Quality Assessment (QA) in the Indian Health Service dental program began in the late 1960’s with the development of criteria to assess technical quality of dental care. These evaluations were originally conducted by Area Dental Officers and later by senior IHS dental clinicians specifically trained as QA evaluators.
In 1981 a major revision of the QA document was accomplished. At that time criteria were developed to assess management and community components of dental programs to complement the technical QA criteria. Subsequent to 1981 additional criteria have been developed which address the indirect evaluation of dental care via chart audit, the evaluation of dental disease prevention activities, the evaluation of infection control procedures, and radiologic health and safety. In 1992, the JCAHO subsection was expanded to include examples of important aspects of care, indicators, and a data collection grid to facilitate implementation of the continuous quality improvement monitoring and review process. The prospective and concurrent approach of CQI driven by customer-defined quality complements the retrospective, point-in-time approach of the Technical QA and Chart Review.
After nearly three decades of evaluation, the quality assessment process has become increasingly complex and broad in scope. Consequently, the original format of “in-mouth” review of patients during a “normal” clinic day is no longer entirely adequate to meet present quality assessment needs of all levels of the IHS Dental Program.
To address these multiple areas of need, the current quality assessment documents address five major areas. These include: the technical quality of dental care, dental program management, community involvement, indirect methods of assessing clinical quality, and a section on preparation for JCAHO surveys.
The existence of these multiple documents affords the opportunity to customize the quality assessment process to meet distinct areas of need. Following is a brief description of the five QA formats that are included in this section:
Format A: JCAHO
The JCAHO format for quality assessment consists of meeting the accreditation requirements contained in current issues of the Accreditation Manual for Hospitals (AMH) or the Accreditation Manual for Ambulatory Care (AMAC), which are published annually and revised at least bi-annually by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). This format currently focuses on improving organizational performance in an interdepartmental manner, rather than on monitoring and evaluating intradepartmental aspects of care as it has in the past.
As of 1996, the AMH and the AMAC were divided into eleven functional chapters, which are themselves divided into Patient-Focused functions and Organization functions. The Patient-Focused functions include Patient Rights and Organization Ethics, Assessment of Patients, Care of Patients, Education of Patients and Family, and Continuity of Care. Organization functions include Improving Organization Performance, Leadership, management of the Environment of Care, Management of Human Resources, Management of Information, and Surveillance, Prevention, and Control of Infection.
Format A gives a brief history and overview of IHS involvement in JCAHO accreditation activities. However, due to the rapid changes that have been occurring in the AMH and AMAC, specific requirements for JCAHO accreditation must be obtained from the most recent issues of the JCAHO manuals.
Format B: Evaluation of Technical Quality of Care
This format consists of the traditional evaluation of clinical quality of care. It involves an on-site visit by a quality of care evaluator and includes the assessment of specific patients scheduled during a “normal” clinic day using the Technical QA Document. When the assessment involves patients being treated by a dental hygienist, the evaluator and hygienist may refer to those criteria marked by an asterisk (*) to indicate criteria applicable to hygienists.
Format C: Chart Review
This format consists of the indirect review of clinical quality of care. A chart review is performed using the criteria found in the “Indirect Review of Clinical Quality and Risk-Management” subsection of Section VII.
An alternate format combines Format B and Format C. It consists of the specific scheduling of patients who have had services completed at an earlier date. Evaluation of these services in conjunction with a review of patient records affords the opportunity to review completed cases as well as records documentation.
Each of these formats should also include a review of laboratory cases.
Format D: Evaluation of Community Involvement
The Evaluation of Community Involvement may be conducted concurrently with review of technical quality of care or reviewed separately. The community and management evaluation documents, while professionally conceived, are not limited exclusively to use by dental professionals. They may be assessed by nondental persons with general background knowledge in these areas. Uses for the documents include orientation of new staff, self-evaluation by individual professionals, establishment of program standards, and assessment of program activities which impact on oral health.
