Assessing the Patient Safety Culture in Dentistry.

OBJECTIVES: Medical errors are among the leading causes of death within the United States. Studies have shown that patients can be harmed while receiving care, sometimes resulting in permanent injury or, in extreme cases, death. To reduce the risk of patient safety incidents, it is imperative that a robust culture of safety be established. The primary objective of this study was to evaluate the patient safety culture among providers at 4 US dental institutions, comparing the results with their medical counterparts in 2016. METHODS: This cross-sectional study uses the Medical Office Survey on Patient Safety Culture that was modified for dentistry and administered at 4 US dental institutions during the 2016 calendar year. All dental team members were invited to complete electronic or paper-based versions of the questionnaire. RESULTS: Among 1,615 invited participants, 656 providers responded (rate, 40.6%). Medical institutions outperformed the dental institutions on 9 of the 10 safety culture dimensions, 6 of the 6 overall quality items, and 8 of the 9 patient safety and quality issues. The surveyed dental institutions reported the strongest average percentage positive scores in organizational learning (85%) and teamwork (79%). CONCLUSION: These findings suggest that the patient safety culture progressed over time. However, there is still heterogeneity within safety culture among academic dental, private (nonacademic), and medical clinics. KNOWLEDGE TRANSFER STATEMENT: Patient safety is the first dimension of quality improvement. Administering the Medical Office Survey on Patient Safety Culture within dental clinics represents a key measure to understand where improvements can be made with respect to patient care safety.

An International Working Definition for Quality of Oral Healthcare.

To assess and improve the quality of oral healthcare, we must first agree on what constitutes good care. Currently there is no internationally accepted definition for quality of oral healthcare. Therefore, the purpose of the study was to establish a working definition for quality of oral healthcare that would help to advance further improvements in the field of quality improvement in oral healthcare. The development of the working definition included a 3-step approach: 1) literature screening; 2) expert-based compilation of an initial list of topics, leaning on the National Academy of Medicine framework for quality of care; and 3) a World Café with voting, which took place during the annual general meeting of the International Association for Dental Research in 2018. Following this approach, the collective intelligence of involved participants yielded a comprehensive list of items, prioritized by relevance. The resulting working definition comprises 7 domains­patient safety, effectiveness, efficiency, patient-centeredness, equitability, timeliness, access to care­and 30 items, which together characterize quality of oral healthcare. This aspirational working definition provides the potential to facilitate further conversations and activities aiming at quality improvement in oral healthcare. KNOWLEDGE TRANSFER STATEMENT: This special communication describes the development of a working definition for quality of oral healthcare. The findings of this study are intended to raise awareness of the relevance of quality improvement initiatives in oral healthcare. The working definition described here has the potential to facilitate further conversations and activities aiming at quality improvement in oral healthcare.

Finding Dental Harm to Patients through Electronic Health Record-Based Triggers.

BACKGROUND: Patients may be inadvertently harmed while undergoing dental treatments. To improve care, we must first determine the types and frequency of harms that patients experience, but identifying cases of harm is not always straightforward for dental practices. Mining data from electronic health records is a promising means of efficiently detecting possible adverse events (AEs). METHODS: We developed 7 electronic triggers (electronic health record based) to flag patient charts that contain distinct events common to AEs. These electronic charts were then manually reviewed to identify AEs. RESULTS: Of the 1,885 charts reviewed, 16.2% contained an AE. The positive predictive value of the triggers ranged from a high of 0.23 for the 2 best-performing triggers (failed implants and postsurgical complications) to 0.09 for the lowest-performing triggers. The most common types of AEs found were pain (27.5%), hard tissue (14.8%), soft tissue (14.8%), and nerve injuries (13.3%). Most AEs were classified as temporary harm (89.2%). Permanent harm was present in 9.6% of the AEs, and 1.2% required transfer to an emergency room. CONCLUSION: By developing these triggers and a process to identify harm, we can now start measuring AEs, which is the first step to mitigating harm in the future. KNOWLEDGE TRANSFER STATEMENT: A retrospective review of patients' health records is a useful approach for systematically identifying and measuring harm. Rather than random chart reviews, electronic health record-based dental trigger tools are an effective approach for practices to identify patient harm. Measurement is one of the first steps in improving the safety and quality of care delivered.

