Unintended consequences and challenges of quality measurements in dentistry.

BACKGROUND: In recent years, several state dental programs, researchers and the Dental Quality Alliance (DQA) have sought to develop baseline quality measures for dentistry as a way to improve health outcomes, reduce costs and enhance patient experiences. Some of these measures have been tested and validated for various population groups. However, there are some unintended consequences and challenges with quality measurement in dentistry as observed from our previous work on refining and transforming dental quality measures into e-measures. MAIN BODY: Some examples of the unintended consequences and challenges associated with implementing dental quality measures include: a de-emphasis on patient-centeredness with process-based quality measures, an incentivization of unethical behavior due to fee-for-service reimbursement systems, the risk of compromising patient and provider autonomy with plan-level measures, a disproportionate benefits of dental quality measurement going toward payers, and the risk of alienating smaller dental offices due to the resource-intensive nature of quality measurement. CONCLUSION: As our medical counterparts have embraced quality measurement for improved health outcomes, so too must the dental profession. Our ultimate goal is to ensure the delivery of high quality, patient-centered dental care and effective quality measurement is the first step. By continuously monitoring the performance of dental quality measures and their continued refinement when unintended consequences are observed, we can improve patient and population health outcomes.

Development of an Inventory of Dental Harms: Methods and Rationale.

OBJECTIVES: While adverse events (AEs) are all too prevalent, their underlying causes are difficult to assess because they are often multifactorial. Standardizing the language of dental AEs is an important first step toward increasing patient safety for the dental patient. METHODS: We followed a multimodal approach building a dental AE inventory, which included a literature review; review of the MAUDE database; a cross-sectional, self-administered patient survey; focus groups; interviews with providers and domain experts; and chart reviews. RESULTS: One hundred eight unique allergy/toxicity/foreign body response, 70 aspiration/ingestion of foreign body, 70 infection, 52 wrong site/wrong patient/wrong procedure, 23 bleeding, 48 pain, 149 hard tissue injury, 127 soft tissue injury, 91 nerve injury, 171 other systemic complication, and 177 other orofacial complication were identified. Subtype AEs within the categories revealed that allergic reaction, aspiration, pain, and wrong procedure were the most common AEs identified among known (i.e., chart reviews) and hypothetical (i.e., interviews) sources. CONCLUSIONS: Using a multimodal approach, a broad list of dental AEs was developed, in which the AEs were classed into 12 categories. Hard tissue injury was noted frequently during interviews and in actuality. Pain was the unexpected AE that was consistently identified with every modality used. PRACTICAL IMPLICATIONS: Most AEs result in temporary harm with hard tissue injury being a common AE identified through interviews and in actuality through chart reviews. Acknowledging that AEs happen is an important step toward mitigating them and assuring quality of care for our patients.

Perspectives of Dental Patients About Safety Incident Reporting: A Qualitative Pilot Study.

OBJECTIVES: Patient reporting of safety incidents is one of the hallmarks of an effective patient safety protocol in any health care setting. However, very little is known about safety reporting among dental patients or effective strategies for engaging them in activities that promote safety. The goal of this study was to understand the perceptions of dental patients about the barriers and benefits of reporting safety incidents. We also sought to identify strategies for improving patient reporting of safety incidents in the dental care setting. METHODS: We conducted 3 focus group sessions with adult dental patients (n = 16) attending an academic dental center from November 2017 to February 2018. Audio recordings were transcribed and analyzed using a hybrid thematic analysis approach with NVivo software. RESULTS: Dental patients mainly attributed safety incidents to provider-related and systemic factors. They were most concerned about the financial implications, inconvenience of multiple visits, and the absence of an apology when an incident occurred. The major recommended strategies for engaging patients in safety-related activities included the following: proactive solicitation of patient feedback, what-to-expect checklists, continuous communication during visits/procedures, after-visit summary reports, clear incident reporting protocols, use of technology, independent third-party safety incident reporting platforms, and a closed feedback loop. CONCLUSIONS: This study offers a roadmap for proactively working with dental patients as vigilant partners in promoting quality and safety. If properly engaged, dental patients are prepared to work with dental professionals to identify threats to safety and reduce the occurrence of harm.