Dentist Experiences in the Primary Healthcare System

Introduction

To improve service delivery, quality, and performance in the healthcare system, each employee should work on two jobs when they report for duty. Healthcare quality improvement is a process that needs the concerted effort of the managers, practitioners, patients, and other stakeholders in the healthcare system. The goals for each healthcare system are to provide better system performance, better patient outcomes, and enhanced professional development to address the daily problems associated with service delivery in the healthcare system. This study attempts to solve daily problems dentist experiences in the primary healthcare system using quality improvement tools to identify the root cause of the problems with a solution-based plan to measure the level of success and reinforce the rationale for implementing a quality improvement process.

This is a case study of a dentist newly posted with 6 months of working experience as a general practitioner (GP) dentist in the primary healthcare center in one dental clinic governed by the ministry of health in UAE. The clinic functions on a system with a schedule of 12 appointments for every 30 minutes each day appointment to treat patients with emergency cases that show up during the day between the appointments. The dentist works with one assistant who is a general nurse without any dental background knowledge.

The current situation in the dental clinic

The dental clinic has a recurring problem of being unable to complete scheduled treatments each time a new patient reports at the clinic. That is because of frequent and multiple interruptions on the dentist’s schedule while treating new cases of patients requiring emergency treatments. Based on the current system, the dentist is required to perform multiple procedures like giving appointments to patients, answering referred phone calls, processing x-rays, and performing the assistant nurse’s duties because she is an untrained dentist. Disruptions occur because the dentist introduces these cases in between appointments and many emergency treatments cases take causes discouragement and anger. The procedure of delivering patient files takes about 3-8 minutes as the dentist is forced to wait until the x-ray file arrives to check any patient medical history. Waiting for longer than the appointed time increases a patient’s anxiety levels (Jabnoun 2002, p 3; Hmud & Walsh 2009, p 2). The extra tasks place stress on the nurse and adversely impact the dentist’s health and quality of work (Broomfield, Humphris & Kaney 1996, p.2). Here, studies show the main work factors that cause stress are fragility of the dentist-patient relationship, time and scheduling pressure, staff, and technical problems. Continued exposure to stress deteriorates the dentist’s health resulting in serious problems such as depression, obesity, and sleep difficulties (Broomfield, Humphris & Kaney 1996, p.2; Talha 2004, p. 3). Here, the dentist does not have adequate time to communicate positively with patients and allow them to discuss in detail their cases and required treatment (Øvretveit 2000, p3). Studies show that the most important factor to achieve patient satisfaction is a good doctor-patient relationship and clear information about the treatment provided Mazzei, Russo & Crescentini 2009, p. 3). Communicating with the patient raises the success rate of treatment and overall service quality (Adebanjo & Kehoe, 2001, p. 23; Mazzei, Russo & Crescentini 2009, p. 3)

An assessment of the current system shows that it is inefficient and lacks organization with frequent interruptions resulting in patient dissatisfaction during the treatment period, causing partial treatment which leads to new appointments. Emergency patients are dissatisfied because they are forced to wait for 15-30 minutes beyond their appointment time to be treated.

A questionnaire survey conducted to determine the factors that affect patient dissatisfaction showed that 46% of patients surveyed changed their dental clinic because they were dissatisfied with the dental experience in that clinic. In another study, the results showed that the patient level of satisfaction correlated strongly with treatment quality (Mazzei, Russo & Crescentini 2009, p. 3). In the above study, the clinic is located in a primary center governed by the ministry of health. One of the solutions identified was to use an electronic system for appointments or a modern x-ray system or employ more trained dental staff or receptionists, which are issues controlled by the ministry. The following was the proposed solution to the problem.

SPO to assess the system

To solve this problem, the dentist formed a team comprising the center manager, the dentist, the assistant, and the receptionist) and started brainstorming sessions to list the possible causes preventing the dentist from completing scheduled treatment within the appointment time Lotich, n.d, p.2). Brainstorming is a solution-intensive approach from team members (Manktelow & Amy Carlson 2012, p 1). The dentist used a three-level structured framework consisting of processes and outcomes as inspired by Donabedian’s health system analysis to describe and measure the possible causes of the problem (Martins & Toledo 2000, p 4).

