X-RAY VISION: HOW AUDIT CAN HELP YOU REVEAL THE QUALITY OF YOUR RADIOGRAPHY ANDREW TOY BDS, MMSCI, MFGDP(UK), FGDP(UK) BOARD MEMBER, GENERAL DENTAL PRACTITIONER AND CHIEF EXECUTIVE OFFICER OF THE DENTAL BUSINESS ACADEMY AND ALSO KENNETH A EATON, DHC, PHD, MSC, BDS, FFGDP(UK), MGDS, FFPH, FHEA, FICD, FGDP(UK) BOARD MEMBER AND DENTAL TUTOR FOR KENT, CANTERBURY, UK

Introduction The clinical governance of radiography is probably the most researched and practised of all procedures in dentistry. In the UK, managing the quality of our radiographs has been a requirement for many years. The authors of this article have been involved with clinical audit since its introduction into dentistry in the mid 1990s. Between us, we have observed many, many hundreds of audits of radiograph quality over that period. Over the first few years, a large proportion of radiographs were poorly positioned, using the bisecting angle technique. The usual outcome from the audit was the purchase of a positioning device. As this aspect improved, clinical audits helped practitioners to identify that good radiographs were often unreadable months later because of poor processing and storage. Action plans now included the introduction of automatic developers and written protocols (programmes) for changing developing and fixing liquids. The increasing use of digital imaging has moved the focus to high quality written records. These records improve communication within the dental team and with patients and reduce medicolegal risk. If you had asked practitioners of the 1980s if they needed to improve the quality of their radiography, most would have responded that the quality of their radiographs was ‘just fine, thanks’ and no changes were required. Our experience of radiography audits shows that this was (and to some extent still is) patently untrue. Legislation requiring the practice to manage the quality of its radiographs has led to a steady improvement in every aspect of the process.1 There is absolutely no doubt that, with a few exceptions, today’s practitioners are taking better radiographs because of the improvements that go hand in hand with progressive auditing and a meaningful clinical governance system.

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Why aim for perfection in radiography? Achieving a consistently high standard in radiography has a host of benefits for the patient, the operator and the prescribing dentist. An aid to clinical diagnosis, screening for health or disease, measuring the success of treatment and minimising radiation dose are perhaps the most obvious. A less obvious benefit is the reduced risk of medicolegal challenge, where patient records are used as evidence to support or defend a complaint. The evidence of such records carries greater validity than a verbal statement relating to an incident that was probably several years in the past. Clearly, skilled, ethical practitioners will want to show that their care was of the highest standard and excellent radiographs could be a key part of the defence. For the dentist, a poor quality image resulting from positioning or processing errors means a retake and loss of valuable time. We also know how frustrating it is when we cannot find that small PA x-ray from the last visit. In these circumstances, the team have to work more quickly to make up for the lost time, which only adds to the pressure of the day. Additionally, lost time also reduces the financial performance of the practice. Nor should we forget the professional satisfaction gained from completing the challenging task of taking intraoral radiographs to a very high standard. Dental radiography is one of those common tasks in daily practice and can easily be taken for granted. However, it is also the part of our practice that provides almost immediate feedback of our performance. Taking great radiographs is an opportunity to give ourselves and team members an immediate sense of achievement

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– an essential component for enjoying our work. So, the simple radiograph carries great significance in our daily practice of dentistry and investing some resources to get it right will provide a great return.

Why bother with audit? Beware of cynicism or ignorance There is no doubt in our minds that the most powerful means of achieving high standards in radiography is the intelligent use of the audit process. However, what actually constitutes an audit can often be misunderstood. It is the authors’ observation that some practices believe that simply collecting grades counts as an audit of the quality of radiography at the practice. This is very far from the truth. In its simplest form, the audit process has four main components: 1 Setting a standard: ‘What should we be doing?’ 2 Observing our current practice: ‘What are we doing?’ 3 Action plan to meet the standard: ‘What do I need to do to be better at radiography?’ 4 Evaluation (re-audit): ‘How do I know I am better at it?’ Recording a lot of numbers without collating and analysing the information does not allow the practice to answer component 3: ‘What do I need to do to be better at radiography?’ Another common mistake appears at the all important grading stage. We often find that the person grading the radiograph is not qualified or is insufficiently monitored to ensure that the grades are correct and that the appropriate reason for poor quality is noted. There is also a natural tendency for practitioners to look at their results through rose-tinted glasses, giving themselves a higher grade than they

