Over the past three years the continuously changing nature of care quality compliance has become clearer to Registered Providers and Managers across the UK. At first many thought that to own a folders of policies and procedures would tick all the boxes, now they recognise that those policies and procedures must be definitions of how things are to be done and are looking to develop practical routes for the implementation of quality care measures in-line with the Fundamentals Standards (Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulations 2014 (Part 3) and the all-important Key Lines of Enquiry (KLOE).
Care Coordination
In private and specialist dental practices, the benefits of care coordination are now widely recognised. When well-planned and structured care coordination is successfully embedded into practice activities it offer a range of benefits, these include compliance benefits, alongside benefits for patients and dental professionals, in addition to increased profitability.
Under the terms of the HSCA, Regulations 9, 10, 11 patients’ participation in making their healthcare choices is a fundamental requirement. Therefore it is a logical step for teams to include a team member with advanced communication skills combined with practical understanding of dental procedures to ensuring patients are able to give ‘informed consent’ for dental procedures.
Opportunities to develop team roles
Roles and responsibilities within dental teams are regulated and defined in the General Dental Councils, Scope of Practice guidance. Whilst it is recognised that patients benefit when integrated teams of dental professionals cooperate to provide high quality care. Each registrant group has a responsibility to ensure all activities are within their skills and abilities.
Care coordination can provide excellent career development opportunities for dental care professionals provided that the care coordination programme is:
- Designed to meet current regulatory requirements;
- Well-lead;
- Caring;
- Structured;
- Standardised;
- Monitored and evaluated.
When care coordination involves the whole team in the maintenance of consistent clinical pathways, new and returning patients will recognise their dental visits as being the pathway to better oral health, better treatment, and better value.
Effective care coordination is a whole team activity. Unless each team member buys-in to the concept of involving, informing and enabling patients to achieve and maintain the highest possible quality of oral well-being, any investment made by the practice to embed care coordination into its culture will not secure the best return on investment.
- Set the aims objectives;
- Define practice policy;
- Allocate work in line with permitted duties;
- Create procedures and working instructions;
- Provide required material resources;
- Train the team;
- Run the programme;
- Monitor, audit and evaluate results;
- Use finding to develop the programme.
The Business Case for Care Coordination
The business case for care coordination is best made in the context of marketing and quality management. Effective care coordination is beneficial in both NHS and private practice, its success invariably depends upon the extent to which care coordinator(s) know and understand the features of the market
- Private practice objectives for care coordination may be to raise patients dental IQs and to enable them to understand the benefits (value) of top end dental procedures and also how to maintain best standards of oral well-being.
- NHS practice objectives may be to achieve the most efficient use of resources.
Communication Skills
Care Coordinators need to understand that each person has preferred ways for communicating. Some people are strong visual communicators and like to read or, watch information, whereas others are more comfortable with the spoken word or practical activities. These preferences are influenced by character traits, personality, experiences and education. Skilled Care Coordinators are able to pick up the cues and recognise each patient’s communication needs, and then adapt their communication techniques to deliver effective communications. Before patients can make enlightened decisions they need to be able to thoroughly understand treatments options prescribed for them.
Providing information for decision- making
When presenting information to patients to enable them to understand treatment options, it is important to apply the central principles of learning theory. For care coordination the four-stage cycle of learning, in which the care coordinator provided the patient with
- Information to provide a basis for;
- Observation and reflection, in some cases this means sending patients home with information;
- Information is then considered, giving rise theories;
- Which are then actively tested with more questions.
This is a cycle a cycle of experiencing, reflecting, thinking, and acting.
Appointment Planning
The lack of an effective appointments system is frequently the cause of the poor performance of care coordination systems. A badly organised appointment book can cause chaos and result in poor relationships between all concerned.
Effective appointment planning requires with a clearly defined pathway for the patient journey, from when they first decide to book an appointment at the practice, through to the successful completion of their first course of treatment. Procedures and processes need to be agreed and standardised and contingency plans agreed for those times when events hamper the smooth running of the process.
