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Objectives: To develop outcomes of care quality measures derived from the dental electronic health record (EHR) to assess the occurrence and timely treatment of tooth decay. Methods: Quality measures were developed to assess whether decay was treated within 6 months and if new decay occurred in patients seen. Using EHR-derived data of the state of each tooth surface, algorithms compared the patient's teeth at different dates to determine if decay was treated or new decay had occurred. Manual chart reviews were conducted at three sites to validate the measures. The measures were implemented and scores were calculated for three sites over four calendar years, 2016 through 2019. Results: About 954 charts were manually reviewed for the timely treatment of tooth decay measure, with measure performance of sensitivity 97%, specificity 85%, positive predictive value (PPV) 91%, negative predictive value (NPV) 95%. About 739 charts were reviewed for new decay measure, with sensitivity 94%, specificity 99%, PPV 99%, and NPV 94%. Across all sites and years, 52.8% of patients with decay were fully treated within 6 months of diagnosis (n = 247,959). A total of 23.8% of patients experienced new decay, measured at an annual exam (n = 640,004). Conclusion: Methods were developed and validated for assessing timely treatment of decay and occurrence of new decay derived from EHR data, creating effective outcome measures. These EHR-based quality measures produce accurate and reliable results that support efforts and advancement in quality assessment, quality improvement, patient care and research.

While adverse events (AEs) are all too prevalent, their underlying causes are difficult to assess because they are often multifactorial. Standardizing the language of dental AEs is an important first step toward increasing patient safety for the dental patient.We followed a multimodal approach building a dental AE inventory, which included a literature review; review of the MAUDE database; a cross-sectional, self-administered patient survey; focus groups; interviews with providers and domain experts; and chart reviews.One hundred eight unique allergy/toxicity/foreign body response, 70 aspiration/ingestion of foreign body, 70 infection, 52 wrong site/wrong patient/wrong procedure, 23 bleeding, 48 pain, 149 hard tissue injury, 127 soft tissue injury, 91 nerve injury, 171 other systemic complication, and 177 other orofacial complication were identified. Subtype AEs within the categories revealed that allergic reaction, aspiration, pain, and wrong procedure were the most common AEs identified among known (i.e., chart reviews) and hypothetical (i.e., interviews) sources.Using a multimodal approach, a broad list of dental AEs was developed, in which the AEs were classed into 12 categories. Hard tissue injury was noted frequently during interviews and in actuality. Pain was the unexpected AE that was consistently identified with every modality used.Most AEs result in temporary harm with hard tissue injury being a common AE identified through interviews and in actuality through chart reviews. Acknowledging that AEs happen is an important step toward mitigating them and assuring quality of care for our patients.

Chart review is central to understanding adverse events (AEs) in medicine. In this article, we describe the process and results of educating chart reviewers assigned to evaluate dental AEs.We developed a Web-based training program, "Dental Patient Safety Training," which uses both independent and consensus-based curricula, for identifying AEs recorded in electronic health records in the dental setting. Training included (1) didactic education, (2) skills training using videos and guided walkthroughs, (3) quizzes with feedback, and (4) hands-on learning exercises. In addition, novice reviewers were coached weekly during consensus review discussions. TeamExpert was composed of 2 experienced reviewers, and TeamNovice included 2 chart reviewers in training. McNemar test, interrater reliability, sensitivity, specificity, positive predictive value, and negative predictive value were calculated to compare accuracy rates on the identification of charts containing AEs at the start of training and 7 months after consensus building discussions between the 2 teams.TeamNovice completed independent and consensus development training. Initial chart reviews were conducted on a shared set of charts (n = 51) followed by additional training including consensus building discussions. There was a marked improvement in overall percent agreement, prevalence and bias-adjusted κ correlation, and diagnostic measures (sensitivity, specificity, positive predictive value, and negative predictive value) of reviewed charts between both teams from the phase I training program to phase II consensus building.This study detailed the process of training new chart reviewers and evaluating their performance. Our results suggest that standardized training and continuous coaching improves calibration between experts and trained chart reviewers.

Few clinical datasets exist in dentistry to conduct secondary research. Hence, a novel dental data repository called BigMouth was developed, which has grown to include 11 academic institutions contributing Electronic Health Record data on over 4.5 million patients. The primary purpose for BigMouth is to serve as a high-quality resource for rapidly conducting oral health-related research. BigMouth allows for assessing the oral health status of a diverse US patient population; provides rationale and evidence for new oral health care delivery modes; and embraces the specific oral health research education mission. A data governance framework that encouraged data sharing while controlling contributed data was initially developed. This transformed over time into a mature framework, including a fee schedule for data requests and allowing access to researchers from noncontributing institutions. Adoption of BigMouth helps to foster new collaborations between clinical, epidemiological, statistical, and informatics experts and provides an additional venue for professional development.

