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References

Dauphinee WD. Revalidation of Doctors in Canada. Br Med J. 1999; 319:1188-1190
Revalidation Consultation Paper. 2010;
HM Gov. Better Regulation – Dept for Business Innovation & Skills. 2010. http://www.bis.gov.uk/policies/bre/principles-of-regulation
Eve RichardOxford: Radcliffe Medical Press;
Pringle M, Bradley CP, Carmichael CM Significant event auditing. A study of the feasibility and potential of case-based auditing in primary medical care. Occas Pap R Coll Gen Pract. 1995; (70)i-viii
: Faculty of Dental Surgery, Royal College of Surgeons of England;

Revalidation in primary care – a personal view

From Volume 39, Issue 9, November 2012 | Pages 610-612

Authors

Alasdair G Miller

BDS, FDS, FFGDP, F.AoME

Parkfield Dental Surgery, Taunton, Somerset TAI 4RL

Articles by Alasdair G Miller

Abstract

This article explores an approach to Revalidation based on the principles of quality assurance.

Clinical Relevance: The delivery of safe, effective clinical care is the goal of every practitioner and the use of appropriate quality assurance processes can promote this and, at the same time, meet the General Dental Council's likely requirements for Revalidation.

Article

The General Dental Council, in response to Government instruction, is working on plans to introduce Revalidation for the profession from about 2014.1 The General Medical Council introduced Revalidation in 2012. The Department of Health, in 2008, defined Revalidation as:

“…ensure that health professionals remain up to date and continue to demonstrate that they continue to meet the requirements of their professional regulator”2

The General Dental Council defines it as:

“…the means by which, in the future, registrants will be required to periodically demonstrate that they are up to date and compliant with our Standards for Dental Professionals”3

The GDC, like the GMC, suggests that the appropriate cycle for Revalidation should be 5 years. It has advocated a 3-stage approach to Revalidation which follows the model used by the Canadian physicians4 and other healthcare groups (Table 1). The Canadian approach suggests that the process should be formative and benefit the registrant. It is believed that most registrants will be able to revalidate at Stage 1. The GDC, in its proposals in 2010, suggested that external verifiers are needed to assess evidence to recommend revalidation.5 Those working in salaried dental services, eg hospitals and community dental services, armed forces, already have appraisals and clinical performance management, and so an employee should be able to demonstrate that he/she is fit for Revalidation based on his/her annual review. The challenge is how primary dental care practitioners (NHS and independent), who do not normally have a formal review, can, in a timely cost-effective way, demonstrate that they meet the standards and so Revalidate.


Stage 1 – compliance check, which will apply to all dentists.Stage 2 – remediation phase, which will provide an opportunity to dentists who do not pass Stage 1 to remedy deficiencies.Stage 3 – in-depth assessment, which will apply to dentists who fail to demonstrate their compliance at the end of the remediation phase.

The key principles of better regulation were specified in 2010 (Table 2).6


  • Does the government need to regulate?
  • Do the regulations harness insights of behavioural economics?
  • Is there no alternative to regulation?
  • Is there a clear case for regulation?
  • Are the regulations necessary and proportionate?
  • Do they provide a cost benefit?

    • This article gives a personal view of how Revalidation might be introduced into primary dental care and achieve the desired result in a timely and cost-effective way and meet most of these principles.

    The underlying goal of revalidation must be the delivery of safe, effective dental care for patients. It is about delivering a consistent quality of care.

    W Edwards-Demming, the father of quality management in industry, suggested 14 points for quality in manufacturing. These were adopted by Japanese companies in 1950 and demonstrated in the quality and consistency of their products (Table 3).


  • Create constancy of purpose.
  • Adopt a new philosophy.
  • Cease dependency on inspection to achieve quality.
  • End the award of business based on price.
  • Improve constantly production and service.
  • Institute training on the job.
  • Institute leadership – the aim being to assist people to do their job better.
  • Drive out fear – to maximize worker effectiveness.
  • Break down barriers between departments.
  • Eliminate slogans, exhortations and targets.
  • Eliminate work standards (quotas).
  • Remove barriers that rob workers of their pride of workmanship.
  • Institute a vigorous programme of education and self-improvement.
  • Put everybody in a company to work to accomplish the transformation.

