r
i
Wmm ftl
P E R S P E C T IV E
_______ ___ __________
Quality assurance in dentistry Joe T. H illsm an, DDS, Hyattsville, Md
i Q l u a l i t y a s s u r a n c e , o n e o f th e m o st d if fic u lt a n d c o m p le x is s u e s fa c in g th e d e n ta l p r o fe s s io n to d a y , c a m e in to sh a rp fo c u s w ith th e e n a c tm e n t o f th e P r o fe s s io n a l S ta n d a r d s R e v ie w O r g a n iz a tio n le g i s la tio n in 1 9 7 2 . M o re r e c e n t h e a lth le g is la tio n h a s e m p h a s iz e d q u a lity o f c a r e a n d v ir tu a lly e v e ry p ro p o s a l fo r n a tio n a l h e a lth in s u r a n c e p ro v id e s fo r s o m e ty p e o f q u a lity a s s u r a n c e . A d d itio n a lly , c o n s u m e rs a re e x p r e s s in g g ro w in g in te r e s t in th e a re a .
In response to demands for quality assurance, the dental profession established and is maintain ing peer review committees at the constituent and component society level to examine quality in ad judicating claims and settling disputes between patients and practitioners. Over the years, various methods and systems have been devised to assess aspects of dental qual ity. Examples that come readily to mind are the Bailit system of clinical criteria setting and appli cation,1 the Ryge and Snyder system of clinical as sessment,2 the Friedman system of dental care evaluation,3 and the Indian Health Service system of dental program evaluation,4 among others.5'9 These systems were devised to examine various aspects of quality and, thus, differ considerably in complexity, formality, applicability, and uses. The criteria applied may be implicit or explicit, inter nal or external, random or routine. The cost, feasi bility, and use of peers as evaluators or reviewers vary among the systems, and evaluation may be accomplished by means of either self-assessment or assessment by others.
Despite the experience with these systems, an uncoordinated approach to and an unclear under standing of the basic issues related to quality as surance continue to cause problems and the lack of widely accepted definitions of terms remains a source of confusion. Even the term “quality assur ance” itself has no commonly accepted definition. Moreover, attempts to focus on quality assurance only from the perspective of clinical criteria or standard setting have oversimplified, rather than clarified, these problems. A broad framework (Illustration) is suggested here in which quality assurance options can be discussed and evaluated. In this framework, all known quality assurance systems may be clas sified according to their use of the three major methods: clinical assessment, record audit, or data utilization. Some systems use only one of these methods; others apply a combination. C lin ic a l a s se s sm e n t
Clinical assessment, which requires a peer eval uator, may be performed directly by clinical examination or indirectly by observation of clin i cal treatment or examination of postoperative radiographs. In either case, the cooperation of the patient and the dentist being evaluated must be ensured. Only the dentist’s clinical technique and capability are being evaluated in a clinical assess ment system. Several of the aforementioned clinical assess JADA, Vol. 97, November 1978 ■ 787
P E R S P E C T IV E
M ode of
R e q u ire m e n t fo r
M e th o d _________ A p p lic a tio n 1.
W h a t is
A p p lic a tio n _______ E v a lu a te d ?
Clinical Assessment 1. S e rv ic e re n d e re d
A . D ir e c t
m ent m ethods are being used routinely or are being applied as portions of larger quality assur an ce system s. Third party payors (Delta Dental Plans, B lu e Cross and Blue Sh ield , and com m er cial carriers), as w ell as peer review com m ittees, also use clin ica l assessm ent as a part of their qual ity assurance systems. The profession’s reaction to clin ica l assessm ent as a m ethod of quality assurance has been m ixed. Program s such as that of B a ilit and co-w orkers have been w ell received, apparently because m em bers of the profession participated in setting and applying the clin ica l criteria on w hich evalua tion is based. However, there appears to be opposi tion to this m ethod if the criteria, mode of ap p lica tion, or the peers are not considered part of the profession. The large-scale use of clin ical assessm