KEY POINTS * Understand the system of clinical audit and peer review in the South West. * Appreciate how clinical audit can lead to improvements in patient care. * Appreciate the role of

clinical audit in a practitioner's clinical governance requirements. ABSTRACT With the introduction of personal dental services (PDS) into the South West the Local Assessment Panel

(LAP) devised a new scheme consisting of 'cookbook' audits and piloted the scheme amongst the PDS dentists of South and West Devon, Somerset and Avon in 2005/2006. When the new

contracting arrangements came into force, and in the absence of guidance from above, the LAP in consultation with the PCTs decided to consolidate the successful pilot audit scheme for PDS

rating of 99% which cannot be improved on. We have redesigned this audit to try and make it more challenging and informative. The improvement in clinical record keeping was particularly

marked. With the advent of new contractual arrangements in April 2009 it is essential that practitioners are able to demonstrate quality assurance in their practice and we believe that the

South West scheme is a dentist friendly scheme, relevant to everyday dental practice. You have full access to this article via your institution. Download PDF SIMILAR CONTENT BEING VIEWED BY

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2023 INTRODUCTION When the new contracting arrangements for general and personal dental services were introduced in April 2006 the obligation for clinical audit was included in the new

standard contracts but was left up to the individual PCT to administer rather than the centralised system that had existed before. The system of clinical audit and peer review had started as

a pilot scheme in 1991 and had become a Terms of Service requirement in April 2001. All practitioners with a general dental services (GDS) contract had an obligation to participate in 15

hours of clinical audit and peer review activity in any three year period. This activity was monitored and administered by Local Assessment Panels (LAP) under the guidance of a Central

Assessment Panel (CAP). Practitioners were remunerated separately for their audit activity and trained audit facilitators were available to help practitioners create and complete their audit

activity. With the introduction of PDS into the South West the LAP devised a new scheme consisting of 'cookbook' audits and piloted the scheme amongst the PDS dentists of South

and West Devon, Somerset and Avon in 2005/2006. As usual the majority of the profession worked hard to produce thoughtful and informative audits which improved patient care and the small

minority had to be dragged kicking and screaming into the twenty-first century. The pilot scheme for PDS dentists met with overwhelming support from the participating dentists and the PCTs.

With the advent of the new contract the CAP and the central administrative arrangements ceased and PCTs were left to incorporate clinical audit and peer review into their own clinical

governance arrangements. The obligation to participate in audit activity was still in the contract and the funding had, theoretically, been incorporated into the contract sums. The Local

Assessment Panel working in the South West had been organising clinical audit and peer review for dentists in Somerset, South and West Devon, Avon and Gloucester administered by Taunton

Deane PCT. When the new contracting arrangements came into force, and in the absence of guidance from above the LAP in consultation with the PCTs decided to consolidate the successful pilot

audit scheme for PDS dentists and extend the new scheme to all the participating PCTs and their performers. The current scheme covers Devon, Somerset, Avon and Gloucester PCTs and is

administrated by Mrs Jackie Derrick on behalf of Somerset PCT. SOUTH WEST CLINICAL AUDIT AND PEER REVIEW SCHEME In the pilot scheme we devised a series of 'cookbook' audits for

practitioners to complete. The first three were on: * Infection control and decontamination * Clinical record keeping * Quality of radiographs. With the advent of the new contract in April

2006 we added three more audits: * Patient satisfaction * Recall intervals based on NICE guidelines * Contractual obligations for nGDS and nPDS. Each practitioner with an NHS contract for

dental services with the participating PCTs was expected to complete an audit each year representing five hours of audit activity. No additional remuneration was available as the contracts

notionally contained an amount to cover this activity and the PCTs administrative expenses came from their clinical governance budgets. Each practitioner could choose one of the six audits

and was given three months to complete the audit and return it to the LAP. The audits were designed as two stage audits with an initial set of results, an opportunity to examine the results

and decide on any necessary changes to clinical practice, followed by a second cycle to see if any improvement had occurred. The audits were designed to easily demonstrate whether these

gains had actually happened. We have included specific aims and objectives for each audit and practitioners must record whether they feel these have been met. We also have a section for

feedback which is regularly used and are able to certificate five hours of CPD for each completed audit. The LAP read all the audits submitted and ensures that a satisfactory level of audit

activity has been carried out by each dentist. We will return audits for further attention if they are deficient. As with the original scheme the individual results were confidential to the

participating dentist and the LAP. The panel felt that this would encourage the educational aspect of the audits and allow dentists to examine and improve their clinical practice without

anxiety about PCTs monitoring their results. We are, however, aware of our responsibilities as registered dentists and to patient safety and if we see an audit which in our opinion

highlights an issue of unsafe practice we will refer it to the relevant PCT. The results of all the audits are carefully recorded and presented to the participating PCTs in an anonymised

form so that they can see any improvement in clinical practice by the dentists in their PCT area and compare it with the data from the South West as a whole. Each dentist is also sent the

yearly results so they can compare their own results with that of their colleagues in the South West. Each year the LAP runs a half day workshop for the participating PCTs and invites

