Clinical governance is “a system through which NHS organisations are accountable for continuously improving the quality of their services.” (Scally and Donaldson 1998, p.61) This is achieved by the maintenance of quality and safety for high standards of patient care. The Care quality commission (CQC) is “the independent regulator of health and social care in England.”
They are concerned with the safety, quality and care of patients within healthcare services. As a clinician or member of a team which deals with patients, the main priority should be the care of patients. By critically analysing the various frameworks and guidelines which surround healthcare in relation to issues arising within a practice we should be able to improve our services and prevent repetition of the same issues from occurring.
The scenario which has occurred within a dental practice is as follows; patients were being seen by both the hygienist and then the dentist one after the other on the same day. Periodontal screenings were being carried out by both the dentist and the hygienist, within this, Basic Periodontal Examinations (BPE) were completed. The dentist was noticing that his BPEs were different to the hygienists. Along with this the hygienist noticed patients complaining that the dentist had said their “gums were looking healthy” in contrast to the hygienist telling them that they had early signs of gum disease. This understandably became an issue for the patients who were receiving conflicting advice as well as for the clinicians as something was obviously going wrong within the way that they were practicing. The dentist approached the hygienist regarding this issue and suggested that the hygienist did not carry out a separate BPE if the dentist had already done one that day. The hygienist did not think this was a viable option as regardless of the dentist carrying out a BPE the hygienist felt she needed to do her own as well to make sure it was accurate, and the correct treatment plan was carried out for the patient. The practice manager who was also a dentist suggested carrying out a clinical audit to highlight the number of discrepancies within the BPEs of both clinicians. She also suggested both clinicians complete continued professional development (CPD) within the periodontal field to improve their knowledge and skill base.
This issue touches on several key lines of enquiry (KLOE) stated in the CQC dental care provider handbook. These are as follows;
“Effective; E1 – are peoples’ needs assessed and care and treatment delivered in line with current legislation, standards and evidence-based guidance?” (CQC 03/15 p.36) Patients’ needs have not been assessed accurately due to the differences which have arisen from the BPE scores completed by both clinicians. Discrepancies between scores resulted in different treatment plans created for the same patient by each clinician. The management of these patients could be inaccurate and could potentially pose a risk to the patients’ dental health if active disease is missed and not treated.
“The BPE is a simple and rapid screening tool that is used to indicate the level of further examination needed and provide basic guidance on treatment needed.” (Prof. Ian Needleman, March 2016, p.10) By completing or following an incorrect BPE recording the clinician is at risk of not delivering treatment in line with evidence-based guidance such as the BSP guidelines. The following of this guidance is essential in treating patients effectively to manage their periodontal condition. The scenario in discussion could have been helped by this guidance if more time and emphasis was put on recording a BPE score accurately by the practice. By taking more time to complete a BPE score for each patient less human error would be made and more accurate scores would have been recorded thus more appropriate treatment would be advised for the patient. To improve this aspect of the scenario the practice could allow longer appointment times and nurse assistance for every clinician to record accurate scores. Longer appointment times and nurse assistance would help eliminate any pressure the clinicians may feel to rush treatment which could also result in more mistakes being made by the clinicians.
“E2 – Do staff have the skills, knowledge and experience to deliver effective care and treatment?” (CQC 03/15 p.37) This question resulted from the scenario as all three skills, knowledge and experience could be factors which influenced the inconsistencies in BPE scores. If the clinicians were lacking in one or all these points the BPE score may have been inaccurate. Having a lack of skill or knowledge would mean the clinician may not know how to complete a BPE or even why they are doing one. This may make the clinician more careless as they may not see the importance of the BPE score which in turn increases the chance of mistakes. If one of the clinicians is less experienced than the other this may affect the outcome of their BPE as they may miss pockets or falsely chart a pocket when there is not one present. On the other hand, this could also make the more experienced clinician complacent, again possibly resulting in inaccurate scores due to lack of concentration or attention.
It is imperative for every clinician to have the appropriate skills and knowledge to carry out treatment within their scope of practice. The GDC guidance regarding CPD states “Continuous, lifelong learning and maintenance of skills are commitments you make as a professional to provide safe and appropriate services to the public.” (GDC, 30/05/18, p.3) This reinforces the need of training for all clinicians regardless of experience, skills and knowledge that they already have. This is useful to this scenario as neither clinician involved can justify not learning more about the BPE scoring system and periodontal disease. Thereby, making it easier for a third party such as the practice manager to suggest to both clinicians to carry out further CPD in this specific area in a bid to resolve the discrepancies in BPEs. This also reinforces the NHS value of “the patient will be at the heart of everything” as clinicians complete CPD they feel relevant to their needs, trying to improve their clinical skills and knowledge for optimal patient care.
