DEFINING CLINICAL GOVERNANCE IN GENERAL DENTAL PRACTICE: THE WINDS OF CHANGE? A TOY1
Effective Introduction It is this author’s quest to help dental professionals to improve their understanding of clinical governance (CG) and its application in general dental practice. On this journey, it is often necessary to explain to colleagues what is actually meant by the term. This has been a real challenge. It’s like trying to describe the wind: we all know what it is, but can you tell me what it looks like? Attempts to find a universally accepted, generic definition of clinical governance have been unsuccessful. This could be because it is too complicated to define in a short paragraph, or is grossly misunderstood by confused healthcare professionals; or perhaps it can only be understood by relating it to a particular area of healthcare. This is a bit like describing the effects of the wind, rather than the wind itself. This article will attempt to provide the busy dental professional with a partial working definition of CG, so that they may begin to benefit from the use of its principles.
Simple words Back in 2000, van Zwanenberg and Harrison described CG as “a powerful, new and comprehensive mechanism for ensuring that high standards of clinical care are maintained throughout the NHS and the quality of service is continuously improved.”1 These are very grand words, and probably quite appropriate for the corporate world of the modern NHS. However, for this author, these words don’t seem to fit with the world of general dental practice. This may explain why many members of the dental profession don’t really see that CG is of very great relevance or value to them. This is a shame, because the foundations of CG are rooted in total quality management (TQM) – a successful approach to running businesses and
organisations that has been tried and tested over many decades. TQM can be defined as “a process designed to focus on customer expectations, the prevention of problems, building commitment to continuous improvement in everyone and the promotion of participative management.”2 More words of a slightly less grand nature, but still a long way from the everyday reality of general practice. Let’s simplify the language a little more and see if it makes more sense. Try these nine simple words for a description of CG:
“Do the right thing right, first time, every time” 3
1
Andy Toy
BDS, MMEDSCI, MFGDP(UK)
32
“Do the right thing…” means providing care that is appropriate for that patient, taking into account their clinical and social circumstances, their wants and needs. It describes the most effective care for the patient. In this definition, “wants” might be described as the patient’s perception of the dental issue for which they have attended. “Needs” might be described as the clinician’s perception of that same issue. For instance, the patient may attend “wanting” tooth-coloured fillings to replace their metal ones. After careful examination, the clinician may discover that the patient actually “needs” some periodontal treatment as well as some form of aesthetic restorations to improve their appearance. A good professional would consider the patient’s expectations for treatment or “wants,” but would also consider their “needs.” The professional’s role is to use their specialised knowledge and expertise to establish a full picture of the patient’s expectations and social circumstances and marry that with a thorough assessment of their clinical condition, both for now and the likely future. Then they will be able to ascertain what the “right thing” (or things) for the patient may be. In short, to do the right thing, the professional must first really get to know the patient.
Efficient “Do the… thing right.” Rather than being effective, “doing the thing right” is about being efficient. This means using the resources of the practice with the minimum of waste. Resources can be defined as people, time, finance, materials, equipment and space. In terms of general dental practice, the most important resource is probably people, which is closely related to the efficient use of time. Both of these resources carry significant costs, so efficient use
P R I M A R Y D E N TA L J O U R N A L
of people and their time will inevitably make better use of the practice’s financial resources, too. Clinicians generally think that they are very efficient, because they learn to deliver NHS dentistry very quickly to meet all those targets. Indeed, a number of these colleagues become disillusioned with NHS dentistry because they can’t spend as much time on a procedure as they would like. However, observing many colleagues in practice, this author has come to the conclusion that while a dentist may be very fast at providing dental care, they can, at the same time, be very inefficient. Take the use of rubber dam in endodontics, for example. Using rubber dam has several obvious benefits: 1 Patient safety – no sharp instruments or chemicals down the throat 2 Improved clinical results 3 Improved vision for the dentist and DCP 4 Greater comfort for all concerned 5 Minimal risk of litigation. Even if you discount benefits 2-5, the benefit of patient safety is surely enough to justify its use 99% of the time. This author has often observed a flurry of panic in the team when a rubber dam is called for. The DCP usually has to go and find the kit in another room (if they can remember where it is). That creates a delay. They’re not really sure how to put it together, so they have to ask a more senior colleague (who is probably busy with another patient – another delay). Can you hear the “ping” of a flying rubber dam clamp as it falls from the flustered DCP’s grasp? After several more minutes of delay they arrive back in the surgery to find the dentist smiling on the outside and screaming on the inside. Given this scenario, it’s not surprising that research has shown that fewer than 20% of dentists actually use rubber dam.4 When questioned, dentists gave reasons such as “it takes too long to apply,” “the NHS fees didn’t justify its use,” and “I haven’t been trained.” Using the CG principle of identifying and managing risk, these reasons do not bear scrutiny. A well-trained team can apply a rubber dam within 30 seconds, which equates to an extra £1.50 at an hourly surgery cost of £180 (plus a few pennies for the disposable dam sheet).
