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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 11  |  Issue : 3  |  Page : 107-111

Clinical governance in general dental practice


1 Department of Community Oral Health, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Department of Community Based Education of Health System, School of Management and Medical Education Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3 Department of Community Oral Health, School of Dentistry; Preventive Dentistry Research Center, Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Date of Web Publication25-Jun-2019

Correspondence Address:
Prof. Mohammad Hossein Khoshnevisan
Preventive Dentistry Research Center, Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_10_19

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  Abstract 

Clinical governance as a vital strategy is important for quality improvement in health-care services while protecting staff, patients, and the public. Similarly, such strategies are widely applicable to dental health care and services. In general, clinical governance is a structure in which establishments are responsible for continues improvement of their services using the best standards of care available. The main objective of this study was to conduct an extensive review of literature to identify the efficacy status of clinical governance implementations in general dentistry. A comprehensive review of literature in English language was conducted using PubMed and Emerald databases from 1997 to 2017. Clinical governance, dental services, quality assurance, dental practice, and dental care were used as principal selected keywords. All identified papers were fully assessed and critically evaluated. Evidently, data were very scarce. Eleven relevant articles were selected for data extraction and summary production. Some studies reported a lack of understanding and awareness about how clinical governance can be implemented and how it can influence the dental practice. In response to such concern, others emphasized the importance of professional development through mentorship for successful learning method by dental practitioners. This method has a great potential for improving the quality of dental care and is crucial for the enhancement of dental practice. Excellence in dental clinical practice is best possible by continually improving standards of care through clinical governance. However, supports of dental health educators are immensely required to use mentoring strategies. This would enhance knowledge and confidence in the implementation of clinical governance while dental providers are in clinical practice.

Keywords: Clinical governance, Dental care, Dental practice, Dental services, Quality assurance


How to cite this article:
Dehghanian D, Heydarpoor P, Attaran N, Khoshnevisan MH. Clinical governance in general dental practice. J Int Oral Health 2019;11:107-11

How to cite this URL:
Dehghanian D, Heydarpoor P, Attaran N, Khoshnevisan MH. Clinical governance in general dental practice. J Int Oral Health [serial online] 2019 [cited 2019 Nov 17];11:107-11. Available from: http://www.jioh.org/text.asp?2019/11/3/107/261260


  Introduction Top


The delivery of quality dental care is a key to the long-term success. Quality improvement in the provision of health-care services has been a primary focus of successful governments. For better understanding, the term “quality” has been defined as surpassing customers' prospects and requirements throughout the life of the product. Quality in health care is a multidimensional concept and consists of five main areas including availability, accessibility, acceptability affordability, equity, and effectiveness.[1] The idea of clinical governance was first introduced in 1997 with the publication of the “ first White paper on NHS New Labors Health Policy.” Since then, it has become a significant part of quality assurance.[2] In the last decade, Harvey and Swage attributed the need for clinical governance because of the overall decline in standards of health-care services in the UK.[3] There are several quality assurance models in public health. They are all aiming at improving the quality of health-care services including International Standardization Organization (ISO-9000, 9001–9004), Dental Excellence Quality Model of European Federation for Quality Management (EFQM), Total Quality Management (TQM), European Practice Assessment model, as well as the clinical governance.[4] Quality management ISO 9000 series were introduced in 1987 and formed the basis of quality assurance worldwide. TQM is more comprehensive than ISO and consists of customer or patient satisfaction, staff satisfaction, social and environmental responsibility (equity) as well as medical outcome and financial results.[5] In 1991, the European Foundation for Quality Management created the EFQM-excellence model.

The aim of this model was to assess superiority levels achieved by administrations, aiming for uninterrupted enhancement. The word “excellence” was used because of the model emphases on organizations' functions, for providing excellent services or products for its stakeholders.[4] The approach of clinical governance is always to build on and not to replace the present form of quality assurance.[2] The principles and values of clinical governance can be well expanded broadly into community clinics. The clinical governance, therefore, covers all activities that help maintaining and promoting patient care standards and never negates other quality management systems.[6]

