applying quality improvement methodologies in dental settings

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Center for Healthy CommunitiesOffice of Oral Health

Applying Quality Improvement Methodologies in Dental

SettingsPart 2

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Acknowledgements

This training was produced by Jennifer Byrne, MSc, the Sonoma County Department of Health Services’ Dental Health Program, and the California Department of Public Health’s Office of Oral Health. This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number H47MC28480, Children’s Oral Healthcare Access Program for a total award of $1,000,000. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

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Introductions

• Chat Box – Technical difficulties

• Q&A Box – Ask a question

• Exercises – COHTAC Website: https://oralhealthsupport.ucsf.edu

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https://oralhealthsupport.ucsf.edu

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Learning Objectives (1/2)

Following completion of this program, you will be able to:

– Develop SMARTIE goals and objectives– Create Process Maps using Lean methodology – Identify QI opportunities– Test small process changes

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Learning Objectives (2/2)

Following completion of this program, you will be able to:

– Identify, develop, and interpret data metrics– Explain a case-study example—applying a QI

approach to achieve measurable improvements– Identify QI tools and resources to share with your

dental teams

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What are we trying to accomplish?

Model for Improvement

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PDSA Tool

Download the Plan-Do-Study-Act Worksheet to use throughout

your quality improvement project.

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Poll #1A. Yes, I know

what SMARTIE represents

B. No, I’ve never heard of SMARTIE

C. Kind-of, I’ve heard of SMART before…

Are you familiar with the

“SMARTIE” approach to

developing goal and objective statements?

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S.M.A.R.T.I.E. Goals and Objectives

Component What it means

Specific Direct, meaningful, and detailed.

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Measurable Quantifiable progress toward goal achievement.

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Achievable Ambitious, but feasible given available resources (e.g., time, money, personnel, tools).

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Achievable Ambitious, but feasible given available resources (e.g., time, money, personnel, tools).

Relevant Aligned with team/organization mission.

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Achievable Ambitious, but feasible given available resources (e.g., time, money, personnel, tools)

Relevant Aligned with team/organization mission

Time-Bound Has a clear timeframe and deadline.

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Inclusive Brings traditionally marginalized people into the process in a power-sharing way.

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Inclusive Brings traditionally marginalized people into the process in a power-sharing way.

Equitable Includes an element of fairness to address inequity and injustice.

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Not S.M.A.R.T.I.E. ExampleDecrease the number of dental appointment ”no-shows” among pregnant women.

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S.M.A.R.T.I.E. ExampleTo increase the number of pregnant women receiving dental care, Mt. Rose Dental Clinic will reduce the number of dental appointment no-shows among pregnant women referred by its Comprehensive Perinatal Services Program by 10 percentage points from the baseline (67%) by September 30, 2020, with at least 2% reduction among homeless women, as measured by Mt. Rose Dental Clinic’s appointment scheduling program.

Specific, Measurable, Attainable, Relevant,

Time-Bound, Inclusive, Equitable

Case Study

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Section Check-In: Q&A

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What changes can we make that may result in an improvement?


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PDSA Tool: PLAN

Refer to the Plan-Do-Study-Act Worksheet.

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The Purpose of Process Maps

• Flowcharts create a picture of the sequence of steps in a process

• Making the process visible helps to– simplify the steps – improve efficiency – decrease opportunity for error

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Process Mapping Benefits

• Engages all stakeholders• Replaces pages of written word with a

picture• Spotlights wasted efforts, delays, missteps

and duplication in the process• Corrects misunderstandings about a

process• Helps build a common understanding and

consensus

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Why Develop a Process Map?

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Process Map Symbols

• Process beginning or end

• Activity step

• Process flow direction

• Decision points

• Wait or delay

• Swim Lane

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OB

Prov

ider

Den

tal O

ffic

e

Conduct Prenatal Intake Appt.

Schedule Follow-Up Appt. (Conduct

Dental Orientation)Pain?

