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Resolution of a Practice Issue, Part 2 – Priscilla Kaljanac
Practice Issue
The practice of omitting services that are not billable, such head and neck and intra oral exams in private practice due to pressures/constraints of economics and time.
Introduction
Approximately 3,400 new cases of oral cancers were identified in Canada in 2009, and about 1,150 deaths occurred as a result of the disease.1 The 5-year survival rate for oral and pharyngeal cancers is only 53 percent and is one of the lowest of the major cancers because a majority of the lesions are not diagnosed until they are in their advanced stages.2 Thus early detection is essential to increase the chances of survival.2
Approximately 64 percent of Canadians aged 12 and over visited a dental office in 2005, which is a significant number of people with access to regular head and neck and intraoral exams. Therefore hygienists have a unique opportunity to catch cancer in its early stages. However, studies clearly show the vast majority of those who visit the dentists do not get oral cancer screening exams, despite the fact the hygienists know it should be done.3,4
Practicing hygienists often find that they are pressured by time constraints, and may choose to forego certain elements of the patient assessment in order to manage scheduled patients in a timely fashion. Some hygienists may think they can look at the oral tissues thoroughly while performing debridement and other routine procedures. Some may decide that only those patients with a history of tobacco and/or alcohol use need to be carefully examined, or they may decide that children do not need to be examined because they are too young to have conditions like oral cancer. However this reasoning may be very costly for patients, as results of recent studies indicate that oral cancer has sharply increased in young adults who have no risk factors.5 The cancers being discovered in younger people are also reported to be more aggressive and associated with a poorer prognosis than those seen in older populations.5
Whatever the reasons for deleting or shortening an oral screening exam, they are not good enough to neglect performing this vital service, and it is this practice issue that prompted me to develop the following plan for change.
Plan
Goal: To increase perception of the importance of intra/oral exams, and increase the frequency of intra/extra-oral exams conducted on clients during and post implementation, among dental hygienists in private who participate in my implementation plan.
I implemented a plan to initiate change among the dental hygienists that work at my personal dental office where I am a client, and at some of the dental offices in my area. The plan reminded participants about the importance of intra/extra oral exams, with a goal to convince them to conduct full intra/extra oral exams on all or as many patients as possible, over a four- week period.
The implementation began by recruiting hygienists to participate. A letter (See Appendix 1) introducing myself and the practice issue was delivered to hygienists at my personal dentist’s office and other offices in my area. The letter invited hygienists to contact me for participation. Hygienists were assured that the implementation would not interfere or negatively affect their job, and that their participation would be confidential. They could back out of the implementation at any time. Unfortunately I only received 3 responses from practicing hygienists, so I delayed the start of the implementation to expand my plan to more dental offices in the hope that I would recruit more participants. This required that I shorten the implementation period from four to two weeks. In the end, five hygienists from two dental offices responded to the letter. These hygienists were interviewed to assess their views on the issueand establish a baseline to compare implementation results (See Appendix 2A). Four of the five hygienists proceeded to the implementation stage after the initial interview. Participants were given a questionnaire that could be filled out during appointments or at the end of the day. Hygienists were to record whether they performed full intra/extra oral exams and patient reactions. The questionnaire (See Table 1) was made as simple as possible to encourage participation and compliance, and cause as little disruption to service as possible. At the conclusion of the implementation period, a final post-implementation interview was conducted. Questionnaires were collected and the results were compiled with interview answers foranalysis.
Implementation
Implementation data was recorded by participating hygienists on a 5-question questionnaire (See Table 1). The questionnaire was constructed for maximum efficiency. It was made to be simple and easy to fill out, so as to limit disruption to service. Each question is answered by simply circling a response, and can be completed in seconds at the conclusion of an appointment or whenever time permits. Participants filled out the questionnaire for each client they treated during the two-week implementation. At the beginning of the second week, I contacted each participant to inquire on the progress of the implementation. They each confirmed that they were completing the questionnaires as requested, however by this time, they had all noted that their answers were the same for nearly all their clients. Therefore, they decided to simply record any notable findings throughout the day and fill in the questionnaires at the end of the day. I assured them that this was fine as long as they were diligent with recording their findings. At the conclusion of the implementation, the questionnaires were collected and the results compiled into an outcome chart (See Appendix 2C)
Table 1: Implementation Questionnaire
Question / AnswerDid you perform a head/neck & intraoral exam? / FULL / PARTIAL / NONE
Did conducting the exam negatively affect your schedule? / YES / NO
Was time a factor for omitting an exam? / YES / NO
Did the client make any comments regarding your performance of these exams? / POSITIVE / NEGATIVE / NONE
Did you find an area of concern during your exam? / YES / NO
Outcomes Data
All four hygienists rated the importance of conducting full intra/extra oral exams as a 7 or 8 on a 10-point scale, suggesting that they recognize the importance of such exams for client safety. However this recognition did not translate into action, as before the implementation, none of the four hygienists that participated did full intra/extra oral exams during every visit. Most stated that they would do them for new clients, or if there was significant risk of oral cancer such as those that smoke and drink heavily. They all claimed to conduct their intra oral exams while working in the mouth on other tasks such as during debridement.
