Dental mythbuster 17: Audit and improvement in primary dental services

Clinical audit and quality improvement form part of a service’s quality assurance and risk management.

Audit: why is it important?

Clinical audit reviews current practice and compares this to expected published standards. It:

• helps identify areas of practice that need improvement
• identifies and reinforces areas of good practice.

Ultimately, it is a tool to improve the quality and efficiency of patient care.

Quality improvement: why is it important?

Quality improvement is a systematic approach, using specific techniques to improve quality. It:

• allows real time change in current practice and provides opportunity to evaluate effect
• promotes teamwork and collaboration (Peer review)
• prevents poor practice.

What we look for on inspection

We expect providers to be involved in audit and/or quality improvement to:

• demonstrate good governance (Regulation 17)
• deliver care and treatment safely (Regulation 12), and
• ensure premises and equipment are clean and suitably maintained (Regulation 15).

You may also be required to conduct specific audits as part of your local contractual arrangements with NHS England.

We may ask to see evidence that audits have been carried out as part of your quality assurance and risk management processes. This would include evidence of:

• the audit data collection
• the action plan
• subsequent action taken. 

Audits

Essential (must do) audits:

You must have effective quality assurance programmes covering:

• Infection prevention (decontamination) and control: complying with HTM01-05 (Decontamination in primary care dental practices) shows you have valid quality assurance systems in place. As a minimum, audit decontamination processes every 6 months, with an appropriate review dependent on audit outcomes. You could use the Department of Health dental toolkit. 
• X-rays: both IRR17 and IR(ME)R 2017 place a legal responsibility on practices to establish and maintain audits for dental radiology. There are details of how to carry out the audit under section 5.4.2 of “Guidance Notes for Dental Practitioners on the Safe Use of X-ray Equipment” endorsed by the College of General Dentistry (CGDent).
• Accessibility: All organisations providing services to the public must audit their facilities and ensure they comply with the Equality Act 2010.

Desirable (should do) audits or improvement projects:

• antimicrobial prescribing
• clinical record keeping
• other audit topics suitable for your practice.

How to carry out an audit

1. Identify the audit topic

   This may be a recommended topic as discussed above, or one that you have chosen to address particular issues in your practice. For example, patient satisfaction.

2. Set the standard

   This may be a standard already set out in guidance (for example, quality ratings of radiographs as set out in the Faculty of General Dental Practice UK (FGDP) guidance), or a standard you have set as a goal for your own improvement. Decide the inclusion and exclusion criteria for the data collection, as well as the methodology.

3. Collect the data

   This can take place in any form, such as a survey (for example, patient satisfaction), tick-box (for example, clinical record keeping) or observations (for example, hand hygiene).

4. Analyse the data

   Compare the data with the standard, identify reasons why standards have not been met, and what change can be implemented to address the issue.

5. Implement the change

   Ensure that results are disseminated appropriately and take action based on the findings.

6. Re-audit 

   Repeat the audit cycle to measure what changes have occurred as a result of the action taken.

Example audit

1. Topic 

   Quality ratings of radiographs. 

2. Standard

   90% diagnostically acceptable film radiographs (FGDP).

3. Data collected 

   Retrospectively over the last 6 weeks. Results show 75% diagnostically acceptable (show method).

4. Data analysed 

   Recurring theme identified that radiographs taken in surgery 2 are more likely to be diagnostically unacceptable. Discussed with dentist who reports that X-ray machine arm doesn’t stay in place.

5. Change implemented 

   Arranged for servicing of X-ray machine. Discussed at practice meeting and agreed to re-audit 6 weeks after machine serviced to see if outcome improved. 

6. Re-audit 

   Repeat the cycle at the proposed interval.

Peer review

The Oral Health Regulation Strategic Leadership Forum (OHRSLF) recommend peer review as one way of maintaining good practice and preventing poor practice from emerging.  We consider peer review to be one of the hallmarks of a well led practice. Toolkits you could use, for example, are:

• South Staffordshire Local Dental Committee dental peer review group toolkit.