Step by Step Guidance on how to Conduct a Clinical Audit in. Dental Radiography Core Subject

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1 Step by Step Guidance on how to Conduct a Clinical Audit in Dental Radiography Core Subject Aims: To describe the purpose of a clinical audit and its importance as part of a good practice quality assurance programme in radiography. Objectives: You will be able to demonstrate an understanding of the importance of clinical audit as part of a quality assurance programme in radiography by completing the multiple choice questions in the exam after reading this article. By completing this verifiable CPD you will be able to assist in undertaking a clinical audit in radiography in your dental practice. Introduction What is quality assurance? Quality assurance consists of quality measurement and quality improvement. 1 One way of measuring standards within the practice (quality measurement) and then improving them (quality improvement) is through the undertaking of a clinical audit which can be defined as a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. 2 As part of their terms of service requirements, dentists practising in the general dental service are required to have a practice-based quality

2 assurance system in place and ensure that all members of the dental team participate in the process. 3 Why is quality assurance important in dental radiography? A quality assurance programme for the taking and processing of dental radiographs is important as part of an overall risk management strategy to ensure patient and staff safety. A clinician should take into consideration the benefit to a patient s clinical management before deciding to carry out a radiographic examination. The Faculty of General Dental Practitioners outlines reasons why there is a need to minimise and/or prevent radiographic examinations: Where the results are unlikely to affect patient management and/or prognosis. When radiographs are repeated unnecessarily. When radiographs are duplicating those taken previously. When radiographs are inappropriate to the clinical management of the patient. Where avoidable lapses in quality assurance impact upon patient dose and care. 4 The justification for taking radiographs is that by taking one it could contribute to an optimal standard of diagnosis which, therefore, will be of benefit to the patient in terms of their clinical management. 5 To summarise, taking radiographs should be necessary to make a diagnosis for the patient and assist the clinician in completing satisfactory treatment for the patient that could be compromised without the radiographs. Dental Care Professionals (DCPs) are required by the General Dental Council (GDC) to complete 5 hours of verifiable continuing professional development (CPD) in dental radiography over a 5 year cycle. 6 This article will provide stepby step guidance on how to conduct a clinical audit in dental radiography providing useful guidance which could be adapted to complete a variety of audits in the dental practice.

3 Conducting a clinical audit in dentistry A clinical audit can fulfil a range of functions including; Monitoring compliance with statutory requirements. Monitoring adherence to clinical guidelines. Monitoring adherence to non-clinical but necessary operational processes and systems in the practice. Minimising and managing clinical and non-clinical risk. Identifying learning needs by revealing gaps in skills and knowledge. Minimising stress at work. Maintaining the viability of the practice. 7 It enables the dental care professional to critically examine areas of their work with the ultimate aim to raise the standard of care that the patient receives. Several of these functions may be fulfilled depending on the subject chosen for audit. Step 1: Choosing the topic In the practice there are many subjects you could choose to audit. This could range from an audit to explore how many patients are seen on time for their appointments to an audit into taking and recording patients medical history details at each appointment. There are many different audits you can undertake for dental radiography. Some of the types of audit that can be considered are: Mounting, labelling and filing of radiographs. Was it carried out correctly and were the x-rays available for the patient s next appointment? Stock control. Is stock stored correctly? Is it in date? Reporting on the radiographs. Has this been completed and recorded in the patient s clinical notes? Taking radiographs. Are they correctly exposed and developed? Was it necessary to retake the radiograph and if so why? 8 Justification of radiographs. Was the justification for taking the radiograph clearly marked on the notes? The topic for audit should be decided by consulting with the whole dental team. The following section of this article will provide you with an example of how to undertake an audit in radiography.

4 Step 1: The topic chosen for audit You will need to state the topic you have chosen for audit. For example: A clinical audit was carried out in the dental practice over a six month period to evaluate the diagnostic quality of radiographs taken. 9 Step 2: Setting the aims and objectives Once you have decided your topic you need to consider your reasons for choosing this so you have a clear idea of what you want to achieve from the audit. Your aims and objectives should be SMART (specific, measurable, realistic/relevant and timed) in the same way as the goals for your personal development plan. In the example we have chosen, the aims and objectives may be as follows: Aim The aim of the audit is to ensure that any exposure to ionising radiation benefits the patient in terms of their clinical management. Objective The objective of the audit is to evaluate the diagnostic quality of radiographs taken in the dental practice over a six month period. Step 3: Setting the standards and selecting the criteria How you set your standards for the audit will depend on the topic you choose. Some standards will be based on best practice or known standards; some topics will have national standards or guidelines.