Schedule Dental Appt. for Patient Using Electronic Practice Mgmt.

System

Conduct Same-Day Dental Appt.

(Exam + Treatment)

Share Dental Progress Notesw/ OB Provider

No

Yes

No

Yes

Patie

ntOB

Nur

seOB

Pr

ovid

erDe

ntist

Call Health Center

Health Center

Member?

Schedule Prenatal Intake Appointment (Appt.) for Medical

Orientation

Register Patient with the Health

Center

Perinatal Appointment Scheduling Process

Case StudyCurrent State

Patie

ntOB

Nur

seOB

Pr

ovid

erDe

ntist

Call Health Center

Health Center

Member?

Schedule Dental Appt. for Patient Using Electronic Practice Mgmt.

System

Share Dental Progress Notesw/ OB Provider

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Patie

ntCP

SP

Prov

ider

Dent

al F

ront

O

ffic

e St

aff

Participate in CPSP Appt.

Explain Health Benefits of

Dental Care & Advises Patient to Visit Dentist

Confirm Dental Appt.

Complete Dental Appt.

Schedule Dental Appt?

No Dental Appt.

No

Yes

Show-Up for Dental

Appt.?

No Dental Appt.

No

Yes



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Tips for Useful Process Maps (1/2)

DOFIRST• Assemble a representative team• Elicit input from all members of

the practice, including patients

SECOND• Identify the process to map• Determine beginning and end

points and level of detail

THIRD• Brainstorm the

current activities• Draft the flowchart

with post-it notes, involving all members with a role in the process

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Tips for Useful Process Maps (2/2)

• Have one person or discipline complete the chart

• Use a pre-determined template• Map the process as you want it to be—plot how

it actually is today

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DON’T

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Process Mapping Exercise

Map the Process: Boiling Eggs

• Choose a start and end point

• Map how you did it yesterday, not how you plan to do tomorrow.

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Boiling Eggs

Get eggs

out of fridge

Get potFill pot

with water

Place pot on stove

Bring water to boil

Hard or

soft boil?

Place eggs in pot

Place eggs in pot

Set timer for 10 minutes

Peel off egg shells

Set timer for 3 minutes

Peel off egg shells

Serve eggs

Soft Boil

Hard Boil

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Poll #2

A. YesB. NoC. Kind-of

Was your process map for boiling

an egg similar to the example we

just walked through

together?

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Patie

ntCP

SP

Prov

ider

Dent

al F

ront

O

ffic

e St

aff



Dental Care & Advise Patient to

Visit Dentist



Schedule Dental Appt?

No Dental Appt.

No

Yes

Show-Up for Dental

Appt.?

No Dental Appt.

No

Yes



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LEAN

• Employs a set of tools to identify and eliminate waste

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Types of Waste: DOWNTIME (1/2)

D

O

W

N

Defects/Rework• Unclear directions, mistakes, errors, re-work

Over Production• Unneeded reports, duplication, leftover

Waiting• Waiting for others to complete work, test results

Not Used Talent• Unused creativity

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Types of Waste: DOWNTIME (2/2)

T

I

M

E

Transportation• Moving things (rather than pre-position)

Inventory • Over-/under-stock, expired supplies

Motion• Excess searching, gathering, walking

Excess processing• Over-using more supplies or information

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• No method to prevent/catch errors• Ineffective design/layout of facilities• Fragmented, poorly designed processes• Equipment failures• Unorganized workspace• No standards, non-compliance with

standards• Unbalanced workloads

Root Causes of Waste (1/2)

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• Lack of flexible workforce

• Inadequate or no training

• Poor communication• No visibility to performance

• Lack of integrated systems & poor systems functionality

Root Causes of Waste (2/2)

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Patie

ntCP

SP

Prov

ider

Dent

al F

ront

O

ffic

e St

aff




Schedules dental appt?

