Unintended Consequences and Challenges of Quality Measurements in Dentistry

Enihomo M. Obadan-Udoh; Jean M. Calvo; Sapna Panwar; Kristen Simmons; Joel M. White; Muhammad F. Walji; Elsbeth Kalenderian


BMC Oral Health. 2019;19(38) 

In This Article


From the early debates of an elitist profession bewildered by the advent of quality assurance and the reluctance to subject one's practices to external scrutiny[1,2] to the widespread prevalence of accreditation standards that serve as prerequisites for acceptance into the dental profession,[3–6] quality in dentistry has come a long way since its inception. While quality assurance is essential for ensuring the efficacy and effectiveness of dental interventions, it lacks the holistic and systems level focus that encourages continuous learning from engendering small changes to creating lasting solutions.[7] Quality improvement (QI), made popular by the Institute of Healthcare Improvement (IHI) through initiatives such as the Triple Aim,[8] and furthered through efforts by the Joint Commission, has become the hallmark of forward-leaning healthcare institutions and learning healthcare systems.[9,10] One crucial aspect of QI is the utilization of standardized measures of structure, process, and outcomes to assess performance and evaluate system changes.[10,11] For the dental profession to keep pace with the healthcare system in the United States, there must be a shift from dentistry's traditional understanding of quality systems encompassing risk management, quality control and quality assurance, to continuous QI through standardized measurement.[12–14]

In recent years, several state dental programs, researchers and the DQA - a team of dental stakeholders representing payers, educators, professional organizations, federal agencies, providers and the public, have sought to develop baseline quality measures for dentistry as a way to improve health outcomes, reduce costs and enhance patient experiences.[15–17] Some of these measures (n = 18) have been tested and validated for various population groups (e.g. DQA Starter Set of Pediatric Oral Health Performance Measures)[18,19] and nine of them have been endorsed by the National Quality Forum.[20] With the exception of some e-measures, all of these measures are derived from the administrative or claims-based data of public or private dental insurance agencies across the United States. As an integral part of the healthcare delivery system, and since oral health is essential to overall health,[21] dental providers must enthusiastically embrace and support efforts to implement quality measures in the dental office.[22] This is our true north if we are to move towards achieving the six dimensions of quality - safety, timeliness, efficiency, effectiveness, efficacy and patient-centeredness, described by the Health and Medicine Division [previously the Institute of Medicine (IOM)] of the National Academy of Sciences, Engineering and Medicine (NASEM).[23]