Travaglia et al. reported on mapping of the clinical governance concept development which was aimed to further the quality and safety in health-care system. In this study, an effort was made to better understand the clinical governance initiatives, practices and associated themes and concepts that have emerged over the past decades.[7] Initially, four components of clinical governance were identified; promoting quality and safety; effective use of data and evidence; as well as the patient-centered approach. The fifth component was introduced to strengthen the links between clinical health services and corporate governance arenas.[8] Eventually, the overall review of 1998–2009 showed a total of ten major themes in the literature; audit, data, and information, patients and practice, clinical, governance and quality, assessment, care, evidence, drugs, and future.[7] By definition, the clinical governance is a “Framework through which organizations are responsible to improve quality of their services continuously and establish high standards of care by creating an environment in which excellence in clinical care will flourish.”[9]

Based on the earlier literature, the clinical governance was mainly aiming at a new approach to old safety and quality problems. By understanding the clinical governance concept development process, we may be able to come up with ideas to further improve the quality, safety and well-being of patients, health-care personnel and public.[7] The literature offered by attributes the need for clinical governance due to the lack of standards for evaluating the quality of health-care services.[3]

The clinical governance in the UK was originally based on seven pillars approach (NHS approach) including clinical effectiveness, clinical audit, risk management and patient safety, client/career experience and involvement, using information, education and training, and staffing/staff management.[3] [Figure 1] demonstrates these seven domains based on the NHS approach which are based on (a) uninterrupted enhancement in quality assurance, (b) using the best available standards that matches with standard clinical indicators, (c) inspiring clinical effectiveness, (d) conduct accreditation procedures, (e) active risk managing, (f) concentrating on patient protection and safety, (g) enhancing information sharing, (h) supporting open disclosure, (i) effective training and knowledge management, (j) obtaining patient approval, (k) reporting performance feedback, (l) endorsing on job continuous education, (m) building effective conflict and complaint management, (n) inspiring patient participation in decision-making, (o) using accredited medical professionals, and (p) stimulating evidence-based decision-making and treatment planning.[8] The concept of clinical effectiveness is closely related to “evidence-based practice” where individual clinical expertise are integrated with the best available scientific evidence from systematic review and meta-analyses investigations.[10]
Figure 1: Seven pillars of clinical governance based on the NHS approach

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The main purpose of this study was to perform an extensive review of literature to identify the status and effectiveness of clinical governance in general dental practice.


  Materials and Methods Top


The electronic literature search conducted, including PubMed and Emerald databases.

Papers focused on clinical governance in the dental field. Papers published in English language with available abstract since 1997 (when clinical governance was introduced) to 2017.

The articles were appraised by two trained investigators with a good level of agreement. The search strategy for both databases conducted through the following search process: clinical governance was used as a primary keyword and combined with these keywords: (dental care, quality of dental care, dental care providers, quality assurance, and dental practice). Search query based on each keyword and then after combining them in the search process was done [Table 1]. Search strategy in PubMed and Emerald databases was also analyzed [Figure 2]. All titles and abstracts were evaluated by two reviewers independently, using the defined inclusion criteria. The full texts of articles were critically evaluated if reviewers considered the abstracts were potentially relevant. All full-text articles were assessed independently by the same two reviewers. Any disagreement on the inclusion of an article was resolved by a third reviewer. After critical appraisal through a total of 82 relevant articles, 24 full texts evaluated and 11 articles that meet to inclusion criteria were selected to categorize different dimensions of clinical governance in selected articles for further comparison. Ethical code: IR.SBMU.RIDS. REC.1396.549.
Table 1: Search query results

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Figure 2: Search strategy in PubMed and Emerald databases

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  Results Top


The term clinical governance was used as a primary keyword, and then, it was combined with other keywords as follows: “dental practice,” “quality assurance,” “dental care,” and “dental services.” The articles that fulfilled all the selection criteria were analyzed to identify any dimensions of clinical governance assessed in general dental practice. [Table 2] shows properties of the selected articles. All the included articles were critically appraised by two investigators who had good level of agreement. A total of 82 potentially relevant articles were found. Titles were evaluated in the first phase, and 16 articles were excluded. After the abstract review phase, 42 of the 66 articles were excluded as well. This process resulted in the identification of 24 relevant articles. Finally, by conducting full text review, the number of remaining articles reduced to 11 studies.
Table 2: The properties of eleven selected articles

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Seven main dimensions regarding quality improvement were developed from included articles:

  1. Credentialing: May be referred to a formal process of verifying the qualifications, past experience, professional standing, and other relevant professional characteristics of medical practitioners. This evaluation can determine professional suitability for providing high-quality health-care services within specified settings[4]
  2. Clinical risk management and adverse effect reporting
  3. Practice standards, best practice methods, clinical practice guidelines
  4. Clinical audit and peer review
  5. Good data keeping
  6. Continuous learning
  7. Leadership policy making.



