a result, a considerable num ber o f patients w ere review ed in one day. T his m akes the audit p rac tical for use in a group practice setting, such as a neighborhood health center. T he re s u lts . of sampling five o r so patients for each dentist al lowed us to m ake a reasonable evaluation con cerning the effectiveness and abilities o f the staff dentists. ■ Provider acceptance: A m ajor b arrier in using any quality assessm ent m echanism is the resistance o f the providers. W hen the idea o f a quality assurance m echanism was first pre sented to the dentists, many o f them resisted the idea because o f its punitive connotation; there fore, considerable time was spent working with the dentists in developing a model that was es sentially nonthreatening and was seen as a tool for self-education and self-evaluation. T he use o f a partially im plicit evaluation lent a m ore p er sonal touch than the “ grade-like” explicit m ethod. A n interesting phenom enon occurred after the first audit. A lm ost universally, the dentists reacted favorably to results, regardless o f the outcom e. D entists require reinforcem ent for their w ork, not only from patients but also from a peer. T hose dentists who received unfavorable reports treated them as learning experiences. Before the second audit, the dentists show ed lit tle resistance and w ere anxious to see if their Demby— Rosenthal: QUALITY ASSURANCE IN DENTAL SERVICES ■ 1013
A R T IC L E
work either continued to be of good quality or had im proved. ■ E ffectiveness: An audit is o f little value if it does not serve to alter unfavorable behavior. T he second audit showed that frequency of problem s had decreased in both centers. A ppar ently, the dentists benefited from a nonthreaten ing appraisal of their work.
Conclusion A m ethod for assessing the quality o f dental care in neighborhood health centers has been presented. T he audit uses im plicit review for the evaluation o f the overall process of dental care and explicit review for the technical com ponent o f the clinical audit and the evaluation o f the dental record. This com bined approach is fa vored over a totally explicit audit because it is m ore flexible and efficient and less threatening to the dentist. Although the “ soft” structure of this audit could be criticized, the m ajor issue is that a useable, simple quality assurance m echa nism has been successfully used to im prove the quality o f dental care. M odifications of criteria will certainly evolve as quality assurance m ech anism s im prove.
2. A bram ow itz, J., and M ecklenburg, R.E. Q uality of care in dental practice; the approach of the Indian Health Service. J Pub lic Health Dent 32:90 Spring 1972. 3. Friedman, J.W. A guide fo r the evaluation of dental care. Los Angeles, S chool of P ublic Health, University of California, 1972. 4. Morehead, M.A. Evaluating the qu ality o f medical care in the neighborhood health center program o f the O ffice of Econom ic O pportunity. Medical Care 8:118, 1970. 5. S oricelli, D.A. Practical experience in peer review c o n tro l ling quality in the delivery of dental care. Am J P ublic Health 61:2046 Oct 1971. 6. S chonfeld, H.K. Q uality of dental care. Its measurement, de scrip tio n and evaluation. J Am Coll Dent 38:194 Oct 1971. 7. Donabedian, A. Evaluating the qu ality of medical care. Milbank Mem Fund Q 44:166, 1966. 8. Brook, R.H., and Appel, F.A. Q uality-of-care assessment: choosing a m ethod fo r peer review. N Engl J Med 288:1323 June 21, 1973. 9. Loe, H. The Gingival Index, the Plaque Index and the Reten tio n Index Systems. J P eriodontol 38:610 Nov-Dee 1967. 10. Brook, R.H. Q uality of care assessment: po licy relevant is sues. Policy Sci J 317, 1974. 11. McNerney, W.J. The quandary o f qu ality assessment. N Engl J Med 295:1505 Dec 30, 1976. 12. Brook, R.H.; W illiams, K. IV; and Allyson, D.A. Q uality as surance today and tom orrow : forecast fo r the future. Ann Intern Med 85:809 Dec 1976.