-Structural assessment: Gives information about the environment in which services are provided and whether the organizational structure contributes to the problem. It refers to the adequacy of equipment and technology, qualified staff, adequate policies, and regulations that could need to be improved t to meet quality and safety standards (Martins & Toledo 2000, p 7). The team listed all the structural elements that could be the possible causes of the current problem:

• The staff: The assistant is a general nurse and has no dentistry training background knowledge.
• The equipment: x-ray is a manual processing system that takes an average of 3-8 minutes to process x-rays.
• The patient: Some patients come as emergency cases during the day and are treated without appointments while others are late on their appointments.
• The policies and regulations: There are no organized appointment systems making it difficult to control interruptions during the treatment.

Processes assessment: Assesses how the procedures are done. It is evaluated in terms of standards and protocols established by professionals and the degree of compliance with them (Martins & Toledo 2000, p 7). The processes elements that could be possible causes of the current problem:

• Dentist faces interruptions during the treatment (emergency patients, patients who want an appointment, and delay in delivering patient’s files, manual x-ray film processor, and unqualified assistance). Interruptions prevent the dentist from completing scheduled treatments during appointment time.
• There is no policy for organized appointments. There are no clear policies to deal with late patients or emergency patients. Appointments are scheduled for every 30 minutes without considering that some procedures take more time like root canals. This makes it difficult to finish the required treatment in one appointment.

Outcome assessment: Indicates whether the system is failing in meeting the standards and answers why it failed (Martins & Toledo 2000, p 8).The outcomes are:

• Dentist can’t finish the required treatment in one appointment and need to schedule a couple of other appointments to increase the number of patient waiting for appointments.
• Patient dissatisfied: The patient under treatment would be angry because of multiple interruptions during the treatment resulting in incomplete treatment and new appointments. In addition, emergency patients wait for a long time to be treated.
• Dentist is under continuous stress and frustration. Every day he should solve conflicts and fight with patients dissatisfied. He is forced to do multitask causing interruptions with his treatment like answering phone calls, giving appointments, and processing x-rays.

Before Data

The dentist started to collect data to help in understanding the problem and predict the solutions. The results were arranged in a table (Table.1) to follow up identified causes of interruptions during each dental appointment for four days. The time each interruption would waste from the appointment.

The table shows time wasted because of the sources of interruption within 14 days of appointment time. From the table we can calculate the median of wasted time in the following:

• The Telephone: From the table, the median time wasted to answer the telephone within a dental appointment was between 1-2 minutes in each appointment. Most of the calls are for scheduling appointments and consultation.
• The x-ray processing: The median time wasted to process an x-ray was between 4.5 and 5 minutes in each appointment
• Late delivery of patient files: The median of the consumed time to get the patient file was between 2-3 minutes in each appointment
• Interruption from patient outdoor:

The median of time wasted when dealing with an outdoor patient was between 1.5-3.5 minutes in each appointment. Dentists consume time with patients knocking on the door to either ask for an appointment, referral, or ask for emergency treatment. In general the total wasted time in an appointment range between 1-18 minutes.

Also, it was important to know the level of patient satisfaction regarding the current system applied in the dental clinic. A questionnaire survey was conducted and distributed to patients after they finished their treatment. (Table.2)

The result of the survey showed the following:

• 85% of the patients disagreed or strongly disagreed on the ease of making an appointment. The appointment given by the dentist takes a long time to wait because the dentist had to finish working on a given appointment, 60% were dissatisfied.
• 36% of the patient responded that they were dissatisfied with the treatment by the dentist. Many of them commented that they wanted to complete the procedure in one appointment because it was difficult for them to go back for the same treatment several times.
• 52% did not discuss the dentist about their case.
• 49% were not satisfied with the treatment the dentist administered.
• 65% said that the waiting time for the appointment was too long.

Steps toward improvement

Focus PDCA

The team decided to use the FOCUS PDCA tool to identify the root causes of the problems and an opportunity for improvement. FOCUS PDCA is a methodology used to identify improvement opportunities through groups. It creates a systematic approach to implementing changes. This problem-solving model was first used by Walter Shewhart (20).

Find a process to improve

Studies suggested that in the F phase we should select one process to improve 21. The problem the dentists have is waste of time during appointments leading to unfulfilling treatment requirements and frustration of the dentist and the patient. The sources of wasting treatment time are divided into:

• Causes inside the clinic.
• Causes outside the clinic.

The following table shows the main sources of wasting treatment time:

The cause and their implications on the treatment timing will be discussed later in this paper.

