Quality and Audit

Definitions

QUALITY ASSESSMENT is defined by the ADA as the measure of the quality of care provided in a particular setting.

QUALITY ASSURANCE is the assessment or measurement of the quality of care and the implementation of any necessary changes to either maintain or improve the quality of care rendered.

The differences in these definitions are important; quality assessment is limited to the appraisal of whether or not standards of quality have been met, whereas quality assurance includes the added dimension of corrective action to improve the future situation.

There have been many attempts by academics to model and define health care quality. In the United Kingdom the best known of these include Donabedian's¹ distinctions between quality related to structure, process, and outcome and Maxwell's² six dimensions.

Donabedian's model is based on the idea that while the outcome of treatment is of primary importance, a desirable outcome is more likely if the structural arrangements, such as well-designed treatment facilities, proper equipment, and appropriately and properly trained staff, meet adequate standards. A good outcome is also more likely if the processes used, such as diagnostic methods, treatment planning, record keeping, and the treatment procedures themselves follow recognized protocols.

 

STRUCTURE PROCESS OUTCOME
    Facilities
  • Setting
  • Physical structures
  • Layout
  • Amenities
  • Access
    Equipment
  • Operatories
  • Instruments
  • Supplies
  • Sterilization
    Personnel
  • Appropriate types
  • Training
  • Licensure
  • Certification
  • CDE
    Administration
  • Procedures
  • Record systems
    Protocols
    Management
  • Practice
  • Personnel
  • Patient
    Records
  • Content
  • Completeness
  • Availability
  • Legibility
    Diagnosis
  • Appropriateness
  • Documentation
  • Thoroughness
    Treatment plan
  • Written
    Sequencing
    Patient satisfaction
    Oral health status
  • Oral hygiene
  • Tooth loss
  • Periodontitis
  • Caries
    Completion of treatment
  • Timely
  • Appropriate
    Recall pattern
  • Frequency
    Needs at recall

 

Other dimensions of quality that are frequently mentioned, in addition to the technical quality of restorative procedures, are appropriateness of care, access to care, costs of care, and patient satisfaction. Maxwell embraces much of this in his six Dimensions of Health Care Quality:

The definition of clinical quality can be problematic; it has generated a multiplicity of approaches. The World Health Organisation³ has defined clinical quality as consisting of four aspects:

  1. Professional performance (technical competence)
  2. Resource use (efficiency)
  3. Risk management (the risk of injury or illness associated with the service provided)
  4. Patient satisfaction with the service provided

Each of these aspects may be considered pertinent within the domain of service quality within dentistry. Various indices are required with which to measure performance against these parameters.

Taking each aspect in turn then the broad data requirements are:

  1. Professional performance:

    • Patient details
    • Practitioner details
    • Description of state of mouth at examination
    • Description of treatments proposed or carried out
    • Dates as appropriate - e.g. date of completion of treatment

  2. Resource use

    • Costs associated with the assessments, treatments, and other interventions carried out, including at the core: staff and supplies, but also at widest sense costs in relation to equipment and facilities required.

  3. Risk management

    • Measures of outcome (specifically adverse outcomes)
    • Indication of use (or otherwise) of risk control measures such as recommended practice approaches.

  4. Patient satisfaction

    • This is much less amenable to identification through analysis of operational data than the three aspects above and typically requires specific measurement through other means.

Taking a wider perspective, one might consider service quality to include the performance of the service with regard to certain 'policy' aims such as equity of access, regardless of patient status. Such wider issues require that information collated about patients includes data that indicates their status in relation to parameters regarded as pertinent, such as:

¹ Donabedian A. Explorations in quality assessment and monitoring. Vol 1. The definition of quality and approaches to its assessment. Ann Arbor, MI: Health Administration Press, 1980.

² Maxwell R. Quality assessment in health. BMJ 1984:288:1470-2

³ The principles of quality assurance. Copenhagen: WHO, 1983