THE AUTHORS
This paper was presented before the Dental Health S ection of the A m erican P ublic Health Association at the 102nd annual meeting, Oct 20-24, 1974, in New Orleans, La. The op in ions expressed here are those of the authors and should not be construed as representing the op in ions of the US P ublic Health Service or any agency o f the US governm ent. This project was supported by Health Services Development P roject Grant, Section 330 of the P ublic Services Act, Health Ser vices and Mental Health A dm inistration, US P ublic Health Ser vice. 1. Bailit, H., and others. Q uality o f dental care: developm ent of standards. JADA 89:842 Oct 1974.
1014 ■ JADA, Vol. 96, June 1978
DEMBY
ROSENTHAL
Dr. Demby is chief of dental services at the Family Health Center o f the Lutheran Medical Center, 150 55th St, B rooklyn, NY 11220. Dr. Rosenthal is dental dire ctor, East Harlem C ouncil fo r Human Services, N eighborhood Health Center, New York, NY. Address requests fo r reprints to Dr. Demby.
Im p licit and explicit reviews are used for the evaluation of the quality of dental care in tw o neighborhood health centers. Dentists and patients can benefit from a n o nthreatening appraisal of dental care.
Quality assurance in a neighborhood health center: dental services Neal A. Demby, DMD, MPH Murray Rosenthal, DDS, New York City
In the past decade, m uch attention has been fo cused on developing a formal m echanism for the assessm ent of care throughout the health field. T he passage of the Professional S tandards R e view A ct (Public Law 92-903) establishing P ro fessional Standards R eview O rganizations (PSR O s) put pressure on the providers to d e velop and im plem ent such m echanism s. Ini tially, the em phasis for establishm ent o f stan dards was placed on the m edical profession, particularly for inpatient care. H ow ever, inter est in m echanism s for assessing the quality of dental care has increased recently, especially in relation to anticipated expansion o f P SR O ac tivities. In the past ten years, Bailet and o th e rs,1 A bram ow itz and M ecklenburg,2 F riedm an,3 M o rehead,4 Soricelli,5 and Schoenfeld6 have created objective tools for the assessm ent o f the dental care process. This paper describes the developm ent and outcom e o f a dental quality assurance program in tw o neighborhood health centers in N ew Y ork City. 1008 ■ JADA, Vol. 96, June 1978
M ethodology C ertain term s will be used in this paper that re quire defining.7 “ S tructural m easurem ents” are concerned with the input resources of the health delivery system . T hese include the characteris tics o f the facility and providers and the organi zational structure o f the program . “ Process m easures” evaluate both w hat the provider does for the patient and how well the patient m oves through the health system . “ O u tco m e'’ evalu ates the results o f care and is usually m easured by health status indicators to analyze changes in the p atien t’s state o f health. T w o m ethods w ere used for assessing the process o f c a re.8 “ Im plicit review ” relies on the subjective evaluation of the auditor. This m ethod o f review is based on criteria that w ere inter nalized by the individual and may differ accord ing to the individual’s knowledge, training, and experience. “ Explicit review ” is based on
A R T IC L E
criteria th at w ere set or predeterm ined by group consensus o f recognized authorities in the field. In 1972, concern by the dentists o f tw o neigh borhood health centers about the technical qual ity o f dental services and the judgm ent used in developing treatm ent plans prom pted the devel opm ent o f a dental assessm ent m echanism focusing on the process o f care. T he dentists de term ined th at answ ers w ere needed to the fol lowing questions: — W ho should do the review? — Should the review be a review o f charts, or a direct exam ination o f patients, or both? — By w hat m ethod should the charts or the patients be selected? — Should the review be explicit, implicit, or both? — W hat should be the frequency of the re view? — W hat approach should be used w hen in adequate care is found? T hese questions caused considerable discus sion that resulted in a general consensus on each issue. It w as decided that the review er should be a dentist, em ployed outside the center, who was fam iliar with the goals o f dental services in neighborhood health centers. In addition, this person w ould have to be respected