ent to as sure quality seem s unfeasible because of the dif ficu lties involved in the determ ination of valid sam ples and uniform judgm ents, among other fac tors. M oreover, the costs— both in tim e and dollars— would be very high and the m anpow er required for large-scale im plem entation of this method would be prohibitive. A lthough the obstacles to its w idespread use are form idable, clin ica l assessm ent is the only method that can determ ine the tech nical correctness of clin ica l services and the clin ical com petency of the dentist. In addition, it may be the only m ethod by w h ich inform ation needed for d ecisions regard ing m alpractice cases and third party paym ent claim s may be obtained, and by w hich fraud may be detected. R e c o r d a u d it T h e record audit prim arily evaluates the appropri ateness of dental treatm ent, although certain dentist/patient actions and delivery system charac teristics (for exam ple, lack of treatm ent planning, excessive periods between v isits, lack of recall su ccess, excessive num ber of appointm ents, and low productivity) may be inferred from the find ings. Sin gle records are frequently audited to resolve problem s of paym ent of claim s by a third party or to determ ine appropriateness of treatm ent. Groups of records may be audited for internal, selfassessm ent purposes or to determ ine aspects of a practice operation. Record audit can be performed on pretreatm ent records (claim forms), posttreatm ent records or, if appropriate, the com plete rec ord, and m ay be accom plished by a trained non 788 ■ JADA, Vol. 97, November 1978
C lin ic a l e x a m b y e v a lu a to r
2 . P a tie n t w illin g t o b e e x a m in e d
Practitioner
B . In d ir e c t
1. Observation by evaluator 2. Postoperative radiographs
f o b s e rv a tio n : 1. P ro v id e r & p a tie n t w illin g t o b e o b se rve d 2 . S e rv ic e b e in g re n d e re d f x -ra y s : 1. P ro v id e r w illin g t o m a k e x -ra y s a v a ila b le 2 . P a tie n t w illin g t o s u b m it t o x -ra y s
O n ly
II. Record A u d it A . In d iv id u a l
P re -tre a tm e n t
A n a v a ila b le re c o rd o f p la n n e d o r c o m p le te d t r e a tm e n t
Mainly practitioner actions but can examine patient behavior (voluntary & involuntary) vis a vis the delivery system
P o s t-tre a tm e n t B . A g g re g a te (G ro u p )
A v a ila b le re c o rd s o f p la n n e d o r c o m p le te d tr e a tm e n t
P re & P o s t-tre a tm e n t (c o m p le te re c o rd )
i l l . Data U tilizatio n A . S e rv ic e
Profiles of individual practitioners/ patients Profiles of groups of practitioners/ patients
B . P ro g ra m
P ro file s o f in d iv id u a l p ro g ra m s P ro file s o f g ro u p s o f p ro g ra m s
A n o p e r a tin g , re lia b le & s u ffic ie n t m a n a g e m e n t in fo r m a tio n s y s te m f o r se rvice d a ta ( p r o b a b ly c o m p u te r based )
A n o p e r a tin g , r e lia b le & s u ff ic ie n t m an a g e m e n t in fo r m a tio n s y s te m f o r p ro g r a m d a ta ( p r o b a b ly c o m p u te r based) (N o te : T h is in fo r m a t io n s y s te m m a y in c lu d e s e rv ic e d a ta )
Practitioners/ patients actions and interactions
Performance of individual program(s) Program trends & changes over time (Note: includes practitioner/ patient fictions & interactions)
peer using peer-determ ined criteria. (If a problem is identified, however, peer review and judgm ent are necessary.) Record audit seem s to be relatively well ac cepted by the profession as evidenced by third party review of claim forms. The Friedm an and Indian Health Service system s, peer review com m ittees, and some Delta Dental P lan s5 apply indi vidual record audit as a portion of their quality as surance activity. Group record audit may be used by carriers to develop lim ited profiles of prac titioners and beneficiaries. A system of group rec ord audit was developed for the Neighborhood Health Center Program evaluation by M orehead6 and by Haynes and associates7 for sim ilar use. The feasibility of record audit as a quality assur ance method for large-scale use is greater than that of clin ical assessm ent. In fact, the greater the aggregation of records to be audited, the more feasible the method. V ariations in the content,
C haracteristics
Uses
Peer Judgment/ Review Required?