No Dental Appt.

No

Yes

Shows up for appt.?

No Dental Appt.

No

Yes


Dental Care & Advise Patient to

Visit Dentist

Waiting

Not Used Talent



Waiting

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Patie

ntCP

SP

Prov

ider

Dent

al F

ront

O

ffic

e St

aff


Explain Health Benefits of Dental

Care & Initiate Scheduling Appt.

Patient Visited Dentist During

Pregnancy?

Schedule Next CPSP

Appt.

Identify Day & Time that Work Well for Patient

Respond to CPSP IM & Initiate

Video-Call

No

Yes

Send IM to Dental Front Office Staff

Confirm Appt. Time Works Well

for Patient

Book & Confirm

Appt.

Consent to Dental Appt.?

Schedule Next CPSP

Appt.

No

Yes


Case StudyFuture State

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Case

Study

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How do we know if a change leads to an improvement?


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Data for Quality Improvement

UnderstandHow does the current system

perform?

EvaluateDid our

intervention result in improvement?

MonitorIs our improvement

sustained over time?

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A data collection plan includes:

– Data elements and operational definitions– Collection method and data source– Due date

Data Collection Plan

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Types of Data

• Qualitative Data–Words

• Quantitative Data– #, %

CDPH Evaluation Resource Guide for Local Oral Health Programs

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https://oralhealthsupport.ucsf.edu/sites/g/files/tkssra861/f/wysiwyg/Evaluation%20Resource%20Guide-CDPH%20OOH.pdf

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Measurement Example

Goal

Decrease by 10% the number of pregnant women referred by the Comprehensive Perinatal Services Program who miss their dental appointments.

Measurement

# of pregnant women seen by the CPSP at Mt. Rose Community Health Center who completed a dental appointment at Mt. Rose Dental Clinic

from September 1-30, 2020 (measurement month)

# of pregnant women seen by the CPSP at Mt. Rose Community Health Center who schedule a dental appointment at Mt. Rose Dental Clinic

from September 1-30, 2020 (measurement month)

Case Study

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DoPrepare the Team to Conduct the Test

• Develop the new protocol and data collection system• Conduct training• Test new system

Collect Data

• Gather data during the test period• Schedule time for team to review and analyze data

Case Study

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Poll #3

A. TrueB. FalseC. I don’t know

Data for quality improvement

should be readily available, easy to

obtain, and tracked over

time.

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Run ChartsKey Elements• Graphic Display of Observed Data• Data Plotted Chronologically– x-axis shows the time period – y-axis shows the value measured

• Annotations of Improvement-Impacting Conditions

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Calculating Run Chart Elements

• Median = the most-middle number– All data points: 14, 19, 3, 8, 12, 60, 25– Ordered least to greatest: 3, 8, 12, 14, 19, 25, 60– Middle value: 14

• Mean = average– Easily skewed by outliers

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Key Elements in a Run Chart

0%

5%

10%

15%

20%

25%

30%

1-Jun 1-Jul 1-Aug 1-Sep 1-Oct 1-Nov 1-Dec 1-Jan 1-Feb 1-Mar

Oral Health Assessments At Site A

OHA Completed Median

Current System’s

Performance

EHR Upgrade

EHR Update

Start Reminder Calls

Title

Goal

Timeline; x-axis

$, %, #,etc.y-axis

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0%10%

20%30%

40%50%

60%70%

80%

1-Sep

3-Sep

5-Sep

7-Sep

9-Sep

11-Sep

13-Sep

15-Sep

17-Sep

19-Sep

21-Sep

23-Sep

25-Sep

27-Sep

29-Sep

No-Show Rates for CPSP Patient Referrals

Case Study Results

No-S

how

Rat

e

Case Study

DateNo-Show Goal Median

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Variation in Data

• Variation in a process may be due to common and special causes

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Common Cause

Expected variation

Special Cause

Unexpected, not previously observed patterns

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Common Cause Variation

• Common causes are expected!

