A Quality Management Program in Dental Care Practices
A Quality Management Program in Dental Care Practices
To our knowledge, this is the first study that has evaluated and demonstrated quality improvement in primary dental care practices in Germany. In this study, a repeated measurement was used to evaluate the effect of the assessment process using the European Practice Assessment quality management program. The intervention and comparison group practices did not differ remarkably in comparison to general medical practice characteristics. Furthermore, the baseline data and the first assessment of the intervention group showed higher scores than in the comparison group within the five key domains ('infrastructure', 'people', 'information', 'finance', and 'quality and safety'). The comparison of the results of the second assessments in intervention practices with the baseline assessments in comparison group practices showed improvements across all domains, but especially within the domains of 'quality and safety' and 'infrastructure'.
Quality improvement depends on a set of valid and feasible quality indicators that are able to measure quality of care. "Indicators are measurable elements of practice for which there is evidence or consensus that they reflect quality and hence help change the quality of care provided". The implementation of a quality management system in practices can be facilitated by the use of quality indicators. Quality indicators should yield positive assessment on a range of attributes such as clarity, feasibility, reliability, validity and transparency and in order to demonstrate sensitivity to change, benchmarking data are required so that health care providers can assess and compare their own quality of care with others. Moreover, for assessment to lead to improvement it must be part of an ongoing process such as the "plan-do-study-act" (PDSA) cycle. A continuous quality improvement is an essential part of quality management programs for health care services, which includes general medical practices and dental care practices in the primary sector.
The evaluation of quality of care requires a mixture of objective and subjective measures. The European Practice Assessment consists of a set of objective and subjective quality indicators, which evaluate the structure and process of care from the perspective of practice owners, staff, patients and trained external facilitators. For general medical practices, the effectiveness of the European Practice Assessment in showing higher scores at repeat assessment has already been shown. These results regarding general medical practice are comparable to our results regarding the improvement for each domain at dental care practices. The improvement of dimensions and domains in dental care practices follows a similar trend to that of the improvement in general medical practices.
There are different quality improvement activities being initiated in oral health services worldwide ranging from measurements of the process of technical restoration procedures to examination of long term health outcomes for the population. Within this range, one important component is the measurement of dental care practice operations including structure, process and outcomes. However, a systematic and organized agenda for quality improvement in dentistry is still in its fledgling stage. The results of this study suggest that the European Practice Assessment provides a much needed mechanism for assessing quality in dental care practices and improving quality and safety.
Overall, reliable evidence regarding effectiveness of quality management programs in any field of healthcare is limited. Studies on the effectiveness of quality management programs for dental care practices can make an important contribution to the evidence base related to quality in oral health services and also to improving patient outcomes. This is important if oral health services are to stay on par with other health services in terms of quality management. Therefore, raising awareness regarding the development and continuous measurement of quality in dental care practices is important for dentists and oral health services policy makers. One opportunity (enabler) would be the introduction of performance-based reimbursement to incentivize good quality of care. The potential role of performance-based reimbursement for dentistry is currently under discussion in the United Kingdom and it is being piloted. However, performance-based reimbursement is also associated with unintended consequences. For example, the introduction of performance-based reimbursement in general medical care practices has shown short-term gains, but the evidence for its effectiveness long-term is not compelling. Therefore, it should be implemented with caution in dental care settings and its implementation should only be considered within the context of a system wide quality improvement strategy.
Our study has the following limitations. The sample of participating dental care practices was small and may not have been generally representative of dental care practices in Germany. However, all practices that had used the European Practice Assessment twice were included. The allocation of practices to an intervention or a comparison group was not randomized and a baseline measurement in the comparison group was lacking. Moreover, the study design has a weakness in that the pre-post measurement was possible with the intervention group, but with only a single set of observations at a second point in time. Although our results showed improvements in the intervention group, this may reflect a selection effect of dental practices volunteering for the first round of the European Practice Assessment. Therefore, the results of the study have to be interpreted carefully and need to be confirmed in further studies. In addition, although it is known, that a multifaceted quality management program motivates practices to change, there is no reliable evidence from this study about the impact on clinical outcomes because the data presented concentrates on structure and process of care. Because this was the first study evaluating effectiveness of a quality management program in primary dental care settings in Germany, we have no experience on which to base our assessment as to how clinically relevant our results are. At this time, we have no reference standards. This study provides preliminary results as basis for further studies. The study design was explorative. Therefore, no correction for multiple tests was needed. The observed effects should be examined in further study with a larger sample.