Acceptability to Profession
Feasibility
Cost of Implementation
Present Activity Level
1. All clinical criteria systems e.g. Ryge/ Snyder, Baillt, portions of Friedman & Indian Health Service systems 2. Third party payors. 3. Peer review committees 4. Claim or case adjudication (ultimate decision point)
1. A ssess te c h n ic a l q u a lit y o f se rv ic e & c a p a b ilit y o f p r o v id e r 2 . P ro b le m case
V e r y H ig h ,
o r c la im s a d ju d ic a tio n
Yes, B o th I n it ia lly
3 . F ra u d d e te c tio n 4 . D e te r r e n t
A lw a y s Larg e
e f fe c t
Examples
a n d C o n tin u a lly
S ca le
1. Cost awareness (pre- or postfacto) 2. Internal evaluation of practitloner(s) or program 3. Intra-system problem & program assessment
N o t a lw a y s , e.g. n o n p r o b le m c la im s in a c la im s fo r m re v ie w s y s te m ; b u t f o r a d ju d ic a t io n & s e ttle m e n t o f p r o b le m c la im s , p r o v id e r in te r fa c e a n d /o r in tra -s y s te m c hanges, p e e r ju d g m e n t is re q u ire d
F a ir - som e p r o b le m s , m a in ly c a r r ie r / p r o v id e r re la te d
Medium level. Feasibility increases as aggregation of data (i.e. individual records) occurs
H ig h , e s p e c ia lly In te rm s o f d e n ta l p r e p a y m e n t and c la im s f o r m H ig h ,
re v ie w p ro c e s s
I n it ia ll y
and
C o n tin u a lly
1. P ro b le m aw a re n e s s & s o lu tio n 2 . P o s t f a c to c o s t a w a ren ess 3 . A d m in is tr a tiv e p la n n in g t o o l
Not required except fo r peer/ practitioner/ patient interfaces necessary for system change(s)
n o n -p u n ltiv e .a n d th e r e fo r e H ig h i f an a c c e p ta b le a n d s u ffic ie n t m anagem ent in f o r m a t io n sy s te m
1 . P r o b le m aw aren e ss re : p ro g ra m (s ) 2 . C o s t aw are ne ss re : p r o g r a m 3 . A d m in is t r a tiv e p la n n in g 4 . P ro g ra m m anagem ent 5 . D ir e c t io n a l c h a n g e o f p ro g ra m
H ig h , i f fe e d b a c k
is a v a ila b le o r
t o p ro g r a m is
p o t e n t ia lly
n o n - p u n itiv e a nd
a v a ila b le
Initially high, if management inform ation system must be established bu t relatively low after implementation
t h e r e fo r e n o n th r e a te n in g
format, and quality of the records and record keeping systems used by groups, however, may, to some extent, limit large-scale implementation of this method. Although the cost is relatively high, record audit probably would be less expen sive than clinical assessment on a large-scale basis. D ata u tiliz a tio n
This method requires the collection of adequate information of two types: services or program. Service data is derived but separate from treat ment records and includes the cost and occurrence patterns of dental services. (Information amassed from claims form review and payment processes, such as the number of services and the patterns and frequency of their occurrence, costs of services provided, and so forth would be examples.) A quality assurance system of this nature would
F ram ew o rk of quality assu ran ce options.
In present use: 1. Management infor mation system of Chattanooga Incre mental Dental Care Program 2. Marcus Functional Task Analysis Data 3. Some 3rd Party Carriers Potential: 1. Title XIX (esp. EPSDT) Programs 2. Indian Health Service at National Level
H ig h , i f fe e d b a c k t o in d iv id u a ls is
n o n -th re a te n in g
Individual: 1. Claims form review process used by carriers 2. Portion of Friedman system 3. Portion of Indian Health Service system 4. Peer review com m ittee & Delta Dental Plan consultant a c t i v i t i e s ______ Aggregate: 1. Claims form review process 2. Morehead system 3. Haynes et al system
V e ry L o w
Hillsman, Albedini NHC information system
probably be computer based and could produce profiles of dentists and patients. Comparison of these profiles with preestablished norms would reveal, among other things, deviations in provi sion and use of services and numbers of excepted claims. The data also could serve as an administra tive planning tool. Peer review is required only if the service data identifies a significant deviation from norms. At tempts to understand and resolve any identified difficulties in the delivery of services would prob ably be acceptable if made in a nonthreatening way. Some third party carriers and a few PSROs are using this method of quality review. The Indian Health Service has used service data to provide in formation about overall program activities. The management information system of the Chat tanooga (Tenn) Incremental Dental Care Program8 and the functional task analysis data collection Hillsm an : QUALITY ASSURANCE IN DEN TISTRY * 789
P E R S P E C T IV E
system developed by Marcus9 are other examples of this quality assurance method. Medicaid and the Early Periodic Screening, Diagnosis, and Treatment programs are potential sources of data that could be used for application of this method. The use of program data in quality assurance is similar to that of service data but the concept is newer and not as well established. This method is intended to be flexible enough to include a deliv ery system of any size as a “program.” Program data consist of elements such as budget and staf fing information, types of services provided, aver age costs per patient visit, the number of dentists, operatories, and patients, and demographic infor mation about the patient group. Appropriate analysis of the program data could indicate cost effectiveness, productivity, and efficiency of a program and can be used to make beneficial changes as readily as information from clinical as sessment, record audit, or service data methods. Utilization of program and service data are iden tical in regard to feasibility, acceptability, and cost of implementation. The system of program data use developed by Hillsman and T. Albertini for the Neighborhood Health Centers is the only known example of this quality assurance method.
system aspects of quality of care. It does not ad dress the education of practitioners or the question of treatment results. Quality assurance actually begins early in a health professional’s education and ends with the outcome of treatment. S u m m a ry
There is a continuum among the quality assurance methods of clinical assessment, record audit, and data utilization. A rational and comprehensive ap proach to the issue of quality assurance would in corporate the most appropriate aspects of each method in proper order.