In both NHS and private practices one of the main resources requiring careful management is time, particularly the dentists and hygienist’s time. When patients are booked with more than one clinician it is possible for the time allocations between them to become problematic.
Care quality outcomes for the involving of patients in decision making about their treatments is of primary concern of care quality inspectors. There are numerous reasons why patients do not feel involved in their care decisions, ranging from a lack of intention on the part of the practice to involve them; through to difficulties the individual patient may have in understanding the information provided.
The duties of the care coordinator include a patient advocate role. By building a trusting relationship with the patient, the patient has an ally who will safeguard their best interests and they then will feel able to raise their worries and concerns with their professional friend,
Information Governance (IG)
Information Governance measures lead the way for healthcare organisation to be more interconnected. Many dental professionals have expressed a need to have direct access to information, directly relevant to affect their treatment decisions, held by other health care professionals involved in treating their patient currently or in the past. Information sharing provides many benefits. But at the same time introduce new risk factors. Healthcare services increasingly depend upon information technology. This initiative is a first step toward creating universal safe environment for information sharing secured from electronic attack. With those responsible for governance equipped to take protective measures proportional to the risk.
Until now the skills required to ensure effective information governance were not traditionally part of the skill sets taught to dental professionals
In a dental organisation the IG lead will take a similar role. They will need to have in depth understanding of how information is a vital asset in terms of clinical and practice management and the need to manage it efficiently. It is therefore important that the person taking the Lead role is able to develop and implement an appropriate framework of policies, procedures and management accountability.
Informed Consent
Informed consent is given when an individual has a full understanding of the details of a treatment and can recognise the associated benefits and drawbacks. Dental professionals are duty bound to ensure that their patients are able to make informed decisions and to test that all decision made meet the criteria for valid consent.
It is no longer acceptable for dental professionals adopt an out-dated and paternalistic approach and assume they know what’s best for their patient. It is important to recognize that when a patient signs a consent form this does not record the information used by the patient to make the decision to consent. Neither does it show if any undue influence was exerted to pressure the patient to reach the ‘right’ decision. This is why a detailed record, as would be complied by working through a clinical pathway is better than a signed consent form alone.
The term informed consent is widely used, although some dento-legal bodies prefer the term “enlightened consent”, since it captures the fact that a patient needs to be put into a position from which they can understand the key issues which will influence their willingness (or otherwise) to undergo a particular procedure.
At times patients may consent to a particular treatment because of how the dentist has presented the advantages or benefits. Because the dentists words are so influential it is vital not to over promise on treatment outcomes, rather to use objective, factual information. It is essential to avoid exaggerated statements.
When a patient is given only selected facts and considerations about a prescribed procedure, they may well be very happy to proceed, however if they had been given additional information, may have not consented. “Informed consent” cannot be given if the patient remains unaware of relevant facts that could have influenced their decision.
Consent cannot considered to be “informed” when the patient does not understand the information provided, this could be due to the use of complex technical language, or the way in which the information was presented.
- The clinician has the advantage of knowing much more than the patient, about what the procedure involves, about its risks, benefits, limitations, about alternatives and how they compare in each of these respects and also in terms of relative costs.
- The patient knows about their life and personal circumstances.
The clinician needs to ask the patient the right questions in the right way, at the right time, and needs to listen carefully to the patient’s responses, in order to gain an insight into whether any additional information is required.
In non-emergency cases the emphasis should be on ensuring that a patient has sufficient knowledge about the treatment, including:
- The purpose;
- What it involves;
- The likely effects and consequences;
- Risks, limitations and possible side effects;
- Alternatives and how they compare;
- Costs.
When patients believe that they have been denied sufficient information they often feel angry, misled or indeed violated or assaulted. These are powerful, destructive feelings that are likely to destroy any relationship of trust upon which consent is founded.
Care coordination best practices standardises the patient journey, whilst providing individualised patient care and involving patients in decision-making processes. Care coordination provides opportunities to raise patients’ dental IQs so that they can make informed decisions about their oral well-being.