5 Resources that you may wish to use to set standards for a radiography audit may be the Selection Criteria for Dental Radiography 10, Guidelines on Radiography Standards for Primary Dental Care 11 and the British Dental Association Advice sheet Radiation in Dentistry. 12 The Faculty of General Dental Practice (UK) has a publication titled Standards in Dentistry 13 which sets out tables based on the Self-Assessment Manual and Standards (SAMS) for a range of topics that could be considered for audit in the dental practice. This table outlines the standards used to assess the diagnostic quality of the radiographs taken in the dental practice Quality assessment of radiographs Rating Quality Criteria Targets: percentage Of radiographs taken 1 Excellent - no errors of exposure, positioning or processing Not less than 70% 2 3 Diagnostically acceptable-some errors of exposure, positioning or processing, but which do not detract from the diagnostic utility of the radiograph Unacceptable errors of exposure, positioning or processing which render the radiograph diagnostically unacceptable Not greater than 20% Not greater than 10% Standards Table 14 You also need to decide the criteria you are going to use to place the radiographs into one of the three categories. Consideration would need to be given to the following criteria and it would need to be analysed and collated. Criteria: Patient information Type of radiograph Date radiograph taken Reason for the radiograph Evidence the radiograph was checked Evidence the beam was correctly positioned

6 Correct contrast achieved Processing Sharpness Storage Step 4: Collecting the information To recap you should now: Have chosen a topic and defined what you are going to audit (ensuring that it is SMART) Have set the standard you are going to aim for. Know the criteria you are going to use to place each radiograph taken into one of the 3 categories. The next step is to work out how you are going to collect the information. You can either do a retrospective audit which will involve using radiographs already taken, or a prospective audit which involves using radiographs as they are taken. The details of each radiograph is analysed using the criteria outlined above and the standard of the radiograph is assessed and then recorded by using a data collection sheet. Example data collection sheet

7 Step 5: Interpretation of the results and formulating an action plan Once the data is collected it is important that sufficient time is given by the dental team to analyse and draw conclusions from the data so that positive improvements to current practice can be made as necessary. It is also important that time is given to formulate an action plan to raise the standard of care that the patient receives. It is possible that the audit may, for example, highlight that you have reached the set standards but that improvements can still be made in specific areas. For example: Radiographs need to be retaken due to poor or faulty processing Radiographs were of poor quality due to errors in exposure Radiographs were of poor quality due to incorrect positioning Action plan 15 The dental team should decide which areas of training should be completed to improve the quality of radiographs taken in the dental practice. When this has been completed a re-audit could be planned to measure improvement. Conclusion By stipulating that DCPs have to complete 5 hours of verifiable CPD on Radiography, the GDC recognise that the subject of radiography is an important issue. It is important to have a quality assurance system in place to ensure that the patient receives the highest level of care and is not unnecessarily exposed to ionising radiation. Clinical audit could be considered an important part of an overall quality assurance system for radiography. It measures current practice and identifies

8 areas that can be improved. There are many areas of radiography that can be monitored through the use of a clinical audit and it is possible that, by being involved in the audit process, you will identify areas that you can professionally develop which can be added to your personal development plan. 16 An example of this audit and other examples of audit that may be undertaken within the practice can be found in the non-verifiable CPD on the website. The risks and recommendations for radiographs will be explored in a future verifiable radiology core subject article Nicky Gough and Sue Bagnall All rights reserved

9 1 Rattan, C., Chambers, R. & Wakely, G. (2002) Clinical Governance in General Dental Practice. Oxon, Radcliffe Medical Press. 2 Department Of Health (2008) National Clinical Audit. Available from: (accessed 18th December 2008.) 3 Rattan, C., Chambers, R. & Wakely, G. (2002) Clinical Governance in General Dental Practice. Oxon, Radcliffe Medical Press. 4 FGDP (UK) Good Practice Guidelines. (2004) Selection Criteria for Dental Radiography. London, Faculty of General Dental Practitioners (UK). 5 Faculty of General Dental Practice UK (2007) The Key Skills in Primary Dental Care version 2.0 Radiography (CD-ROM). Available from: Smile-on Ltd. 6 General Dental Council Standards Guidance. (2008) Continuing Professional Development for Dental Care Professionals. London, The General Dental Council 7 Rattan, C., Chambers, R. & Wakely, G. (2002) Clinical Governance in General Dental Practice. Oxon, Radcliffe Medical Press. 8 FGDP (UK) Good Practice Guidelines. (2004) Selection Criteria for Dental Radiography. London, Faculty of General Dental Practitioners (UK). 9 Chuan (2009) My Singaporedentist.com. Available from: (accessed 10th March 2010) 10 FGDP (UK) Good Practice Guidelines. (2004) Selection Criteria for Dental Radiography. London, Faculty of General Dental Practitioners (UK). 11 National Radiological Protection Board. (NRPB; 1994) Guidelines on Radiology Standards for Primary Dental Care. Report by the Royal College of Radiologists and NRPB. Documents of the NRPB. 5 (3). Chilton 12 British Dental Association (2003) Radiation in Dentistry. Advice Sheet A11. London 13 Eaton, K. (2006) Standards in Dentistry. London, Faculty of General Dental Practitioners (UK). 14 National Radiological Protection Board. (NRPB; 1994) Guidelines on Radiology Standards for Primary Dental Care. Report by the Royal College of Radiologists and NRPB. Documents of the NRPB. 5 (3). Chilton 15http:// 16 Caerphilly Teaching Local Health Board. (2008) Clinical Audit Cycle. Available at: (accessed 28 th August 2009)