Certificate in Appraisal of Dental Practices

Faculty of General Dental Practitioners (UK)

The Royal College of Surgeons of England

Introduction

• Historically, little need to conform to standards

• Recent changes to check compliance & ‘quality’

• Network of advisors established

Introduction

• Need for formalised training for advisors

• End result must be better patient care

The Certificate in Practice Appraisal

• Generic Faculty qualification

• How to carry out effective practice appraisal

• With any system

• Not about individual jobs

• Relevant to range of organisations & individuals

Aims

• Train dentists and other team members to appraise the quality of clinical and non-clinical care delivered in the primary care setting

• Establish and maintain standards of practice appraisal

Learning Outcomes

At the end of the course, you should be able to:

• Undertake effective practice appraisals using any recognised quality assurance programme

• Conduct the appraisal process with professionalism and sensitivity

• Provide constructive feedback to appraisees and appropriate agencies on your findings

Learning Outcomes

• Provide accurate advice on all aspects of legislation, statutory requirements, good practice guidelines and GDC regulations

• Participate in the development of quality assurance programmes in primary dental care

The Certificate Explained

• 2 days of face to face learning

• Assessments

• The 3rd (assessment) day

Assessment

• 3 practice appraisal visits between days 2 & 3

• To achieve acceptable standard in each of 4 assessment tools

• Certificate carries 20 postgraduate credits

Assessment Tools

1. Portfolio

2. Simulated scenarios

3. Practice feedback

4. Knowledge testing

Portfolio

A record of what you learned from visits

– Details of each visit

– Piece of writing based on visit and linked to published evidence/research

– Issues arising during visits and linked to learning from course eg change management, handling conflict, legislation issues, handling ‘underperformance’

Portfolio – things to include

• Describe what you aimed to achieve • How did you feel, act, think? Why?• What were the key moments?• What action plan was agreed and how?• How might the appraisees have seen it?• What will you do differently as a result?• What have you learnt about being an appraiser?• References

Hints and Tips

• Demonstrate wide reading and understanding

• Particularly change management theory applied to your visits

• Don’t copy large chunks – summarise & quote

Hints and Tips

• Not too many anecdotes/personal opinions unsupported by evidence

• Less than 3000 words excluding title page, abstract, references or appendices

• Read appendices

• Contact assessors with queries

Recent Distinction

• Friendly, supportive yet shrewd and perceptive • Integrated his readings of the literature with his

observations and analysis of the visits • Narrative brought the visit to life and it

demonstrated how perceptive observations can lead to hypotheses and accurate inferences

• Appendices provided strong supporting evidence

Recent Good Pass

• Well constructed portfolio

• Clear executive summary, a good account of the visit and sound reflections

• Provides a thoughtful analysis of her visits

• Does not make strong links between her observations and analyses and the relevant research literature

Recent Resubmit

• Conveys the impression that he is charming, friendly and orally persuasive

• Report is not strong on reflections, integration with the research literature or systematic writing

• The presentation in graphic form of self and peer appraisals is less informative than a verbal comment

Simulated Scenarios

• Day 3• To assess interpersonal skills and attitudes• Participant takes part of appraiser • 20 minutes with 2 assessors• 1 assessor acts as appraisee, other provides

feedback• Scenario developed to fill gaps in portfolio

Practice Feedback

• You will self-assess performance • Against criteria for effective appraisals• Visited practice assess you with same criteria• Gaps identified addressed during scenarios• Practices get CPD to compensate

Knowledge Testing

• Current legislation,

• Statutory requirements,

• Good practice guidelines,

• GDC regulations

• On-line MCQ between days 2 & 3

• Information on legislation in Appendix 3

Clinical Governance

“Framework through which NHS organisations are accountable for continuously improving the quality of their service and safeguarding high standards of care, by creating an environment in which excellence in clinical care will flourish”

NHS Executive 1998

Clinical Governance

“About being able to demonstrate that you and your team have a safe, well-run practice with well-informed patients who are fully involved in their treatment decisions, with whom you are striving to achieve a measurable health gain”

Denplan Training 2002

Quality Assurance

An essential component of all clinical

governance compliance programmes

Quality Assurance

“The formal and systematic exercise of identifying problems in medical care delivery, designing activities to overcome the problems and following up to ensure no new problems have been introduced and that corrective actions have been effective”

Standards for Better Health

• QA programmes should be based on Standards for Better Health (SBH)

• SBH - Healthcare Commission’s 7 domains of clinical governance and their 24 core standards

Care Quality Comission

• Essential standards of Quality and safety

The Care Quality Commission• Under the Health and Social Care Act 2008, all primary dental care

providers must be registered by the CQC from 1st April 2011

• To be registered, providers must show they are meeting new essential standards of quality and safety in all of their regulated activities

• A provider’s registration is the first step in the new process – you only need to apply once, it is not an annual exercise

• The CQC’s focus then shifts to monitoring your services to ensure they continue to meet the essential standards.