1. B a ilit, H ., an d o th ers. Q u ality o f d e n ta l ca re: d e v elo p m en t o f stan dards. JAD A 8 9 :8 4 2 O ct 1 974. 2. R yge, G ., and S n y d er, M. E v alu atin g c lin ic a l q u a lity o f restoration s. JA D A 8 7 :3 6 9 A ug 1 9 7 3 . 3. F ried m a n , J. A guide to th e ev a lu a tio n o f d en tal care program s. Los A n g eles, U n iv ersity o f C aliforn ia at Los A n g eles, 1 9 7 2 . 4 . D en tal program effic ien cy and d en tal program e ffe ctiv en e ss criteria and standards for th e IH S. W ash in g to n , DC, In d ia n H ealth S erv ice, 1 9 7 4 . 5. Id en tify an d d e scrib e th e q u ality a ssu ra n ce m eth o d o log ies em p lo y ed b y se le cte d th ird party carriers o f prepaid d en tal p lan s. Fin al rep o rt H RA co n tra c t n o . l-D H -4 4 0 6 6 . W a sh in g to n , DC, H ealth R esources A d m in istra tio n , N ovem ber 1 9 7 5 . 6 . M oreh ead , M .A . E v alu atin g q u ality o f ca re in th e n eig h borh ood h ea lth ce n te r program o f th e O ffice o f E c o n o m ic O p p ortu n ity . M ed Care 7 :1 1 8 M a rch -A p ril 1 9 7 0 .
D iscu ssio n
Application of the suggested quality assurance framework permits a detailed examination of each method to determine its particular characteristics, advantages, and disadvantages. It is evident that the use of any one method to the exclusion of others is not advisable. The framework could prove valuable and useful in the development of rational systems of quality assurance. For example, if adequate program data can be collected, norms for cost effectiveness, pro ductivity, and efficacy could be determined and programs operating outside those norms could be identified. Once identified, service data from the aberrant programs could be examined for explana tion and, if necessary, the programs could be scrutinized more intensely by record audit. Should the record audit fail to produce answers, clinical assessment would be used as a final step. The use of quality assurance methods in this sequence would ensure a proper allocation of resources. The most desirable characteristics of each are maximized and the least attractive features minimized. The least feasible methods would be used only when warranted. This framework deals only with the delivery 790 ■ JADA, Vol. 97, November 1978
7. H aynes, A ., and others. P o rtio n o f a fin a l rep o rt o f co n tra ct H SA 1 0 5 -7 4 -1 5 4 . W a sh in g to n , DC, B u reau o f C o m m u n ity H ealth C enters, H ealth S e rv ices A d m in istra tio n , 1 9 7 6 . 8. L e w is, G .P ., and M o n ro e, G .F. C h ild re n ’s in cre m en ta l d en tal care program : an o verv iew o f th e S o u th ea st T en n essee -N o rth w est G eorgia p ro je ct. JAD A 8 8 :7 8 9 A p ril 1 9 7 4 . 9. M a rcu s, M . F in a l report o f grant n u m b er 1 R 2 7 M B 0 0 1 8 -0 1 5 1 . W ash in g ton , DC, B u re a u o f H ealth M an p o w er, H ealth R e so u rce s A d m in istra tio n , 1 9 7 5 .
THE AUTHOR
Dr. H illsm an is deputy d irecto r o f th e D iv isio n o f D en tistry , B u reau o f H ealth M an pow er, 3 -2 2 C en ter B ld g , 3 7 0 0 East-W est H wy, H y attsv ille, Md 20782.
