Quality Assessment, Quality Improvement...Dental Dashboard Quality Indic ators: 1. Percentage of...
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Quality Assessment, Quality Improvement & HRSA’s Oral Health Measures Dan Watt, DDS Marty Lieberman, DDS Wednesday, October 27, 2010
Transcript of Quality Assessment, Quality Improvement...Dental Dashboard Quality Indic ators: 1. Percentage of...
Quality Assessment, Quality Improvement &
HRSA’s Oral Health Measures
Dan Watt, DDS Marty Lieberman, DDS Wednesday, October 27, 2010
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
For More Information…
• Order a printed copy, or download the PDF version of the Fundamentals Chapter at:
http://www.nnoha.org/practicemanagement/manual.html
• Attend other Practice Management Sessions at the Conference!
What is Quality?
For dental terminology it means:
A Measurement of Excellence
Importance of Measurement
• Developing Measurable Outcomes
• Sample Metrics
• Quality Improvement Indicators
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
Quality in Other Review Systems
• JCAHO
• Managed Care Systems
• State QA Requirements
• Chronic Care Model
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.
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
Quality Assessment
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
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
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
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
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
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.
Terry Reilly Health Services
Dental Provider Performance Review From
Quarterly Chart review Date of Rev iew : _______________________________
Rev iew ing Dentist: _______________________________
Quarter Reviewed__________________________
Dentist Rev iew ed: _______________________________
CHART ONE CHART TWO CHART THREE CHART FOUR CHART FIVE
GENERAL CHART INFORMATION YES NO YES NO YES NO YES NO YES NO
1. Patient Information complete?
2. General Consent complete?
3. Medical History complete?
4. Medical History update complete?
5. Are Allergies and Medical conditions documented?
6. Indicators discussed: caries risk ,Diabetes, smoking, etc.?
Comments:____________________________________________________________________________________________
CHART ONE CHART TWO CHART THREE CHART FOUR CHART FIVE
CLINICAL EXAM DATA YES NO YES NO YES NO YES NO YES NO
1. Soft Tissue findings noted?
2. Occlusal findings noted-caries, missing teeth, dental needs?
3. Periodontal findings / Classification noted?
Comments:____________________________________________________________________________________________
CHART ONE CHART TWO CHART THREE CHART FOUR CHART FIVE
RADIOGRAPHS YES NO YES NO YES NO YES NO YES NO
1. Appropriate Surv ey , ty pe of Xray s taken?
2. Adequate Film cov erage, all apices cov ered?
3. Any image defect: cone cuts, retakes needed?
4. Number of Xray s taken documented?
Comments:____________________________________________________________________________________________
CHART ONE CHART TWO CHART THREE CHART FOUR CHART FIVE
PROBLEMS / DIAGNOSIS YES NO YES NO YES NO YES NO YES NO
1. Appropriate testing done:
2. Diagnosis documented?
3. Appropriate consultations made, if needed?
4. Referrals made if needed?
5. Findings documented on treatment plan?
Comments:____________________________________________________________________________________________
CHART ONE CHART TWO CHART THREE CHART FOUR CHART FIVE
TREATMENT PLAN / DENTAL RECORD YES NO YES NO YES NO YES NO YES NO
1. Does Treatment Plan follow appropriate sequence.
2. Record is complete and appropriate for treatment rendered?
3. Follow up appointment is indicated in clinical record?
4. Documentation is complete, tooth area, anesthetic,procedure and/or materials,signed w ith Doctor's and Assistant's names,etc.?
Comments:____________________________________________________________________________________________
Director's Comments ______________________________________________________________________________
______________________________________________________________________________
Dental Director________________________________Signature__________________________________Date___________
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
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”
The Quality Committee establishes Dashboard Indicators
Attachment A
Dashboard Indicators
Medical Dashboard Quality Indicators:
1. What percent of pregnant patients receive care in their first trimester?
2. What percent of 2 year olds are up-to-date on immunizations?
3. What percent of women 21-64 years of age have had cervical cancer screenings?
4. What percent of diabetic patients have A1C< 9.0?
5. New Patient Appointment Lag Time?
6. Established Patient Appointment Lag Time?
7. Chart Audit Outcomes?
8. Medical cost per medical encounter (excl. lab, x-ray and nurse visits)?
9. Patient’s overall satisfaction with services?
Dental Dashboard Quality Indicators:
1. Percentage of Phase One Visits by Clinic?
2. Percentage of Phase Two Visits by Clinic?
3. Percentage of patients who have a complete oral exam and then complete their treatment plan?
4. Independent Audit by outside Review?
5. New Patient Appointment Lag Time?
6. No Show Rate?
7. Patient’s overall satisfaction with services?
Behavioral Health Quality Indicators:
1. Number of charts with 85% compliance with peer review criteria.
2. Outcome data on reduction in trauma symptoms.
3. Outcome data regarding risk to re-offend for offender services.
4. Cancellation and no-show rate?
5. Patient’s overall satisfaction with services?
Administrative Quality Indicators:
1. Total cost per total patient?
Once you establish your “culture of quality” you can then determine a
course of action for quality improvement
Opportunity for Improvement
Actual
Desired (Standards)
What we do
What we know
The Gap
• Access to care • Continuity of services • Cost • Adverse patient events • Oral health outcomes
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
• The difference between Quality Assurance(QA) and Quality Improvement(QI)
• PDSA Cycles- Testing
• QI Plan
• Case history
• Proposed HRSA Quality Measures
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
http://dictionary.reference.com/browse/improvement
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.
QI the Process
• Identify a program or facility problem 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]
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?
Plan-Do-Study-Act Cycle
Ideas Action Learning Improvement
Do Study
Act Plan
• Identify problems and create A plan
• Implement the plan • Monitor and document Results
• Begin analysis of the data
• Complete the data analysis • Compare data to predictions • Summarize what was learned
• Demonstrate improvement • What changes are to be made? • What is the next cycle?
Using the Cycle to Improve
D S
P A
D S
P A
Ideas
Improvement
Very Small Scale Test
Follow-up Tests
Wide-Scale Tests of Change
Implementation of Change
Spread
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
Using the Cycle to Improve
D S
P A
D S
P A
Ideas
Improvement
Very Small Scale Test
Follow-up Tests
Wide-Scale Tests of Change
Implementation of Change
Spread
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?”
HRSA Quality Measure (proposed)
Percentage of all dental patients for whom the Phase I treatment plan is completed within a 12 month period.
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.
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:
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.
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.
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
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”
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
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
2500
3000
3500
4000
4500
5000
Oct-
09
Nov-0
9
Dec-0
9
Ja
n-1
0
Feb
-10
Mar-
10
Ap
r-1
0
May-1
0
Ju
n-1
0
Ju
l-10
Au
g-1
0
Se
p-1
0
Total Visits for All Clinics
0
5
10
15
20
25
Oct-
09
Nov-0
9
Dec-0
9
Ja
n-1
0
Feb
-10
Mar-
10
Ap
r-1
0
May-1
0
Ju
n-1
0
Ju
l-10
Au
g-1
0
Se
p-1
0
Percent No Show
3.0
6.0
9.0
12.0
15.0
Oct-
09
No
v-0
9
Dec-0
9
Ja
n-1
0
Feb
-10
Mar-
10
Ap
r-1
0
May-1
0
Ju
n-1
0
Ju
l-10
Au
g-1
0
Se
p-1
0
Supply Cost Per Encounter
0
20
40
60
80
100
Oct-
09
No
v-0
9
Dec-0
9
Ja
n-1
0
Feb
-10
Mar-
10
Ap
r-1
0
May-1
0
Ju
n-1
0
Ju
l-10
Au
g-1
0
Se
p-1
0
Treatment Plan Completion Rate
0
10
20
30
40
50
60
70
80
Oct-
09
Nov-0
9
De
c-0
9
Ja
n-1
0
Feb
-10
Mar-
10
Ap
r-1
0
May-1
0
Ju
n-1
0
Ju
l-10
Au
g-1
0
Se
p-1
0
Percent Children
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
2.0
Oct-
09
Nov-0
9
Dec-0
9
Ja
n-1
0
Feb
-10
Mar-
10
Ap
r-1
0
May-1
0
Ju
n-1
0
Ju
l-10
Au
g-1
0
Se
p-1
0
Visits Per Hour
80
100
120
140
160
180
200
220
Oct-
09
Nov-0
9
Dec-0
9
Ja
n-1
0
Feb
-10
Mar-
10
Ap
r-1
0
May-1
0
Ju
n-1
0
Ju
l-10
Au
g-1
0
Se
p-1
0
Unit Cost
15%
25%
35%
45%
55%
65%
75%
Oct-
09
Nov-0
9
Dec-0
9
Ja
n-1
0
Feb
-10
Mar-
10
Ap
r-1
0
May-1
0
Ju
n-1
0
Ju
l-10
Au
g-1
0
Se
p-1
0
Percent Medicaid
2.50
3.00
3.50
4.00
4.50
5.00
5.50
6.00
Oct-
09
Nov-0
9
De
c-0
9
Ja
n-1
0
Feb
-10
Mar-
10
Ap
r-1
0
May-1
0
Ju
n-1
0
Ju
l-10
Au
g-1
0
Se
p-1
0
RVUs Per Visit
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
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.
Practice Management Quality Chapter
• Almost done
• Committee
• Understand Quality Concepts and help you integrate them into your health center programs.