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should. On the other hand, colleagues grading each other’s radiographs are likely to provide a more objective result, an opportunity for peer review and a greater chance of improving quality. The need for clinical governance of radiographs requires little debate as it is embodied in legislation and there are clear standards and procedures to be followed. Any regulator worth its salt, such as the GDC or CQC, is likely to look at a practice’s approach to radiography audit as a key measure of how well they understand their responsibilities for clinical governance and the significance that they place on patient safety. A practice that fails to audit radiographs effectively is demonstrating a level of ignorance of or cynicism towards their professional responsibilities that could sow doubts in the minds of an inspector. These doubts may prompt an inspector to look more deeply into other aspects of the practice’s clinical governance. An opportunity for the whole practice to improve Auditing the radiography process is also a good way to introduce the principles of clinical governance to a practice team. Radiography can involve all members of the team either in the prescribing, positioning, processing or storing of radiographs, so it is easy to demonstrate the interrelated steps and every team member’s responsibility to create a great result. The standards in

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X-RAY VISION: HOW AUDIT CAN HELP YOU REVEAL THE QUALITY OF YOUR RADIOGRAPHY

TA B L E 1

QUALITY STANDARDS FOR BITEWING RADIOGRAPHY* radiography are very clearly defined and therefore provide an excellent professional development guide for the dental team.2 The descriptive nature of the standards give students of radiography a clear target to aim for and a means of specific, unambiguous feedback. Already taking great radiographs? What happens when practices are already performing well in audits of positioning and processing of radiographs? The practice may wish to use a very light touch audit programme, which means that they audit a sample of, say, 20 radiographs per operator every six months – enough to satisfy the legislative requirements and provide proof that standards are being met. However, not every practice will want to rest on its laurels. Clinical governance embodies the principle of continuous improvement, and audit (with its inbuilt action plan and evaluation components) is the change management tool that will translate this principle into action. A high performing practice could focus attention on record-keeping, for instance. Are there good written records showing the justification for and reporting on all radiographs? Although the practitioner may not feel these records are essential for the immediate care of the patient, they are putting themselves at professional risk in the event of a complaint or investigation months or years later. Practices involved in complex, expensive or cosmetic dentistry are particularly vulnerable as the risk of litigation continues to rise. Practice owners who make a commitment to continuous improvement in radiography, even when the target has been achieved, are making an important statement to the whole team that high standards are expected throughout the business. In the authors’ experience, it is this sort of quality focused culture that will lead to fewer mistakes, minimise wasted

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A

Evidence of optimal image geometry

•

There should be no evidence of bending of the image of the teeth

•

There should be no foreshortening or elongation of the teeth

•

Ideally, there should be no horizontal overlap. If overlap is present, it should not obscure more than one half the enamel thickness. This may be unavoidable due to anatomical factors (ie. overcrowding, shape of dental arch) requiring an additional bitewing or a periapical radiograph

B

Correct anatomical coverage

•

The film should cover the distal surfaces of the canine teeth and the mesial surfaces of the most posterior erupted teeth

•

The periodontal bone level should be visible and equally imaged in the maxilla/mandible, confirming ideal centring

C Good density and contrast •

There should be good density and adequate contrast between the enamel and the dentine

D Adequate number of films •

When the third molars are erupted or partially erupted and impacted and all the other teeth are present, two films may be needed on each side to evaluate the dentition

•

Extreme curvature of the arch may impact on the number of films required

E

Adequate processing and darkroom techniques

•

No pressure marks on film, no emulsion scratches

•

No roller marks (automatic processing only)

•

No evidence of film fog

•

No chemical streaks/splashes/contamination

•

No evidence of inadequate fixation/washing

F

Other

•

If the patient clinically exhibits periodontal bone loss of >6mm, two vertically positioned films (ie. with the narrower length positioned parallel to the floor of the mouth) are required to enable the bone of the periodontium to be imaged

•

Access to previous radiographs may reveal the need for vertical bitewings

*Source: European Guidelines on Radiation Protection in Dental Radiology 2004 (Table 5.3; p. 57)2

resources, reduce risk and, ultimately, lead to greater profit.