One of the five key themes within clinical governance is Staff focus – “When staff are positive about levels of support this can lead to improved patient satisfaction.” RCN (2018) By highlighting areas in which both clinicians could improve their skills and knowledge they should feel supported in trying to resolve the problem resulting in improved patient treatment and therefore satisfaction. “Well -led; W3 – How is quality assurance used to encourage continuous improvement?” (CQC 03/15 p.42)
To improve the differing results in BPE scores a clinical audit was completed. This involved recording the number of BPEs which were different by more than one number in each sextant. For example, if one BPE stated the upper right quadrant was a 0 and the other BPE for the same patient stated the upper right quadrant was a 2 this would be marked as one discrepancy. The BPEs looked at, were the ones which were completed by both clinicians on the same patient, on the same day. This audit was completed over a time frame of 3 months. A percentage was then calculated to give the amount of discrepancies between the two clinicians over the period of 3 months. 35% of all BPEs recorded for the same patient by both clinicians on the same day had discrepancies within them. The audit was completed by another clinician within the practice who was neutral to both clinicians involved.
The audit is useful as it gives numerical value to the issue at hand making the size of the problem easier to visualise and understand. It also gives a baseline to the clinicians which can be used in the future to compare any other audits which may be completed once changes and improvements have been made. This encourages continuous improvement of the practice for the patients by setting goals of what to achieve for the clinicians within their clinical practice. However, the results of the audit are only limited to highlighting the extent of the problem not offering a solution to resolve it.
Moving forward the practice could utilise this information further by re-visiting the patients with the discrepancies and have an independent third clinician carry out another BPE and periodontal assessment to determine an accurate BPE score. This would be in the best interest of the patient as they would be able to have an accurate treatment plan devised for them.
Another key theme within clinical governance is effective quality improvement – “providing services based on evidence and which produce a clear benefit.” (RCN, 2018) All dental practices regardless of which type of service they provide in either an NHS or private setting should be providing evidence- based treatment. In this scenario there is a strong evidence base justifying the need of BPEs in periodontal treatment. Which when completed accurately will be of clear benefit to each patient. The treatment needs of the patient can be correctly assessed with an accurate BPE as well as other clinical information such as gingival tissue assessment, radiographs and a detailed medical history. Although the “BPE should be used for screening only and should not be used for diagnosis” is it still “crucial for detection of disease.” (Prof. Ian Needleman, March 2016, p.10) This links back to E1 and the delivery of evidence- based guidance.
“Responsive; R4 – How are people’s concerns and complaints listened and responded to and used to improve quality of life?” (CQC 03/15 p.40) Patients were raising concerns with both clinicians complaining of conflicting advice and information regarding their dental health. This was due to the difference in BPE scores which was determining different outcomes of treatment according to the scores. These concerns were listened to by the clinicians from their patients. They were responded to by constructive communication between the two clinicians, firstly both raising the concern of inconsistencies in their BPE scores which was resulting in patient confusion and complaint. Secondly, by the clinicians then taking the initiative to devise a plan to resolve the issue with the help of the practice manager. Several things were done including a clinical audit, completing further relevant CPD and both clinicians being willing to accept that there was an issue which needed to be resolved. This improved the patients’ quality of life as they were more likely to be receiving the correct advice and treatment plan for their needs.
The practice in this situation could have completed patient surveys with questions relating to advice they have received from clinicians and if it has been the same from different people they have seen. This would then give the clinicians direct feedback from their patients from which you could ascertain if patients were confused with conflicting information or confident in the same message being put out by the practice. With this information the clinicians would be able to discuss a way of sending out a coherent and consistent message to all patients which in turn would build confidence in the patients with regards to dentistry as a profession.
In conclusion, the scenario discussed is likely to occur in most practices due to the simple fact all clinicians carry out treatments and screenings slightly differently. However, if there is strong communication within the team and willingness to admit and learn from mistakes, the practice in question will be able to improve their services. This practice was able to overcome these obstacles by identifying the issue and working through several methods to resolve them, overall improving their patient care.
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