for his abili ties as a dentist. It was agreed that the m ost ap propriate individual would be an esteem ed den tist from an o th er neighborhood health center. T he audit w as to include both a review o f the chart and a clinical assessm ent o f the patient. Patients w ere to be selected who had com pleted treatm ent th ree to six m onths before the review. F ive patients of each dentist would be chosen. C harts would be selected random ly by clerical personnel. L etters would be sent to these pa tients explaining the intent o f the study and re questing their cooperation. T he audit would be explicit for evaluations of the technical com ponent and review o f the chart and would be implicit for evaluations o f the treatm ent plan and overall process o f care. The assessm ent would be sem iannual. All patients requiring corrections o r further treatm ent would be given an appointm ent at the tim e o f the audit. ■ T he quality assessm ent fo rm a t: T he audit, as originally conceived, consists o f tw o parts, a di rect clinical evaluation (Fig 1) and an evaluation o f the chart (Fig 2). T he clinical evaluation form is categorized into four parts. T he “ technical” area m easures the process of dental care using
explicit criteria relevant to the practice o f good dentistry. T hese criteria are scored on a twopoint scale, adequate and inadequate. T he “ prevention” area m easures the outcom e o f the patient’s oral hygiene, using a m odification of the Plaque Index developed by L o e.9 T he “ treatm ent plan” area evaluates the judgm ent of the dentist in logically developing a plan on the basis of the needs of the patient and taking into consideration all pertinent variables. B ecause of the difficulty in establishing explicit criteria in this area, an implicit approach is used. If the re view er finds fault with the treatm ent plan, a brief discussion of alternative approaches and their rationale is expected. T he “ Sum m ary” al lows the review er to integrate all the findings into a general statem ent and provides an oppor tunity for making recom m endations. In the sec tion entitled “ R ecom m endations to professional supervisor,” corrections can be suggested in those aspects of treatm ent that, either by their presence or their absence, may have im paired the p atien t’s oral condition and need im m ediate rectification. T hese conditions may include se vere caries, either uncharted or recurrent; an ill-fitting prosthesis that causes discom fort to the patient and injury to the tissue; o r periodon tal and orthodontic problem s that w ere over looked. D entists receiving these recom m enda tions are expected to rem edy the problem s as soon as possible. Patients will be recalled at the time o f the next audit to determ ine w hether the indicated corrections w ere m ade. T he evaluation o f the chart m akes certain that adequate records are kept to facilitate care and to prevent legal com plications. It consists o f ex plicit criteria widely accepted in dental practice. T he com pleted evaluation is placed on the p a tien t’s chart and becom es a part o f his or her perm anent record. All recom m endations m ade by the review er and deem ed applicable by the professional supervisor are expected to be com plied with by the dentist, who m ust subm it a follow-up report to the professional supervisor, thereby assuring com pliance and im proved care. ■ Clinical evaluation: Tw o audits w ere p er form ed in each of the tw o health centers during 1973 and 1974. Both authors served as the re view ers of each o th er’s dental departm ent. Five patients w ere selected for each staff dentist; how ever, only half o f these patients appeared for the audits, resulting in a m ore extensive evaluation o f some dentists than o f others. T he Demby— Rosenthal: QUALITY ASSURANCE IN DENTAL SERVICES ■ 1009
~
~
CD
"'
c.... c:
!"
•
.... 0 .... 0
3.---------------
2. ______________
Auditors 1. ________________
Radiographic evaluation--4 bitewings
Open margins on crowns
A.
Marginal percolation of
5. Open contact areas excluding diastema
4. Uneven marginal ridges or no marginal ridges (irregular tooth position will be taken into consideration)
3. Premature occlusion with gross facets--can be checked by testing active mobility on tapping
2. Overhangs or poor contour of fillings at the gingival margin
1.
Operative and crown and bridge
Clinical evaluation
fillings
2.
C. Caries not removed unless chart indicates an indirect pulp cap
B.
