Niall McGoldrick BDS, MFDS RCPS(Glasg), Derek Richards BDS, FDS, MSc, DDPH,FDS(DPH)

Introduction

Implementing the best available evidence and enabling positive sustainable change in practice is an enviable goal for anyone providing healthcare services. In this final article of a three-part series we will discuss applying
the evidence and methods of evaluating the outcome, as the final two parts of taking an evidence-based approach. These final two parts are arguably the most important but are often perceived as the two most difficult to achieve. 

In general dental practice there are any number of barriers to implementing effective change, including the healthcare system, the will of staff, patient expectations and time available. That said, this stage does not need to be overly complex but it does need to be planned and there are
a number of tools we can use to deliver evidence-based dentistry to each and every patient. This article is focused on giving some practical advice and pointers. 

Systems thinking

Any challenge is easier when it is broken down into smaller chunks. So think of what you are trying to achieve, then the process that takes place to get to that goal and the system it is part of. Everything we interact with is a system, and there are processes within that system. As soon as we walk out the door in the morning we begin to interact with systems, and we start processes. 

The footpath network is part of a national infrastructure system with which we interact; queuing for a coffee at the train station is part of a small local system, the surgery at work is a complex local system with many interacting and moving parts. Within these systems there are various different processes; for example, the footpath network has a series of pedestrian crossings, the process to crossing the road will often start by pushing a button and waiting for the green man on the traffic lights, but, of course, it is often a lot more complex than this.

In order to understand the system and how best to implement evidence within a system, you need to be able to map the processes you are thinking of changing and determine what might influence the application of evidence. This is called process mapping. Once you have the map, then you can think about the possible barriers to applying the best evidence and equally think about what would enable application of best evidence. The ultimate system makes it easy to do the right thing without relying on humans to do so. Equally, an effective system can make it difficult to do the wrong thing.

Figure 1 illustrates how a process map for crossing the road might look. This map is very simple and doesn’t take into account all potential choices or influences, but it should give you an idea of how to go about constructing a process map.

Let’s return to our clinical example of our paediatric patient in practice whose parent has withheld consent for fluoride varnish application. After completing parts 1,2 and 3 of an evidence-based approach, (1: Asking the right question, 2: Searching for the best available evidence, 3: Critically appraising the evidence), and based on the evidence found, we are confident that for this child, fluoride varnish application would be the best approach to prevent decay. The current barrier to you doing so is the lack of consent from the parent. We need a pragmatic solution to the problem, and providing the information only at the time of application at chair side may not be the best solution. 

There are many different elements of the system and processes that lead up to that point that could influence the outcome. The appointment booking, check-in, walking to the chair, interaction between you the child and the parent. How many members of staff have been parts of the process? Any change will need to take the system, processes and staff into account. Likewise, there have been a number of tools used, including IT, telephones and dental instruments that also need to be taken into account. A good way to visualise the process and possibly facilitate brainstorming sessions with staff is to again create a process map, similar to Figure 2 (right). This figure is quite obviously simplified, as in reality there are many more influences and choices.

So thinking of the system, the processes and the current barrier, how about if a leaflet had gone out with the appointment in advance that explained the benefits of the treatment to the parent, would it have helped? This could be a change idea to test out in the practice. There are a number of ways that you could implement and evaluate this change. 

We will look at a few methods at our disposal. First: Quality improvement methodology. 

What is quality improvement (QI)?

QI is an approach we can use to build change into processes and systems that is sustained. It is a new kid on the block in dentistry, but it has been around in healthcare for more than 30 years and for much longer in industry. 

The first formal introduction to QI in Scottish dentistry was through the Scottish Patient Safety Programme in 2016. 

Our healthcare colleagues working in the acute and other Scottish primary care services have been doing QI for just over 10 years now. We have some catching up to do, but the benefit is that we can learn from those that have gone before. There are plenty of QI success stories published in
a bespoke journal for QI, BMJ quality and safety – access it here: qualitysafety.bmj.com/ 

QI methodology and science take a pragmatic approach to implementation of change in a system, focused on tests of change and clear measures so we understand the implications of any change. This controlled approach to implementing change is ideal for use in dental practices. QI is also ideal for finding ways to implement best practice that is supported by evidence. 

There is a level of skill and knowledge required to maximise all the QI tools available. NES has developed a number of useful resources that can be accessed online to help navigate QI and can be accessed here

Changes to the SDR in October 2017 mean that dentists can now include quality improvement work where this would have been traditionally audit activity. 

Peer review

Another method to achieve the final two parts of an evidence-based approach might be to use peer review. This is a process of collaborative working with colleagues to establish a group that facilitates peer-to-peer discussion. It involves practitioners outside your practice and could bring a fresh point of view to the processes in your practice. NES has laid out some advice on the requirements of a peer review group on their website, have a look here

If done correctly this approach can be used to fulfil quality improvement hours.

One way to use peer review to improve care might be for discussion and implementation of the updated SDCEP guidance on paediatric dentistry that has recently been published ¹. 