Obtaining basic management skills and including management and leadership as essential components of the curriculum is a critical part of dental students' education. This research evaluated the understanding of management concepts of dental students at the Federal University of Paraíba (UFPB), before and after participating in a Management and Professional Guidance course. This quantitative study assessed the level of knowledge of management skills and competencies of dental students through a validated questionnaire. The data were analyzed using descriptive and inferential statistics, adopting a significance level of 5%. The sample consisted of 47 students, 18 from the 1st semester, 18 from the 7th semester and 11 from the 10th semester of the course. All students considered knowledge about management extremely important for the dentist. The level of knowledge about management skills and leadership is low among students, with no statistically significant difference between student year of training. Specifically, concerning students midway through their dental training, there was a significant increase in knowledge for all management skills after attending the Management and Professional Guidance course (p

Contains fulltext : 232750.pdf (Publisher’s version ) (Open Access) OBJECTIVE: To develop a minimum Adult Oral Health Standard Set (AOHSS) for use in clinical practice, research, advocacy and population health. MATERIALS AND METHODS: An international oral health working group (OHWG) was established, of patient advocates, researchers, clinicians and public health experts to develop an AOHSS. PubMed was searched for oral health clinical and patient-reported measures and case-mix variables related to caries and periodontal disease. The selected patient-reported outcome measures focused on general oral health, and oral health-related quality of life tools. A consensus was reached via Delphi with parallel consultation of subject matter content experts. Finally, comments and input were elicited from oral health stakeholders globally, including patients/consumers. RESULTS: The literature search yielded 1,453 results. After inclusion/exclusion criteria, 959 abstracts generated potential outcomes and case-mix variables. Delphi rounds resulted in a consensus-based selection of 80 individual items capturing 31 outcome and case-mix concepts. Global reviews generated 347 responses from 87 countries, and the patient/consumer validation survey elicited 129 responses. This AOHSS includes 25 items directed towards patients (including demographics, the impact of their oral health on oral function, a record of pain and oral hygiene practices, and financial implications of care) and items for clinicians to complete, including medical history, a record of caries and periodontal disease activity, and types of dental treatment delivered. CONCLUSION: In conclusion, utilising a robust methodology, a standardised core set of oral health outcome measures for adults, with a particular emphasis on caries and periodontal disease, was developed.

BackgroundA learning health system (LHS) is a health system in which patients and clinicians work together to choose care on the basis of best evidence and to drive discovery as a natural outgrowth of every clinical encounter to ensure the right care at the right time. An LHS for dentistry is now feasible, as an increased number of oral health care encounters are captured in electronic health records (EHRs).MethodsThe authors used EHRs data to track periodontal health outcomes at 3 large dental institutions. The 2 outcomes of interest were a new periodontitis case (for patients who had not received a diagnosis of periodontitis previously) and tooth loss due to progression of periodontal disease.ResultsThe authors assessed a total of 494,272 examinations (new periodontitis outcome: n= 168,442; new tooth loss outcome: n= 325,830), representing a total of 194,984 patients. Dynamic dashboards displaying performance on both measures over time allow users to compare demographic and risk factors for patients. The incidence of new periodontitis and tooth loss was 4.3% and 1.2%, respectively.ConclusionsPeriodontal disease, diagnosis, prevention, and treatment are particularly well suited for an LHS model. The results showed the feasibility of automated extraction and interpretation of critical data elements from the EHRs. The 2 outcome measures are being implemented as part of a dental LHS. The authors are using this knowledge to target the main drivers of poorer periodontal outcomes in a specific patient population, and they continue to use clinical health data for the purpose of learning and improvement.Practical implicationsDental institutions of any size can conduct contemporaneous self-evaluation and immediately implement targeted strategies to improve oral health outcomes.

Background Although sealants are an established and recommended caries-preventive treatment, many children still fail to receive them. In addition, research has shown that existing measures underestimate care by overlooking the sealable potential of teeth before evaluating care. To address this, the authors designed and evaluated 3 novel dental electronic health record–based clinical quality measures that evaluate sealant care only after assessing the sealable potential of teeth. Methods Measure I recorded the proportion of patients with sealable teeth who received sealants. Measure II recorded the proportion of patients who had at least 1 of their sealable teeth sealed. Measure III recorded the proportion of patients who received sealant on all of their sealable teeth. Results On average, 48.1% of 6- through 9-year-old children received 1 or more sealants compared with 32.4% of 10- through 14-year-olds (measure I). The average measure score decreased for patients who received sealants for at least 1 of their sealable teeth (measure II) (43.2% for 6- through 9-year-olds and 28.4% for 10- through 14-year-olds). Fewer children received sealants on all eligible teeth (measure III) (35.5% of 6- through 9-year-olds and 21% of 10- through 14-year-olds received sealant on all eligible teeth). Among the 48.5% who were at elevated caries risk, the sealant rates were higher across all 3 measures. Conclusions A valid and actionable practice-based sealant electronic measure that evaluates sealant treatment among the eligible population, both at the patient level and the tooth level, has been developed. Practical Implications The measure developed in this work provides practices with patient-centered and actionable sealant quality measures that aim to improve oral health outcomes.

Objectives: Medical errors are among the leading causes of death within the United States. Studies have shown that patients can be harmed while receiving care, sometimes resulting in permanent injury or, in extreme cases, death. To reduce the risk of patient safety incidents, it is imperative that a robust culture of safety be established. The primary objective of this study was to evaluate the patient safety culture among providers at 4 US dental institutions, comparing the results with their medical counterparts in 2016. Methods: This cross-sectional study uses the Medical Office Survey on Patient Safety Culture that was modified for dentistry and administered at 4 US dental institutions during the 2016 calendar year. All dental team members were invited to complete electronic or paper-based versions of the questionnaire. Results: Among 1,615 invited participants, 656 providers responded (rate, 40.6%). Medical institutions outperformed the dental institutions on 9 of the 10 safety culture dimensions, 6 of the 6 overall quality items, and 8 of the 9 patient safety and quality issues. The surveyed dental institutions reported the strongest average percentage positive scores in organizational learning (85%) and teamwork (79%). Conclusion: These findings suggest that the patient safety culture progressed over time. However, there is still heterogeneity within safety culture among academic dental, private (nonacademic), and medical clinics. Knowledge Transfer Statement: Patient safety is the first dimension of quality improvement. Administering the Medical Office Survey on Patient Safety Culture within dental clinics represents a key measure to understand where improvements can be made with respect to patient care safety.

