The Department of Health is already introducing policies to enhance patient-centred treatment which not only includes employing qualified, occupationally competent staff participating in continuing professional development (CPD) but also clinical governance. Clinical governance is defined by the Department of Health as ‘a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards by creating an environment in which excellence in clinical care will flourish’. Clinical governance does, however, also apply to dental care provided outside the NHS. It may be stated more simply as ensuring that patients and their carers get the best possible deal out of the healthcare service provided.

Quality care

Clinical governance is all about providing quality care and quality management but it is important to remember that it does not happen by accident; it has to be planned. Clinical governance should include:

  • Clear lines of responsibility and accountability for the quality of clinical care

  • A comprehensive programme which improves quality

  • A means by which all members of the dental team can be involved in the development of good practice

  • A means by which patients can be involved in the development of dental care services as well as being appropriately informed about their proposed treatment

  • Clear policies for managing risk

  • Procedures for all members of the dental team to identify and remedy poor performance

  • A programme of continual quality improvement including CPD and audit.

There was a time when health care was delivered with little or no reference to the patient. The dentist decided what treatment should be provided without any discussion with the patient either before or during treatment. Times have radically changed and it is now an ethical responsibility placed on the dental team to obtain informed consent from a patient prior to undertaking any treatment. In addition, patients not only want value for money, they want quality for money. However, it is important to be able to prove not only to patients that quality issues are being addressed but also to all members of the dental team and healthcare providers such as the NHS. This involves being able to answer the following questions:

  • Do the dental team understand the practice quality policy?

  • Have the entire dental team been consulted?

  • Have reasonable, measurable and achievable performance standards been set?

  • Do these standards relate to patient needs?

  • Is training provided?

  • Is there a monitoring system in place?

  • Is corrective action taken when necessary?

As can be seen, these questions address issues which are relevant to all members of the dental team. Some practical examples of clinical governance are:

  • Criteria for extraction of wisdom teeth

  • Patient satisfaction surveys

  • Criteria for taking radiographs

  • Criteria for infection control within the clinical environment

  • Clinical examination, record keeping standards and protocols.

Standards

There are three important areas to be considered.

Setting standards

Self-regulation

This is undertaken by the General Dental Council (GDC), which is responsible for the protection of the patient by setting standards of both clinical care and education of those members of the dental team registered with the GDC. The GDC has undergone a considerable modernisation process. In the NHS Plan for England, the Government set out minimum requirements for the modernisation of regulatory bodies. It stated that ‘they must be smaller with much greater patient and public representation, have faster, more transparent procedures and develop accountability to the public and the Health Service’. The GDC has committed itself to this modernisation and the structure has now been radically changed to include a much greater lay and DCP (dental care professionals) representation. The changes also include a new look at the education, training and development of the dental team.

National Institute for Health and Clinical Excellence (NICE)

The role of NICE is to provide clinical guidelines based on clinical and cost-effectiveness and to advise on clinical methodology and information on best practice. It has so far had a limited input into dentistry but has produced guidance on the extraction of wisdom teeth, recall examination intervals, and the use of prophylactic antibiotics prior to invasive dental treatment.

National Service Framework

This body advises on the organisation of services within the NHS to meet specific health problems and advises on the standards that these services will have to meet.

Delivering standards

Quality improvement

This includes reviewing one's own clinical practice and then measuring it against a recognised standard (audit), undertaking evidence-based practice and using clinical indicators as an external measure of clinical performance. Examples of clinical indicators in dentistry are the number of teeth present, the number of carious teeth and the Basic Periodontal Examination (BPE) score. Since these indicators can now be recorded electronically as part of routine clinical record keeping, it makes it easier to monitor the effects of clinical advice or treatment on the dental health of a patient or group of patients.

Continuing professional development

Following statutory registration, compulsory CPD requirements were introduced in August 2008 by the GDC. Details of these can be obtained from the GDC website at www.gdc-uk.org.

Examples of clinical indicators in dentistry are number of teeth present, number of carious teeth and the Basic Periodontal Examination (BPE) score.

Continuing professional development (CPD) is often perceived as education that continues if and when required by the individual. It is in fact lifelong learning that should be ongoing throughout a person's working life. It does not always involve formal studies, and can be achieved through various methods of learning.