A. Overhangs of 1 mm or more on amalgam restorations
1. Adequate Inadequate
I. Treatment area--Using the following explicit criteria as a guide for inadequate treatment, indicate by either a check if work is adequate or by location (tooth/quadrant) if work is inadequate.
Guidelines for evaluation of clinical work three to six months after treatment is completed.
Practitioners. _____________________________
Name. _____________________________________
Clinical Evaluation Overcontouring of crowns in
Open margins on crowns
Prosthetics
Pedodontics
Impingement on rest position
Fabricated but inadequate
Not fabricated when indicated
Fabricated when indicated
1. Deciduous molars extracted without space maintenance is unacceptable unless orthodontics is considered or permanent tooth expected to erupt within six months of the extraction.
c.
7.
6. Retromolar pad not covered by lower denture
5. Flabby or irritated tissue underlying denture
4. Poor occlusion causing skiding on denture base
3. Borders grossly overextended or underextended
2. Abutments for the partial denture in poor periodontal condition (tooth in excessive 2-3 mm mobility, with less than half of root in bone)
1. The partial frame does not seat properly--check patient's history as he may have distorted the partial denture or not worn it.
B.
a) Improper embrasures b) Concavities on gingival surface of pontic, resulting in inability to remove plaque
8. Poor hygiene qualities on bridges which includes:
cervical area
7.
6.
Demby— Rosenthal: QUALITY
ASSURANCE
IN DENTAL SERVICES
■ 1011
Prevention area
____________________ _
____________________ __
______________________
______________________
______________________
______________________
Discuss:
Treatment plan
IV.
3.
2.
1.
Recommendations to professional supervisor
Recommendations to dentist
General assessment
Summary
Whether treatment plan is logical and demonstrates a concept of total care
Whether medical problems were integrated into treatment plan____
Whether all oral problems were treated or mentioned in treatment plan (uncharted caries and overlooked periodontal problems)
III.
Fig 1 ■ Clinical evaluation form.
Evaluate each tooth above; if the tooth is missing, do not evaluate another tooth. Figure the average plaque index for the patient: add each score and divide by the number of teeth evaluated for the total plaque index_______________
Lingual surface of mandibular left first molar or deciduous left second molar Labial surface of mandibular left central incisor or deciduous left central incisor Buccal surface of mandibular right second bicuspid or deciduous right first molar
Buccal surface of maxillary right first molar or deciduous second molar Labial surface of maxillary right central incisor or deciduous right central incisor Buccal surface of maxillary left second bicuspid or deciduous left first molar
Plaque score per tooth
up to 1, good; 1.1 to 2.0, fair; 2.1 to 3.0, poor.
Evaluate the following teeth
Key for index:
0— No stainable material observed after application of disclosing solution to tooth surface. 1— Discreet, discontinuous areas of stainable material observed on the tooth surface. 2— A continuous layer of thin stainable material at the area of the gingival margin. 3— A thick, continuous layer of material at the gingival margin, often covering half or more of the clinical crown.
Use modified plaque index to determine efficacy of plaque removal:
II.
2.
Auditors 1.
Easily located
Treatment plan
Yes________
No________
Check the following for the initial charting Complete____________________ Incomplete__________________ Not done____________________ Comments:
Quality
Fig 2 ■ Chart evaluation form.
Logical services planned and outlined by more than one treatment phase
(periodontal, operative)______________________________________
No full-mouth survey
Incomplete full-mouth survey
Complete (minimum of 16 radiographs or 1 panoramic radiograph and 4 bitewings)
Radiographs
( ) ( )
( ) ( )
Charting
( )
( )
C o m p l e t e ______________ Incomplete__________________ Not taken___________________ Consent signed when indicated_________________________ Plaque control Fluoride for children 12 and under Scaling for adults
No
Yes
7.
( ) ( )
( ) ( )
( ) ( )
( ) ( ) ( )
( ) ( ) ( )
( ) ( )
Check if following information included if indicated
Prevention
Date of each visit Progress notes complete Progress notes legible Work to be done next at following appointment Name of therapist
Never
Sometimes
Always
Check if following information included:
Continuation sheet
Medical history
Logical services planned and outlined by treatment phase only
4.