Background Longitudinal patient level data available in the electronic health record (EHR) allows for the development, implementation, and validations of dental quality measures (eMeasures). Objective We report the feasibility and validity of implementing two eMeasures. The eMeasures determined the proportion of patients receiving a caries risk assessment (eCRA) and corresponding appropriate risk-based preventative treatments for patients at elevated risk of caries (appropriateness of care [eAoC]) in two academic institutions and one accountable care organization, in the 2019 reporting year. Methods Both eMeasures define the numerator and denominator beginning at the patient level, populations' specifications, and validated the automated queries. For eCRA, patients who completed a comprehensive or periodic oral evaluation formed the denominator, and patients of any age who received a CRA formed the numerator. The eAoC evaluated the proportion of patients at elevated caries risk who received the corresponding appropriate risk-based preventative treatments. Results EHR automated queries identified in three sites 269,536 patients who met the inclusion criteria for receiving a CRA. The overall proportion of patients who received a CRA was 94.4% (eCRA). In eAoC, patients at elevated caries risk levels (moderate, high, or extreme) received fluoride preventive treatment ranging from 56 to 93.8%. For patients at high and extreme risk, antimicrobials were prescribed more frequently site 3 (80.6%) than sites 2 (16.7%) and 1 (2.9%). Conclusion Patient-level data available in the EHRs can be used to implement process-of-care dental eCRA and AoC, eAoC measures identify gaps in clinical practice. EHR-based measures can be useful in improving delivery of evidence-based preventative treatments to reduce risk, prevent tooth decay, and improve oral health.

Background Dentists strive to provide safe and effective oral healthcare. However, some patients may encounter an adverse event (AE) defined as "unnecessary harm due to dental treatment." In this research, we propose and evaluate two systems for categorizing the type and severity of AEs encountered at the dental office. Methods Several existing medical AE type and severity classification systems were reviewed and adapted for dentistry. Using data collected in previous work, two initial dental AE type and severity classification systems were developed. Eight independent reviewers performed focused chart reviews, and AEs identified were used to evaluate and modify these newly developed classifications. Results A total of 958 charts were independently reviewed. Among the reviewed charts, 118 prospective AEs were found and 101 (85.6%) were verified as AEs through a consensus process. At the end of the study, a final AE type classification comprising 12 categories, and an AE severity classification comprising 7 categories emerged. Pain and infection were the most common AE types representing 73% of the cases reviewed (56% and 17%, respectively) and 88% were found to cause temporary, moderate to severe harm to the patient. Conclusions Adverse events found during the chart review process were successfully classified using the novel dental AE type and severity classifications. Understanding the type of AEs and their severity are important steps if we are to learn from and prevent patient harm in the dental office.

© Wolters Kluwer Health, Inc. All rights reserved.Background Burnout is a threat to patient safety. It relates to emotional exhaustion, depersonalization, and lack of personal accomplishment. Work engagement conversely composed of levels of vigor, dedication, and absorption in one's profession. The aim of this study was to examine burnout and work engagement among US dentists. Methods This study used the extensively validated Maslach Burnout Inventory-Human Services Survey and Utrecht Work Engagement Scale to measure burnout in a self-administered survey of 167 US dentists who attended continuing education courses held in Boston, Pittsburg, Iowa City, and Las Vegas. The mean scores on the 3 subscales of Maslach Burnout Inventory-Human Services Survey and Utrecht Work Engagement Scale were computed. The interscale correlations between the components of burnout and work engagement were assessed using Pearson correlations. We used 1-way analysis of variance and independent 2 sample t tests to examine the relationship between burnout and work engagement across sex and various age categories. Prevalence of burnout in our study population was also computed. Results We observed that 13.2% of our study population experienced burnout and 16.2% of our study population was highly work engaged. There was a statistically significant, unadjusted association between burnout risk and work engagement (χ2 = 22.51, P < 0.0001). Furthermore, the scores in the subscales of burnout were significantly correlated with scores in the subscales of work engagement. Conclusions In this preliminary study, we observed some evidence of burnout among practicing US dentists. It is imperative that the dental profession understands this and works to promote professional practices that increase work engagement and decrease burnout.

Objective To examine whether quality of dental care varies by age and over time and whether community-level characteristics explain these patterns. Data source Deidentified medical and dental claims from a commercial insurer from January 2015 to December 2019. Study design A retrospective cohort study. The primary outcome was a composite quality score, derived from seven dental quality measures (DQMs), with higher values corresponding to better quality. Hierarchical regression models identified person- and zip code-level factors associated with the quality. Data collection/extraction methods Continuously enrolled US dental insurance beneficiaries younger than 21 years of age. Principal findings Quality was assessed for 4.88 million person-years covering 1.31 million persons. Overall quality slightly improved over time, mostly driven by substantial improvements among children aged 0-5 years by 0.153 points/year (95% confidence interval [CI]:0.151, 0.156). Quality was poorest and declined over time among adolescents with only 20.5% of DQMs met as compared to 42.6% among aged 0-5 years in 2019. Dental professional shortage, median household income, percentages of African Americans, unemployed, and less-educated populations at the zip code level were associated with the composite score. Conclusion Quality of dental care among adolescents remains low, and place of residence influenced the quality. Increasing the supply of dentists and oral health promotion strategies targeting adolescents and low-performing localities should be explored.