Comparisons with post-implementation data suggest that the intervention has had a positive effect on the hygienists. Whereas pre-implementation hygienists rated the importance of full intra/extra oral exams in the 7-8 range, they now rate the importance between 9 and 10. That is a two-point increase on an already high score. This result indicates that my goal to increase perception of the importance of intra/extra oral exams has been achieved.
Another goal was to increase the frequency of intra/extra-oral exams conducted on clients during and post implementation. Implementation data shows that hygienists performed at least a partial exam 100% of the time, and full intra/extra oral exams on 98% of clients during the two-week implementation. It is unlikely that they will continue this level of compliance into the future, however there are positive signs. When asked how inclined they were to conduct full exams on their patients before the implementation, all responded with a likelihood in the range of 2-4. Post-implementation, all hygienists indicated that they are more likely to conduct full intra/extra oral exams. Results improved 3 to 4 points to a range of 5-8, which is a significant improvement over pre-implementation scores. This suggests that hygienists are more likely to conduct full intra/extra oral exams on their patients following the implementation.
A secondary goal of the implementation was to collect data on hygienist/client views on the practice issue, the perceived value of the service from the client’s perspective, and the actual time/profitability impact these services have on hygiene care appointments. Out of over 150 clients seen by the four hygienists over the two-week period, there were no instances in which conducting the exams caused a delay in their schedule. Therefore it can be said that these exams have no impact on schedules, or the profitability of hygiene care appointments. Furthermore, the hygienists reported only positive comments from clients regarding their performance of these services. Although, the overwhelming majority of clients made no comment, the fact that a few clients indicated a positive opinion on the exams, suggests that clients at the very least tolerate the service, and probably value it, even if most do not voice their approval.
Analysis
The success of the implementationis based on two factors: increased perception of the importance of intra/extra-oral exams, and increased frequency of intra/extra-oral exams. A significant increase in either or both of these factors constitutes positive change. Change was measured by comparing data from the interview taken before the implementation and comparing it with with data compiledduring and after the conclusion of the implementation. As the outcomes clearly show, there was significant positive change recorded in these two areas, indicating that the implementation was a success.
The change that took place during this implementation can be explained by the transtheoretical model of change, which describes how people modify a problem behaviour or acquire a positive behaviour through a process of movement through stages of change.6 Before implementing my plan, these hygienists were in the precontemplation stage because they were uninformed or underinformed about the consequences of their behaviour.6 At this point, they believed thatthe pressures of time and economics outweighed the benefits to the client. The process of change began with consciousness raising, which occurred when hygienists read my letter outlining the practice issue. The letter explained the practice issue, the importance of intra/extra-oral exams, and informed them of the costs and benefits of change. The hygienists that contacted me for an interview had moved into the preparation stage.6 The act of contacting me showed they were willing to take steps towards change. By simply participating in the two-week implementation, the hygienists have moved into the next stage of change. By modifying their dental hygiene services to perform full intra/extra-oral exams, they have moved into the action stage.6
Theoutcomes data shows that the participating hygienists have a higher appreciation for the importance of intra/extra-oral exams than before the implementation, and are more willing toconduct them on clients going forward. Now that the implementation is over, it is up to the hygienists to make sure they do not relapse into omitting the exams. However it is unrealistic to expect that they will maintain the near 100% compliance to full intra/extra oral exams.
The limitations of the plan are made evident by the low participation rate. The plan involved making a large quantity of letters for distribution to dental offices. After explaining the issue and implementation to a receptionist or hygienist, it was up to them to pass the letters on. Unfortunately there was no way to ensure that all of the hygienists read the letter. Hygienists also had to contact me for an interview. Unfortunately time, logistics, issues of privacy prevented me from contacting hygienists directly, which would have ensured a greater participation rate, and affected even more positive change in the community.