Conducting a radiography audit Setting a standard, target and exceptions Having identified the reason for conducting an audit (ie. you have identified a problem, you need to meet

your statutory obligations or you want to take your practice to a higher level), the next stage is to decide what standard you would like to achieve, along with a target and exceptions. The standard may be described in terms of an outcome, process or structure:

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TA B L E 2

QUALITY STANDARDS FOR PERIAPICAL RADIOGRAPHY* A

Evidence of optimal image geometry

•

There should be no evidence of bending of the teeth and the periapical region of interest on the image

•

There should be no foreshortening or elongation of the teeth

•

Ideally, there should be no horizontal overlap. If overlap is present, it must not obscure pulp/root canals

B

Correct anatomical coverage

•

The film should demonstrate all the tooth/teeth of interest (ie. crown and root[s])

•

There should be 2-3mm of periapical bone visible to enable an assessment of apical anatomy

C Good density and contrast •

There should be good density and adequate contrast between the enamel and the dentine

D Adequate number of films •

In endodontic treatment, it may be necessary to separate superimposed root canals using two radiographs at different horizontal angles. Obtain one ‘normal’ film and one with a 20° oblique horizontal beam angle for all molars and maxillary first premolars

•

Assessment of some horizontally impacted mandibular third molars may require two films to image the apex. Obtain one ‘normal’ film and one with a more posterior 20° oblique horizontal beam angle

E

Adequate processing and darkroom techniques

•

No pressure marks on film, no emulsion scratches

•

No roller marks (automatic processing only)

•

No evidence of film fog

•

No chemical streaks/splashes/contamination

•

No evidence of inadequate fixation/washing

*Source: European Guidelines on Radiation Protection in Dental Radiology 2004 (Table 5.4; p. 58)2

• Outcome means the ‘end result’ that you are looking for • Process relates to ‘how’ you expect to the patient to be cared for • Structure relates to the equipment or physical facilities Ideally, setting standards is a team effort. This helps to ensure that the whole team ‘buy in’ to the changes that may be necessary. A preliminary discussion between team members responsible for these activities also makes everyone aware of the standards that the practice owners wish to achieve. This is often the most important aspect of any audit and can spontaneously lead to improvements in practice (which is usually the point of an audit!). Many aspects of radiography ‘best practice’ have already been established

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and can be found in resources such as: • NRPB Guidance Notes for Dental Practitioners on the Safe Use of X-Ray Equipment (2001)3 • European Guidelines on Radiation Protection in Dental Radiology (2004)2 • The Health Protection Agency’s Guidance Notes for Dental Practitioners on the Safe Use of Dental Cone-Beam CT (Computed Tomography) Equipment (2010)4 • The British Dental Association’s Radiation in Dentistry (1997)5 • The FGDP(UK)’s Selection Criteria for Dental Radiography (2004) The NRPB has suggested the grading of radiographs from 1, ‘excellent’, to 3, ‘unacceptable’.3 To reduce the element of subjectivity in grading, the European Commission has defined more clearly exactly what constitutes various

levels of quality in the positioning and processing of bitewing, periapical, panoramic and cephalometric radiographs (see Table 1 and 2).2 These detailed descriptors are excellent training tools for helping the team really understand exactly what they are aiming for to achieve a high quality radiography service. Setting the target and exceptions for reaching the standard is the next aspect to consider. One hundred per cent success in all aspects of dental radiography is ideal but highly unlikely. A lower target that will still provide a high standard of image while minimising radiation exposure is more realistic. The NRPB already has a recommended target for radiographs of more than 70% grade 1 and less than 10% grade 3. This makes allowances for those difficult patients who gag, have missing teeth and so on. However, when it comes to equipment servicing, you may feel it reasonable to expect that 100% of your machines are serviced correctly. When setting a standard, target and exceptions, it is important to make a reasonable judgment; otherwise, the team will not respect the audit process and are less likely to make the improvements that you are looking for. (See Table 3 for an example of standards, targets and exceptions in radiography audit.)

Collecting data Prospective or retrospective data? Most audits in dentistry are of outcome or process. Information needed to compare performance with standards either can be drawn from clinical records of patients seen in the past (an audit of retrospective data), or can be collected from patients from a date in the future (an audit of prospective data). Using retrospective data relies on good record-keeping in the period that you are auditing. You should also ensure that the records relate to a

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X-RAY VISION: HOW AUDIT CAN HELP YOU REVEAL THE QUALITY OF YOUR RADIOGRAPHY

TA B L E 3

EXAMPLES OF STANDARDS, TARGETS AND EXCEPTIONS FOR RADIOGRAPHY AUDITS OF OUTCOME, PROCESS AND STRUCTURE Outcome

Process

Structure

Standard

Grade 1: no errors of patient preparation, exposure, positioning, processing or film handling

Justification, grading and reporting should be noted in the computerised records on the day of the patient’s visit

X-ray machines are all serviced according to manufacturer’s instructions

Target

>70% grade 1

>95% of records have all

100%