Process-of-care quality measure research can be used to identify gaps in the delivery of dental services to pregnant patients. The aim of this study was to evaluate the types of dental services that pregnant patients received in four dental clinics over five years as documented in the electronic health record (EHR). To accomplish this objective, the authors modified and validated a previously published claims-based dental quality measure for EHR use. After the electronic dental quality measure specifications were defined, the number of pregnant patients was calculated at three academic dental institutions and one large accountable care organization, and the types of dental care services they received over a five-year period (2013-17) were determined. Calibrated reviewers at each institution independently reviewed a sub-sample of patient charts to validate the information obtained from EHR queries, and the concordance between manual chart reviews and EHR query reports was analyzed. Of the 335,078 women aged 15-44 years who received care at the four clinics for the five reporting years, 3.9% (n=13,026) were pregnant. Among these pregnant patients, 48.9% (n=6,366) received a periodic dental examination; 30.0% (n=3,909) received a comprehensive dental exam; and 21.5% (n=2,799) received additional dental services, irrespective of comprehensive or periodic oral evaluations. Overall, the mean proportion of pregnant patients seeking care in these academic dental and group practice clinics was low, but 78.9% of them received either a periodic or comprehensive oral evaluation. Given the importance of oral health care during pregnancy, these findings suggest a need for curriculum development to incorporate prenatal oral health education in the training of dental students.

To assess and improve the quality of oral healthcare, we must first agree on what constitutes good care. Currently there is no internationally accepted definition for quality of oral healthcare. Therefore, the purpose of the study was to establish a working definition for quality of oral healthcare that would help to advance further improvements in the field of quality improvement in oral healthcare. The development of the working definition included a 3-step approach: 1) literature screening; 2) expert-based compilation of an initial list of topics, leaning on the National Academy of Medicine framework for quality of care; and 3) a World Café with voting, which took place during the annual general meeting of the International Association for Dental Research in 2018. Following this approach, the collective intelligence of involved participants yielded a comprehensive list of items, prioritized by relevance. The resulting working definition comprises 7 domains—patient safety, effectiveness, efficiency, patient-centeredness, equitability, timeliness, access to care—and 30 items, which together characterize quality of oral healthcare. This aspirational working definition provides the potential to facilitate further conversations and activities aiming at quality improvement in oral healthcare. Knowledge Transfer Statement: This special communication describes the development of a working definition for quality of oral healthcare. The findings of this study are intended to raise awareness of the relevance of quality improvement initiatives in oral healthcare. The working definition described here has the potential to facilitate further conversations and activities aiming at quality improvement in oral healthcare.

Objectives Dental utilization is an important determinant of oral health and well‐being. The aim of this study was to evaluate potential associations between a variety of biopsychosocial factors and dental utilization in north‐central Appalachia, USA, a region where oral health disparities are profound. Methods This study used household‐based data from the Center for Oral Health Research in Appalachia (COHRA1) study in north‐central Appalachia, including 449 families with 868 adults. The generalized estimating equation (GEE) approach was used to determine the best‐fitting predictor model for dental utilization among adult family members. Results On average across West Virginia and Pennsylvania, having dental insurance was associated with greater dental utilization over a 3‐year time period (OR = 2.20, 95% CI = 1.54, 3.14). When stratified by state, the association held for only West Virginia (OR = 2.41, 95% CI = 1.54, 3.79) and was nonsignificant for Pennsylvania residents (OR = 1.50, 95% CI = 0.80, 2.79). Individuals from Pennsylvania were more likely to utilize dental care and participants from West Virginia less so (2.31, 95% CI = 1.57, 3.40). Females from Pennsylvania were more likely than males to regularly seek dental care (OR = 1.44, 95% CI = 1.00, 2.05), and a higher income was associated with greater frequency of regular dental visits (OR = 1.21, 95% CI = 1.09, 1.34) in West Virginia. Individuals from Pennsylvania who scored higher on the Physiological Arousal subscale of the Dental Fear Survey were more likely to attend routine care visits (OR = 1.18, 95% CI = 1.03, 1.35). Across both states, more fatalistic beliefs related to oral health care also predicted less routine care (OR = 0.87, 95% CI = 0.81, 0.94), and more investment in or more positive attitudes towards one's oral health also was associated with higher utilization (OR = 1.18, 95% CI = 1.13, 1.23). Conclusions Overall, the findings of this study suggest state residency, sex, insurance, income, fatalistic beliefs, health values, and aspects of dental care‐related anxiety and fear predicted dental care utilization in north‐central Appalachia. These findings reinforce the need to address insurance and other economic factors affecting utilization and to consider how individual‐level fatalistic beliefs and oral health values may affect utilization of routine oral health care.