3.
2.
Complete____________________ Incomplete__________________
1. Top of chart— to include: name, address, household numbers, third party coverage, phone number, birth date.
Practitioners
Name_________________________________
CHART EVALUATION
A R TIC L E
process established for the audit proceeded sm oothly at both centers. F irst, the patient had bitewing radiographs taken. W hile these w ere being developed, a hygienist or oral health edu cato r calculated the Plaque Index and, if neces sary, reem phasized appropriate oral hygiene techniques. Finally, the review er com pleted both parts o f the audit.
Results T h ere w as little difference in the results o f the audit at both centers. T he m ost com m on prob lem s in all four audits w ere lack o f a logical se quential treatm ent plan; incom plete charting of caries; radiographs that w ere inadequate for diagnostic purposes; and a lack o f adequate evaluation and treatm ent o f both periodontal and orthodontic problem s. H ow ever, the tech nical proficiency o f the dental w ork w as, in m ost cases, at least adequate and often excel lent. T h e one distinct difference betw een the centers was th at one program show ed a signifi cantly low er m ean on the P laque Index than did the other. T his was directly attributed to the greater em phasis on prevention in th at program . T h e results o f the second audit at both centers show ed an im provem ent in the quality o f care, with the exception o f the Plaque Index, which actually increased in one center. A lthough the frequency o f problem s decreased, the problem s listed previously rem ained the m ost prevalent.
Discussion M ethods for the assessm ent o f the quality of health care are a source o f increasing con troversy. M ost m ethods developed have evalu ated the process o f care in the hope th at the ac tual health status o f the patient is im proved. Brook and A ppel8 found th at judgm ent o f the process used correlated w eakly with outcom e. T o com plicate m atters further, m ost process evaluations have used an explicit approach, re flecting a need to quantify standards and im prove the reliability o f the evaluation. H ow ever, several problem s are inherent in the explicit ap proach. F irst, to ensure m axim um adherence to standards, several expensive and, perhaps, inef fective item s are included.10,11 F o r exam ple, is it necessary to do routine culturing in endodon-
tics? Second, criteria for decision m aking are not com m only “ b ra n ch ed ,” m aking each step in the process not conditional on the previous ste p .12 T hird, explicit criteria m ake assum ptions that reflect a certain universality that m ay not be correct when the m ost recent research and the social, econom ic, and psychological needs of the individual patient are co n sid ered .11 F o r exam ple, how would one construct explicit criteria for the treatm ent o f periodontal disease? C onversely, the im plicit approach is only as good as the knowledge and skills o f the review er and does not provide any m easure o f reliability in the evaluation process. T hese problem s do not invalidate the use of the quality assessm ent m echanism s as an indicator for the quality of dental services. T he audit presented here was developed to provide the m ost effective, effi cient, and flexible approach for use in a nonacadem ic, public health setting. ■ E fficiency: T en to 15 m inutes was the aver age time taken for the review er’s evaluation. As a result, a considerable num ber o f patients w ere review ed in one day. T his m akes the audit p rac tical for use in a group practice setting, such as a neighborhood health center. T he re s u lts . of sampling five o r so patients for each dentist al lowed us to m ake a reasonable evaluation con cerning the effectiveness and abilities o f the staff dentists. ■ Provider acceptance: A m ajor b arrier in using any quality assessm ent m echanism is the resistance o f the providers. W hen the idea o f a quality assurance m echanism was first pre sented to the dentists, many o f them resisted the idea because o f its punitive connotation; there fore, considerable time was spent working with the dentists in developing a model that was es sentially nonthreatening and was seen as a tool for self-education and self-evaluation. T he use o f a partially im plicit evaluation lent a m ore p er sonal touch than the “ grade-like” explicit m ethod. A n interesting phenom enon occurred after the first audit. A lm ost universally, the dentists reacted favorably to results, regardless o f the outcom e. D entists require reinforcem ent for their w ork, not only from patients but also from a peer. T hose dentists who received unfavorable reports treated them as learning experiences. Before the second audit, the dentists show ed lit tle resistance and w ere anxious to see if their Demby— Rosenthal: QUALITY ASSURANCE IN DENTAL SERVICES ■ 1013
A R T IC L E
work either continued to be of good quality or had im proved. ■ E ffectiveness: An audit is o f little value if it does not serve to alter unfavorable behavior. T he second audit showed that frequency of problem s had decreased in both centers. A ppar ently, the dentists benefited from a nonthreaten ing appraisal of their work.
