Quality in Orthodontic Practice

Quality has become the buzzword of the '90s. Interest in it was stimulated in the United States with the establishment by Congress of the Malcolm Baldrige National Quality Award in 1987. Its purpose is to promote quality awareness, to recognize quality achievements of U.S. companies, and to publicize successful quality strategies. Toward this end, seven areas were chosen as award criteria: leadership, information and analysis, planning, human resource utilization, quality assurance of products and services, quality results, and customer satisfaction.

Using these criteria as a starting point, guidelines were published to help firms evaluate their quality and to provide an outline for award application. This has not only resulted in a growing number of applications for the award, but it appears to have given a broad spectrum of business and professional entities a framework within which to examine the status of quality in their enterprises, and an outline for a program of quality improvement.

What is Quality?

In Robert Pirsig's Zen and the Art of Motorcycle Maintenance, the main character is an antihero who spends a great deal of time and emotional energy trying to understand what quality is and to define it. He finally comes to realize that there is ambiguity in the word "quality". He concludes that quality exists, but cannot be defined. An example he might have used is the word "giant". We may not have an exact measurement that determines what a giant is, but we surely can point one out. However, in a race of giants the term would have no meaning.

The idea that quality cannot be defined is a kind of philosophical mysticism that orthodontists have difficulty with. We deal with millimeters and degrees, and we believe that quality should be measurable. After all, technology is an offspring of science, and technology is objective and quantifiable.

Quality by its nature is subjective, and orthodontists want to, or even need to, make it objective. So when we use measurements we are really saying, "This is better than that", and we call it quality. But not all aspects of orthodontic treatment are measurable. Quality of orthodontic treatment involves more than a disembodied set of models.

Quality in Orthodontics

Dr. W. Edwards Deming, who is given credit for much of the remarkable economic achievement in Japan, emphasizes the designing of production to eliminate imperfect results, and the importance of a continuous effort to improve quality in the system of production and service.

If orthodontists tend to pay more attention to the quality of the operatory product than to that of the service as a whole, Deming would encourage us to adopt a formula that constantly builds quality into all aspects of the work, and to view quality as a combination of all the support elements that could contribute in any way to achieving the goal. In orthodontic practice, as in commercial enterprise, quality management refers to quality of the process as well as quality of results.

As a guide for orthodontists in an assessment of quality in their practices, I have devised a quality quiz based on the Baldrige guidelines.

Remedial Measures

There is no quick fix. It takes a commitment to quality forever, and constant quality improvement is a bit-by-bit process. The value of the Baldrige guidelines, and of this quiz, is that they immediately point to the area or areas in which a practice is deficient. Then the work begins.

Leadership

This is the easiest area to remedy and the key to all the rest. The orthodontist must believe that quality across the board in a practice is the single most important factor in success in terms of doctor satisfaction, staff satisfaction, and--most important--patient satisfaction. He or she must make a conscious commitment to quality in all the areas of the practice.

To sign on to that commitment, the orthodontist, together with staff, develops a mission statement defining the value system of the practice in terms of quality.

Information and Analysis

Information about the practice is crucial, if quality building and quality control are a serious undertaking. Practice records, properly kept and properly analyzed, contain a wealth of information that tells where the practice has been and where it is currently. That information forms the basis for making decisions about where the practice may be headed, and what steps should be taken to achieve desired goals.

One must consider what can be known about a practice1 and organize the data gathering and analysis that are pivotal to the whole process of building a high-quality practice. If one insists on accomplishing this step manually, one does not have a total commitment to quality. Nowadays, high-quality data management is done by computer.

Strategic Quality Planning

Planning is the process that sets the course of quality performance after evaluating the information and analysis. It is a systematic scheme for upgrading practice management2--a continuous process of evaluation, goal setting, selection, implementation, and re-evaluation.

Staff Utilization and Involvement

It is basic that the staff must be committed to quality and capable of producing quality in all aspects of the practice. This implies a selection process that can find such people, a training program that brings them to the highest level of performance and maintains them there, and a salary policy that rewards high-quality performance adequately.

Service Quality Assurance

Part of a practice evaluation is a consideration of service standards, and part of quality assurance is to see that those standards are constantly evaluated and upgraded. This includes such factors as how long people must wait for their appointments, how long various procedures take, how long a course of treatment takes, effectiveness of appliances and appliance adjustments, number of emergencies, case acceptance rate, number of x-ray retakes and laboratory remakes, number of complaints, number of instances of lack of cooperation, and number of broken and canceled appointments.

Quality Results

Barney Jankelson said, "If you can't measure it, it is not a fact." He might have added, "If you don't measure it, it is not a fact." It would appear from the responses to the 1990 JCO Study of Orthodontic Diagnosis and Treatment Procedures that not all orthodontists routinely take after-treatment study models and x-rays.3 Without a comparison of pre- and post-treatment models and x-rays, it is unlikely that one would be able to evaluate the quality of one's treatment results. At least one other method has been proposed for a qualitative analysis of treatment results.4

Quality results are not just those shown by qualitative or quantitative post-treatment analysis. Quality results are also what patients perceive to be quality results, and that has to do with the extent to which the results of treatment meet the patient's expectations.

In trying to measure the quality of results and to judge concordance with patient expectations, the purpose is not only to judge the level of quality, but also to evaluate how it can be improved.

Patient Satisfaction

Patient satisfaction is the bottom line in orthodontic practice. In the unlikely event that the most perfect occlusion could be obtained without the patient being satisfied, the result could not be judged to be of high quality. The essence of the pursuit of quality in a practice is the evaluation of patient satisfaction from beginning to end of the orthodontic-patient relationship, and a constant effort to improve patient satisfaction.

It has been said that the most successful outcomes result from exceeding patients' expectations. Before one can exceed patients' expectations, one must know what those expectations are. The more the evaluations of patient satisfaction can be made person-to-person, the more valuable the information is likely to be.

Conclusion

While it may be clear what is involved in quality management, the question is how to make it happen. Each of the Baldrige categories requires thorough evaluation followed by action. This is a discipline that must involve everyone in the practice--doctor, staff, and patients. It is intensive, extensive, and ongoing. When a quality level is achieved, however, its management will be as normal as breathing.