Structural Components of Quality: In-Office Quality Assessment
Basic to the quality of care is the knowledge and skills of the dentist. But, a multitude of other factors can affect the quality of care indirectly, but importantly. Such factors include accessibility of care; cost and reimbursement of care; infection control in the office; oral health record keeping; office emergency procedures; and environmental hazards. These factors are considered the “structural” components of quality and refer to factors that provide the supports in which care can be delivered. Without good supports, the ability to perform clinical care can be compromised or the benefits of clinical care can be lessened. Below are Web sites that address some of the major “structural” factors that can affect the quality of care; sources of information include ADA policies, governmental regulations, and practice management advice. The dentist may refer to these resources to better understand how these factors contribute to the quality of care and to understand those components that are mandated by legislation and other regulatory bodies.
To aid the dentist in regularly monitoring these components of quality in his or her office, the Council on Dental Benefit Programs, Office of Quality Assessment and Improvement, developed a checklist | PDF file/58k  for voluntary use by the dentist. It may be adapted by the dentist to suit his or her particular practice.
Infection Control
The prevention of the transmission of infectious diseases is a factor in producing good outcomes and beneficial care for patients. Because infectious diseases are preventable through standard infection control measures, it is an area of practice that is regulated by local, state, and federal governmental agencies. Because of the importance of the subject, dentists can benefit from accessing information directly from their sources to fully understand the recommendations and regulations regarding infection control. The Centers for Disease Control (CDC) and the Occupational Health and Safety Administration (OSHA) are 2 federal agencies that regulate infection control. State dental boards and local public health departments are additional sources of regulation.
The American Dental Association policies on infection control support the prevention of infectious disease transmission and provide much guidance on infection control and issues that are related to infection control.
ADA Policies and Resources
CDC Recommendations
In its infection control policy, the ADA makes reference to the Centers for Disease Control (CDC) Guidelines for Infection Control in Dental Health Care Settings . The CDC document provides specific information and recommendations on infection control regarding: 1) educating and protecting dental health-care personnel; 2) preventing transmission of bloodborne pathogens; 3) hand hygiene; 4) personal protective equipment; 5) contact dermatitis and latex hypersensitivity; 6) sterilization and disinfection of patient-care items; 7) environmental infection control; 8) dental unit waterlines, biofilm, and water quality; and 9) special considerations (e.g., dental handpieces and other devices, radiology, parenteral medications, oral surgical procedures, and dental laboratories).
OSHA Recommendations
The Occupational Health and Safety Administration (OSHA) issues standards and regulations designed to protect the health and well being of the work force by facilitating the prevention of injuries and illness caused or occurring in the workplace. Regarding infection control, OSHA provides regulation regarding the protection of employees, such as the dental team members, who may be exposed to bloodborne pathogens.
The ADA provides information on how to comply with OSHA requirements in following–up when a dental team member has been exposed to bloodborne pathogens.
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Bi-Products of Diagnostic and Treatment Procedures
The dental team, as well as patients, can be affected by exposures to certain bi-products of diagnostic and treatment procedures. Exposure can be somewhat controlled by careful handling and disposal of treatment materials and judicious use of some diagnostic and treatment procedures. Concerns about exposure most commonly include amalgam particles, nitrous oxide gases, and radiation from radiographs.
Communication and classification of hazardous materials
The ADA policy on hazard communication and classification supports that manufacturers/distributors of hazardous materials used in the dental office should supply material safety data sheet (MSDS) and that such manufacturers/distributors comply with federal standards, guidelines and policies regarding communication and labeling of hazardous materials (see page 120 of the ADA’s compilation of current policies). The ADA refers to OSHA’s rules regarding the communication of hazardous materials.
Amalgam
Nitrous oxide
Radiation
The ADA recommends the use of radiographic techniques that limit the amount of radiation received during dental radiography. Thus the ADA supports the principle of using radiation exposure “as low as reasonably achievable (ALARA principle) which
includes taking radiographs based on the patient's individual diagnostic needs (as determined by an examination), using the least exposure time compatible with the diagnostic task, collimating the beam to a size as close to that of the film as feasible and using leaded aprons and thyroid shields when they would not interfere with the image.
The ADA and FDA jointly updated guidelines on the selection of patients for radiographic examination: http://www.ada.org/prof/resources/topics/topics_radiography_examinations.pdf
The ADA also makes reference to the National Council on Radiation Protection and Management (NCRPM) , which has a publication on dentistry and radiation which can be purchased from the NCRPM as either a hard copy or downloadable document.
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Office Medical Emergency Procedures
Dental office emergencies that affect the quality of care are medical emergencies suffered by the patient, such as cardiovascular events, seizures, choking, and allergic reactions. These kinds of emergencies require the dental team to directly provide certain emergency care to the patient and to quickly get necessary emergency care for the patient. Thus it is imperative that the dental team know how to handle these emergencies, that their knowledge and ability be kept up-to-date and that there are clearly written and accessible procedures to follow in such emergencies. The resources below provide information on how the dental office can be organized and equipped to handle medical emergencies.