HILLSMAN
E ssa y s o f o p in io n on cu rren t issu es in d e n tistry are p u b lish e d in th is s e c tio n o f T h e Journal. T h e o p in io n s ex p ressed or im p lied are strictly th o se o f th e a u th o rs and do n o t n ec essa rily re fle c t th e o p in io n or o fficia l p o lic ie s o r p o sitio n o f th e A m e rica n D en tal A sso cia tio n .
i
Wmm ftl
P E R S P E C T IV E
_______ ___ __________
Quality assurance in dentistry Joe T. H illsm an, DDS, Hyattsville, Md
i Q l u a l i t y a s s u r a n c e , o n e o f th e m o st d if fic u lt a n d c o m p le x is s u e s fa c in g th e d e n ta l p r o fe s s io n to d a y , c a m e in to sh a rp fo c u s w ith th e e n a c tm e n t o f th e P r o fe s s io n a l S ta n d a r d s R e v ie w O r g a n iz a tio n le g i s la tio n in 1 9 7 2 . M o re r e c e n t h e a lth le g is la tio n h a s e m p h a s iz e d q u a lity o f c a r e a n d v ir tu a lly e v e ry p ro p o s a l fo r n a tio n a l h e a lth in s u r a n c e p ro v id e s fo r s o m e ty p e o f q u a lity a s s u r a n c e . A d d itio n a lly , c o n s u m e rs a re e x p r e s s in g g ro w in g in te r e s t in th e a re a .
In response to demands for quality assurance, the dental profession established and is maintain ing peer review committees at the constituent and component society level to examine quality in ad judicating claims and settling disputes between patients and practitioners. Over the years, various methods and systems have been devised to assess aspects of dental qual ity. Examples that come readily to mind are the Bailit system of clinical criteria setting and appli cation,1 the Ryge and Snyder system of clinical as sessment,2 the Friedman system of dental care evaluation,3 and the Indian Health Service system of dental program evaluation,4 among others.5'9 These systems were devised to examine various aspects of quality and, thus, differ considerably in complexity, formality, applicability, and uses. The criteria applied may be implicit or explicit, inter nal or external, random or routine. The cost, feasi bility, and use of peers as evaluators or reviewers vary among the systems, and evaluation may be accomplished by means of either self-assessment or assessment by others.
Despite the experience with these systems, an uncoordinated approach to and an unclear under standing of the basic issues related to quality as surance continue to cause problems and the lack of widely accepted definitions of terms remains a source of confusion. Even the term “quality assur ance” itself has no commonly accepted definition. Moreover, attempts to focus on quality assurance only from the perspective of clinical criteria or standard setting have oversimplified, rather than clarified, these problems. A broad framework (Illustration) is suggested here in which quality assurance options can be discussed and evaluated. In this framework, all known quality assurance systems may be clas sified according to their use of the three major methods: clinical assessment, record audit, or data utilization. Some systems use only one of these methods; others apply a combination. C lin ic a l a s se s sm e n t
Clinical assessment, which requires a peer eval uator, may be performed directly by clinical examination or indirectly by observation of clin i cal treatment or examination of postoperative radiographs. In either case, the cooperation of the patient and the dentist being evaluated must be ensured. Only the dentist’s clinical technique and capability are being evaluated in a clinical assess ment system. Several of the aforementioned clinical assess JADA, Vol. 97, November 1978 ■ 787
P E R S P E C T IV E
M ode of
R e q u ire m e n t fo r
M e th o d _________ A p p lic a tio n 1.
W h a t is
A p p lic a tio n _______ E v a lu a te d ?
Clinical Assessment 1. S e rv ic e re n d e re d
A . D ir e c t
