Top tips for clinical governance in primary care

Clinical governance can in simple terms be described as everything and anything related to quality of outcomes in the clinical environment. More technically, clinical governance can be defined as a framework through which UK National Health Service (NHS) organisations and their staff are accountable for continuously improving the quality of patient care.¹ Whilst the pillars of clinical governance are often quoted as clinical effectiveness, risk management, patient experience and involvement, communication, resource effectiveness, strategic effectiveness and learning effectiveness, in this short paper we will describe in our opinion key areas related to primary dental care and its delivery.¹

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• 1. Use of guidelines and standards

Guidelines and standards exist to support and assist all dental team members in delivering safe, high-quality and effective care to patients, but the different terms can sometimes lead to confusion.² Standards in dentistry define each as:³

Clinical guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.

A standard is a definable measure against which existing structures, processes or outcomes can be compared.

Guidelines and standards have subtly different purposes. Guidelines provide recommendations in the management of oral conditions that take into account the context in which the care is being provided, the best available evidence, what good practice looks like and recognise that it is not practical or reasonable to expect every patient to receive identical healthcare.³ Every patient is unique and care should be delivered that meets their individual oral health care needs, taking into account a range of factors.

Clinical standards are specific and measurable.³ They define specific elements of clinical care that need to be correct to optimise outcomes for patients. Standards often represent a minimum essential level of patient care and they may additionally be enforced through systems of governance to promote accountability and patient confidence.

The differences highlighted are described in detail in CGDent's Standards in dentistry, which can be accessed online for free at https://cgdent.uk/wp-content/uploads/2021/08/Standards-in-Dentistry-2018-text.pdf.

There are a plethora of guidelines and standards continually being developed and/or updated and it can be challenging keeping up to date with the latest versions. Membership of professional organisations, attendance at CPD events and reading key dental journals can be an effective way of keeping up to date, and many organisations now have social media accounts that regularly share updates for the dental profession such as the British Dental Journal and the British Dental Association.

• 2. Audit - a tool for improvement

Clinical audit is a key requirement for all healthcare settings and an expectation of dental regulators across the four UK nations. Performing clinical audit can sometimes feel like a burden but it is essential for establishing and maintaining standards in clinical care. Clinical audit can be defined as 'the systematic review of activity in practice against standards, in order to improve patient care'.⁴ While traditionally audit has been regarded as a quality assurance process, it is increasingly being recognised as one of the fundamental tools in quality improvement, the difference being improvement deliberately intends to bring about immediate, positive change in the system rather than merely observing a defined standard.

Using audit for quality improvement can be a force for good in practice, and involving all members of the dental team can foster a spirit of common purpose and ownership in roles and responsibilities, ultimately improving patient care but also benefitting the working culture of a practice and improving its effectiveness and efficiency. A recent guide has been published providing tips on carrying out audit and the various elements that comprise audit activity.⁴

A good way to embed audit into the fabric of practice is to include it as part of the practice's annual quality improvement plan, which sets out the framework for how the practice meets regulatory compliance and demonstrates quality is at the heart of the service. Having a clear plan for service improvement can also help to reassure patients and members of the public that service standards are continually reviewed and that the practice is a progressive and forward-thinking provider. For those interested in the various quality improvement tools, the West of England Academic Health Science Network has produced an excellent guide.⁵

• 3. Risk management

Identifying and managing risks in dental practice is an increasingly complex area covering a diverse range of topics. Risk assessment is a systematic examination of work activities to identify what could go wrong and cause harm, and whether adequate controls are in place.³ The BDA provides comprehensive information to assist practices in meeting these requirements through advice, model polices and protocols, and changes in policy made by regulators (www.bda.org).

One particular area of risk management that warrants further attention is learning from clinical incidents to help develop a culture of patient safety. While this is routine in large healthcare organisations, it is still underdeveloped and implemented in primary dental care.^3,6 Identification of clinical incidents, their reporting and monitoring is fundamental to clinical risk management and preserving patient safety. Being open, transparent and honest when things go wrong is a professional responsibility and the cornerstone of ethical practice. It is important to learn from incidents to prevent their reoccurrence and to instigate changes to systems, processes or staff training through a process of root cause analysis to improve clinical outcomes and prevent harm. In addition, all staff should understand their professional responsibilities to raise concerns about the quality of care if they feel they are below acceptable standards without fear of personal reprisal or blame.