Organize a team that knows the process

In this case, it is suggested that a team familiar with the processes should be built to discuss, suggest ideas and work to improve the selected process. The writer gathered a team of people as part of the solution and discussed the current situation and their roles in implementing the solutions. The team mainly consisted of 4 members: the dentist, the assistant, the center manager, and the receptionist. The four will be a part of the solution. Teams are the basic unit of performance in any organization because teamwork always leads to better results than individuals when they work with clear performance objectives (Katzenbatch & Smith 1993, p. 3).

Clarify current understanding

In this stage, the team should have a clear understanding of the process to be improved. Improvement efforts based on a complete process analysis of the current situation are not compatible (Flowcharting, Mastering Details’ n.d, p.1). Flowcharting was a tool for providing better solutions because it is a diagram used to show each step in a process. The main problem was the wasted time during each dental appointment (Flowcharting, Matsering Details’ n.d, p.1). The possible causes of the problems were different sources of interruptions during the appointment. A flowchart that showed the sources of interruption during the dental treatment process as in (Figure 1)

Understand causes of process variation

The team to clearly understand the underlying cause of the problem to introduce and use a cause-and-effect diagram to better understand the factors that contribute to the problem. 21 Brainstorming used the fishbone diagram drawn with four main factors: Method, environment, people, and equipment. The basis is opinions considered as sources of ideas, but not of data according to 23 (Figure 2), to analyze the root causes of the external and internal problems (Manktelow & Carlson 2012, p. 1).

Causes of wasted time inside the clinic

• The telephone
  The telephone rings at least once in each appointment. Most of the callers are either patients who want to make an appointment or patients who want to consult the dentist. The assistant deals with the calls and helps the dentist in the treatment. Answering the telephone takes 2-3 minutes of the appointment time.
• The x-ray manual processor
  It takes 3-8 minutes to process a dental x-ray in a manual processor.70% of the dental patients need at least one x-ray in each appointment. It could save time if a modern x-ray system was used in the clinic. Because the assistant is not trained to process x-rays, it forces the dentist to stop the treatment and waste time in processing the x-rays.
• Untrained assistant
  A trained and qualified dental assistant could help save treatment time. Dental assistants organize clinical instruments, hand them to the dentist, mix materials, fill charts, and process x-rays. If all these procedures are done quickly it could save a lot of time. Unfortunately, the assistant in the clinic is a nurse with no dental background. She needs to be trained to do her required job efficiently.
• Unorganized instruments
  The assistant takes time to look for instruments required during the treatment. The instrument should be arranged in drawers and labeled for ease of access.
• Short appointments
  The dentist should schedule an appointment for every 30 minutes. Some procedures like root canal and fillings need more than 40 minutes. The dentist should arrange the time of the appointment according to the procedure he will plan to do.

Causes of wasted t time outside the clinic:

1. Patient want appointments

According to the old system, the dentist is the one who schedules appointments. Many interruptions are from patients who want to take appointments quickly and leave.

• emergency patient

Emergency patients show up within the day, between 8:30 and 10:00.

• patient late: Patients arriving late required the processing of new appointments
• late arrival of the patient file

It is important for the patient’s file to be made available once the patient arrives to review the medical history and the treatment required in the visit. He found that a file takes 3-8 minutes to reach the clinic. This really wastes the appointment time.

Select the process improvement

A team should be ready to suggest improvements at this stage for all staff members.

Plan

This was the planning stage for service improvements. Each member should understand how the change will be implemented. Lack of teamwork and lack and poor delegation of responsibilities contributed further.

The technique to identify quickly the root of the problem was by asking why and what caused the problem.25

The dentist

The dentist will build a new appointment system to reduce interruptions during treatment. He will divide appointment time according to the following procedure. Instead of a fixed 30 minutes timing for all procedures, he will extend the timing to 40 minutes for root canal cases and the evening appointments will be about 20 minutes for filling, scaling, and checkups. The dental appointment recording book will be handled by the receptionist to schedule appointments with a new policy implemented for patients who report late. All patients will be informed about this policy once they come to schedule an appointment. For emergency patients, the dentist will fix a special time for urgent cases. Instead of introducing emergency patients between appointments and causing late to the appointment patients, an emergency hour will be placed from 9:30 to 10:30 daily to treat emergency patients. The dentist will train the assistant for 15 minutes for four days at the end of the working day to ensure more efficiency in her work. He will teach her how to fill patient records and how to process x-rays.

1. The dental assistant
   The dental assistant will undergo training for better performance on ways to arrange dental instruments and mix materials more quickly and process x-rays instead of the dentist so that the dentist
2. The receptionist
   The receptionist will be the one who handles the appointment book and schedules appointments for patients. He will answer all the calls and refer urgent calls to the dental clinic.
3. The center manager
   The center manager will be asked to write a request to the ministry of health to provide the clinic with an electronic appointment system with a modern digital x-ray system and will follow up the requests in addition to managing patient-dentist conflicts amicably.