m ent m ethods are being used routinely or are being applied as portions of larger quality assur an ce system s. Third party payors (Delta Dental Plans, B lu e Cross and Blue Sh ield , and com m er cial carriers), as w ell as peer review com m ittees, also use clin ica l assessm ent as a part of their qual ity assurance systems. The profession’s reaction to clin ica l assessm ent as a m ethod of quality assurance has been m ixed. Program s such as that of B a ilit and co-w orkers have been w ell received, apparently because m em bers of the profession participated in setting and applying the clin ica l criteria on w hich evalua tion is based. However, there appears to be opposi tion to this m ethod if the criteria, mode of ap p lica tion, or the peers are not considered part of the profession. The large-scale use of clin ical assessm ent to as sure quality seem s unfeasible because of the dif ficu lties involved in the determ ination of valid sam ples and uniform judgm ents, among other fac tors. M oreover, the costs— both in tim e and dollars— would be very high and the m anpow er required for large-scale im plem entation of this method would be prohibitive. A lthough the obstacles to its w idespread use are form idable, clin ica l assessm ent is the only method that can determ ine the tech nical correctness of clin ica l services and the clin ical com petency of the dentist. In addition, it may be the only m ethod by w h ich inform ation needed for d ecisions regard ing m alpractice cases and third party paym ent claim s may be obtained, and by w hich fraud may be detected. R e c o r d a u d it T h e record audit prim arily evaluates the appropri ateness of dental treatm ent, although certain dentist/patient actions and delivery system charac teristics (for exam ple, lack of treatm ent planning, excessive periods between v isits, lack of recall su ccess, excessive num ber of appointm ents, and low productivity) may be inferred from the find ings. Sin gle records are frequently audited to resolve problem s of paym ent of claim s by a third party or to determ ine appropriateness of treatm ent. Groups of records may be audited for internal, selfassessm ent purposes or to determ ine aspects of a practice operation. Record audit can be performed on pretreatm ent records (claim forms), posttreatm ent records or, if appropriate, the com plete rec ord, and m ay be accom plished by a trained non 788 ■ JADA, Vol. 97, November 1978
C lin ic a l e x a m b y e v a lu a to r
2 . P a tie n t w illin g t o b e e x a m in e d
Practitioner
B . In d ir e c t
1. Observation by evaluator 2. Postoperative radiographs
f o b s e rv a tio n : 1. P ro v id e r & p a tie n t w illin g t o b e o b se rve d 2 . S e rv ic e b e in g re n d e re d f x -ra y s : 1. P ro v id e r w illin g t o m a k e x -ra y s a v a ila b le 2 . P a tie n t w illin g t o s u b m it t o x -ra y s
O n ly
II. Record A u d it A . In d iv id u a l
P re -tre a tm e n t
A n a v a ila b le re c o rd o f p la n n e d o r c o m p le te d t r e a tm e n t
Mainly practitioner actions but can examine patient behavior (voluntary & involuntary) vis a vis the delivery system
P o s t-tre a tm e n t B . A g g re g a te (G ro u p )
A v a ila b le re c o rd s o f p la n n e d o r c o m p le te d tr e a tm e n t
P re & P o s t-tre a tm e n t (c o m p le te re c o rd )
i l l . Data U tilizatio n A . S e rv ic e
Profiles of individual practitioners/ patients Profiles of groups of practitioners/ patients
B . P ro g ra m
P ro file s o f in d iv id u a l p ro g ra m s P ro file s o f g ro u p s o f p ro g ra m s
A n o p e r a tin g , re lia b le & s u ffic ie n t m a n a g e m e n t in fo r m a tio n s y s te m f o r se rvice d a ta ( p r o b a b ly c o m p u te r based )
A n o p e r a tin g , r e lia b le & s u ff ic ie n t m an a g e m e n t in fo r m a tio n s y s te m f o r p ro g r a m d a ta ( p r o b a b ly c o m p u te r based) (N o te : T h is in fo r m a t io n s y s te m m a y in c lu d e s e rv ic e d a ta )
Practitioners/ patients actions and interactions
Performance of individual program(s) Program trends & changes over time (Note: includes practitioner/ patient fictions & interactions)
peer using peer-determ ined criteria. (If a problem is identified, however, peer review and judgm ent are necessary.) Record audit seem s to be relatively well ac cepted by the profession as evidenced by third party review of claim forms. The Friedm an and Indian Health Service system s, peer review com m ittees, and some Delta Dental P lan s5 apply indi vidual record audit as a portion of their quality as surance activity. Group record audit may be used by carriers to develop lim ited profiles of prac titioners and beneficiaries. A system of group rec ord audit was developed for the Neighborhood Health Center Program evaluation by M orehead6 and by Haynes and associates7 for sim ilar use. The feasibility of record audit as a quality assur ance method for large-scale use is greater than that of clin ical assessm ent. In fact, the greater the aggregation of records to be audited, the more feasible the method. V ariations in the content,
C haracteristics
Uses
Peer Judgment/ Review Required?