feedback from the PCT officers on how the scheme is operating and if any changes are necessary. This enables us to plan the following year's audits using the feedback from PCTs and

participating dentists. The changes made for 2007/2008 following our workshop were: * Introduced peer review * Made modifications to the existing audits, especially the patient satisfaction

audit * Made an action plan a mandatory requirement for each audit which will be shared with the PCT * Introduced a new audit on antibiotic prescribing * Have included Devon PCT in the

scheme. RESULTS OF 2006/2007 SCHEME The results of the audits will be given in some detail for the cross infection and radiographic quality subjects and a brief resume of the others will be

given. If further details are required please email Mrs Derrick on [email protected]. 1. CROSS INFECTION CONTROL AND DECONTAMINATION STRUCTURED AUDIT AIMS AND OBJECTIVES * To

enable dental performers to evaluate their standard of cross infection control * To use the results to promote discussion and necessary change * To decide on and make any necessary

improvements * To review the changes made. This audit consists of 100 statements concerning cross infection control and for each statement the participating dentist recorded: * A Fully

comply with the statement * B Partial compliance but further work needed * C Do not comply. SAMPLE STATEMENTS * 10. All clinicians and staff involved in invasive procedures are vaccinated

against hepatitis B and have had a sero conversion test. * 20. There is evidence that the appropriate PPE is available in the decontamination area, ie gloves, aprons and face protection. *

30. Instruments are checked for cleanliness before sterilisation. * 40. Have operators of the device (autoclave) received any training regarding its use? * 50. Gloves are non powdered,

hypoallergenic and low protein. The results are recorded as a percentage for each of A, B and C. The practitioner is advised to examine their results and consider with their practice team if

any improvements are required and how they could be implemented. The BDA Advice sheet 12 on infection control is recommended. Any changes to practice procedures and policies which are

thought necessary should be implemented. Conclusions and any changes made are recorded in the box marked 'Conclusions and changes' The audit is then repeated after any changes are

implemented and the results of the second audit recorded as before. In a final box marked FEEDBACK the practitioner is asked to record their thoughts on the audit and how it could be

improved. Also if they have a view on how the PCT could assist dental practices in maintaining a high standard of infection control they are requested to please let us know. It should be

noted that the audit contains some questions which mean that a finding of 'not applicable' needs to be recorded. (eg Q39 if you do not have a vacuum autoclave) or that some

questions contradict each other. The purpose of the audit is not to register a 'perfect score' but to enable practitioners to evaluate cross infection control processes and

hopefully improve them. RESULTS Two hundred and forty-seven audits showed a 17% improvement in cross infection control standards (Fig. 1). SOME OF THE CHANGES RECORDED * Nurses to use heavy

duty gloves for cleaning instruments and surfaces 37 * Cross infection control policy printed and available 57 * Immunisation records updated 31 * Ultrasonic cleaner to be drained and

cleaned at the end of each day 30 * Face masks to be changed after each patient 19 * Disposable bibs to be used 9 * Improve disposal of extracted teeth 33 AND * Practice owner does like us

to wear uniforms * Gloves to be changed between patients * Changes not completed due to cost * Below average score due to company policy to employ unqualified nurses * The nurses do not get

proper training before they start work. SUMMARY OF THE CONCLUSIONS * Cross infection procedures much better * This procedure made me think more deeply about cross infection control * Surgery

uniforms now worn * After the changes had been implemented, the second audit cycle assured us that the set standard had been achieved * Improved our cross infection control considerably *

Basic infection control is of a high standard * After 30 years in dentistry I'm not going to start using rubber dam now * Increased staff awareness. EXAMPLES OF FEEDBACK * Seemed to be

doing quite well but must not be complacent * I wasn't sure how much detail you wished to receive on 'changes/conclusions after the first cycle' * What does question 66 mean?

Skin disinfection. Does this mean washing of hands, removing jewellery? * Many thanks for this structured audit, very helpful. Where do we find a sample of a written cross infection policy?

* Some areas of audit not so clear ie Q44 & 45 * The PCT could assist dental practices in maintaining high standards of infection control by allocating funding specifically for

washer/disinfector equipment and updated autoclaves * Q5 – Feel this is not appropriate for non-clinical staff and could lead to incorrect information being given * I am a single-handed

practitioner, courses costing hundreds of pounds held by various companies are too expensive. Please run some. ASSESSMENT OF AIMS AND OBJECTIVES See Figure 2. CONCLUSIONS The audit satisfied

the aims and objectives and contributed to a significant improvement in cross infection control in the South West. 2. QUALITY OF RADIOGRAPHS AIMS * 1 To set criteria and standards for good

practice in the taking of radiographs * 2 Compare current practice with the standard set * 3 To collect data which will help decide what action is to be taken to improve performance (eg

improvement in technique, processing and performance of X-ray equipment) * 4 To make changes where appropriate and to re-audit on a regular basis. OBJECTIVES * 1 To reduce radiation exposure

to patients * 2 To improve the diagnostic capabilities of radiographs. METHOD The audit consists of two cycles, a retrospective audit and a prospective audit. The retrospective audit

involves the practitioner analysing a random selection of 50 recently taken radiographs. Each radiograph should be graded according to NRPB standards in quality, which are: * 1 Excellent -

no errors of exposure, positioning or processing * 2 Diagnostically acceptable-some errors, but these errors do not detract from the diagnostic utility of the radiograph * 3

Unacceptable-errors present, which render the radiograph diagnostically unusable. With reference to the grading system, the practitioner analyses each film and put them into grades 1, 2 or

3. Radiographs from grades 2 and 3 are further examined in order to determine the causes of error and these are classified into faults due to: * a Positioning * b Exposure * c Processing.