Format E: Evaluation of Management of Oral Health Programs
Use of Evaluation
This evaluation was developed as a measurement of productivity, cost-effectiveness, and appropriateness of dental services delivered in public health dental programs which exist in Tribal and IHS programs. The evaluation and results provide useful measurements as a baseline for changing program emphasis, direction, and plans. Much of this can only be measured by reviewing process indicators which are believed to contribute to effectiveness and efficiency of the program. More specific outcome measurements are derived by reviewing the dental data indicators listed on page VII-102 and VII-103. Results can be compared to averages from other IHS and Tribal programs and data from contracting patients to private practice.
Considerable latitude exists for using a combination of subsections found in Section VII of the Oral Health Program Guide to match situational requirements. Each individual utilizing the document should recognize the dynamic nature of its contents and be encouraged to contribute to its improvement. Future experience in the quality assessment arena will permit and foster continued evolution of the program.
Policies and Responsibilities for Implementing the Quality Assessment System
1. The overall responsibility for the quality of health care in the Area lies with the Area Director, with specific responsibility for quality of dental care falling to the Area Dental Consultant or other senior Dental Program staff. The Chief, Area Contracting Branch is responsible for Tribal/638 program evaluation and may delegate the responsibility for evaluation of the dental component to the ADO. The ADO may delegate this responsibility to other dentists. Other programs implementing this system will have administrative lines of authority which will modify this requirement.
2. Technical evaluation should be performed on each dentist new to the program within the first six months of his/her entering upon duty and thereafter as appropriate. After an initial baseline evaluation, community involvement and management of oral health programs should be reevaluated at least every two or three years. Some programs may prefer to use the results of the technical evaluation every two years in support of privileging, but most of that support should come from provider profiles derived from results of continuous monitoring and review.
3. Private dentists or dental hygienists under IHS contractual agreement working in IHS or Tribal clinics should be evaluated periodically by a trained evaluator, utilizing methodology and evaluation criteria/indicators acceptable to them.
4. The evaluatee must be provided the criteria/indicators and standards for the evaluation prior to the evaluation. No evaluation can be conducted upon services provided or methods employed prior to the time the evaluatee was provided the criteria and standards for the evaluation.
5. The evaluation will be by personal contact between the evaluator and evaluatee and review of existing records as appropriate.
6. Contact with the Service Unit Director or the Tribal Health Administrator is a requirement before the evaluation. A sample letter for follow up of this contact is suggested on pages VII-68 and VII-69.
7. Tact and discretion must be preeminent throughout the evaluation process. The dignity of the evaluatee must be preserved in all instances.
8. When the quality of a service provided is considered questionable by the evaluator, but is not definitely unsatisfactory, the decision must be in favor of the evaluatee and rated satisfactory.
9. Differences in training backgrounds are recognized as sources of potential philosophical differences in criteria for dental procedures performed by dental practitioners. Differences may also arise between the evaluator and evaluatee as to the extent or significance of a deficiency for any criterion. A mechanism is provided for addressing these differences. An example of the process is given on page VII-25, criterion #3, using tooth preparation and restoration as an example. If concurrence of satisfactory or unsatisfactory cannot be agreed upon through discussion between the evaluator and evaluatee, the criterion will not be counted as unsatisfactory. However, the nature of the dispute concerning the criterion will be documented in a narrative summary. Where it is possible that the discussion of the disputed criterion can take place without the evaluatee returning to observe the deficiency, discussion of the disputed criterion will be delayed until the closeout meeting. This process can be applied to any disputed criterion in Section VII.
10. The evaluation must include a confidential closeout meeting where all reports are signed by both the evaluator and evaluatee. Reports for each subsection being evaluated are included at the end of each subsection.
11. The evaluatee and responsible administrative authorities must be advised of all evaluation findings. Further dissemination of findings must be by mutual consent of the evaluatee and responsible administrative authorities.