Acceptability to Profession
Feasibility
Cost of Implementation
Present Activity Level
1. All clinical criteria systems e.g. Ryge/ Snyder, Baillt, portions of Friedman & Indian Health Service systems 2. Third party payors. 3. Peer review committees 4. Claim or case adjudication (ultimate decision point)
1. A ssess te c h n ic a l q u a lit y o f se rv ic e & c a p a b ilit y o f p r o v id e r 2 . P ro b le m case
V e r y H ig h ,
o r c la im s a d ju d ic a tio n
Yes, B o th I n it ia lly
3 . F ra u d d e te c tio n 4 . D e te r r e n t
A lw a y s Larg e
e f fe c t
Examples
a n d C o n tin u a lly
S ca le
1. Cost awareness (pre- or postfacto) 2. Internal evaluation of practitloner(s) or program 3. Intra-system problem & program assessment
N o t a lw a y s , e.g. n o n p r o b le m c la im s in a c la im s fo r m re v ie w s y s te m ; b u t f o r a d ju d ic a t io n & s e ttle m e n t o f p r o b le m c la im s , p r o v id e r in te r fa c e a n d /o r in tra -s y s te m c hanges, p e e r ju d g m e n t is re q u ire d
F a ir - som e p r o b le m s , m a in ly c a r r ie r / p r o v id e r re la te d
Medium level. Feasibility increases as aggregation of data (i.e. individual records) occurs
H ig h , e s p e c ia lly In te rm s o f d e n ta l p r e p a y m e n t and c la im s f o r m H ig h ,
re v ie w p ro c e s s
I n it ia ll y
and
C o n tin u a lly
1. P ro b le m aw a re n e s s & s o lu tio n 2 . P o s t f a c to c o s t a w a ren ess 3 . A d m in is tr a tiv e p la n n in g t o o l
Not required except fo r peer/ practitioner/ patient interfaces necessary for system change(s)
n o n -p u n ltiv e .a n d th e r e fo r e H ig h i f an a c c e p ta b le a n d s u ffic ie n t m anagem ent in f o r m a t io n sy s te m
1 . P r o b le m aw aren e ss re : p ro g ra m (s ) 2 . C o s t aw are ne ss re : p r o g r a m 3 . A d m in is t r a tiv e p la n n in g 4 . P ro g ra m m anagem ent 5 . D ir e c t io n a l c h a n g e o f p ro g ra m
H ig h , i f fe e d b a c k
is a v a ila b le o r
t o p ro g r a m is
p o t e n t ia lly
n o n - p u n itiv e a nd
a v a ila b le
Initially high, if management inform ation system must be established bu t relatively low after implementation
t h e r e fo r e n o n th r e a te n in g
format, and quality of the records and record keeping systems used by groups, however, may, to some extent, limit large-scale implementation of this method. Although the cost is relatively high, record audit probably would be less expen sive than clinical assessment on a large-scale basis. D ata u tiliz a tio n
This method requires the collection of adequate information of two types: services or program. Service data is derived but separate from treat ment records and includes the cost and occurrence patterns of dental services. (Information amassed from claims form review and payment processes, such as the number of services and the patterns and frequency of their occurrence, costs of services provided, and so forth would be examples.) A quality assurance system of this nature would
F ram ew o rk of quality assu ran ce options.
In present use: 1. Management infor mation system of Chattanooga Incre mental Dental Care Program 2. Marcus Functional Task Analysis Data 3. Some 3rd Party Carriers Potential: 1. Title XIX (esp. EPSDT) Programs 2. Indian Health Service at National Level
H ig h , i f fe e d b a c k t o in d iv id u a ls is
n o n -th re a te n in g
Individual: 1. Claims form review process used by carriers 2. Portion of Friedman system 3. Portion of Indian Health Service system 4. Peer review com m ittee & Delta Dental Plan consultant a c t i v i t i e s ______ Aggregate: 1. Claims form review process 2. Morehead system 3. Haynes et al system
V e ry L o w
Hillsman, Albedini NHC information system
probably be computer based and could produce profiles of dentists and patients. Comparison of these profiles with preestablished norms would reveal, among other things, deviations in provi sion and use of services and numbers of excepted claims. The data also could serve as an administra tive planning tool. Peer review is required only if the service data identifies a significant deviation from norms. At tempts to understand and resolve any identified difficulties in the delivery of services would prob ably be acceptable if made in a nonthreatening way. Some third party carriers and a few PSROs are using this method of quality review. The Indian Health Service has used service data to provide in formation about overall program activities. The management information system of the Chat tanooga (Tenn) Incremental Dental Care Program8 and the functional task analysis data collection Hillsm an : QUALITY ASSURANCE IN DEN TISTRY * 789
P E R S P E C T IV E
system developed by Marcus9 are other examples of this quality assurance method. Medicaid and the Early Periodic Screening, Diagnosis, and Treatment programs are potential sources of data that could be used for application of this method. The use of program data in quality assurance is similar to that of service data but the concept is newer and not as well established. This method is intended to be flexible enough to include a deliv ery system of any size as a “program.” Program data consist of elements such as budget and staf fing information, types of services provided, aver age costs per patient visit, the number of dentists, operatories, and patients, and demographic infor mation about the patient group. Appropriate analysis of the program data could indicate cost effectiveness, productivity, and efficiency of a program and can be used to make beneficial changes as readily as information from clinical as sessment, record audit, or service data methods. Utilization of program and service data are iden tical in regard to feasibility, acceptability, and cost of implementation. The system of program data use developed by Hillsman and T. Albertini for the Neighborhood Health Centers is the only known example of this quality assurance method.
system aspects of quality of care. It does not ad dress the education of practitioners or the question of treatment results. Quality assurance actually begins early in a health professional’s education and ends with the outcome of treatment. S u m m a ry
There is a continuum among the quality assurance methods of clinical assessment, record audit, and data utilization. A rational and comprehensive ap proach to the issue of quality assurance would in corporate the most appropriate aspects of each method in proper order.