When the results of the first cycle have been collected the practitioner is able to see whether their technique for taking and processing radiographs requires any improvements. Analysis of

the data from the grade 2 and 3 groups will highlight any changes that are required to improve on the results from the retrospective audit. Changes can then be implemented and assessed with

the use of the prospective audit cycle, consisting of another sample size of 50 radiographs. RESULTS There were 230 audits and there was an 18% improvement in quality (Fig. 3). SOME OF THE

CHANGES RECORDED * Developing and fixing chemicals changed more frequently * More careful positioning of film and X-ray head * X-ray holders used more often * Better staff training * New

equipment purchased. SUMMARY OF CONCLUSIONS * High standards were achieved in first cycle but improvements were still recorded * Care with alignment and processing produced better all round

results * Increasing use of digital systems will eliminate chemical processing problems, but not other common difficulties with positioning EXAMPLES OF FEEDBACK * Easy to use and helped to

improve techniques * New equipment, especially film holders purchased * Will do this audit every year to maintain standards * Spent more time on staff training * Very pleased with quality on

first cycle. CONCLUSION The audit satisfied the aims and objectives and contributed to a significant improvement in the quality of radiographs (Fig. 4). SUMMARY RESULTS OF REMAINING AUDITS

PATIENT SATISFACTION SURVEY * Number of audits 185 * Percentage improvement 0.6 AUDIT OF RECALL INTERVALS IN DENTAL PRACTICE BASED ON NICE GUIDELINES * Number of audits 38 * Improvement in

factors considered and recorded at a dental examination 44% CONTRACTUAL OBLIGATIONS IN THE NGDS AND NPDS * Number of audits 39 * Percentage improvement 22.5% CLINICAL RECORD KEEPING * Number

of audits 183 * Improvement in clinical records with 0 items missing 150% CONCLUSION All the audits showed improvement with the exception of the patient satisfaction survey where the first

audit cycle showed an average patient satisfaction rating of 99% which cannot be improved on. We have redesigned this audit to try and make it more challenging and informative. The

improvement in clinical record keeping was particularly marked. SUMMARY The LAP feel that the South West clinical audit and peer review scheme has been a great success with both the PCTs

involved and the vast majority of participating practitioners. The overwhelming feedback has been positive and the quality of many of the audits has been exceptional. We are currently

looking forward to 2008/2009 and have a workshop in February to discuss with the PCTs how they want the scheme to progress and integrate with their own clinical governance arrangements. Some

of the issues we will be discussing will be confidentiality, poor performance, non compliance and the production of new relevant audits. With the advent of new contractual arrangements in

April 2009 it is essential that practitioners are able to demonstrate quality assurance in their practice and we believe that the South West scheme is a dentist friendly scheme, relevant to

everyday dental practice. The underlying principle of the audits is to enable practitioners to examine their clinical practice in a non-threatening, structured and measurable way to give

themselves the opportunity to examine their findings and make any necessary changes to improve their practice. It also gives practitioners an opportunity to compare their standards with that

of their colleagues in the South West working under similar conditions. We encourage all participating practitioners to keep a copy of their completed audits as evidence to include in their

personal or practice clinical governance portfolios. ACKNOWLEDGEMENTS My thanks go to Bernard and Stuart for their wise counsel, sense of humour and hard work. My biggest thank you,

however, on behalf of myself, Bernard and Stuart, and all the dentists working in Devon, Somerset, Avon and Gloucester goes to Jackie Derrick without whose dedication, beyond the call of

duty, the scheme could not operate. AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Chair, Local Assessment Panel, Pinhoe Dental Centre, 402 Pinhoe Road, Exeter, EX4 8EH, Devon P.

Howard-Williams Authors * P. Howard-Williams View author publications You can also search for this author inPubMed Google Scholar CORRESPONDING AUTHOR Correspondence to P. Howard-Williams.

ADDITIONAL INFORMATION REFEREED PAPER RIGHTS AND PERMISSIONS Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Howard-Williams, P. Clinical audit and peer review scheme for the

South West post-new 2006 dental contract: a report on progress so far. _Br Dent J_ 206, 37–41 (2009). https://doi.org/10.1038/sj.bdj.2008.1124 Download citation * Accepted: 22 September 2008

* Published: 10 January 2009 * Issue Date: 10 January 2009 * DOI: https://doi.org/10.1038/sj.bdj.2008.1124 SHARE THIS ARTICLE Anyone you share the following link with will be able to read

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