    • The key to Demming's views on quality are based on the concept that ‘the best person to deliver quality of a task is the person doing the task’. Inspection at any stage after the activity adds cost and is time consuming. If the person undertaking the tasks can quality assure it, then it can be very effective.

    Not all of Demming's principles are within the control of the dentist, if he/she works in the NHS, but there are many they can adopt (Table 4).


  • Establish constancy of purpose – constantly trying to improve.
  • Adopt a new philosophy – working with those around them to raise quality.
  • Require statistical evidence of quality – result of audit.
  • Institute training on the job – in house training, coaching.
  • Institute leadership – the aim being to assist people to do their job better.
  • Drive out fear – to maximize worker effectiveness.
  • Break down barriers between departments, eg surgeries and reception.
  • Remove barriers that rob workers of their pride of workmanship – appropriate equipment and materials, etc.
  • Institute a vigorous programme of education and self-improvement – CPD.
  • Put everybody in a company to work to accomplish the transformation.

    • Ultimately, it is the practitioner who benefits from striving to provide a service/dental care to a consistent standard. There are likely to be fewer failures of treatment, happier patients, less stress, more trust and hence higher uptake of discretionary treatments.

    How to make this happen?

    The individual and ideally the practice need to adopt the philosophy of always trying to identify how to improve the care to patients and then working to deliver it. The main tool of quality improvement is audit; looking at what one is doing and seeing how it compares with agreed standards. Where these standards are not reached, there is a need to identify why not and then to implement changes to try and improve results. A re-audit at a later stage is usually necessary to see if the improvement has worked. This works well for clinical activity and can be adapted for service aspects of the practice. The use of patient satisfaction questionnaires can be used to ask questions that relate to service standards of the practice, eg Did you receive options and prices for treatments? Were you provided with all the information you required?

    Other tools for improving quality are given in Table 5.


  • PUNs and DENs7 – Patient Unmet Needs, Dentists Education Needs.
  • Peer review – discussion amongst providers.
  • SEA – Significant Event Analysis.8 Reflective commentaries – on CPD activities.
  • Inspections – CQC, NHS other bodies.
  • SAMS – as a source for clinical standards.9
  • Feedback – staff, colleagues 360°.
  • Patient feedback – positive and complaints.

    • Improving quality takes time and Demming recognized this and this is where leadership comes in, with the need for short- and medium-term plans, eg one year and longer to achieve goals. These take the form of practice development plans and personal development plans of each person in the practice to contribute to improving what is delivered to patients. From these plans, the learning needs of the individuals and the practice can be determined (practice and personal development plans). Training can be instituted, based on these plans, either in house or through external courses. It may be that the skills are already within the practice; coaching by members of the team may be appropriate. Review of the plans needs to take place, ideally every six months, to check that actions agreed are taking place and how the results of the changes are being monitored. This could be by appraisal or by review meetings.

    Returning to Revalidation. The GDC needs to be assured that practitioners are practising to, or above, the published standards; this needs some form of review. In salaried dental services, this may follow the medical model of having a Responsible Officer, a doctor who certifies to the GMC that all the doctors employed by his/her organization meet the requirements to Revalidate. Based on Demming's principles, and putting the responsibility as close to the point of delivery of the service as possible, I would suggest that the practice owner or clinical leader should be responsible for individual practices. The registrant who needs to Revalidate would need to keep records of his/her activities in relation to quality improvement and personal development; these would benefit from annual review. The owner or clinical leader at any given site could conduct the review of dentists on that site. They could also act as the Responsible Officer making the declaration to the GDC every 5 years. Where practitioners work on their own, or in expense-sharing arrangements, they could choose another registrant, or another approved third party could act as the Responsible Officer. The GDC would need some way of assuring itself that the Responsible Officer is acting appropriately. This could be by random sampling of data of individual Returning Officers or by checking by a third party, eg FGDP, BDA or CQC, and by all Responsible Officers having undertaken approved training in the role.

    In summary, continuously trying to improve quality in a practice, through in house training and development, is good for the success of a practice, providing a stimulating working environment and could, with appropriate record-keeping, provide an effective, proportionate, fair, formative, inclusive approach to quality control, be cost-effective and hence be accredited as Revalidation.