Utilization and Validity of the Dental Diagnostic System over Time in Academic and Private Practice.

INTRODUCTION: To fill the void created by insufficient dental terminologies, a multi-institutional workgroup was formed among members of the Consortium for Oral Health Research and Informatics to develop the Dental Diagnostic System (DDS) in 2009. The adoption of dental diagnosis terminologies by providers must be accompanied by rigorous usability and validity assessments to ensure their effectiveness in practice. OBJECTIVES: The primary objective of this study was to describe the utilization and correct use of the DDS over a 4-y period. METHODS: Electronic health record data were amassed from 2013 to 2016 where diagnostic terms and Current Dental Terminology procedure code pairs were adjudicated by calibrated dentists. With the resultant data, we report on the 4-y utilization and validity of the DDS at 5 dental institutions. Utilization refers to the proportion of instances that diagnoses are documented in a structured format, and validity is defined as the frequency of valid pairs divided by the number of all treatment codes entered. RESULTS: Nearly 10 million procedures ( n = 9,946,975) were documented at the 5 participating institutions between 2013 and 2016. There was a 1.5-fold increase in the number of unique diagnoses documented during the 4-y period. The utilization and validity proportions of the DDS had statistically significant increases from 2013 to 2016 ( P < 0.0001). Academic dental sites were more likely to document diagnoses associated with orthodontic and restorative procedures, while the private dental site was equally likely to document diagnoses associated with all procedures. Overall, the private dental site had significantly higher utilization and validity proportions than the academic dental sites. CONCLUSION: The results demonstrate an improvement in utilization and validity of the DDS terminology over time. These findings also yield insight into the factors that influence the usability, adoption, and validity of dental terminologies, raising the need for more focused training of dental students. KNOWLEDGE TRANSFER STATEMENT: Ensuring that providers use standardized methods for documentation of diagnoses represents a challenge within dentistry. The results of this study can be used by clinicians when evaluating the utility of diagnostic terminologies embedded within the electronic health record.

The effectiveness of an initial continuing education course in leadership for dentists.

PURPOSE/OBJECTIVES: The purpose of this study was to measure the effectiveness of a continuing education course in leadership presented to postdoctoral dentist-leaders. METHODS: The authors developed a 3-day course on leadership and management with topics including self-awareness, leadership qualities, emotional intelligence, communication skills, social skills, conflict management, personal branding, quality improvement and team motivation. Twenty-two course participants with a median age of 37.5 years and an average of 13.7 years of professional experience were assessed using three different metrics: satisfaction with the course and presenters immediately following the course; pre-course and post-course tests on knowledge of leadership topics; and self-assessments of leadership competency skills prior to the course, immediately following the course and then 6 months after the course. RESULTS: Participant satisfaction with both instructors' effectiveness and the overall course design was very high. A survey 6 months following the course showed that participants were very positive regarding the practical use of the leadership skills they acquired in the course. The average of all participants' scores on the objectively assessed leadership knowledge test showed a statistically significant (P<.001) difference between pre-course and post-course scores. At 6-month follow-up, participant self-assessment of leadership competency significantly improved following the course. CONCLUSION: A well-designed course in leadership skills can have a positive impact on the leadership knowledge and competency of dentist-leaders. This unique leadership course was effective in increasing leadership knowledge and self-perceived leadership competency. The course and the skilled instructors were rated very highly by participants.

Strategic Shift to a Diagnostic Model of Care in a Multi-Site Group Dental Practice.

