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.