Unit 5. Quality Assurance and Quality Improvement
Quality Assurance & Quality Improvement

Section 3. Measuring to Improve Quality

Initiating Peer Review

Peer Review Through Existing Components of Local Dental Societies

Not all local dental societies have a peer-review component, but if yours does, you may be able to use the peer-review process to help resolve issues your patients have concerning the care in question. The procedure for initiating peer review usually is to contact the component (local) dental society and request a peer review. A peer-review committee, comprising member-dentist volunteers, evaluates all available evidence pertaining to each dispute and follows specific procedures to make a fair and impartial determination. The committee conducts the peer review and conveys its decision to the dentist and other involved party. Under some circumstances, decisions of the peer-review committee at the component level can be appealed to the state dental association by either the dentist or the other involved party. The peer-review system is designed to resolve patient/dentist disputes. Generally, no matter will be accepted for peer review if either party has initiated litigation concerning any aspect of the dental services in question. ADA offers peer-review resources.

Peer Review Within the Dental Office

HRSA requires a peer-review process for federally qualified health centers (FQHCs). Even if your clinic is not an FQHC, you might consider setting up a process for identifying, processing, and adjudicating patient complaints; staff concerns about patient care; or patient harm discovered through the QA/QI process. You should review the mechanism that exists for the medical department and ensure that it includes dental.

The dental director should initiate the process once any dental incidents are discovered. If the health center has only one dentist or if the incidents involve the dental director, if there are other community dental clinics in the area, consider a reciprocal agreement to conduct each other's reviews.

When and how the peer-review process is conducted should be defined clearly in the clinic's policy and procedures manual. All health professionals should be apprised of the peer-review process and standards during their initial orientation.

Like other practice guidelines, the review criteria should be based on the best available science and expert input. Peer-review records should be kept secure and separate from personnel files because they are frequently protected against legal discovery by the Federal Healthcare Quality Improvement Act of 1986 and by state statutes.

Case law has firmly established that health care organizations have both the right and the responsibility to ensure that the services provided by their employees and others in the clinic meet the standard of care. It is incumbent on the clinic administrator to establish a peer-review system that is fair, objective, and as palatable to the health professionals as possible.

By definition, peer review must be conducted by a professional peer; for example, a general dentist should review general dentists, and a pediatric dentist should review pediatric dentists.

The Review Process

Begin with a complete review of all the information available:

  • Treatment notes
  • Radiographs
  • Patient interview
  • Staff input (as needed)
  • Specialty referral notes (as needed)

It is ideal to have another individual at the health center that deals with quality issues but who is not in the dental department to work with the dental director on these issues. Once the case review is completed and an issue has been identified, a corrective action plan must be determined. The action plan will address:

  1. What, if any, corrective action is needed for the dentist involved? This could include anything from a discussion of the care to revoking clinical privileges. (Note: revocation of dental privileges requires a report to the National Practitioner Data Bank.)
  2. What should be done, if anything, to correct the clinical issue? Examples: Redo the work, refer to a specialist, remove charges.
  3. Who will pay for any additional care that may be needed? While payments from your health center for dental care needed to resolve a clinical issue are allowed in most states, you must check with your state and insurance regulations before payments for care are initiated.
  4. Who will discuss review results with the patient?

To be effective and to reduce patient, dentist, and health center risks, it is vital that you develop a review process that everyone at the center understands, can be initiated quickly, results in a complete and fair review, and resolves the issues in a timely manner.