A Quality Management Program in Dental Care Practices
Improving the quality of healthcare is a high priority in Western health care systems driven by factors such as reducing adverse events, optimizing efficiency, and enhancing patient satisfaction. An excellent definition of quality in healthcare is given by Mills & Batchelor. In essence, however, quality of care can been defined and evaluated in terms of structure, process and outcomes. Whilst the presence of specific organizational structures does not necessarily result in better clinical processes and outcomes, organizational aspects are certainly enablers of higher performance. Little is known about how to improve quality of organizational aspects of primary sector dental care. The majority of literature and the evidence base for defining and measuring quality in primary care come from general medical practice and not from oral health care settings. However, assessing and monitoring the quality of dental care play an important role in quality assurance and quality improvement.
In most health care systems, a variety of quality improvement initiatives have been implemented to enhance both health care management broadly speaking and dental health care specifically speaking. For instance, in the United Kingdom quality indicators were developed for the new National Health Service (NHS) dental contract which targets measuring the quality of patient care as well as performance. In 2005, in Scotland, the "Action Plan for Improving Oral Health and Modernising NHS Dental Services" was announced. Since 1997, in the United States, an assessment instrument developed and initiated by MetLife has been implemented for dental care providers. Particularly countries such as the United Kingdom, the United States and Canada have shown expertise in development and implementation of quality management systems. Quality management means quality assurance: the systematic measurement and monitoring of process, structure and outcome of care and results in a continuous improvement process. For example, the plan-do-study-act cycle, to ensure quality of care. In 2006, the German government stipulated that general dental practitioners should implement a system of annual assessment of quality management, in the same way that general medical practices are expected to do. Although, to date, there are no formal sanctions, so participation remains voluntary. The result has been that different quality management systems have become available for health care providers in primary care settings. These different quality management systems measure structure and process of care as well as non-clinical outcomes of patients.
However, while such quality management programs are available for dental care, evidence on their impact and effectiveness is sparse, with some exceptions. There is an urgent need for validated quality assessment tools for dental care. The European Practice Assessment is a comprehensive, integrative and multifaceted tool for quality assessment and quality improvement in health care in terms of quality management. It is based on quality indicators developed for use in primary medical care settings to evaluate the structure and process of care. The European Practice Assessment tool has shown effectiveness in improving the management of general medical practices. The current study focuses on the implementation and repeated measurement of European Practice Assessment tool in primary dental care settings and examined whether improvements occurred in dental care practice that completed the European Practice Assessment twice compared with dental care practices that completed the European Practice Assessment once.
The study conforms to the STROBE-Guidelines. A before-after study design was used with an intervention group and a comparison group of dental care practices. We included dental care practices in Germany that had completed the European Practice Assessment as part of a quality management program. For the intervention group, we identified all 45 dental care practices which had completed the European Practice Assessment twice, with their first assessment between April 2005 and December 2008 and their second assessment between April 2008 and January 2012. The interval between first and second assessment was around 36 months. During the period between April 2008 and May 2011 when the intervention practices were undergoing their second assessment, 57 dental care practices were undergoing their first assessment with the European Practice Assessment program but none had yet had a second assessment. These were called upon as our comparison group. One dental care practice was integrated into a general medical care centre and was excluded from the analysis. Therefore, 56 practices in total were included in the comparison group. Figure 1 shows the distribution of dental care practices to intervention and comparison groups respectively.
(Enlarge Image)
Figure 1.
Selection of private dental care practice for the intervention and comparison.
The analyses were performed using SPSS version 20.0 (SPSS Inc., IBM). Continuous data were summarized using means and standard deviations. Categorical data were presented as frequency counts and percentages. The practice characteristics of the intervention and comparison groups were compared using Students t-test for continuous data and Chi test for categorical data.
Z scores were used to compare the overall mean score across all domains and dimensions of the European Practice Assessment instrument, in the intervention (second assessment) and comparison groups. Z scores were used to normalize raw scores. The mean scores of all domains and dimensions were based on the proportion of indicators for which a positive response was achieved by all of the practices, on a scale of 0 to 100. The 95% confidence intervals were calculated for the differences in scores between the first and second assessment and for the differences between the second assessment and the comparison group. Furthermore, linear regression analyses were performed with aggregated scores on each of the five domains as dependent outcomes; practice characteristics as well as the affiliation to intervention (second assessment) or comparison group were handled as potential predictors. An alpha level of p < 0.05 was used for tests of statistical significance.
Ethical approval was not required because we used secondary data available from the routine implementation of a quality management program in primary dental care sector in Germany. All elements of the European Practice Assessment and the information from the trained external facilitators were anonymized for data analysis in our study. No additional information or data from patients or staff were collected.
