Kiran Madesha, Legal Advisor, dentalcorp; Kristy Pilatzke, Risk and Compliance Officer, dentalcorp; Michelle Budd, D.D.S, Patient Safety Consultant, dentalcorp
Now, more than ever before, dental practitioners can seamlessly communicate with their colleagues through an array of online platforms, forums, and social media groups. While this modern technology allows practitioners to conveniently share interesting cases, ask questions, and learn from others, this informal type of interaction has a number of limitations as it relates to information control, including accountability, tracking, and follow-up. This is where formal professional peer review, also known as collaborative clinical audit, can become an incredibly useful tool for dental practitioners1.
What is professional peer review?
Professional peer review is well-established and accepted in the acute healthcare sector as a means of promoting professionalism and maintaining patient trust. It is designed as an educational process – an open space where peers collaboratively work together to review aspects of practice, share experiences, and identify areas for change. The primary purpose of peer review is to improve the quality and safety of patient care; however, it can also help to ensure regulatory compliance and meeting standard of care expectations. Ultimately, the peer review process is intended to balance the practitioner’s right to exercise clinical judgment freely with the obligation to do so wisely and temperately2.
While peer review is relatively unheard of in dentistry, the similarities between medicine and dentistry suggest that this process can easily be adapted for use in dental practice. Peer review is intrinsically valuable in the continued professional development of dental practitioners and may be used in the identification of their professional development goals1.
The dental context
In general, there are three methods to assess clinical quality in dentistry: direct observation of patient care; review of information in the dental record; and quality metrics3. However, direct observation is often intrusive and impractical, and quality metrics are not always available. Alternatively, peer review has several advantages, including:
- The presence of a patient is not required
- A single aspect of care can easily be focused on by reviewing only charts of patients who received specific dental services
- All aspects of clinical practice can be reviewed by using a random sample of patient charts
- A large amount of data can be gathered in a relatively short amount of time
Imagine missing an issue on a radiograph only to have it progress to the point of poor treatment prognosis. Having a second set of eyes will provide patients with better outcomes, help the dental practitioner avoid complaints, and potentially lead to increased case acceptance and production.
Dental practitioners seeking to adopt a formal peer review process in their practice should consider the below foundational elements.
1. Establish a peer group. Dental practitioners should partner with those in similar specialties. This is not limited to one’s own practice or even the same city – expanding membership to those outside of one’s practice provides an opportunity to review unique and novel cases. Members representing diverse backgrounds, genders, and experiences in the dental industry should be considered for inclusion with the goal of reducing certain biases like groupthink5. Keeping membership to a small group of providers may also help foster a connection, including establishing trust amongst members.
2. Create a process for referring and selecting cases. Peer reviews can be triggered using indicators found in the coding or the documentation process6. Reviews can also be triggered by complaints of dental quality of care and appropriateness of treatment and/or events with adverse outcomes but can also be selected randomly in the absence of triggers6. In addition, anonymity and confidentiality are important practices to adhere to when sharing cases amongst the peer group. Providing anonymous case information ahead of time will support members with an appropriate amount of time to review the cases, current literature, and policies (from both the practice and regulating bodies) and gain external perspective if needed. Adhering to this practice will enable busy members to have fruitful discussions without being required to dedicate hours to group discussions.
3. Define clear roles and responsibilities for case review and discussion. This element of peer review includes appointing a meeting facilitator and establishing meeting frequency, structure, and objectives. Depending on how many cases are referred, discussion time can be scheduled quarterly or more frequently. The cases should be reviewed using a standard case questionnaire with a point scoring system (e.g., a 4-point scoring scale) to measure the level of quality care concerns7. Review should be performed based on the documentation in the clinical dental record and knowledge of the organization/practice.
4. Implement measurement and reporting. When standard scoring questionnaires are used, data can be tracked over time and then extracted and analyzed to reveal trends. Remember, the ultimate goal is to provide actionable items to improve techniques, skills, and abilities. These findings should be shared with others to collectively make dental care safer for all patients.
Evidence suggests that the quality of clinical record keeping is a strong indicator of the quality of care provided3. Regular peer reviews are an important step in ensuring that a dental practitioner is delivering quality patient care by providing information to determine trends in quality of care, identifying areas for improvement, continuing professional development needs, and fostering a culture of self-awareness and accountability. It is a dental practitioner’s responsibility to ensure that appropriate steps are taken to meet the standard of care and all dental regulatory requirements, which may include a consistent process of self-audit and peer review.
1Bullock, Alison & Butterfield, S & Belfield, Clive & Morris, Z & Ribbins, P & Frame, J. (2000). A role for clinical audit and peer review in the identification of Continuing Professional Development needs for General Dental Practitioners: a discussion. British dental journal. 189. 445-8. 10.1038/sj.bdj.4800795.
2Peer review & due process. American Medical Association. https://www.ama-assn.org/delivering-care/ethics/peer-review-due-process.
3Methods of measuring clinical quality. Safety Net Dental Clinic Manual. Unit 5. Quality Assurance and Quality Improvement. https://www.dentalclinicmanual.com/5-quality/sec3-06.php.
4How the dental peer review system works and what you expect from it. American Dental Association. http://www.ada.org/~/media/ADA/Member%20Center/Files/peer_review_overview.pdf.
5Swaroop R. Disrupting physician clinical practice peer review. Perm J 2019;23:18-207. DOI: https://doi.org/10.7812/TPP/18-207.
6Paterick, Zachary & Paterick, Timothy. (2019). Peer Review – Legal and Ethical Issues Faced by Medical Staff: The Mandate for Physician Leadership. Hospital Practices and Research. 4. 76-79. 10.15171/hpr.2019.15.
7Deyo-Svendsen ME, Phillips MR, Albright JK, Schilling KA, Palmer KB. A Systematic Approach to Clinical Peer Review in a Critical Access Hospital. Qual Manag Health Care. 2016 Oct/Dec;25(4):213-218. doi: 10.1097/QMH.0000000000000113.
About the Authors
Kiran Madesha is a licensed lawyer with the Law Society of Ontario and works as a Legal Advisor at dentalcorp on the Compliance team. Kiran holds a Bachelor of Laws degree from the University of Liverpool and a Master of Laws degree with a concentration in Health Law from the University of Toronto.
Kristy Pilatzke is an experienced quality and compliance professional with over 13 years of experience in regulated healthcare industries, from pharmaceuticals manufacturing and specialty pharmacy to acute care. She currently holds the position of Risk and Compliance Officer at dentalcorp. Kristy holds a Master of Science in Healthcare Quality from Queen’s University.
Dr. Michelle Budd works with dentalcorp’s Compliance & Risk Management team as a Patient Safety Consultant. She graduated from Western University with a Doctor of Dental Surgery degree and subsequently earned a Master of Public Health degree. Michelle has been a dental consultant for several insurance companies and government agencies and has travelled throughout Canada to help dental practices achieve and maintain professional compliance.