The team predicts that the following result would occur in one month period:

1. The wasted time will reduce from maximum of 18 minutes one appointment to a proximally not more than 2 minutes
2. The required dental treatment in an appointment will be fulfilled in a percentage of 80-100%
3. The patient satisfaction questionnaire will show a greater level of satisfaction level (Mazzei, Russo & Crescentini 2009, p. 3).

Do it

The dentist carefully monitors the flow of work to ensure improvements according to plan. 21

Check the status

New data showed dissatisfaction with emergency patients with the new policies. A solution was to refer patients for advice on accepting new policies.

Act to maintain change

Initial success was found after gathering the data and the surveys. Using Table 1 to gather data, the result showed a reduction in time wasted for each appointment to a maximum of 2 minutes. It was difficult to gather valid patient satisfaction information in one week, but in general, we can observe a significant reduction in the number of patient complaints and conflicts.

Conclusion

The team was satisfied with the results as the flow and treatment of patients was evidently fast happy with a significant reduction of conflicts with patients. They decided to implement the plan. It was important to ensure that initial gains made were not lost in the future by holding monthly meetings to discuss possible challenges and problems that were likely to occur after implementing the plan. Once the team was satisfied that the system was stable and had attained an acceptable level of patient satisfaction, cycles of continuous quality improvement (CQI) will be introduced to achieve better levels of patient satisfaction. However, some issues such as the problem of broken appointments need to be solved. It was clear that using quality frameworks and techniques could help in analyzing the problem at every step to identify the root cause of the problems. Constraining in solving the root cause will save us time and effort.

Reference

Broomfield D, Humphris G & Kaney, S 1996,”Stress in junior hospital medical and dental staff: a descriptive account of their concerns and needs”, Health Manpower Management, Vol. 22 Iss: 3 pp. 5 – 9

‘Flowcharting, Matsering Details’ n.d. Web.

Manktelow J & Carlson A 2012, 5 Whys Quickly Getting to the Root of a Problem. Web.

Harr, R 2001,”TQM in dental practice”, International Journal of Health Care Quality Assurance, Vol. 14 Iss: 2 pp. 69 – 81

Hmud R & Walsh LJ 2009, Dental anxiety: causes, complications and management approaches: Journal Of Minimum Intervention In Dentistry. Web.

Lotich, P n.d, ‘SMART’ Church Management, What Is Focus PDCA Methodology? Web.

Katzenbatch, J R & Smith, D K 1993, The wisdom of teams, creating high performance Organization, Harvard Business School Press. Web.

Mazzei, A, Russo, V & Crescentini, A 2009,”Patient satisfaction and communication as competitive levers in dentistry”, The TQM Journal, Vol. 21 Iss: 4 pp. 365 – 381

Manktelow, J & Amy Carlson, A 20102, Brainstorming Generating Many Radical, Creative Ideas. Web.

Mazzei, A, Russo, V & Crescentini, A 2009,”Patient satisfaction and communication as competitive levers in dentistry”, The TQM Journal, Vol. 21 Iss: 4 pp. 365 – 381

‘Quality Improvement Toolkit’ n.d, Introduction to Quality Improvement and the FOCUS-PDSA Model. Web.

Reflection

Six months ago I was transferred to work as a dentist in one of the primary healthcare centers that is governed by the Ministry of Health in the United Arab Emirates. The center has only one dental clinic.I was responsible for everything related to the clinic. Beside dental treatment, I was responsible for managing the clinic, following up the quality of work, training the dental staff, and scheduling dental appointments. In the first three months I worked using the same system that was used in the clinic by the previous dentist. I found that there were some problems that should be identified and solved. Patients were dissatisfaction and their anger was rising each day. I was experiencing difficulties in knowing exactly where the root cause of the problem lay and what should be done to solve the problem in a way to achieve patient satisfaction.

After attending module 1 and 2, I had a clearer idea about the frameworks and tools that could help me identify the root cause of the problem and build a plan to solve the problem. It was difficult for me to decide if the method I was trying to implement was a Total Quality Management (TQM) or a Continues Quality Improvement (CQI).I started searching for more information about both methods. Most of the documents and searches I went through showed that CQI is a concept of the TQM philosophy (’Quality Improvement Toolkit’ n.d, p.1).Other sources define CQI as a quality improvement method that prevents the occurrence of quality problems during the process rather than measuring them after they occur (‘Total Quality Management’ n.d, p 3).