BackgroundAn increasing number of healthcare quality measures are designed for annual reporting. These measures require an entire year of data to accurately report the percentage of patients who met the measure. Annual measures give providers latitude to prioritize clinical workload and patient needs; however, they do not provide a direct means to monitor performance throughout the reporting year. Although there are many possible methods for measuring annual measures at finer-grained timescales, our applied work showed that the most obvious methods could give a misleading and inaccurate view of progress throughout the year. Neither the definitions of the annual measures, nor the research literature, provided any guidance on the best methods for interim monitoring of annual measures.ObjectiveOur objective was to evaluate four different methods for monitoring annually reported quality measures monthly to best predict year-end performance throughout the reporting year.MethodsWe developed four methods for monitoring annual measures by month: 1) Monthly Proportion: The proportion of patients with one or more encounters in the month who still needed to meet the measure at their first encounter of the month and met the measure by the end of the month; (2) Monthly Lookback Proportion: The proportion of patients seen in the month who met the measure by the end of the month, regardless of whether it was met in that month or previously in the reporting year; (3) Rolling 12 Month: The annual measure reported as if each month was the twelfth month of a twelve-month reporting period; and (4) YTD (Year-to-Date) Cumulative: The proportion of patients with one or more visits from the start of the reporting year through the month who satisfy the measure. We applied each method to two annual dental quality measures using data from two reporting years, and four different dental sites. We used mean squared error (MSE) to evaluate year-end predictive performance.ResultsMethod 3 (Rolling 12 Month) had the lowest MSE in 11 out of 16 cases (2 measures X 2 years X 4 sites) and lowest total MSE (262.39) across all 16 cases. In 5 of the 16 cases, YTD Cumulative had the lowest MSE.ConclusionsThe Rolling 12 Month method was best for predicting the year-end value across both measures and all four sites.

Contains fulltext : 229166.pdf (Publisher’s version ) (Closed access) OBJECTIVES: Despite a significant national investment in oral health, there is little understanding of the return in terms of quality. Value-based payments aim to refocus provider reimbursement based on the value created to the patient. Our objectives were to apply a set of dental quality measures to help determine the value of preventive dental care provided to children at two academic dental school clinics. METHODS: We queried the institutional electronic health records (EHRs) for patients between the ages of 6-14 years with sealable first or second permanent molars, determined caries risk status, identified if dental sealants were placed, and finally if the teeth showed evidence of new caries experience. In order to determine the cost-effectiveness of EHR-based triage of applying dental sealants, we calculated the incremental cost-effectiveness ratio (ICER) for the dental quality measures supported sealing program. RESULTS: Between the two academic sites, there were 6,155 unique children for a total of 12,302 eligible teeth without a sealant and 32,811 eligible teeth with a sealant. Teeth without a sealant were more likely to have decay (4.8 percent) than those with a sealant (1.7 percent). At both sites, patients with high caries risk were more likely to benefit from sealants compared to those patients with low risk. CONCLUSION: Implementation of caries risk stratified fissure sealant quality measures demonstrates the potential for extracting better value in oral health care.

Background: Patients may be inadvertently harmed while undergoing dental treatments. To improve care, we must first determine the types and frequency of harms that patients experience, but identifying cases of harm is not always straightforward for dental practices. Mining data from electronic health records is a promising means of efficiently detecting possible adverse events (AEs). Methods: We developed 7 electronic triggers (electronic health record based) to flag patient charts that contain distinct events common to AEs. These electronic charts were then manually reviewed to identify AEs. Results: Of the 1,885 charts reviewed, 16.2% contained an AE. The positive predictive value of the triggers ranged from a high of 0.23 for the 2 best-performing triggers (failed implants and postsurgical complications) to 0.09 for the lowest-performing triggers. The most common types of AEs found were pain (27.5%), hard tissue (14.8%), soft tissue (14.8%), and nerve injuries (13.3%). Most AEs were classified as temporary harm (89.2%). Permanent harm was present in 9.6% of the AEs, and 1.2% required transfer to an emergency room. Conclusion: By developing these triggers and a process to identify harm, we can now start measuring AEs, which is the first step to mitigating harm in the future. Knowledge Transfer Statement: A retrospective review of patients’ health records is a useful approach for systematically identifying and measuring harm. Rather than random chart reviews, electronic health record–based dental trigger tools are an effective approach for practices to identify patient harm. Measurement is one of the first steps in improving the safety and quality of care delivered.

Diagnostic errors are increasingly recognized as a source of preventable harm in medicine, yet little is known about their occurrence in dentistry. The aim of this study was to gain a deeper understanding of clinical dental faculty members' perceptions of diagnostic errors, types of errors that may occur, and possible contributing factors. The authors conducted semi-structured interviews with ten domain experts at one U.S. dental school in May-August 2016 about their perceptions of diagnostic errors and their causes. The interviews were analyzed using an inductive process to identify themes and key findings. The results showed that the participants varied in their definitions of diagnostic errors. While all identified missed diagnosis and wrong diagnosis, only four participants perceived that a delay in diagnosis was a diagnostic error. Some participants perceived that an error occurs only when the choice of treatment leads to harm. Contributing factors associated with diagnostic errors included the knowledge and skills of the dentist, not taking adequate time, lack of communication among colleagues, and cognitive biases such as premature closure based on previous experience. Strategies suggested by the participants to prevent these errors were taking adequate time when investigating a case, forming study groups, increasing communication, and putting more emphasis on differential diagnosis. These interviews revealed differing perceptions of dental diagnostic errors among clinical dental faculty members. To address the variations, the authors recommend adopting shared language developed by the medical profession to increase understanding.