V O L 3 N O 2 M AY 2 0 1 4
To achieve this requires a team that has really thought about their quality systems. Namely: • They have been trained to assemble the dam quickly • There are sufficient kits available close to every surgery • The team check the appointment book and plan ahead for the endodontic procedure, even preparing the kit the day before. A dentist who applies a CG/TQM approach to their practice would understand the need for investing some time and money in their quality systems, safe in the knowledge that they will recoup that with interest in the future. Over time there will be a direct payback financially, as minutes are saved at every visit. The rewards of greater patient safety and reduced risk of litigation will be available immediately. And no more internal screaming! In this example the dentist is very quick at the actual dental procedure, but the lack of quality systems means that they are very slow as a team at everything else. Ironically, if the dentist had invested in their systems, they would find they have more time to do the clinical procedures, leading to greater professional satisfaction too.
Consistent The last section of the definition is “first time, every time.” This means providing care that is of a consistent standard. The quality of care will rise if the practitioner simply aims to become more consistent at what they do. This aspect is particularly important in general dental practice because almost everything that happens there involves a team of people working together. Modern dental care is being provided by an ever-expanding group of professionals, with the patient moving from one to another. With every
REFERENCES 3 1
2
van Zwanenberg T, Harrison J. Clinical governance in primary care. Oxford: Radcliffe Press; 2000. Rattan R, Chambers R, Wakely G. Clinical governance in general dental practice.
4
exchange there is the potential for the patient to be “dropped.” This may result in a lower level of service at best, or, at worst, some physical harm. To minimise this risk, it is imperative that every member of the team knows what is expected of them and what they may expect of their colleagues. In a small established team, there is probably enough intuitive understanding for the risks of failure to be minimal. However, as the team size grows, so does the need for clarity of roles and responsibilities. This is where our old friends the written policies, procedures and templates are required. To the paperwork-phobic dentist these may seem an unnecessary burden, but experience of applying TQM in a host of industries shows that the application of written quality systems has a significant impact on raising quality. For instance, written procedures and checklists in emergency rooms have been shown to save lives.5 Please note the use of the term application – a written procedure that sits unused on an office shelf is still an unnecessary burden.
Conclusion Defining clinical governance in general dental practice in a meaningful way is quite a challenge. However, as practitioners, we are not only concerned with abstract concepts; we also want to know how we should apply the concepts in our patient care. Using the simple nine-word phrase does not provide a complete definition, but it can be very useful as a guide in our application of clinical governance. This should help patients, dental team members and dental businesses to benefit from the effects of clinical governance, even if we can’t describe it. A bit like harnessing the wind to benefit from clean, green energy, perhaps?
Oxford: Radcliffe Press; 2002. Donnelly, M. Making the difference: quality strategy in the public sector. Managing Service Quality 1999;9(1):47–52. Whitworth JM, Seccombe GV, Shoker K, Steele JG. Use of rubber dam and irrigant
5
selection in UK general dental practice. Int Endod J 2000;33(5):435–41. Ziewacz E et al. Crisis checklists for the operating room: development and pilot testing. J Am Coll Surg 2011;213(2):212-217.
