1. Quality Assessment, Quality Improvement & HRSA’s Oral Health Measures
Dan Watt, DDS Marty Lieberman, DDS
Wednesday, October 27, 2010

2. Part of NNOHA’s developing Practice Management Resources
Current chapters in development for the Operations Manual for Health Center Oral Health Programs include:
Health Center Fundamentals – Published!
Leadership
Financials
Risk Management
Quality
Integrating Specialty Care Services
Workforce and Staffing
Understanding Reimbursements

3. For More Information…
Order a printed copy, or download the PDF version of the Fundamentals Chapter at:
Attend other Practice Management Sessions at the Conference!

4. For dental terminology it means: A Measurement of Excellence
What is Quality?
For dental terminology it means:
A Measurement of Excellence

5. Importance of Measurement
Developing Measurable Outcomes
Sample Metrics
Quality Improvement Indicators

6. Quality – Evaluation Logic Model
Inputs are the resources invested by the program such as staff, money, time, materials, equipment, technology and partnerships
Outputs are activities performed by the team with the purpose of reaching the target population such as training, curricula development, staff hiring Outputs lead to outcomes.
Outcomes are the results you expect your program to make

7. Quality in Other Review Systems
JCAHO
Managed Care Systems
State QA Requirements
Chronic Care Model

8. Learning Objectives
Understand quality improvement and quality assessment and the differences between the two
Have an awareness of the importance of quality
Be confident in their capability of integrating both continuous quality improvement and quality assurance into their practice in a simple and practical way
Locate sample metrics.

9. Main Sections Definitions
Quality Assurance: Developing a “Culture of Quality”
Quality – Vision Statement, Goals, QI Plan, and Evaluation
Importance of Measurement
Quality in Other Review Systems
Quality Concepts
HRSA Oral Health Measures

10. Quality Assessment

11. Why do we need to assess quality?
The Board of Directors is mandated to monitor the quality of their Health Center
Metrics provide benchmarks that allow improvement comparisons
Some metrics are required by HRSA
Allows each dental center to have measurable outcomes to judge improvement

12. Dental Treatment Outcomes are Almost Impossible to Measure
Are Extractions, restorations “High Quality?
How long did the restorations last?
Were the dentures satisfactory?
Ideal anatomy in restorations?
Dentistry is an art as well as a science and the art is impossible to measure. Look at failed cases, return encounters for same treatment, completed cases/new exams

13. Medicine has developed meaningful assessment criteria
A1c
Immunizations
Blood pressure
Clotting times
Pre-term births and infant mortality
Obesity
Repeat encounter for same issue
Pay for performance of the doctors’ panel

14. What Dentistry needs
Since oral diseases are chronic, transmissible bacterial infections, we need risk assessment.
Measure the level of oral pathogens is both supra-gingival and sub-gingival plaque.
Establish therapeutic targets
Assess and manage the risk of disease

15. Today’s Quality Standards for Dentistry
Peer review – Internal and External
Patient Satisfaction surveys
Patient complaints
Production efficiency
Personnel Issues
Economic issues
Repeat visits for same treatment
Employee satisfaction surveys
Performance evaluations

16. Peer Review Subjective
Internal Chart reviews – Quality of x-rays, chart notes, clinical exam data, including soft tissue, thoroughness of treatment plan and diagnosis, proper signatures, referrals and follow up.
External Reviews – patient exams and x-rays, chart evaluation, patient satisfaction, over-all treatment evaluation, clinical setting, infection control, charted information completeness.

18. Patient Satisfaction
Should be done at least annually, may need professional help to design questionnaire
Although it is subjective, it is one of the best indicators

19. Responsibility for Quality Assessment lies with the Board of Directors
HRSA mandates that Boards need to establish a Quality Committee with at least one physician.
Generally assigned to Board members and includes the ED, and department heads.
Mission is to create a “Culture of Quality”

20. The Quality Committee establishes Dashboard Indicators

22. Once you establish your “culture of quality” you can then determine a course of action for quality improvement

23. Opportunity for Improvement
What we know
Desired (Standards)
The Gap
Access to care
Continuity of services
Cost
Adverse patient events
Oral health outcomes
Actual
What we do 23

24. Who is Marty Lieberman and why is he talking to me about Quality?
Graduated from University of Minnesota Dental School 1983
Private Practice in Chicago, 18 years
Dental Director, Neighborcare Health in Seattle, WA since 2002
IHI- IMPACT
NNOHA and HRSA’s Oral Health Collaborative Pilot-Infant and Perinatal Oral Health
Dentaquest and SNS Quality Improvement Projects

25. The difference between Quality Assurance(QA) and Quality Improvement(QI)
PDSA Cycles- Testing
QI Plan
Case history
Proposed HRSA Quality Measures

26. Improvement
A person or thing that represents an advance on another in excellence or achievement. Has meaning only in terms of observation based on given criteria
Faster
Easier
More efficient
Safer
Less expensive
More effective 26

27. Quality Improvement(QI)
QI processes use baselines established by Quality Assurance.
Assess where you are.
Find ways to improve your program.
QI processes aim to improve the quality of the health care system and the health status of the target population.