Discussion
To our knowledge, this is the first study that has evaluated and demonstrated quality improvement in primary dental care practices in Germany. In this study, a repeated measurement was used to evaluate the effect of the assessment process using the European Practice Assessment quality management program. The intervention and comparison group practices did not differ remarkably in comparison to general medical practice characteristics. Furthermore, the baseline data and the first assessment of the intervention group showed higher scores than in the comparison group within the five key domains ('infrastructure', 'people', 'information', 'finance', and 'quality and safety'). The comparison of the results of the second assessments in intervention practices with the baseline assessments in comparison group practices showed improvements across all domains, but especially within the domains of 'quality and safety' and 'infrastructure'.
Quality improvement depends on a set of valid and feasible quality indicators that are able to measure quality of care. "Indicators are measurable elements of practice for which there is evidence or consensus that they reflect quality and hence help change the quality of care provided". The implementation of a quality management system in practices can be facilitated by the use of quality indicators. Quality indicators should yield positive assessment on a range of attributes such as clarity, feasibility, reliability, validity and transparency and in order to demonstrate sensitivity to change, benchmarking data are required so that health care providers can assess and compare their own quality of care with others. Moreover, for assessment to lead to improvement it must be part of an ongoing process such as the "plan-do-study-act" (PDSA) cycle. A continuous quality improvement is an essential part of quality management programs for health care services, which includes general medical practices and dental care practices in the primary sector.
The evaluation of quality of care requires a mixture of objective and subjective measures. The European Practice Assessment consists of a set of objective and subjective quality indicators, which evaluate the structure and process of care from the perspective of practice owners, staff, patients and trained external facilitators. For general medical practices, the effectiveness of the European Practice Assessment in showing higher scores at repeat assessment has already been shown. These results regarding general medical practice are comparable to our results regarding the improvement for each domain at dental care practices. The improvement of dimensions and domains in dental care practices follows a similar trend to that of the improvement in general medical practices.
There are different quality improvement activities being initiated in oral health services worldwide ranging from measurements of the process of technical restoration procedures to examination of long term health outcomes for the population. Within this range, one important component is the measurement of dental care practice operations including structure, process and outcomes. However, a systematic and organized agenda for quality improvement in dentistry is still in its fledgling stage. The results of this study suggest that the European Practice Assessment provides a much needed mechanism for assessing quality in dental care practices and improving quality and safety.
Overall, reliable evidence regarding effectiveness of quality management programs in any field of healthcare is limited. Studies on the effectiveness of quality management programs for dental care practices can make an important contribution to the evidence base related to quality in oral health services and also to improving patient outcomes. This is important if oral health services are to stay on par with other health services in terms of quality management. Therefore, raising awareness regarding the development and continuous measurement of quality in dental care practices is important for dentists and oral health services policy makers. One opportunity (enabler) would be the introduction of performance-based reimbursement to incentivize good quality of care. The potential role of performance-based reimbursement for dentistry is currently under discussion in the United Kingdom and it is being piloted. However, performance-based reimbursement is also associated with unintended consequences. For example, the introduction of performance-based reimbursement in general medical care practices has shown short-term gains, but the evidence for its effectiveness long-term is not compelling. Therefore, it should be implemented with caution in dental care settings and its implementation should only be considered within the context of a system wide quality improvement strategy.
Limitations
Our study has the following limitations. The sample of participating dental care practices was small and may not have been generally representative of dental care practices in Germany. However, all practices that had used the European Practice Assessment twice were included. The allocation of practices to an intervention or a comparison group was not randomized and a baseline measurement in the comparison group was lacking. Moreover, the study design has a weakness in that the pre-post measurement was possible with the intervention group, but with only a single set of observations at a second point in time. Although our results showed improvements in the intervention group, this may reflect a selection effect of dental practices volunteering for the first round of the European Practice Assessment. Therefore, the results of the study have to be interpreted carefully and need to be confirmed in further studies. In addition, although it is known, that a multifaceted quality management program motivates practices to change, there is no reliable evidence from this study about the impact on clinical outcomes because the data presented concentrates on structure and process of care. Because this was the first study evaluating effectiveness of a quality management program in primary dental care settings in Germany, we have no experience on which to base our assessment as to how clinically relevant our results are. At this time, we have no reference standards. This study provides preliminary results as basis for further studies. The study design was explorative. Therefore, no correction for multiple tests was needed. The observed effects should be examined in further study with a larger sample.