I concluded that the best way to explain the method of quality improvement I was trying to implement in the dental clinic was by building a strong base integrating TQM using small cycles of CQI after maintaining a stable level of quality (‘Total Quality Management’ n.d, p 4).

TQM started in the USA in 1980s. It was introduced first by W.Edward Deming.It encourage the organization’s culture to improve customer satisfaction by using tools, techniques and training (Talha 2004, p.1). It is a comprehensive strategy of organizational and attitude change, that enables organizations to use quality methods to reduce cost and meet patients’ needs and expectations (Øvretveit 2000, p.3). It is important to distinguish between the two aspects of TQM.

1. TQM is an organization wide approach, philosophy, and comprehensive strategy for implementing attitude change in organizations (Øvretveit 2000, p.5).
2. TQM involves a quality team, methods, and frameworks for process involvement (Øvretveit 2000, p.8).The project I planned to start was a TQM quality team.

CQI is a continuous improvement of any process driven by customer satisfaction. It provides health care organizations with an opportunity for a higher levels of increased competitiveness and creates a friendly environment for customer and employee relationships. Some studies view TQM as a management philosophy and CQI as a management method. Others view TQM as the umbrella where CQI and other quality improvement methods lie. To achieve continues improvement it requires a supporting culture that is implemented with TQM. TQM is used to establish standards and CQI develops the capability to make further, regular, long term processes (Martins & Toledo 2000,p.4).

The reasons that made me believe that the project I started to improve was a TQM project were:

1. TQM is a process that would help me establish a system and an environment that supports continues improvement culture. Studies say that TQM is a method that would guide organizations to continual improvement in all aspects of its business. I needed a system that would help me to improve several aspects in my work and start with a solid foundation. I wanted to establish an organized appointment system, to start teamwork and distribute responsibilities, to elevate the efficiency of the dental assistant and to meet my patients’ desires. TQM philosophy in improving several aspects in an organization will help me to achieve the goals (Kaluzny, Mclaughlin & Simpson 1992, p.5).
2. The philosophy of TQM encourages the elimination of wastes or defects through removal of the root causes of these wastes. The problem I was suffering from is availability of different sources of wastes that should be eliminated to save the dental appointment time and help me do the whole required work in one appointment. After starting my improvement project I could detect many sources of wastes during my work and I put a plan to eliminate those wastes by following TQM tools 7
3. TQM encourages organization to build a culture of teamwork.It ensure that success of any organization lies with each team member. A culture of distributed responsibilities will permeate through the organization at every level to ensure maximum benefits are gained. In addition to the problem of patient dissatisfaction and present wastes, I found myself doing more work than I am required to do. I was giving appointments, processing x-rays and completing patient records. I decided to form a team and distribute responsibilities to reduce the stress on myself and to save my time for patients’ treatment (Patel n.d, p.4).
4. The TQM process could be a starting point to build standards to allow continuous quality to go beyond these standards. It is an organized system of continuous quality improvement aimed at meeting customer expectations. It aims to establish a system that measures and manages patient care in a way that provides the optimal medical service for all patients (Jabnoun 2002, p.4).
5. TQM is customer focused and circulates around the concept of customer satisfaction. The TQM philosophy aimed at ensuring that an organization can meet the needs of its customers on a continuous basis. To do this effectively an organization must apply the concept of continuous improvement to meet or exceed the customer satisfaction (Talha 2004, p.3). I used the philosophy of TQM to obtain and maintain patient satisfaction to an acceptable level. I am planning to build a culture of continuous improvement in the future which can help me satisfy the needs of my patients on an ongoing basis.
6. TQM focuses mainly on the system as the source of the error. It emphasizes on understanding the current status of the system and improving the errors in the system. By understanding the current system we will have a better opportunity to improve the services further. In my project it was clear that there was a problem with the current system and it is impossible to start any improvement without understanding the current status of the system (Talha 2004, p.3).

After building and maintaining an organized system in the dental clinic, I am planning to start small CQI projects to meet or exceed patient satisfaction. For example, I’m planning to search for solution that would reduce broken appointments which occur on a daily basis. This can be easily implemented after I have already started an effective appointment system with TQM.

Finally, in my opinion, achieving the goal is difficult but maintaining the results of the goal is more difficult. TQM together with CQI could help in maintaining a stable standard for the organization.

References

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