• Examples– Normal wait times

for an appointment– Amount of time to

perform dental cleaning, exam, etc.

– Electronic dental record response time

– Normal wear and tear of equipment

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3035404550556065

Jan-01Jan-02

Jan-03Jan-04

Jan-05Jan-06

Jan-07Jan-08

Jan-09Jan-10

Jan-11Jan-12

Average Length of Time for Daily Dental Cleanings at Green Meadows Dental Clinic

Common Cause Variation: Example

Tim

e (m

inut

es)

DateCleaning Time Goal Median

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Special Cause Variation

• Special causes are new or unexpected!

• Examples– Computer crash– Launching a single

EHR program enabling primary care, OB, or CPSP to book same-day dental appointments for patients

– Number of appointments requiring rescheduling due to dentist out sick

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56

02468

101214161820

1-Jun

2-Jun

3-Jun

4-Jun

5-Jun

6-Jun

7-Jun

8-Jun

9-Jun

10-Jun

11-Jun

12-Jun

Daily Child (<5 yrs. old) Oral Health Assessments Completed at Green Meadows Dental Clinic

Special Cause Variation: Example

Give Kids a Smile Event

Date

# of

Ass

essm

ents

OHA Goal Median

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Poll #4

A. Natural variation within a process

B. Cause for alarmC. I don’t know

Common Cause

Variation is…

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Poll #5A. Something new or

unanticipated B. Variation outside of

historical knowledge base

C. present in order to determine if a change resulted in an improvement

D. All of the above

Special Cause Variation is…

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Run Chart RulesRULE 1: SHIFT• 6 POINTS IN A ROW ON SAME SIDE OF MEDIAN LINE

• Points on the centerline do not cancel, nor do they contribute to, the count towards a shift

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RULE 3: EXTREME OUTLIER• AN OBVIOUSLY DIFFERENT VALUE

RULE 2: TREND• 5 POINTS IN A ROW HEADED IN THE SAME DIRECTION (up or down)

• Consecutive points with the same value do not stop the count towards trend, nor do they add to the count

Only ONE rule needs to be fulfilled to suggest special cause variation

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Shift

0%5%

10%15%20%25%30%35%40%45%

1-Jun 1-Jul 1-Aug 1-Sep 1-Oc t 1-Nov 1-Dec 1-Jan 1-Feb 1-Mar 1-Apr 1-May

% of Infant Patients Receiving Oral Health Assessments

% A

sses

smen

ts

DateOHA Goal Median

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Trend

0%5%

10%15%20%25%30%35%40%45%

1-Jun 1-Jul 1-Aug 1-Sep 1-Oc t 1-Nov 1-Dec 1-Jan 1-Feb 1-Mar 1-Apr 1-May

Infant Oral Health Assessments At Site A

% A

sses

smen

ts

DateOHA Goal Median

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Extreme Outlier

0%

10%

20%

30%

40%

50%

60%

1-Jun 1-Jul 1-Aug 1-Sep 1-Oct 1-Nov 1-Dec 1-Jan 1-Feb 1-Mar 1-Apr 1-May

Child (<5 yrs. Old) Oral Health Assessments At Site A

X Wrong data pointü 20 extra RDAs on

site for Give Kids A Smile event

% A

sses

smen

ts

DateOHA Goal Median

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Using Data for QI Exercise

• Download and complete the exercise titled Interpreting Run Charts Exercise

• Exercise Overview:– Interpret first three run charts– Finish plotting the fourth run chart and

interpret

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Chart 1: Oral Health Assessments Conducted in Primary Care Setting