Right of Appeal
12. The evaluatee has the right of appeal for a reevaluation by the same or a different evaluator.
The Joint Commission on Accreditation of Health Care Organizations
For many years, all Indian Health Service (IHS) facilities have been directed to become accredited by the Joint Commission on Accreditation of Health Care Organizations (JCAHO). Additionally, all hospitals must be accredited by either the Health Care Financing Administration (HCFA) or the JCAHO in order to collect Medicare reimbursements, which comprise up to one-third of the operating budgets of many IHS facilities. For this reason, as well as the prestige that is conferred on a facility by JCAHO accreditation, many Tribal and Urban programs also choose to seek JCAHO accreditation.
For the past ten years, the JCAHO accreditation criteria have been undergoing rapid and frequent revision. In 1986, the JCAHO embarked on what it calls the “Agenda for Change,” which is altering the focus of the survey process from the structure of the health care organization (i.e., the resources available to the organization to provide care) to a focus on the processes that exist within the institution to provide services, and ultimately to a focus on outcome measures. Additionally, the JCAHO had anticipated initiating an Indicator Monitoring System (IMS), with a set of standard indicators that would be monitored by all facilities undergoing accreditation, by the mid 1990’s. However, as of this writing, the IMS has not yet been formally adopted, and none of the indicators under development relate to dental programs.
Since 1990, the Accreditation Manuals for Hospitals (AMH) and for Ambulatory Health Care have changed from departmentalized criteria and Quality Assurance to the concept of Continuous Quality Improvement (CQI) in the 1992 AMH and finally to manuals which are currently organized around important organizational functions and organizational Performance Improvement (1995 AMH and 1996 Ambulatory Health Care Manual). Surveys now focus on inter- rather than intra-departmental activities, so dental programs will have to coordinate their programs with the rest of their facility’s in order to pass muster. It is reasonable to assume that these changes will continue into the foreseeable future with each new issuance of the various JCAHO manuals.
IHS Dental Program and JCAHO Accreditation
The information contained in this document is meant to assist IHS Dental Programs in becoming a meaningful part of the accreditation process of the JCAHO. Even though it is difficult to predict how thoroughly a dental program will be evaluated, some historical patterns provide guidance in preparation for future surveys. Programmatic components which seem to have a higher probability of review include: policy and procedure manuals, in house quality improvement (now Performance Improvement) programs, infection control protocols, facilities and biomedical maintenance, safety procedures, evidence of staff meetings and inservice training, privileging and credentialing of dental officers, emergency drug kits, nitrous oxide or sedation protocols, and adequacy of documentation of the medical record for dental treatment procedures.
Frequently Reviewed Components
A number of other observations may assist field dental programs in preparation for JCAHO surveys. Hospital based dental programs seem to receive more attention than those located in outpatient facilities, although this discrepancy has been closing in recent years. The review procedure is becoming more process and outcome oriented, and active ongoing interdepartmental quality improvement is being examined more critically. It should be noted that the traditional IHS quality of dental care evaluation using IHS Technical Quality of Care documents is not sufficient to meet the requirements for ongoing quality improvement, although it can be an important part of peer review activities in the dental program.
The actual application of JCAHO standards to IHS Dental Programs will most likely remain variable and subject to change. Area Dental Programs should monitor JCAHO interaction with field programs and to assist field programs in preparation for these accreditation surveys.
JCAHO Survey and Accreditation Process
The JCAHO defines hospital sponsored ambulatory care services as “the delivery of care pertaining to non-emergency, adult, adolescent, and pediatric ambulatory encounters, whether performed through the clinical departments of the hospital or an organized ambulatory program, regardless of the physical location of such services (that is, within the hospital, on its campus, or at off campus satellite facilities).” Hospital sponsored ambulatory care services are provided by one or more organizational unit(s), or components thereof, of the hospital under the responsibility of the governing body. Standards are applied to evaluate a hospital’s performance in providing ambulatory care services.
Those dental clinics residing in a hospital meet the above definition and should comply with the standards in the Accreditation Manual for Hospitals (AMH). Those dental clinics located in outpatient facilities should comply with the standards contained in the Accreditation Manual for Ambulatory Health Care. These may be checked out from the Dental Field Support and Program Development Section, IHS HQ West, Albuquerque, NM (505-248-4175). Most facilities that have applied for accreditation will have a Quality Improvement Coordinator who has copies of these documents.