The aim of this study was to translate and adapt a questionnaire on dentistry leadership skills to the Brazilian culture. For this purpose, the instrument created at the Harvard School of Dental Medicine (HSDM) went through the stages of translation, back-translation and cross-cultural adaptation by an expert group to be submitted afterwards to a pre-test with a group of dentists. To facilitate a clear interpretation. It was observed that some terms needed to be adapted for better interpretation, after which the instrument was considered easy to understand by professionals of the area of interest. To use the questionnaire for research in Brazil, further psychometrc validation is required.

Natalie B Hastings,1 Linda S Centore,2 Stuart A Gansky,3 Frederick C Finzen,4 Joel M White,5 Eric Wong,6 Grayson W Marshall,7 Lisa Chung,3 Elsbeth Kalenderian3 1Division of Clinical General Dentistry, Department of Preventive and Restorative Dental Sciences, University of California, San Francisco (UCSF) School of Dentistry, San Francisco, CA, USA; 2Division of Behavioral Sciences & Community Dental Education, Department of Preventive and Restorative Dental Sciences, University of California, San Francisco (UCSF) School of Dentistry, San Francisco, CA, USA; 3Division of Oral Epidemiology & Dental Public Health, Department of Preventive and Restorative Dental Sciences, University of California, San Francisco (UCSF) School of Dentistry, San Francisco, CA, USA; 4Division of Prosthodontics, Department of Preventive and Restorative Dental Sciences, University of California, San Francisco (UCSF) School of Dentistry, San Francisco, CA, USA; 5Division of Preclinical Simulation, Department of Preventive and Restorative Dental Sciences, University of California, San Francisco (UCSF) School of Dentistry, San Francisco, CA, USA; 6Division of Endodontics, Department of Preventive and Restorative Dental Sciences, University of California, San Francisco (UCSF) School of Dentistry, San Francisco, CA, USA; 7Division of Biomaterials and Bioengineering, Department of Preventive and Restorative Dental Sciences, University of California, San Francisco (UCSF) School of Dentistry, San Francisco, CA, USA Purpose: We report on an accelerated and effective way of assimilating a new leader into a team at a large academic dental school department.Methods: At University of California, San Francisco (UCSF), a new Chair was recruited through a national search to lead its largest department in the School of Dentistry. Two months after arrival, the new Chair embarked on a process of leadership assimilation among her executive team, facilitated by a professional consultant. Within four weeks, team members participated in one-on-one interviews with the professional facilitator consultant and then completed the leadership assimilation questionnaire and returned it electronically to the facilitator. The facilitator then summarized all answers into themes and met with the team members without the Chair to debrief. Thereafter, the facilitator met with the Chair to discuss the major themes. Next, the Chair met with the team members in a facilitated session to discuss the results and negotiate a path forward.Results: Approximately half of the feedback described the “how” of leadership: comments on communication, building relationships, building trust, and understanding UCSF history. The remaining half described the “what”: comments on vision, strategy, and operations. Team members indicated that the first debriefing session was helpful to alleviate initial anxiety and to start building team spirit. The session with the Chair was perceived as open and fruitful in which team members were able to express their concerns and hopes for the Department, while the Chair showed commitment to the team and the communication process.Conclusion: Leader assimilation allows teams to share their expectations and anxieties with the new leader early in the relationship in an open way, before new habits and beliefs are formed. Conversely, for the leader, it effectively and efficiently allows a window into the team members’ thinking at a critical time period when otherwise first impressions occur. With a safe space created for open communication, the process allowed siloed individual division leaders to move toward a cohesive group while at the same time solidifying a commitment to the success of the new leader. Keywords: dental school, leadership, new leader assimilation, feedback, team, transition

Purpose/Objectives The purpose of this study was to measure the effectiveness of a continuing education course in leadership presented to postdoctoral dentist-leaders. Methods The authors developed a 3-day course on leadership and management with topics including self-awareness, leadership qualities, emotional intelligence, communication skills, social skills, conflict management, personal branding, quality improvement and team motivation. Twenty-two course participants with a median age of 37.5 years and an average of 13.7 years of professional experience were assessed using three different metrics: satisfaction with the course and presenters immediately following the course; pre-course and post-course tests on knowledge of leadership topics; and self-assessments of leadership competency skills prior to the course, immediately following the course and then 6 months after the course. Results Participant satisfaction with both instructors’ effectiveness and the overall course design was very high. A survey 6 months following the course showed that participants were very positive regarding the practical use of the leadership skills they acquired in the course. The average of all participants’ scores on the objectively assessed leadership knowledge test showed a statistically significant (P

INTRODUCTION: From the perspective of patients, quality of care can be defined as the ability of healthcare products and services to satisfy their stated or implied needs. Dental professionals have a moral obligation to deliver the best quality care in today's increasingly informed, consumer-driven society AIM: To jumpstart the discussion on assessing quality of dental care, using patient perceptions DESIGN: A cross-sectional study of South African dental patients METHODS: Questionnaires were distributed to all non-emergency, adult patients at a teaching dental hospital in South Africa The outcome variables were: a) Access to Care; b) Technical Quality; c) Structure and Facilities; d) Communication; e) Global Rating of Safety. RESULTS: Overall, 58.6% of the participants had a positive view about the quality of dental care in South Africa. Age, race, marital status, child status, employment status, household income and educational status were associated with higher quality ratings THE QUESTION: "The instrument used in treating me appeared clean" (97.6%) was rated highly, while the question "Whenever I was sent to a new dentist, I had to repeat the tests that I did at the previous dentist" rated very low (36.9% CONCLUSIONS: The findings suggest that the dental profession still has challenges in meeting the expectations of patients