33
Effective Introduction It is this author’s quest to help dental professionals to improve their understanding of clinical governance (CG) and its application in general dental practice. On this journey, it is often necessary to explain to colleagues what is actually meant by the term. This has been a real challenge. It’s like trying to describe the wind: we all know what it is, but can you tell me what it looks like? Attempts to find a universally accepted, generic definition of clinical governance have been unsuccessful. This could be because it is too complicated to define in a short paragraph, or is grossly misunderstood by confused healthcare professionals; or perhaps it can only be understood by relating it to a particular area of healthcare. This is a bit like describing the effects of the wind, rather than the wind itself. This article will attempt to provide the busy dental professional with a partial working definition of CG, so that they may begin to benefit from the use of its principles.
Simple words Back in 2000, van Zwanenberg and Harrison described CG as “a powerful, new and comprehensive mechanism for ensuring that high standards of clinical care are maintained throughout the NHS and the quality of service is continuously improved.”1 These are very grand words, and probably quite appropriate for the corporate world of the modern NHS. However, for this author, these words don’t seem to fit with the world of general dental practice. This may explain why many members of the dental profession don’t really see that CG is of very great relevance or value to them. This is a shame, because the foundations of CG are rooted in total quality management (TQM) – a successful approach to running businesses and
organisations that has been tried and tested over many decades. TQM can be defined as “a process designed to focus on customer expectations, the prevention of problems, building commitment to continuous improvement in everyone and the promotion of participative management.”2 More words of a slightly less grand nature, but still a long way from the everyday reality of general practice. Let’s simplify the language a little more and see if it makes more sense. Try these nine simple words for a description of CG:
“Do the right thing right, first time, every time” 3
1
Andy Toy
BDS, MMEDSCI, MFGDP(UK)
32
“Do the right thing…” means providing care that is appropriate for that patient, taking into account their clinical and social circumstances, their wants and needs. It describes the most effective care for the patient. In this definition, “wants” might be described as the patient’s perception of the dental issue for which they have attended. “Needs” might be described as the clinician’s perception of that same issue. For instance, the patient may attend “wanting” tooth-coloured fillings to replace their metal ones. After careful examination, the clinician may discover that the patient actually “needs” some periodontal treatment as well as some form of aesthetic restorations to improve their appearance. A good professional would consider the patient’s expectations for treatment or “wants,” but would also consider their “needs.” The professional’s role is to use their specialised knowledge and expertise to establish a full picture of the patient’s expectations and social circumstances and marry that with a thorough assessment of their clinical condition, both for now and the likely future. Then they will be able to ascertain what the “right thing” (or things) for the patient may be. In short, to do the right thing, the professional must first really get to know the patient.
Efficient “Do the… thing right.” Rather than being effective, “doing the thing right” is about being efficient. This means using the resources of the practice with the minimum of waste. Resources can be defined as people, time, finance, materials, equipment and space. In terms of general dental practice, the most important resource is probably people, which is closely related to the efficient use of time. Both of these resources carry significant costs, so efficient use
P R I M A R Y D E N TA L J O U R N A L
of people and their time will inevitably make better use of the practice’s financial resources, too. Clinicians generally think that they are very efficient, because they learn to deliver NHS dentistry very quickly to meet all those targets. Indeed, a number of these colleagues become disillusioned with NHS dentistry because they can’t spend as much time on a procedure as they would like. However, observing many colleagues in practice, this author has come to the conclusion that while a dentist may be very fast at providing dental care, they can, at the same time, be very inefficient. Take the use of rubber dam in endodontics, for example. Using rubber dam has several obvious benefits: 1 Patient safety – no sharp instruments or chemicals down the throat 2 Improved clinical results 3 Improved vision for the dentist and DCP 4 Greater comfort for all concerned 5 Minimal risk of litigation. Even if you discount benefits 2-5, the benefit of patient safety is surely enough to justify its use 99% of the time. This author has often observed a flurry of panic in the team when a rubber dam is called for. The DCP usually has to go and find the kit in another room (if they can remember where it is). That creates a delay. They’re not really sure how to put it together, so they have to ask a more senior colleague (who is probably busy with another patient – another delay). Can you hear the “ping” of a flying rubber dam clamp as it falls from the flustered DCP’s grasp? After several more minutes of delay they arrive back in the surgery to find the dentist smiling on the outside and screaming on the inside. Given this scenario, it’s not surprising that research has shown that fewer than 20% of dentists actually use rubber dam.4 When questioned, dentists gave reasons such as “it takes too long to apply,” “the NHS fees didn’t justify its use,” and “I haven’t been trained.” Using the CG principle of identifying and managing risk, these reasons do not bear scrutiny. A well-trained team can apply a rubber dam within 30 seconds, which equates to an extra £1.50 at an hourly surgery cost of £180 (plus a few pennies for the disposable dam sheet).