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One Trend

No Astronomical Points

No Shifts

20%21%

22%

9%8%

9%

20%

22%23%

24%

19%

23%22%

24%25%

17%

15%

19%

22%

0%

5%

10%

15%

20%

25%

30%

Ja n 1 ,2 0 20

F eb 1 ,2 0 20

M a r 1,2 0 20

Ap r 1 ,2 0 20

M a y 1 ,2 0 20

Ju n 1,2 0 20

Ju l 1,2 0 20

Au g 1 ,2 0 20

S ep t 1 ,2 0 20

Oc t 1,2 0 20

No v 1 ,2 0 20

De c 1 ,2 0 20

F eb 1 ,2 0 21

F eb 1 ,2 0 21

M a r 1,2 0 21

Ap r 1 ,2 0 21

M a y 1 ,2 0 21

Ju n 1,2 0 21

Ju l 1,2 0 21

DateOHA Goal Median

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75%

77%

75%76%

77%

75%

80%

84%85%

84%

87%

89%90%

95%

99%98%

97%96%

99%

70%

75%

80%

85%

90%

95%

100 %

Ja n 1 ,2 0 20

F eb 1 ,2 0 20

M a r 1,2 0 20

Ap r 1 ,2 0 20

M a y 1 ,2 0 20

Ju n 1,2 0 20

Ju l 1,2 0 20

Au g 1 ,2 0 20

S ep t 1 ,2 0 20

Oc t 1,2 0 20

No v 1 ,2 0 20

De c 1 ,2 0 20

F eb 1 ,2 0 21

F eb 1 ,2 0 21

M a r 1,2 0 21

Ap r 1 ,2 0 21

M a y 1 ,2 0 21

Ju n 1,2 0 21

Ju l 1,2 0 21

Chart 2: Availability of Pregnancy-Only Dental Appointments in OB/GYN Appt. System

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One Trend


Two Shifts

DateAppt. Avail. Goal Median

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5

6 6

4

7

17

7

6

4

3

2

4 4

0

6

5

3

7

4

0

2

4

6

8

10

12

14

16

18

Jan 1,2020

Feb 1,2020

Mar 1,2020

Apr 1,2020

May 1,2020

Jun 1,2020

Jul 1,2020

Aug 1,2020

Sept 1,2020

Oct 1,2020

Nov 1,2020

Dec 1,2020

Feb 1,2021

Feb 1,2021

Mar 1,2021

Apr 1,2021

May 1,2021

Jun 1,2021

Jul 1,2021

One Astronomical Points

Chart 3: Days Until Next Available Appointment

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One TrendOne Shift

DateAppt. Avail. Goal Median

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1%1.50%

1%

2%

3%

1%

2%

3%

4%

5%

3%

4%

5%

7%

9%

10%

11%

9%

10%

12%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0

Chart 4: Daily Rate of Pregnant Women Seen in Dental Office

PDSA Cycle 1: Change Occurred

Two Trends


Two Shifts

Visit Rate Median Goal

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QI Project: Case StudyCase Study

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0%10%

20%30%

40%50%

60%70%

80%

1-Sep

3-Sep

5-Sep

7-Sep

9-Sep

11-Sep

13-Sep

15-Sep

17-Sep

19-Sep

21-Sep

23-Sep

25-Sep

27-Sep

29-Sep

No-Show Rates for CPSP Patient Referrals

Case Study Results

No-Show Rate Median Goal

TrendsShift

Case Study

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QI Project: Case StudyCase Study

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CALL TO ACTION

Share the Quality Improvement (QI) Quick-Start Guide with your Dental Teams–Quality improvement overview– Plan-Do-Study-Act (PDSA) worksheet– How-to develop a process map template– How-to interpret data template

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Lessons Learned

•SMARTIE goals

•Process mapping

•Plan-do-study-act cycle•Interpreting run charts to determine if a change resulted in an improvement•Explain a case study example

•Share QI approaches, tools, and resources with your dental teams

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Additional Resources (1/3)American Dental AssociationThe American Dental Association hosts the Dental Quality Alliance (DQA), which was established to develop performance measures for oral health care. The DQA hosts a variety of resources related to dental quality measures, educational resources, and improvement resources.