The US dental system is not likely to see major expansions in dental care use in the foreseeable future. The rise of dental care utilization among low-income children as well as wealthy seniors did not offset flat dental utilization among adults since the Great Recession. Similarly in Spain, the increase in the number of dental practitioners surpasses the rate of population growth. Hence, in order to remain economically viable in this competitive market, one important aspect for every dental office is to retain patients besides attracting new ones. Patients may be lost to follow-up due to a number of factors, including a lack of attention from the dental practice or a lack of trust in the provider. The “7/12" patient touch point strategy of marketing builds consumer loyalty as a result of a strong patient–provider relationship. Furthermore, this method aims to facilitate the patient’s decision to visit their dentist when it is time for preventative treatments. The purpose of this study was to measure the efficacy of a “7/12” patient touch point strategy when compared to the traditional annual recall with respect to number of active patients, percentage of word-of-mouth-recommended patients, and overall number of first-visit patients. We executed the relationship marketing concept through a novel “7/12” patient touch point approach, in which the patient was exposed to seven separate exposures in a period of 12 months. The efficacy of the “7/12” patient touch point was analyzed for 48 months across 10 clinics (24 months before and 24 months after the “7/12” strategy implementation). The “7/12” patient touch point strategy resources consisted of online and printed materials with a focus on oral health knowledge. fter analyzing the efficacy of the “7/12” patient touch point, we found an average increase of 86.91% in the number of active patients, 24.12% in the number of word-of-mouth-recommended patients, and 38.05% in the number of first visits across all clinics. This novel “7/12” patient touch point approach may be successful in increasing the retention of existing patients and generating new patients. Furthermore, this method promotes preventative care and oral health maintanance for patients and economic progress for the dental clinic.

Objectives Electronic health records (EHRs) are rarely shared among medical and dental providers. The purpose of this study was to assess current information sharing and the value of improved electronic information sharing among physicians and dentists in Germany and the United States. Materials and Methods A survey was validated and distributed electronically to physicians and dentists at four academic medical centers. Respondents were asked anonymously about EHR use and the medical and dental information most valuable to their practice. Results There were 118 responses, a response rate of 23.2%. The majority (63.9%) of respondents were dentists and the remainder were physicians. Most respondents (66.3%) rated the importance of sharing information an 8 or above on a 1-to-10 Likert scale. Dentists rated the importance of sharing clinical information significantly higher than physicians (p = 0.0033). Most (68.5%) providers could recall an instance when access to medical or dental information would have improved patient care. Dentists were significantly more likely to report this than physicians (p = 0.008). Conclusion Physicians would value a standardized measure of “oral health” in their EHR. Dentists were less likely to find specific medical diagnostic test results of value. Both dentists and physicians agreed that oral–systemic health was important; interoperable EHRs could facilitate information transfer between providers and enhance research on oral–systemic health connections. Both dentists and physicians believed that an interoperable EHR would be useful to practice, but desired information was different between these groups. Refinement of the information needed for shared practice is required.

Introduction: To fill the void created by insufficient dental terminologies, a multi-institutional workgroup was formed among members of the Consortium for Oral Health Research and Informatics to develop the Dental Diagnostic System (DDS) in 2009. The adoption of dental diagnosis terminologies by providers must be accompanied by rigorous usability and validity assessments to ensure their effectiveness in practice. Objectives: The primary objective of this study was to describe the utilization and correct use of the DDS over a 4-y period. Methods: Electronic health record data were amassed from 2013 to 2016 where diagnostic terms and Current Dental Terminology procedure code pairs were adjudicated by calibrated dentists. With the resultant data, we report on the 4-y utilization and validity of the DDS at 5 dental institutions. Utilization refers to the proportion of instances that diagnoses are documented in a structured format, and validity is defined as the frequency of valid pairs divided by the number of all treatment codes entered. Results: Nearly 10 million procedures ( n = 9,946,975) were documented at the 5 participating institutions between 2013 and 2016. There was a 1.5-fold increase in the number of unique diagnoses documented during the 4-y period. The utilization and validity proportions of the DDS had statistically significant increases from 2013 to 2016 ( P < 0.0001). Academic dental sites were more likely to document diagnoses associated with orthodontic and restorative procedures, while the private dental site was equally likely to document diagnoses associated with all procedures. Overall, the private dental site had significantly higher utilization and validity proportions than the academic dental sites. Conclusion: The results demonstrate an improvement in utilization and validity of the DDS terminology over time. These findings also yield insight into the factors that influence the usability, adoption, and validity of dental terminologies, raising the need for more focused training of dental students. Knowledge Transfer Statement: Ensuring that providers use standardized methods for documentation of diagnoses represents a challenge within dentistry. The results of this study can be used by clinicians when evaluating the utility of diagnostic terminologies embedded within the electronic health record.