  Discussion Top


Clinical governance has been introduced to public health since 1997, as a key strategy for improving health care services. Van Zwanenberg and Harrison defined clinical governance as a comprehensive approach to achieve high standards of care.[17] The clinical governance focuses on customer/patients expectations, preventing problems, and commitment for quality improvement.[5] In relation to the publication site, a comparison of the selected studies demonstrates that they were mostly published in the UK (77%). Yamalik explained that measuring quality in dental practice is a complex process because different quality assurance and quality improvement tools evaluate unique features of health care. However, it is necessary to know core values in quality assurance and quality improvement applicable to dental care. Such values may include credentialing (accreditation, certification, and licensure), clinical risk management as well as adverse effect reporting, clinical practice guidelines, good data keeping, and self-assessment.[4] Hugh and Anup developed a framework for 5 years' period and a vision of conducting annual revision to address how health is improving and inequalities are narrowing. Bringing together, the patient safety and managing risks associated with preventive dental care and identifying poor services were the major areas of this framework. Improving planning and better utilization of financial resources are some of the strengths of this framework.[6] Ball as members of the national dental advisory committee in Scotland developed a framework by focusing on quality accreditation, evidence-based dentistry, and patient satisfaction.[2] Cameron et al., used a qualitative and quantitative method to evaluate the role of individuals who guide and advise for quality enhancement of clinical governance in the dental office. This study identified that, the clinical governance process and systems were poor among the study population in Glasgow. They recommended that self-assessment checklists could be used for promoting staffs in dental care.[15] Snowden et al. reported quality improvement, risk management, governance, and dental policy as important dimensions of dental clinical governance. However, the concept of clinical governance is still challenging to providers of dental services. Their study also identified a distinct paucity of research regarding dental clinical governance, and recommended to enhance clinical governance in dental practice.[11] Maidment conducted a review of literature regarding themes of clinical governance and concluded that, employing clinical governance can reassure patients about the use of standards and reassuring professionalism by any health-care team.[18] McCormick and Langford explored dentists attitude and opinions regarding clinical governance using a Likert scale questionnaire. This survey identified some problems about introducing clinical governance among general dental practitioners. The authors are suggesting the importance of practitioners' awareness on potential problems and applying clinical governance concepts for resolving them.[16] Kakudate et al. evaluated the application of Japanese clinical guidelines among 148 dentists in a cross-sectional study. They concluded using clinical guidelines and evidence-based practice is still inadequate in Japanese dentists. However, the rate of using clinical practice guidelines were significantly improved with increasing number of years since graduation and accumulation of more clinical experience.[12] Vakani et al. performed a three-level quality assessment in a dental hospital using the EFQM model. He used a purposive sampling method including 9 managers, 3 academic faculty members, and 2 students. Using all the key quality aspects of EFQM model, 14 in-depth interviews were conducted using a semi-structured interview guideline. The results of this study showed that continuous learning, innovation, improvement, partnership development, and corporate social responsibility were all significantly relevant. However, this study was conducted in one institution, used a small sample size, therefore, findings are not generalizable.[14] Suhaym and Kunal conducted a review of literature to evaluate the quality of clinical practice guidelines in dentistry. After performing a literature search, a total of 162 dental guidelines that were published during 2000–2014 were identified. The process and quality of clinical guideline development was individually assessed for each guideline using the AGREE II instrument. This is a 23-item checklist which is categorized into six domains. The scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence were the main domains. This search was restricted to English publications and individual/patient level interventions. Based on the findings of this study, despite constant improvement between 2000 and 2014, the dental guidelines are of suboptimal quality. It should be considered that this instrument has some limitations for evaluation because some guidelines may get a high score despite having bias, methodological errors, or inadequate critical appraisal. On the other hand, it may assign a low score for well-conducted guidelines if the reporting process of guideline development was inadequate. Both factors can result in a false impression to clinicians.[13] One limitation of the current study can be the use of few databases for searching the literature although there was sufficient information available to answer the study questions at this juncture.

Although abundant literature is addressing clinical governance in nursing, the numbers of citations in dentistry is still very limited. Nevertheless, we believe that clinical governance framework should be extended to dental schools to train dental students with such principals. The implementation of clinical governance in dental schools can greatly advance the quality of dental care, education, research, and at the same time, the quantity of standard services provided. Under clinical governance, all service levels can be improved (Level 1 = Prevention; Level 2 = Treatment; and Level 3 = Rehabilitative Care).