Conclusion A m ethod for assessing the quality o f dental care in neighborhood health centers has been presented. T he audit uses im plicit review for the evaluation o f the overall process of dental care and explicit review for the technical com ponent o f the clinical audit and the evaluation o f the dental record. This com bined approach is fa vored over a totally explicit audit because it is m ore flexible and efficient and less threatening to the dentist. Although the “ soft” structure of this audit could be criticized, the m ajor issue is that a useable, simple quality assurance m echa nism has been successfully used to im prove the quality o f dental care. M odifications of criteria will certainly evolve as quality assurance m ech anism s im prove.
2. A bram ow itz, J., and M ecklenburg, R.E. Q uality of care in dental practice; the approach of the Indian Health Service. J Pub lic Health Dent 32:90 Spring 1972. 3. Friedman, J.W. A guide fo r the evaluation of dental care. Los Angeles, S chool of P ublic Health, University of California, 1972. 4. Morehead, M.A. Evaluating the qu ality o f medical care in the neighborhood health center program o f the O ffice of Econom ic O pportunity. Medical Care 8:118, 1970. 5. S oricelli, D.A. Practical experience in peer review c o n tro l ling quality in the delivery of dental care. Am J P ublic Health 61:2046 Oct 1971. 6. S chonfeld, H.K. Q uality of dental care. Its measurement, de scrip tio n and evaluation. J Am Coll Dent 38:194 Oct 1971. 7. Donabedian, A. Evaluating the qu ality of medical care. Milbank Mem Fund Q 44:166, 1966. 8. Brook, R.H., and Appel, F.A. Q uality-of-care assessment: choosing a m ethod fo r peer review. N Engl J Med 288:1323 June 21, 1973. 9. Loe, H. The Gingival Index, the Plaque Index and the Reten tio n Index Systems. J P eriodontol 38:610 Nov-Dee 1967. 10. Brook, R.H. Q uality of care assessment: po licy relevant is sues. Policy Sci J 317, 1974. 11. McNerney, W.J. The quandary o f qu ality assessment. N Engl J Med 295:1505 Dec 30, 1976. 12. Brook, R.H.; W illiams, K. IV; and Allyson, D.A. Q uality as surance today and tom orrow : forecast fo r the future. Ann Intern Med 85:809 Dec 1976.
THE AUTHORS
This paper was presented before the Dental Health S ection of the A m erican P ublic Health Association at the 102nd annual meeting, Oct 20-24, 1974, in New Orleans, La. The op in ions expressed here are those of the authors and should not be construed as representing the op in ions of the US P ublic Health Service or any agency o f the US governm ent. This project was supported by Health Services Development P roject Grant, Section 330 of the P ublic Services Act, Health Ser vices and Mental Health A dm inistration, US P ublic Health Ser vice. 1. Bailit, H., and others. Q uality o f dental care: developm ent of standards. JADA 89:842 Oct 1974.
1014 ■ JADA, Vol. 96, June 1978
DEMBY
ROSENTHAL
Dr. Demby is chief of dental services at the Family Health Center o f the Lutheran Medical Center, 150 55th St, B rooklyn, NY 11220. Dr. Rosenthal is dental dire ctor, East Harlem C ouncil fo r Human Services, N eighborhood Health Center, New York, NY. Address requests fo r reprints to Dr. Demby.