The Care Quality Commission• The Care Quality Commission (CQC) is the independent regulator

of health and adult social care services in England.

Their mandate is to:• Drive improvement across health and adult social care• Put people first and champion their rights• Act swiftly to remedy bad practice• Gather and use knowledge and expertise and work with others to

avoid duplication

It’s just more of the same isn’t it?

• No, no and no!

• The goal posts have moved

• There has been a paradigm shift in emphasis and responsibilities between the ‘old’ way i.e. Clinical Governance requirements and the ‘new’ way i.e. CQC requirements

CG versus CQC

CG• All have a personal responsibility

to be compliant

• No registered manager

• Focused on checklists of structure and process

• Planned inspections with plenty of notice, therefore time to prepare

• Little formal follow-up

• Few enforcement powers

CQC• The provider is accountable and

responsible (no individual accountability at performer level)

• Practices need a registered manager on site who has local accountability

• Focus is on outcomes patients experience as a result of the structures and processes

• Inspections are unannounced or 24-48 hours notice

• QRP and formal, ongoing follow-up

• Onerous enforcement powers

The StandardsParliament Dept of Health

Care Quality Commission (Registration)

Regulations 2009

Health and Social Care Act 2008

(Regulated Activities)

Regulations 2009

CQC

Single system of registration

Single set of standards

Strengthened and extended enforcement powers

Regulated Activities• There are 15 categories of regulated activities

• A provider must register for each of the regulated activities it provides

• The regulated activities most likely to apply to dental care providers are:

1. Treatment of disease, disorder or injury

2. Surgical procedures

3. Diagnostic and screening procedures

• You must decide if you also need to register for any other activities from the list

The 17 Outcomes• Respecting and involving people

who use services

• Consent to care and treatment

• Fees

• Care and welfare of people who use services

• Meeting nutritional needs

• Cooperating with other providers

• Safeguarding people who use services from abuse

• Cleanliness and infection control

• Management of medicines

• Safety and suitability of premises

• Safety, availability and suitability of equipment

• Requirements relating to workers

• Staffing

• Supporting workers

• Assessment and monitoring the quality of service provision

• Complaints

• Records

Quality

customer Supplier

What do you want from me?ProductPriceService proposition

What is Quality?

• If only I had the answer

• Subjective

• Dynamic

What Is Quality?

• A degree of excellence

• Exceeding customer’s expectations

• Consistent conformance to consensus standards

• Whatever the customer says it is

• When the customer returns and the product doesn’t!

• Doing right things right.

“Quality is never an accident; it is always the result of high intention, sincere effort,

intelligent direction and skilful execution; it represents the wise choice of many

alternatives” William A Foster

Quality

“Quality is everyone’s responsibility”W. Edwards Deming

Donabedian Principles

Avedis Donabedian

Linked 3 components of healthcare to ‘goodness’

Donabedian Principles

Goodness of…..

• Technical care (clinical effectiveness)

• The team and how they interact

• The practice

Clinical Effectiveness

“The ability to achieve the greatest improvement in oral health that science, technology and clinical skill can offer at any moment in time”

Donabedian

Donabedian’s Triad

A framework for measuring and assessing quality

of:

• Structure

• Process

• Outcome

Structure

Physical features

• Practice premises

• Numbers of team members

• Range and type of equipment

• Easily measured

• Presence doesn’t mean quality delivered

• Absence means quality can’t be delivered

Process

Everything that happens in a practice

• Infection control procedures

• Health and Safety procedures

• Treatment carried out

• Patient records

Outcome

• Changes in patient’s health attributable to past intervention

• More difficult to measure than structure or process

• Clinical audit is one way of measuring

Structure x Process = Outcome

Clinical Audit

“…the systematic and critical analysis of the quality of clinical care, including the procedures used for diagnosis, treatment and care, the associated use of resources and the resulting outcome and quality of life for the patient”

DoH 1989 Working for Patients

Clinical Audit

• Logical progression to national guidelines, criteria and standards but….

• Some interventions work better for one dentist than another

• FGDP guidance ‘Standards in Dentistry’

Standards in Dentistry

Attempts to define:

• Ideal standard (Grade A)

• Acceptable standard (Grade B)

• Unacceptable standard (Grade C)

Clinical interventions are graded..

• Grade A - A standard of excellence has been achieved

• Grade B - The minimum acceptable standard, below which there is potential for damage to the patient to occur, has been achieved

• Grade C – The patient concerned has either been damaged or there is potential for them to be damaged

Quality Assessment & Assurance

• Quality assessment – ‘the comparison of care against pre-determined

levels of performance’

• Quality assurance – goes one step further– requires action to be taken on deficiencies

Certificate in Practice Appraisal

• Authorities will vary in what they want

• Some want quality assessment, most quality assurance

• Principles for appraising practices are the same