There is increasing research and policy interest in this area and it is likely patient safety reporting in primary dental care will become easier, better defined and routine in years to come.³

• 4. Complaints handling

All members of the dental team strive to achieve optimal outcomes for their patients, often under the most challenging of circumstances which may be clinical, operational or where patient expectations exceed the outcome that can be reliably predicted. Understandably, therefore, our first instinct upon receipt of a verbal or written complaint may be to take the matter personally and respond defensively.

Successful complaint handling involves the whole team, from 'front of house' right through to the responsible person who signs off the final response; amongst the key elements are prompt acknowledgement, the provision of a copy of the practice complaints protocol and keeping lines of communication open. It's counter-intuitive, but making it easy for patients to complain at practice level gives an early opportunity to achieve local resolution and reduce the risk of escalation to third parties.

Identifying and managing risks in dental practice is an increasingly complex area

Get early-stage guidance and support from your indemnity organisation, particularly if the patient is seeking compensation. On a practical level, it is important to aim to understand the concerns from the patient's perspective and what they are looking for by way of satisfactory resolution. This may not always be reasonable or feasible, but at least you have a good starting point to resolve the complaint.

In many cases, a simple clarification of a misunderstanding or the offer of a second opinion to explain any biological complication and to discuss further options may be sufficient. If things haven't gone so well, the duty of candour requires that the patient receives an honest explanation, and you should set out what you are able to do to remedy the situation.

Receipt of a complaint does not necessarily mean that the relationship between the patient and dental professional is irretrievably broken - although this may sometimes be the case. As in other public-facing areas of life such as the retail and service sectors, where complaints are well handled and equitable solutions found, patients can often become great advocates for the practice.

While complaints offer an opportunity for reflective learning and improvement, they can, at the time, be stressful for hard-working dental professionals to deal with. These stresses can be mitigated by a well-trained team approach and accessing support networks including those provided by your defence organisation. Above all else, keep things in perspective and don't try to deal with them in isolation.

• 5. Patient involvement

Engaging with patients effectively is key to achieving the best possible outcomes in patient care. It is, therefore, important to ensure that patient involvement remains at the forefront throughout the whole of the patient journey. It is human nature for us to be more receptive and feel more positive towards an experience, when we believe that our views are being listened to and our opinions are valued.

The concept of shared decision-making is widely recognised across the profession as being fundamental to providing high-quality patient care. Evidently, it plays a significant part in the regulatory assessment framework adopted by the Care Quality Commission (and similar bodies in the other UK nations) forming several parts of the Key Lines of Enquiries (KLOEs) that demonstrate a service is both responsive and well led. So, how do we ensure that we portray a positive and open approach that will empower patients to play an active role?

It is important to remember that one size does not fit all and that patients engage in different ways. With that in mind, try to devise and encourage as many different mechanisms and forums for patients to provide their views, opinions and feedback as possible. Encourage open channels of communication for receiving both positive and negative feedback.

Make patient surveys easily accessible by providing them in both electronic and paper formats available in reception areas, including web links on patient letters and emails, and promoting through social media to gather volumes of anonymous feedback that when collated can help to identify reoccurring themes and trends. Promote patient participation at regular patient focus groups, which can be held either in person or remotely. This provides a forum for patients to give their personal experiences but also allows an opportunity for channelling questions directly.

Not only is it important to engage and listen to patients' feedback, but it is even more important to learn from patient experiences and use them to elicit positive change. Utilise the feedback gathered from patient surveys, focus groups and the learning outcomes from complaint investigations and disseminate them to all members of the team. Create a culture of celebrating successful outcomes and acknowledging and learning from when things have gone wrong.

• 6. Data protection

The General Dental Protection Regulation (GDPR) came into force in 2018 and changed the landscape of data protection. What are the key aspects?

Appoint a Data Protection Officer (DPO): practices that provide NHS services must appoint a DPO'to monitor internal compliance, inform and advise on your data protection obligations, provide advice regarding Data Protection Impact Assessments (DPIAs) and act as a contact point for data subjects and the Information Commissioner's Office (ICO)'.

The ICO state that the DPO must have expert knowledge in the area of data protection and may be an existing member of staff, an external employment or shared with another organisation.

Review privacy notices: ensure that you are providing the required information to patients regarding how you will manage their personal data. This should include:

• The legal purpose for processing

• Retention periods

• Who the information is shared with.

Subject access request: review the process for subject access requests and ensure that it meets the requirements under GDPR, which can be found on the ICO website.⁷ Make sure the process is clearly communicated to patients.

In these top tips, we build on the clinical tips discussed previously, expanding on routes to quality improvement in day-to-day practice. As with clinical tips, the aspiration is to improve outcomes for patients and improve satisfaction in day-to-day clinical work for all team members.