  Conclusions Top


The concept of clinical governance in dental practice is relatively new and establishing frameworks for evaluating dental services based on clinical governance is a crucial need for obtaining excellence in dental clinical services. Although clinical governance in general dental practice has been established in some countries to help patients, providers, and public with better care; it has a lot of room for improvements. Furthermore, it seems to be very hard to reach out every single dental practitioner for clinical governance through on job training after graduation. Health policy makers' support is incredibly needed to improve quality and effectiveness of preventive and curative dental services. A potential option would be the use of dental schools to train dental students so they can be well prepared to apply all aspects of clinical governance in private practice after graduation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Mills I, Batchelor P. Quality indicators: The rationale behind their use in NHS dentistry. Br Dent J 2011;211:11-5.  Back to cited text no. 1
    
2.
Ball G. Clinical Governance in Dental Primary Care. Scotland-Edinburgh: National Dental Advisory Committee; 2001. p. 1-29.  Back to cited text no. 2
    
3.
Rob MC, Paddy P. Clinical governance and national health service. In: Clinical Governance a Guide to Implementation for Health Care Professionals. 3rd ed. New Delhi: Willey-Blackwell; 2011. p. 2.  Back to cited text no. 3
    
4.
Yamalik N. Quality systems in dentistry part 2. Quality assurance and improvement (QA/I) tools that have implications for dentistry. Int Dent J 2007;57:459-67.  Back to cited text no. 4
    
5.
Harr R. TQM in dental practice. Int J Health Care Qual Assur Inc Leadersh Health Serv 2001;14:69-81.  Back to cited text no. 5
    
6.
Hugh B, Anup KA. Model Dental Governance Framework for General Dental Services Provided by the Local Health Boards. Ver. 1; 2013. p. 1-69. Available from: http://www2.nphs.wales.nhs.uk: 8080/DentalPublicHTDocs./Dental%20Clinical%20Govern. [Last accessed on 2019 Mar 26].  Back to cited text no. 6
    
7.
Travaglia JF, Debono D, Spigelman AD, Braithwaite J. Clinical governance: A review of key concepts in the literature. Clin Gov Int J 2011;16:62-77.  Back to cited text no. 7
    
8.
Braithwaite J, Travaglia JF. An overview of clinical governance policies, practices and initiatives. Aust Health Rev 2008;32:10-22.  Back to cited text no. 8
    
9.
Holden LC, Moore RS. The development of a model and implementation process for clinical governance in primary dental care. Br Dent J 2004;196:21-4.  Back to cited text no. 9
    
10.
Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: What it is and what it isn't. BMJ 1996;312:71-2.  Back to cited text no. 10
    
11.
Snowden M, Ellwood F, McSherry R, Halsall JP, Hough D. Clinical governance: A friend or foe to dental care practice in the UK? Int J Percept Public Health 2017;1:112-20.  Back to cited text no. 11
    
12.
Kakudate N, Yokoyama Y, Sumida F, Matsumoto Y, Gordan VV, Gilbert GH. Use of clinical practice guidelines by dentists: Findings from the Japanese dental practice-based research network. J Eval Clin Pract 2017;23:96-101.  Back to cited text no. 12
    
13.
Suhaym M, Kunal P. Assessing the quality of dental clinical practice guidelines. J Dent 2001;6:102-6.  Back to cited text no. 13
    
14.
Vakani F, Fatmi Z, Naqvi K. Three-level quality assessment of a dental hospital using EFQM. Int J Health Care Qual Assur 2011;24:582-91.  Back to cited text no. 14
    
15.
Cameron WA, Taylor GK, Broadfoot R, O'Donnell G. The role of the clinical governance adviser in supporting quality improvement in general dental practice: The Glasgow quality practice initiative. Br Dent J 2007;202:193-201.  Back to cited text no. 15
    
16.
McCormick RJ, Langford JW. Attitudes and opinions of NHS general dental practitioners towards clinical governance. Br Dent J 2006;200:214-7.  Back to cited text no. 16
    
17.
Toy A. Defining clinical governance in general dental practice: The winds of change? Prim Dent J 2014;3:32-3.  Back to cited text no. 17
    
18.
Maidment YG. Clinical governance, what is it and how can it be delivered in dental practices? Prim Dent Care 2004;11:57-61.  Back to cited text no. 18
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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