QUALITY AS AN ISSUE OF ETHICS

QUALITY of CARE DEFINED

“The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

Institute of Medicine

National Academy of Sciences

PRACTICE GUIDELINES

Systematically developed statements to assist practitioner and patient in making decisions about appropriate health care for specific clinical circumstances.

“Standards of Care”

“Practice Parameters”

“Practice Policies”

Includes:

* Goals of therapy

* Indications for therapy

* Contraindications for

therapy

* Considered Risks

Desirable Attributes of Dental Practice

Guidelines

• Appropriate Development Process

• Clinical Applicability

• Reliability

• Validity

Appropriate Development

• Documentation of procedures used in developing

• Methods used to obtain expert opinion

• Strength of evidence used

• Assumptions employed

• Evidence that affected groups were involved in the process

Clinical Applicability

• Describe the patients and clinical conditions to which they apply.

• Information that would make the guideline non-applicable in certain cases.

• Treatment alternatives available presented logically so that easy to use

Reliability

• Sufficiently reliability so that practitioners can interpret and apply them consistently.

• Reliability means being capable of being depended upon. Does the guideline demonstrate that it can be relied on time after time to offer consistent results.

Validity

• Guidelines should be based on outcomes and rooted in the scientific literature.

• Evidence should exist that the guideline will, when followed, lead to the projected health outcome as determined from the literature and expert opinion.

• Assessment of outcomes should include patient perceptions and preferences.

Developers of Guidelines

• Professional dental organizations: ADA, AAOMFS, AAPD, AAP

• Government agencies: FDA, AHCPR

• Nonprofit organizations: AHA

• Third party payers: Medicaid, Delta Dental

• Managed care organizations: UKHMO, Cigna, United

Quality Assessment

• Clinical practice guidelines and quality assessment (QA) measures are to be distinguished from one another, though they share many common characteristics.

• QA focuses retrospectively on structural and procedural aspects of care, e.g., marginal integrity of restorations, etc. These characteristics cannot be translated directly into outcomes such as tooth loss, etc.

• QA criteria focus on immediate and intermediate measures of the technical aspects of care, rather than long-term outcomes of care. .

Conclusion

Clinical practice guidelines (parameters of care) are decision aids that are based on evidence of outcomes. They are designed to be use prospectively in improving decisions concerning treatment.

It is important to note, that clinical practice guidelines, when properly developed, become standards of care for the profession.

Clinical Performance Predictors

• 3,000 correlations between various predictors of clinical performance and performance measures. Predictors included experience, grades, age, sex, standardized test scores, etc.

• Performance measures are measures used to monitor the extent to which the actions of a health professional conform to practice guidelines.

• Study concluded that all correlations that existed could have been produced by chance; no significant correlations

• No correlation between knowledge and clinical performance.

• In follow-up study, 90% of the residents failed to follow-up on laboratory findings.

• A conference was held with the residents devoted to the subject.

• Performance did not improve after the conference.

Three Most Distinguishing

Characteristics of Poor Performance...

…were moral failings:

• negligence in caring for patients

• appearing before monitoring committees for infractions of procedures in care.

• deviousness

Study by Price, et. al.

Study of Clinical Performance and Moral Reasoning

• Correlated Moral Reasoning (Integrity), using Kohlberg’s Defining Issues Test, with the clinical performance of residents as evaluated by their attending faculty.

• High moral reasoning virtually precludes the possibility of poor performance.

• Highest level of clinical performance rarely achieved by those with poor moral reasoning skills.

William Harvey’s Six Desirable Qualities in a

Physician(Dentist)

• Intelligence

• Work Ethic

• Common Sense/Judgement

• Understanding of Scientific Method

• Knowledge of Medicine/Dentistry

• Integrity

INTEGRITY

• Sense of wholeness

• Personal Value System

• Priorities in Value System

• Responsibleness

• Sense of right and wrong

• Commitment to doing the right thing

Clinicians’ understanding and appreciation of the role of ethics in clinical care, and their commitment to a moral stance in caring for their patients, is a critical ingredient in the quality of clinical care received by patients.