Background In recent years, several state dental programs, researchers and the Dental Quality Alliance (DQA) have sought to develop baseline quality measures for dentistry as a way to improve health outcomes, reduce costs and enhance patient experiences. Some of these measures have been tested and validated for various population groups. However, there are some unintended consequences and challenges with quality measurement in dentistry as observed from our previous work on refining and transforming dental quality measures into e-measures. Main body Some examples of the unintended consequences and challenges associated with implementing dental quality measures include: a de-emphasis on patient-centeredness with process-based quality measures, an incentivization of unethical behavior due to fee-for-service reimbursement systems, the risk of compromising patient and provider autonomy with plan-level measures, a disproportionate benefits of dental quality measurement going toward payers, and the risk of alienating smaller dental offices due to the resource-intensive nature of quality measurement. Conclusion As our medical counterparts have embraced quality measurement for improved health outcomes, so too must the dental profession. Our ultimate goal is to ensure the delivery of high quality, patient-centered dental care and effective quality measurement is the first step. By continuously monitoring the performance of dental quality measures and their continued refinement when unintended consequences are observed, we can improve patient and population health outcomes.

s Background Although complete and accurate clinical records do not guarantee the provision of excellent dental care, they do provide an opportunity to evaluate the quality of care provided. However, a lack of universally accepted documentation standards, incomplete record-keeping practices, and unfriendly electronic health care record (EHR) user interfaces are factors that have allowed for persistent poor dental patient record keeping. Methods Using 2 different methods—a validated survey, and a 2-round Delphi process—involving 2 appropriately different sets of participants, we explored what a dental clinical record should contain and the frequency of update of each clinical entry. Results For both the closed-ended survey questions and the open-ended Delphi process questions, respondents had a significant degree of agreement on the "clinical entry" components of an adequate clinical record. There was, however, variance on how frequently each of those clinical entries should be updated. Summary Dental providers agree that complete and accurate record keeping is essential and that items such as histories, examination findings, diagnosis, radiographs, treatment plans, consents, and clinic notes should be documented. There, however, does not seem to be universal agreement how frequently such items should be recorded. Clinical Implications As the dental profession moves towards prevalent use of electronic health care records, the issue of standardization and interoperability becomes ever more pressing. Settling issues of standardization, including record documentation, must begin with guideline-creating dental professional bodies, who need to clearly define and disseminate what these standards should be and everyday dentists who will ultimately ensure that these standards are met and kept.

A person's right to access his or her protected health information is a core feature of the U.S. Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. If the information is stored electronically, covered entities must be able to provide patients with some type of machine-readable, electronic copy of their data. The aim of this study was to understand how academic dental institutions execute the Privacy Rule's right of access in the context of electronic health records (EHRs). A validated electronic survey was distributed to the clinical deans of 62 U.S. dental schools during a two-month period in 2014. The response rate to the survey was 53.2% (N=33). However, three surveys were partially completed, and of the 30 completed surveys, the 24 respondents who reported using axiUm as the EHR at their dental school clinic were the ones on which the results were based (38.7% of total schools at the time). Of the responses analyzed, 86% agreed that clinical modules should be considered part of a patient's dental record, and all agreed that student teaching-related modules should not. Great variability existed among these clinical deans as to whether administrative and financial modules should be considered part of a patient record. When patients request their records, close to 50% of responding schools provide the information exclusively on paper. This study found variation among dental schools in their implementation of the Privacy Rule right of access, and although all the respondents had adopted EHRs, a large number return records in paper format.

Background Quality improvement requires using quality measures that can be implemented in a valid manner. Using guidelines set forth by the Meaningful Use portion of the Health Information Technology for Economic and Clinical Health Act, the authors assessed the feasibility and performance of an automated electronic Meaningful Use dental clinical quality measure to determine the percentage of children who received fluoride varnish. Methods The authors defined how to implement the automated measure queries in a dental electronic health record. Within records identified through automated query, the authors manually reviewed a subsample to assess the performance of the query. Results The automated query results revealed that 71.0% of patients had fluoride varnish compared with the manual chart review results that indicated 77.6% of patients had fluoride varnish. The automated quality measure performance results indicated 90.5% sensitivity, 90.8% specificity, 96.9% positive predictive value, and 75.2% negative predictive value. Conclusions The authors’ findings support the feasibility of using automated dental quality measure queries in the context of sufficient structured data. Information noted only in free text rather than in structured data would require using natural language processing approaches to effectively query electronic health records. Practical Implications To participate in self-directed quality improvement, dental clinicians must embrace the accountability era. Commitment to quality will require enhanced documentation to support near-term automated calculation of quality measures.

Nursing home residents over the age of 65 years are at high risk for poor oral health and related complications such as pneumonia and adverse diabetes outcomes. A preliminary study found that Massachusetts’ nursing homes generally lack the training and resources needed to provide adequate oral health care to residents. In this study, an intervention targeting Certified Nurses’ Aides (CNAs) was developed and tested. We hypothesized that following the training, CNAs would have increased knowledge and self-efficacy toward providing oral health care to the residents in their charge.This pilot study used a one-group pretest-posttest design to test the effectiveness of a psycho-educational training intervention. Utilizing the constructs of knowledge and self-efficacy from the Theory of Planned Behavior and the Social Cognitive Theory, we framed the content of a training intervention and administered a 21-item instrument. The survey was distributed to the CNA staff of a single midsize nursing home immedi...