V O L 3 N O 2 M AY 2 0 1 4
To achieve this requires a team that has really thought about their quality systems. Namely: • They have been trained to assemble the dam quickly • There are sufficient kits available close to every surgery • The team check the appointment book and plan ahead for the endodontic procedure, even preparing the kit the day before. A dentist who applies a CG/TQM approach to their practice would understand the need for investing some time and money in their quality systems, safe in the knowledge that they will recoup that with interest in the future. Over time there will be a direct payback financially, as minutes are saved at every visit. The rewards of greater patient safety and reduced risk of litigation will be available immediately. And no more internal screaming! In this example the dentist is very quick at the actual dental procedure, but the lack of quality systems means that they are very slow as a team at everything else. Ironically, if the dentist had invested in their systems, they would find they have more time to do the clinical procedures, leading to greater professional satisfaction too.
Consistent The last section of the definition is “first time, every time.” This means providing care that is of a consistent standard. The quality of care will rise if the practitioner simply aims to become more consistent at what they do. This aspect is particularly important in general dental practice because almost everything that happens there involves a team of people working together. Modern dental care is being provided by an ever-expanding group of professionals, with the patient moving from one to another. With every
REFERENCES 3 1
2
van Zwanenberg T, Harrison J. Clinical governance in primary care. Oxford: Radcliffe Press; 2000. Rattan R, Chambers R, Wakely G. Clinical governance in general dental practice.
4
exchange there is the potential for the patient to be “dropped.” This may result in a lower level of service at best, or, at worst, some physical harm. To minimise this risk, it is imperative that every member of the team knows what is expected of them and what they may expect of their colleagues. In a small established team, there is probably enough intuitive understanding for the risks of failure to be minimal. However, as the team size grows, so does the need for clarity of roles and responsibilities. This is where our old friends the written policies, procedures and templates are required. To the paperwork-phobic dentist these may seem an unnecessary burden, but experience of applying TQM in a host of industries shows that the application of written quality systems has a significant impact on raising quality. For instance, written procedures and checklists in emergency rooms have been shown to save lives.5 Please note the use of the term application – a written procedure that sits unused on an office shelf is still an unnecessary burden.
Conclusion Defining clinical governance in general dental practice in a meaningful way is quite a challenge. However, as practitioners, we are not only concerned with abstract concepts; we also want to know how we should apply the concepts in our patient care. Using the simple nine-word phrase does not provide a complete definition, but it can be very useful as a guide in our application of clinical governance. This should help patients, dental team members and dental businesses to benefit from the effects of clinical governance, even if we can’t describe it. A bit like harnessing the wind to benefit from clean, green energy, perhaps?
Oxford: Radcliffe Press; 2002. Donnelly, M. Making the difference: quality strategy in the public sector. Managing Service Quality 1999;9(1):47–52. Whitworth JM, Seccombe GV, Shoker K, Steele JG. Use of rubber dam and irrigant
5
selection in UK general dental practice. Int Endod J 2000;33(5):435–41. Ziewacz E et al. Crisis checklists for the operating room: development and pilot testing. J Am Coll Surg 2011;213(2):212-217.
33