It is an individual's responsibility to undertake CPD in order to maintain, enhance and broaden professional knowledge already gained. The benefits of this process can include:

  • Increased job satisfaction

  • Promotion of awareness of issues or problems

  • Improved communication with colleagues

  • Improved efficiency

  • Improvement in career prospects

  • A greater commitment to the workplace.

CPD will enable the dental team and help prepare them for changing roles or circumstances in the practice or clinic and help make them safer workers who understand the implications of the roles and responsibilities they are undertaking in the workplace. It can also prevent complacency and inertia, which could potentially put patients or staff at risk.

To achieve a high quality standard and appropriateness of CPD, it needs planning thoroughly via appraisals or performance review. This process will identify the needs of the individual and the needs of the organisation within the requirements imposed by the GDC. It encompasses the short-term and long-term goals that need to be met, and how these can best be achieved. These needs will be addressed through:

  • Implementation: What, where, when and how these needs can be met

  • Evaluation: Was the CPD appropriate and of high quality?

  • Review: Where do we go now?

If carried out properly, CPD will produce an efficient, enthusiastic, safe and understanding individual in the workplace who will be a great asset to any employer.

The GDC plan to introduce revalidation for all the dental team over the next five years. This will bring the profession in line with the medical model already in place.

Clinical risk management

It is necessary to have a means of recording adverse effects as a result of using a drug, material or technique as well as having mechanisms for recognising and dealing with poor performance. These include:

  • Identification of risks

  • Risk assessment

  • Risk reduction, elimination and transfer

  • Reporting and recording adverse events.

Complaints handling

Protocols should be developed, followed and observed by all members of the dental team with appropriate training where necessary. Every practice or clinic should have an infection control policy.

The procedures for dealing with patient complaints should be defined and made known to the patients. For patients receiving treatment within the NHS, the procedure has been well established. However, in response to a Government initiative, a Patients Complaints Service was established in 2007 to deal specifically with complaints from patients receiving treatment on a private payment basis: details about this service are available from the GDC website although the Complaints Service has its own website at www.dentalcomplaints.org.uk which is more readily accessible to patients.

Compliance with Health and Safety regulations

Protocols should be developed, followed and observed by all members of the dental team with appropriate training where necessary. Every practice or clinic should have an infection control policy. Advice sheets on both health and safety and infection control are available from the British Dental Association (www.bda.org) and the British Association of Dental Nurses (www.badn.org.uk).

Monitoring standards

Commission for Health Improvement/Healthcare Commission

This body was set up by the NHS in 2000 to independently guarantee quality in the NHS and to undertake rolling reviews of NHS trusts. On 31 March 2004 the Commission for Health Improvement (CHI) ceased operating. All its functions were taken over by the Healthcare Commission. The Healthcare Commission was responsible for reviewing complaints about the NHS or independent healthcare services in England that have not been resolved locally. The Healthcare Commission fulfilled its role in promoting quality in healthcare through providing an independent assessment of the standards of services provided by the NHS, private healthcare and voluntary organisations. It achieved this by:

  • Regulating and inspecting NHS, private and voluntary healthcare providers

  • Reviewing formal complaints about the NHS that have not been resolved

  • Handling complaints about private and voluntary healthcare service providers

  • Investigating serious failures in NHS, private and voluntary services.

The Health and Social Care Act (2008) has replaced the Healthcare Commission with the Care Quality Commission which came into operation in April 2009.

National performance frameworks

These have been established to judge how well each part of the NHS delivers quality services. They measure performance from a patient's point of view and look at such issues as:

  • Health improvement gained, ie the outcome of healthcare provided

  • Access to care facilities, ie what are the facilities available and are they what the patient needs and are they easy for the patient to get to?

  • The efficiency of the services provided

  • The experiences (both positive and negative) of the patient or carer.

Patient surveys

These can give an important overview of patient opinion on many aspects of patient care in different areas of the practice or clinic. They can be made quite specific which makes them quicker for patients to complete and are thus more likely to result in a higher response rate. Surveys can also be undertaken as part of an audit programme or research project.

To take part in Vital verifiable CPD and complete the questions based on this article, turn to page 56 for instructions on how to subscribe.