You could establish a local group of dentists to come together and discuss the guidance, using it as your standard of care and benchmarking against it, then working together to make changes that will benefit patients and improve the quality of care. 

In our example of using a leaflet as a test of change, the practice down the road might have more success in winning parents over because they give the leaflet out with appointment letters rather than when they arrive at the reception desk. Or they might have more experience of paediatric dentistry and could share some tips on behavioural management and helping kids accept treatment.

Behaviour change models

Sometimes implementation can come up against a lot of barriers and it seems like there is no path through all the issues and reasons not to change. Susan Michie’s research group at University College London has produced a number of models and theories that could be helpful. 

The TRIADS (translational research in a dental setting) team uses some of these methods alongside guidance development and implementation of SDCEP guidance ². Thinking about barriers to change, it is sometimes down to the physical confines of the working environment or maybe it is the people within it. There are various methods for helping to work through the barriers and understand how to break them down and facilitate positive behaviour change. 

The theoretical domains framework is made up of 14 domains that can help you understand what the barriers are by providing a framework to create questions from ³. 

For example, the first domain is knowledge, questions in this domain might look like: Do practitioners know that new SDCEP guidance for paediatrics has been published? The second domain is skills; a question in this domain might be: Do dentists in the practice know how to place a Hall crown? 

Once you gain answers to these questions you can begin the frame ideas and develop facilitators that will enable application of evidence-based practice and guidance. That might be issuing each practitioner with the guidance and arranging a team meeting to discuss it, changing pro-formas on the surgery operating system to include risk assessments that hadn’t been previously included or arranging for the practice to have a training day on fitting Hall crowns. You can only come up with effective solutions if at first you understand the real underlying barriers. You can read more about the TDF in a free open access journal here

Evaluating theoutcome further

All of the approaches above have evaluation built in. The usual go to mechanism for measuring and evaluating change tends to be a traditional style audit of pre- and post- intervention data collection. This is an effective method of evaluating an outcome, but it only gives a snapshot, usually of quantitative data, of an ongoing and dynamic system. This type of audit activity still has a place to ensure standards are met and identify areas where there could be improvements but we shouldn’t be restricted to it.

There are a many other ways of evaluating outcomes and presenting evidence of effective change. It is important though, to distinguish between process measures and outcome measures. In the fluoride varnish example, a process measure might be the number of successful applications of varnish applied, but the outcome measure would be the reduction in caries rate or continued prevention of caries for the patient. Having the ultimate health outcome in mind throughout the project is important, as after all everything the project is striving to achieve is improve the quality of care we provide to patients and improve their health.

Qualitative feedback from staff on a new process is an important measure when evaluating outcomes and could be gathered in staff meetings or in questionnaire form. Staff often come up with pragmatic and innovative ideas that might not have been thought of previously.

Gathering patient feedback is another very valuable measure. The Scottish Government’s Health and Social Care standards provide some useful questions and themes to base outcome markers on ⁴. 

An example of the headline outcomes in the document are ‘I have confidence in the people who support and care for me’ and ‘I am fully involved in all decisions about my care and support’. The document is worth a read; the standards are meant to compliment already existing standards set out by various legislative bodies. 

Staff and patient feedback could be combined with quantitative data as part of the evaluation of a project in your practice. Returning to QI, the method of quantitative data collection in QI uses a sustained approach to data collection. QI has a programme of active data collection taking place throughout the change process. Instead of collecting large amounts of data at two time points, QI asks that you collect smaller amounts of data at more regular time points. This provides greater levels of regular feedback that can help you understand the implications of any changes you have made earlier.

Conclusion

The three articles we have published in this magazine should give you a good basis for moving forward and practicing evidence-based dentistry. Providing high-quality care and sustaining it is the end goal. Backing up your clinical decision-making and informing your treatment plans with evidence will inevitably help you achieve that. Hopefully the top tips in these articles help you to do that.  

If you are further interested in the implementation of evidence in practice and want to be part of testing ideas more formally, then the Scottish Dental Practice Based Research Network will be of interest to you, check out their website to find out about their current projects how to get involved: http://www.sdpbrn.org.uk 

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References

1. SDCEP. www.sdcep.org.uk. [Online] 2018. [Cited: July 20, 2018.] http://www.sdcep.org.uk/wp-content/uploads/2018/05/SDCEP-Prevention-and-Management-of-Dental-Caries-in-Children-2nd-Edition.pdf

2. The translation research in a dental setting (TRiaDS) programme protocol. al, Jan E Clarkson et. 57, s.l. : Implementation Science, 2010, Vol. 5.

3. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Lou Atkins, Jill Francis, Rafat Islam, Denise O’Connor, Andrea Patey, Noah Ivers, Robbie Foy,
Eilidh M.Duncan, Heather Colquhon, Jeremy M. Grimshaw, Rebecca Lawton, Susan Michie. 77, s.l. : Implementation Science, 2017, Vol. 12

4. Scottish Government. Health and Social Care Standards. Edinburgh :
The Scottish Government, 2017. 978-1-78851-015-8.

Tags: 2019, Dentistry, evidence