https://www.ada.org/en/science-research/dental-quality-alliance

Association of State and Territorial Dental DirectorsThe Association of State and Territorial Dental Directors links to a variety of evidence-based quality improvement resources.

https://www.astdd.org/evaluation-and-quality-improvement/

Centers for Medicare and Medicaid ServicesThe Centers for Medicare and Medicaid Services issued a report for improving oral health care delivery in Medicaid and CHIP. The report is a toolkit to help state’s achieve the CMS Oral Health Initiative through QI.https://www.medicaid.gov/sites/default/files/2019-12/oral-health-quality-improvement-toolkit-for-states.pdf

Health Resources and Services AdministrationThe Health Resources and Services Administration published a report in 2011 explaining what QI is, why it’s important, the role of organizational leadership, how to prepare for change, the Model for Improvement, and other topics critical to QI.https://www.hrsa.gov/sites/default/files/quality/toolbox/508pdfs/qualityimprovement.pdf

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Additional Resources (2/3)Public Health FoundationThe Public Health Foundation provides QI tools, training, and resources.

QI Quick Guide:

http://www.phf.org/focusareas/qualityimprovement/QIQuickGuide/Pages/Welcome_to_the_Guide_to_Quality_Improvement.aspx

QI Tools: http://www.phf.org/programs/QItools/Pages/Quality_Improvement_Tools_to_Advance_Public_Health_Performance.aspx

Institute for Healthcare ImprovementThe Institute for Healthcare Improvement hosts a variety of resources, tools, and trainings.

Free Resources are available: http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

Free Tools are available (http://www.ihi.org/resources/Pages/Tools/default.aspx

The Dental QI Training, developed in collaboration with the Dental Quality Alliance, was the first QI

training exclusively for dental professionals: http://www.ihi.org/education/IHIOpenSchool/Courses/Pages/Dental-Quality-Alliance-DQA.aspx

The Certificate in Quality Improvement courses: http://www.ihi.org/education/IHIOpenSchool/Courses/Pages/OpenSchoolCertificates.aspx

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https://www.ada.org/en/science-research/dental-quality-alliance

https://www.astdd.org/evaluation-and-quality-improvement/

https://www.medicaid.gov/sites/default/files/2019-12/oral-health-quality-improvement-toolkit-for-states.pdf

https://www.hrsa.gov/sites/default/files/quality/toolbox/508pdfs/qualityimprovement.pdf

http://www.phf.org/focusareas/qualityimprovement/QIQuickGuide/Pages/Welcome_to_the_Guide_to_Quality_Improvement.aspx

http://www.phf.org/programs/QItools/Pages/Quality_Improvement_Tools_to_Advance_Public_Health_Performance.aspx

http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

http://www.ihi.org/resources/Pages/Tools/default.aspx

http://www.ihi.org/education/IHIOpenSchool/Courses/Pages/Dental-Quality-Alliance-DQA.aspx

http://www.ihi.org/education/IHIOpenSchool/Courses/Pages/OpenSchoolCertificates.aspx

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Additional Resources (3/3)National Network for Oral Health AccessThe National Network for Oral Health Access developed an operations manual for oral health programs; chapter six focuses on quality. Topics addressed in the toolkit include model for

improvement, PDSA cycles, sample quality measures, case studies and more.https://www.nnoha.org/nnoha-content/uploads/2013/08/OpManualChapter6.pdf

Population Health Improvement PartnersThe Population Health Improvement Partners has eLearning modules (videos), tools and templates to

learn about and apply improvement concepts to your work. https://improvepartners.org/toolbox/toolbox-details/qi-videos-tools/

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https://www.nnoha.org/nnoha-content/uploads/2013/08/OpManualChapter6.pdf

https://improvepartners.org/toolbox/toolbox-details/qi-videos-tools/

applying quality improvement methodologies in dental settings

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