BACKGROUND: Documenting standardized dental diagnostic terms represents an emerging change for how dentistry is practiced. We focused on a mid-sized dental group practice as it shifted to a policy of documenting patients' diagnoses using standardized terms in the electronic health record. METHODS: Kotter's change framework was translated into interview questions posed to the senior leadership in a mid-size dental group practice. In addition, quantitative content analyses were conducted on the written policies and forms before and after the implementation of standardized diagnosis documentation to assess the extent to which the forms and policies reflected the shift. Three reviewers analyzed the data individually and reached consensuses where needed. RESULTS: Kotter's guiding change framework explained the steps taken to 97 percent utilization rate of the Electronic Health Record and Dental Diagnostic Code. Of the 96 documents included in the forms and policy analysis, 31 documents were officially updated but only two added a diagnostic element. CONCLUSION: Change strategies established in the business literature hold utility for dental practices seeking diagnosis-centered care. PRACTICAL IMPLICATIONS: A practice that shifts to a diagnosis-driven care philosophy would be best served by ensuring that the change process follows a leadership framework that is calibrated to the organization's culture.

Treatment planning in dentistry using an electronic health record: implications for undergraduate education.

OBJECTIVE: Treatment planning, an essential component of clinical practice, has received little attention in the dental literature and there appears to be no consistent format being followed in the teaching and development of treatment plans within dental school curricula. No investigation, to our knowledge, has been carried out to explore the subject of treatment planning since the advent of electronic health record (EHR) use in dentistry. It is therefore important to examine the topic of treatment planning in the context of EHRs. METHODS: This paper reports on how 25 predoctoral dental students from two U.S. schools performed when asked to complete diagnosis and treatment planning exercises for two clinical scenarios in an EHR. Three calibrated clinical teaching faculty scored diagnosis entry, diagnosis-treatment (procedure) pairing, and sequencing of treatment according to criteria taught in their curriculum. Scores were then converted to percent correct and reported as means (with standard deviations). RESULTS: Overall, the participants earned 48.2% of the possible points. Participants at School 2 earned a mean of 54.3% compared with participants at School 1, who earned 41.9%. Students fared better selecting the appropriate treatment (59.8%) compared with choosing the correct diagnoses (41.9%) but performed least favorably when organizing the sequence of their treatment plans (41.7%). CONCLUSION: Our results highlight the need to improve the current process by which treatment planning is taught and also to consider the impact of technology on the fundamental skills of diagnosis and treatment planning within the modern educational setting.

Surgical repair of defects in the rabbit temporomandibular joint disc: a comparison of various techniques.

A study was designed to evaluate the effects of different types of repair (suture vs. graft), donor graft tissues (dermis vs. fascia), and methods of graft fixation (sutured vs. laser-assisted) on excisional defects of the rabbit TMJ disc made anterior to the retrodiscal tissue. Groups created to compare the different variables were assessed at 30 and 90 days postoperatively by macroscopic and histologic methods, microangiography, and mechanical strength testing. Without repair, all excisional defects of the disc failed to heal. Suturing of the reapproximated margins did not appear to promote healing or provide much strength beyond the properties of the suture material. Dermal grafts, fixed by suturing, induced healing by becoming incorporated into the disc, restoring discal continuity, and approximating normal disc strength. The use of laser-assisted tissue welding for dermal graft fixation was found to be inadequate and was subsequently abandoned. Fascial grafts could be fixed into position by both suture and laser-assistance, but consistently failed to exhibit successful transplantation and promote healing at the disc site.

Facial nerve graft repair: suture versus laser-assisted anastomosis.

An experimental study was conducted to evaluate the effectiveness of laser-assisted versus conventional suture repair of facial nerve grafts in the rabbit. Electrophysiologic assessment of function revealed no significant difference between the two techniques. Histological differences were apparent, however, early postoperatively from the effects of heat energy on the perimeter of fascicular morphology. At a later stage, this effect had disappeared. The laser technique was also associated with an apparent decreased escape and entrapment of axons.