1. B a ilit, H ., an d o th ers. Q u ality o f d e n ta l ca re: d e v elo p m en t o f stan dards. JAD A 8 9 :8 4 2 O ct 1 974. 2. R yge, G ., and S n y d er, M. E v alu atin g c lin ic a l q u a lity o f restoration s. JA D A 8 7 :3 6 9 A ug 1 9 7 3 . 3. F ried m a n , J. A guide to th e ev a lu a tio n o f d en tal care program s. Los A n g eles, U n iv ersity o f C aliforn ia at Los A n g eles, 1 9 7 2 . 4 . D en tal program effic ien cy and d en tal program e ffe ctiv en e ss criteria and standards for th e IH S. W ash in g to n , DC, In d ia n H ealth S erv ice, 1 9 7 4 . 5. Id en tify an d d e scrib e th e q u ality a ssu ra n ce m eth o d o log ies em p lo y ed b y se le cte d th ird party carriers o f prepaid d en tal p lan s. Fin al rep o rt H RA co n tra c t n o . l-D H -4 4 0 6 6 . W a sh in g to n , DC, H ealth R esources A d m in istra tio n , N ovem ber 1 9 7 5 . 6 . M oreh ead , M .A . E v alu atin g q u ality o f ca re in th e n eig h borh ood h ea lth ce n te r program o f th e O ffice o f E c o n o m ic O p p ortu n ity . M ed Care 7 :1 1 8 M a rch -A p ril 1 9 7 0 .
D iscu ssio n
Application of the suggested quality assurance framework permits a detailed examination of each method to determine its particular characteristics, advantages, and disadvantages. It is evident that the use of any one method to the exclusion of others is not advisable. The framework could prove valuable and useful in the development of rational systems of quality assurance. For example, if adequate program data can be collected, norms for cost effectiveness, pro ductivity, and efficacy could be determined and programs operating outside those norms could be identified. Once identified, service data from the aberrant programs could be examined for explana tion and, if necessary, the programs could be scrutinized more intensely by record audit. Should the record audit fail to produce answers, clinical assessment would be used as a final step. The use of quality assurance methods in this sequence would ensure a proper allocation of resources. The most desirable characteristics of each are maximized and the least attractive features minimized. The least feasible methods would be used only when warranted. This framework deals only with the delivery 790 ■ JADA, Vol. 97, November 1978
7. H aynes, A ., and others. P o rtio n o f a fin a l rep o rt o f co n tra ct H SA 1 0 5 -7 4 -1 5 4 . W a sh in g to n , DC, B u reau o f C o m m u n ity H ealth C enters, H ealth S e rv ices A d m in istra tio n , 1 9 7 6 . 8. L e w is, G .P ., and M o n ro e, G .F. C h ild re n ’s in cre m en ta l d en tal care program : an o verv iew o f th e S o u th ea st T en n essee -N o rth w est G eorgia p ro je ct. JAD A 8 8 :7 8 9 A p ril 1 9 7 4 . 9. M a rcu s, M . F in a l report o f grant n u m b er 1 R 2 7 M B 0 0 1 8 -0 1 5 1 . W ash in g ton , DC, B u re a u o f H ealth M an p o w er, H ealth R e so u rce s A d m in istra tio n , 1 9 7 5 .
THE AUTHOR
Dr. H illsm an is deputy d irecto r o f th e D iv isio n o f D en tistry , B u reau o f H ealth M an pow er, 3 -2 2 C en ter B ld g , 3 7 0 0 East-W est H wy, H y attsv ille, Md 20782.
HILLSMAN
E ssa y s o f o p in io n on cu rren t issu es in d e n tistry are p u b lish e d in th is s e c tio n o f T h e Journal. T h e o p in io n s ex p ressed or im p lied are strictly th o se o f th e a u th o rs and do n o t n ec essa rily re fle c t th e o p in io n or o fficia l p o lic ie s o r p o sitio n o f th e A m e rica n D en tal A sso cia tio n .
