UNIVERSITY OF WASHINGTON SCHOOL OF DENTISTRY

Transcription

1 UNIVERSITY OF WASHINGTON SCHOOL OF DENTISTRY Subject: Quality Assurance Policy Number: Effective Date: November 1993 Revision Dates: April 2002 PURPOSE To develop a systematic and continuous protocol for assessing the patient care delivery system through the collection and analysis of reliable information. GENERAL POLICY Quality assurance is an on-going evaluation system that focuses on patterns of behavior rather than on isolated instances of behavior. Quality assurance is a mechanism for assessing the quality of care and implementing and evaluating changes in the patient care delivery system to maintain or improve the quality of care. Each service area within the School of Dentistry must play an integral part in the quality assurance system. The benefits to be derived from a systematic quality assurance program include the documentation of the effectiveness of the educational and patient care programs, the identification of the areas of the educational and patient care programs that could benefit from improvements, and the establishment of a mechanism for on-going identification of strengths and weaknesses that will support plans for development, revision, improvement, and expansion within the University of Washington School of Dentistry educational and patient care programs. STANDARD 5-1 The dental school conducts a formal system of quality assurance for the patient care program that demonstrates evidence of: a. standards of care that are patient-centered, focused on comprehensice care and written in a format that facilitates assessment with measurable criteria; b. an ongoing review of a representative sample of patients and patient records to assess the appropriateness, necessity and quality of the care provided; c. mechanisms to determine the cause(s) of treatment deficiencies; and d. patient review policies, procedures, outcomes and corrective measures.

2 IMPLEMENTATION The dimensions of quality care have been defined to include structure, process, and outcomes of care. The structural dimension of care includes such factors as facilities, equipment, organization, administration, and personnel. The process of care refers to issues involved in the delivery of care such as diagnosis, sequence of care, appropriateness of care, and technical skill. This dimension of assessment of care can be performed prior to treatment (prospective reviews), during treatment (concurrent reviews), and following treatment (retrospective reviews). The outcomes of care refer to improvements in oral health, health, or other areas as a result of receiving dental care. The elements of a quality assurance review in each of these dimensions must include the following: selection of an aspect of oral health care to be evaluated establishment of criteria and standards for quality oral health care which will be the basis for the assessment of quality comparison of the care/service that has been provided with the established criteria assessment of the quality based on the above comparison and the established standards action on the results of the evaluation to provide positive reinforcement for quality care or implement modifications to address deficiencies assure that actions result in maintenance or improvements in the quality of care I. Structure The Office of Clinical Services (OCS) will evaluate policies, procedures, facilities, equipment, and personnel involved in the central delivery of oral health care. Each department will evaluate policies, procedures, facilities, equipment, and personnel specific to its delivery of oral health care. II. Process The process evaluation of the quality assurance program is primarily built upon the dental record as the primary source of information on the care provided to

3 the patient. The process evaluation includes, but is not limited to, chart audits, infection control assessment, and competency/proficiency exams. A. Office of Clinical Services On a quarterly basis, as a part of the DENT Clinical Practice Management series, the OCS will conduct chart audits that evaluate basic components of care delivery and documentation. B. Departmental Reviews On a quarterly basis, in addition to the records assigned for comprehensive care, the departments of Oral Medicine, Prosthodontics, Periodontics, Pediatric Dentistry and Oral Surgery conduct chart audits through faculty evaluation and student self and peer evaluation of the medical/dental history data collection, clinical examination, radiographic examination, and diagnosis. Patients also receive a thorough exam following the completion of their care (see Appendix A) C. Health and Safety Task Force III. Outcomes On an ongoing basis, the Health and Safety Task Force will direct the Safety Assistant to present documentation of compliance with infection control and safety policies by faculty, students, and staff. The Health and Safety Task Force shall oversee compliance with Health and Safety regulations. A. Office of Clinical Services The OCS will conduct patient satisfaction assessments on an annual basis. The OCS will manage the compilation and dissemination of information gathered from the Patient Satisfaction Survey (see Appendix B) and the Patient Comment and Complaint Brochure (Appendix C). B. Departments of the School of Dentistry Each department will develop and submit to the OCS a protocol for postoperative review of treatment by types of procedures to assess the appropriateness and necessity of the care provided by students and faculty. On an annual basis, the departments will submit a report of the outcomes of the post-operative reviews. The OCS will be responsible for producing fee waiver reports and disseminating this information to the departments. The dissemination of the results of quality assessment activities is essential for the use of the data in quality maintenance and improvement. Each department will be responsible for providing the results of quality assessment

4 activities to the OCS. The OCS will be responsible for the maintenance of a comprehensive file on the quality assessment activities of the School of Dentistry and for publication of results in the Dean s newsletter. Appendices: Appendix A, Completed Treatment Review Appendix B, Patient Satisfaction Survey Appendix C, Patient Comment and Complaint Brochure Dean of UW SOD: Martha Somerman, Dean of the UW School of Dentistry December 22, 2008

5 APPENDIX A Completed Treatment Review University of Washington School of Dentistry Date: Patient # Faculty: Student: CHIEF COMPLAINT: Has the complaint been addressed? O Yes O No O Not Applicable If no, Why not? O Beyond Scope O Done Elsewhere O Overlooked O Patient Availability O Remission O Re-evaluation of need O Patient Decision O Financial Limitations O Medical Restrictions O Other PLANNED CARE: Has all planned care been provided? O Yes O No O No Plan If no, Why not? O Financial Limits O Patient Availability O Re-evaluation of need O Patient decision O Sequence of care not followed O Other SERVICE REVIEW: O All Okay Based on your clinical examination and considering the patient s oral environmental factors, the care outcome is satisfactory except as indicated below: Ref. # Department Tooth # Comments on problems? (use N for new) code or area Meets standard of care: O Yes O No Comments:

6 APPENDIX B: PATIENT SATISFACTION SURVEY WE CARE ABOUT YOUR CARE! Please take a minute to tell us about your recent experience as a patient at the UW School of Dentistry. Patient responses are used in making changes in how we provide treatment and improve our service. Your feedback is anonymous unless you request a response from us (see bottom of survey). This survey is also available on line at Please CHECK only one response to each statement below: Appointment: 1. Appointments were accessible when I needed them. 2. My calls were promptly returned. Strongly Disagree Disagree Neutral Agree Strongly Agree My Care Provider: 3. Talked to me with respect. 4. Listened carefully to me. 5. Explained what was going to happen before each procedure. 6. Seemed concerned about not causing me pain. 7. Used sanitary precautions and procedures. 8. Helped me to understand the overall plan for my treatment. Staff & Faculty: 9. The clinic personnel were courteous & helpful. General: 10. The fees were reasonable. 11. I plan to continue to get my treatment at the School. 12. Overall, I was satisfied with my dental care. Additional Comments: If you would like a response please include your name and address or phone number: Thank you very much for participating in our Patient Satisfaction Survey! Please return this form with your statement.

7 APPENDIX C