Overview of handling emergencies
The following article which was published in the Journal of the American Dental Association provides an overview of handling emergencies in the dental office.
Emergency equipment and drugs
The following link provides additional information on the materials needed for a medical emergency in the office
Sources of emergency equipment
The following link is to a list of sources for obtaining oxygen and anesthesia equipment:
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The Americans with Disability Act
The availability of oral health services and an individual’s access to it is preliminary to getting oral health care. If an individual is able to access only a limited array of services, the quality of their oral health care will be diminished. An individual’s ability to get to a dental office, to understand the patient education they receive or to carry out home care are examples of abilities to access oral health care. Disabilities can be physical, psychological or developmental. Such disabilities impinge not only on the individual’s ability to get health care, but to take advantage of many other opportunities as well, such as the ability to hold a job. The Americans with Disabilities Act of 1990 is federal legislation aimed at broadening access for those with disabilities. It describes how employers, governmental agencies, telecommunications companies, those providing services for the public, and the public environment itself must make their services and opportunities accessible for people with disabilities. Dental offices are affected by this legislation because they provide oral health care services to the public and so are responsible for making their offices accessible to people with disabilities. It also applies to the dental office as an employer. However, the primary purpose of the resources provided here are to address the responsibilities inherent in providing care to patients and complying with the Americans with Disability Act.
The following link provides more information about the Americans with Disability Act
Specific applications of the Act
The following links clarify how this legislation applies to patients with HIV:
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Patient Privacy Legislation-Health Insurance Portability and Accountability Act (HIPAA)
The Health Insurance Portability and Accountability Act (HIPAA) consists of Title I , which protects health insurance coverage for workers and their families when they change or lose their jobs; and Title II, the administrative simplification (AS) provisions, which require the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers and, also requires that patient health information and data be kept private and secure. The section that affects the provision of care in the dental office is the administrative simplification provisions. The following link is to ADA resources that explain the Health Insurance Portability and Accountability Act (HIPAA) and it includes a link for purchasing the HIPAA Kit from the ADA’s Department of Saleable Materials:
ADA resource
Centers for Medicare and Medicaid
The following link is to information from the Centers for Medicare and Medicaid:
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Dental Office Safety
Safety in the dental office is a component of health care quality that refers to the precautions and other measures taken to diminish the risk of injury or harm to patients, the dental staff, and others in the dental office. It includes a wide variety of considerations such as regular maintenance of furniture and equipment; procedures for handling emergencies, such as fires; safeguards against medication errors; and protocol for handling patient behavior and interpersonal situations. The following resources provide further information on dental office safety and safety in health care facilities in general.
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Patient Record and Documentation
Thorough record keeping and documentation of care is necessary for diagnosis, treatment planning and clinical risk assessment, it is also invaluable for liability protection and practice management. The dental record contributes to the quality of care because in documenting the specific diagnostic tests and treatment provided, and the date of tests and treatment, continuity of care can be enhanced; in documenting the health history and other patient factors that may affect diagnosis and treatment, accurate diagnosis and selection of appropriate treatment is more probable; in documenting the patient’s response to treatment or the outcomes of care, the appropriateness of future care provided to the patient is enhanced. Also, the development of electronic records and informed consent is becoming increasingly essential for participating in dental plans. Electronic records are viewed as contributing to efficiency and, hence, higher quality of care. The following resources address specific aspects of the patient record and documentation.
State dental boards
Inadequate documentation can make it difficult for the dentist to defend his or her clinical care when it becomes the subject of a complaint to the state dental board and a subsequent review by the board is done. An excellent resource for understanding the importance of thorough documentation are the Web sites of the state boards of dentistry. They usually provide information on cases and so it is possible to study the most frequent types of inadequate documentation that resulted in adverse decisions against the dentist.
The following link lists state dental boards and provides easy access to them:
http://www.dentalwatch.org/org/boards.html
Content of the patient record
The American Dental Association’s Dental Practice Parameters include a statement on the content of a patient record. The statement is as follows: The health history, and the findings and observations of the comprehensive evaluation and general health assessment, including counseling and recommended preventive measures, as well as consultations with, and referrals to other health professionals, should be included in the patient’s dental record.
The dental practice parameters can be viewed at http://www.ada.org/prof/prac/tools/parameters/index.asp
Health history
For examples of health history forms see the ADA Catalog, item # 18
Dental informatics and electronic patient records
For an explanation of dental informatics and its application to dentistry see http://www.ada.org/prof/resources/standards/informatics.asp
The following links provide information and ADA policy on electronic dental records
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Contact Information
Office of Quality Assessment and Improvement
Telephone: 312-440-2772
E-mail: ellekd@ada.org |