28. QI the Process Identify a program or facility problem Conduct a study
Continuity of care
Access to Care (TPCR)
Emergency care
Adverse patient events
Conduct a study
Develop and implement a plan
Monitor and track results
Demonstrate improvement and restudy the problem [continuously]

29. PDSA Cycles . What are we trying to accomplish?
How will we know that a change is an improvement? Do
Study
Act
Plan
What change can we make that will result in improvement?
PDSA Cycles 29

30. Plan-Do-Study-Act Cycle
Ideas
Action
Learning
Improvement
Identify problems and create
A plan
Demonstrate improvement
What changes are to be made?
What is the next cycle?
Act
Plan
Study Do
Implement the plan
Monitor and document
Results
Begin analysis of the data
Complete the data analysis
Compare data to predictions
Summarize what was learned 30

31. Using the Cycle to Improve
Improvement D S P A D S P A
Spread
Data D S P A
Implementation of Change D S P A
Wide-Scale Tests of Change
Ideas D S P A
Follow-up Tests
Very Small Scale Test 31

32. Our First PDSA Warm towels What are you trying to accomplish?
How will we know the change is an improvement?
What change can we make that will result in improvement?
Surveyed patients (with and without)
Results: Biggest lesson learned

33. Using the Cycle to Improve
Improvement D S P A D S P A
Spread
Data D S P A
Implementation of Change D S P A
Wide-Scale Tests of Change
Ideas D S P A
Follow-up Tests
Very Small Scale Test 33

34. Don’t Assume! First PDSAs should be small There are no bad ideas!
All improvement ideas should be able to stand up to the PDSA test
Always ask, “What are you trying to accomplish? How will we know the change is an improvement? How are you going to measure it?”

35. HRSA Quality Measure (proposed)
Percentage of all dental patients for whom the Phase I treatment plan is completed within a 12 month period.

36. Quality Improvement Plan
Responds to a particular goal
Milestones, measurements, timelines
Needs to define data collection method and frequency
QI team- representative of all staff involved in this particular issue.

37. Sample of a Project Specific QI Plan
Project Goal: By 2010, increase the number of patients that complete phase 1 treatment in 12 months
Project Team Leader: Dr. X
Project Team: DA, Hyg, Front Desk
Baseline: 26%
Timeline: one year
Meeting Time:

38. Anytime Dental Clinic Production was low No-show rates were high
Quality Assurance chart audit revealed that their Treatment Plan Completion Rate (TPCR) was 26%.
By the time most patients were due for their recall appts, phase I treatment had not been completed.

39. What we knew What we found out
Pt. satisfaction scores were low,, “too difficult to schedule an appointment”
No-show phone survey, “I made my appointment so long ago, I forgot”
Supply did not match demand.
There were not enough appointments available for patients to get their treatment plans completed in a timely basis.

40. Do the Math 3 new patients a day per provider
Average of 5.3 restorative appts each new patient needed to complete phase 1 treatment
(3 new patients) X (5.3 appts) = 15.9 appts
Recall appts were generating restorative appts
There were only 8 restorative provider slots per day.
Access capacity did not equal appointment demand

41. New Scheduling Model Increase the number of restorative appointments
Decrease the number of initial exam appointments
PDSAs – designed and implemented by QI teams. There are no “bad ideas”

42. PDSAs Dentist assistant ratio Chairs per provider
Patient Education by DA
Optimized their scheduling system
Each new patient scheduled with only one new patient each day
Scheduling out times
3rd available appointment tool
Staff satisfaction

43. Results Increase in Overall Production Decrease in no-shows
Increase in TPCR to 67% has stayed there for over three years
Increase in patient satisfaction
Increase in staff satisfaction

45. HRSA Proposed Quality Measures
Percentage of oral health patients that are caries free
The percentage of patients who had at least one dental visit during the measurement year.
Percentage of all dental patients with a comprehensive or periodic recall oral exam, for whom the Phase I treatment plan is documented
Percentage of all dental patients for whom the Phase I treatment plan is completed within a 12 month period.
percentage of patients with at least one topical fluoride treatment during the report period

46. HRSA Proposed Quality Measures (Cont’d)
Percentage of children age 12 to72 months with 1 or more fluoride varnish applications documented
The percentage of children between the ages of 6 and 21 years who received at least a single sealant treatment from a dentist.
Percentage of children age 12 to 48 months who received patient education and anticipatory guidance for oral health in the medical setting
Percentage of oral health patients who received oral health education at least once in the measurement year.
Percentage of oral health patients who had a periodontal screening or examination at least once in the measurement year.

47. Practice Management Quality Chapter
Almost done
Committee
Understand Quality Concepts and help you integrate them into your health center programs.