Methods
Improving the quality of healthcare is a high priority in Western health care systems driven by factors such as reducing adverse events, optimizing efficiency, and enhancing patient satisfaction. An excellent definition of quality in healthcare is given by Mills & Batchelor. In essence, however, quality of care can been defined and evaluated in terms of structure, process and outcomes. Whilst the presence of specific organizational structures does not necessarily result in better clinical processes and outcomes, organizational aspects are certainly enablers of higher performance. Little is known about how to improve quality of organizational aspects of primary sector dental care. The majority of literature and the evidence base for defining and measuring quality in primary care come from general medical practice and not from oral health care settings. However, assessing and monitoring the quality of dental care play an important role in quality assurance and quality improvement.
In most health care systems, a variety of quality improvement initiatives have been implemented to enhance both health care management broadly speaking and dental health care specifically speaking. For instance, in the United Kingdom quality indicators were developed for the new National Health Service (NHS) dental contract which targets measuring the quality of patient care as well as performance. In 2005, in Scotland, the "Action Plan for Improving Oral Health and Modernising NHS Dental Services" was announced. Since 1997, in the United States, an assessment instrument developed and initiated by MetLife has been implemented for dental care providers. Particularly countries such as the United Kingdom, the United States and Canada have shown expertise in development and implementation of quality management systems. Quality management means quality assurance: the systematic measurement and monitoring of process, structure and outcome of care and results in a continuous improvement process. For example, the plan-do-study-act cycle, to ensure quality of care. In 2006, the German government stipulated that general dental practitioners should implement a system of annual assessment of quality management, in the same way that general medical practices are expected to do. Although, to date, there are no formal sanctions, so participation remains voluntary. The result has been that different quality management systems have become available for health care providers in primary care settings. These different quality management systems measure structure and process of care as well as non-clinical outcomes of patients.
However, while such quality management programs are available for dental care, evidence on their impact and effectiveness is sparse, with some exceptions. There is an urgent need for validated quality assessment tools for dental care. The European Practice Assessment is a comprehensive, integrative and multifaceted tool for quality assessment and quality improvement in health care in terms of quality management. It is based on quality indicators developed for use in primary medical care settings to evaluate the structure and process of care. The European Practice Assessment tool has shown effectiveness in improving the management of general medical practices. The current study focuses on the implementation and repeated measurement of European Practice Assessment tool in primary dental care settings and examined whether improvements occurred in dental care practice that completed the European Practice Assessment twice compared with dental care practices that completed the European Practice Assessment once.
Design and Participants
The study conforms to the STROBE-Guidelines. A before-after study design was used with an intervention group and a comparison group of dental care practices. We included dental care practices in Germany that had completed the European Practice Assessment as part of a quality management program. For the intervention group, we identified all 45 dental care practices which had completed the European Practice Assessment twice, with their first assessment between April 2005 and December 2008 and their second assessment between April 2008 and January 2012. The interval between first and second assessment was around 36 months. During the period between April 2008 and May 2011 when the intervention practices were undergoing their second assessment, 57 dental care practices were undergoing their first assessment with the European Practice Assessment program but none had yet had a second assessment. These were called upon as our comparison group. One dental care practice was integrated into a general medical care centre and was excluded from the analysis. Therefore, 56 practices in total were included in the comparison group. Figure 1 shows the distribution of dental care practices to intervention and comparison groups respectively.
(Enlarge Image)
Figure 1.
Selection of private dental care practice for the intervention and comparison.
Statistical Analysis
The analyses were performed using SPSS version 20.0 (SPSS Inc., IBM). Continuous data were summarized using means and standard deviations. Categorical data were presented as frequency counts and percentages. The practice characteristics of the intervention and comparison groups were compared using Students t-test for continuous data and Chi test for categorical data.
Z scores were used to compare the overall mean score across all domains and dimensions of the European Practice Assessment instrument, in the intervention (second assessment) and comparison groups. Z scores were used to normalize raw scores. The mean scores of all domains and dimensions were based on the proportion of indicators for which a positive response was achieved by all of the practices, on a scale of 0 to 100. The 95% confidence intervals were calculated for the differences in scores between the first and second assessment and for the differences between the second assessment and the comparison group. Furthermore, linear regression analyses were performed with aggregated scores on each of the five domains as dependent outcomes; practice characteristics as well as the affiliation to intervention (second assessment) or comparison group were handled as potential predictors. An alpha level of p < 0.05 was used for tests of statistical significance.
Ethics Approval
Ethical approval was not required because we used secondary data available from the routine implementation of a quality management program in primary dental care sector in Germany. All elements of the European Practice Assessment and the information from the trained external facilitators were anonymized for data analysis in our study. No additional information or data from patients or staff were collected.
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