Secondly, those who took the step to contact me probably had more appreciation for the issue than those who did not, and were perhaps more receptive to change. Therefore the plan failed to reach those who had the most to gain from the implementation.
The delay in recruiting participants necessitated a shortened implementation. The initial plan called for a four-week implementation, which was cut down to two weeks due to the hard deadline for submission. This may have an impact on relapse, as two weeks is probably too short a duration to habituate the hygienists to performing full intra/extra-oral exams on a daily basis. I am however encouraged by the results that show that they are more inclined to do so than before.
Another limitation to the plan is the fact that I did not witness the implementation. I only have their word that the data is truthful and accurate. However, I trust that the results are reliable, as the demands were simple and unobtrusive, and there was no reason for the hygienists to be untruthful.
In the end, I can be sure that I have made at least some impact, if not for the rest of their careers, but at least for the two weeks of the implication. Even if the hygienists fall back into their old habits, at the very least I can be content knowing that I have increased awareness of the issue. If they do continue with the exams, this implementation may save a life in the future.
References
1. Oral Cancer. [Internet}. Health Canada. [Cited 2010 Nov 24]. Available from:
2. Healthy People 2010: Volume II (second edition). [Internet]. U.S. Department of Health and Human Services, Public Health Service, Nov. 2000. [Cited 2010 Nov 24]. Available from: http://www.healthypeople.gov/Document/HTML/Volume2/21Oral.htm
3. Forrest JL, Horowitz AM, Shmuely Y. Dental hygienists: knowledge, opinions, and practices related to oral and pharyngeal cancer risk assessment. Journal of Dental Hygiene Fall 2001; 75 (IV): 271-281.
4. Horowitz AM, Siriphant P, Canto MT, et al. Maryland dental hygienists: views of oral cancer prevention and early detection. Journal of Dental Hygiene Summer 2002; 76 (III): 186-191.
5. Schantz SP, Yu GP. (2002). Head and neck cancer incidence trends in young Americans, 1973-1997, with a special analysis for tongue cancer. Arch Otolaryngol Head and Neck Surg. 2002;128(3):268-274.
6. Transtheoretical model. [Internet]. University of Rhode Island Cancer Prevention Research Center. [Cited 2010 Nov 24]. Available from: http://www.uri.edu/research/cprc/TTM/detailedoverview.htm
Appendix 1 – Letter to Hygienists
January 17, 2011
Dear Hygienist,
I am a Dental Hygiene student from UBC and I am seeking your thoughts and participation in the implementation of a class assignment on the practice of omitting services that are not billable, such as head and neck and intra oral exams in private practice.
In hygiene school I have been taught that intra/extra-oral exams are a very important aspect of assessment, and one that should not be passed over. My ultimate goal during this assignment is to persuade you to conduct this important assessment exam during every dental visit, and I hope you will read my attached rationale for more information on this practice issue.
Participation in this implementation will provide you with an opportunity to assess the costs and benefits of performing these exams on your clients, and contribute valuable data on hygienist and client views of this practice issue, the perceived value of the service from the client’s perspective, and the time/profitability impact these services have on hygiene care appointments.
Your participation is voluntary and you may withdraw at any time. This assignment involves minimal commitment on your part including an interview about your practice methods and your perceptions of the practice issue. This may be done by email, phone or in person at your convenience. Then if you would like to participate further, it would involve a short 2-week commitment whereby you will log whether you performed intra-extra oral exams for each of your clients with a short note explaining your reasoning, as well as any reactions to the service from clients. Your participation will be unobtrusive and at your discretion, and completely confidential.
Please read the rational on the back of this letter if you would like to know more about his issue. I would greatly appreciate your participation and thank you for your time. Please contact me by email at or by phone at 604-649-4704 if you would like to take part, or if you have any questions.
With warm regards,
Priscilla Kaljanac
Appendix 1 Continued…
Rationale
Approximately 3,400 new cases of oral cancers were identified in Canada in 2009, and about 1,150 deaths occurred as a result of the disease. The 5-year survival rate for oral and pharyngeal cancers is only 53 percent and is one of the lowest of the major cancers because a majority of the lesions are not diagnosed until they are in their advanced stages. Thus early detection is essential to increase the chances of survival.