Outcomes-based practice

by David W. Chambers, EdM, MBA, PhD

Reacting and adjusting instead of improving a practice.

With Level 0 and Level 1 Learning, dentists react to the system's imperfections or conform to its ineffectiveness, rather than striving toward continuous practice improvement.

The outcomes that drive improvements in dental practice are based on a simultaneous awareness of practice goals, practice experience, and practice assessment. The level of learning resulting from outcomes depends on the responses practitioners make. In this article, we will look at two low-grade responses that fail to integrate Goals, Experience, Assessment, and Responses (GEAR).

The first kind of learning - and unfortunately the most common - is called Level 0 Learning. It is simple: Response = Reaction.

Figure 1 depicts Level 0 Learning in the GEAR cycle. It is a back-and-forth struggle between experiences and responses. For example: There isn't enough money at the end of the month, so you raise the fees. Patients complain, so you lower the fees in selective cases. The front-desk person forgot to mention your new whitening program, so you yell at him or her. You have a nagging feeling that you are not doing as well as your colleagues, so you hire a consultant. Your stock is not doing well, so you sell it. In each case, the response is an attempt to correct an unpleasant or unexpected experience.

In the reactive mode, goals and assessment are barely present. The whole program is to reduce surprise and unpleasantness. Raising the overall level of the practice is a dream in the background. Assessment is accidental. There is no plan for collecting data - it forces itself on you in an irregular and biased fashion. Urgency is the order of the day; you will get to the important things as soon as you clear out these crises.

The result of this two-cycle approach to learning is sporadic and superficial change. In fact, there is seldom any meaningful or consistent change using this method. Because Level 0 Learning is ego-driven and designed to make the world conform to what is pleasant and expected, reactive change normally has the effect of simply maintaining the status quo.

The shortcomings of Level 0 Learning include:

• Superficial change - reactions that maintain the status quo.
• Reactivity - events control the dentist rather than the opposite.
• A mistaken view of "discomfort" - the unusual and uncomfortable are really signals that learning has taken place; they are not something to be avoided.

Level 0 Learning is the activity nonlearners engage in to prove that they are in charge without actually having to change anything.

The second most common kind of learning is at Level 1. This is learning where performance is enhanced by driving out inefficiencies in the system. In health-care fields, Level 1 Learning is often known as quality assurance.

The schematic representation of Level 1 Learning is shown in Figure 2. All four components of the GEAR cycle are present and are used to improve performance. A goal is set and articulated, and an assessment system is put in place to monitor the goal in a consistent fashion. Examples include:

• "All charts will be complete, including signatures and progress notes, and a staff member will be assigned to review charts to ensure conformance."
• "Visual inspection will be used to ensure that the margins on all restorations are fully intact."
• "The acceptance rate on treatment presentations will be at least 80 percent as verified by a monthly audit."

In Level 1 Learning, two responses are employed. The first response is to reject examples of work that do not meet goals when assessed. Un friendly, incompetent, slow-to-learn staff members are let go. Insurance companies deny payment on incomplete forms. Overall level of quality can be improved in many cases simply by not counting the duds.

The second form of improvement in Level 1 Learning is to rework the defectives. The incomplete charts are brought up to standard. The less-than-acceptable restoration is redone. Making things right is part of professional behavior and a useful way to improve quality on average.

The responses of reject and rework improve practice by focusing on individual results. They demonstrate integrity, but not much intelligence. Assume that an office has a 5 percent defective rate on insurance reimbursement or chart completion. Adding staff hours to correct this 5 percent rate of error is one alternative, but you can bet your cuspidor that the only result will be a 5 percent increase in overhead and a perpetual 5 percent error rate that still must be corrected. Any practice that brags about its quality-assurance program has institutionalized its inefficiency. This is the great failure of using regulation and quality assurance in an effort to improve health care. It is much easier to demonstrate the rise in cost of these programs than the rise in benefits.

The second problem in Level 1 Learning is more subtle; it has to do with the fact that this approach is based on efficiency. While there is nothing wrong with wanting to be more efficient, this is only part of the solution to continuous practice improvement. If an office is grossly inefficient, systematization through quality assurance will be helpful - but only to the extent that the office was inefficient in the first place.

Driving for efficiency assumes that the system is closed - all of the factors that matter are in the office and potentially under the dentist's control. Acting as though this were the case makes a practice insensitive to changes in the world surrounding the office. (The best gold-foil technique isn't very impressive anymore.)

Every system has a built-in level of error. There is a randomness inherent in all systems. Any attempt to reduce the baseline randomness is a waste of time and a frustration for the dentist and, most certainly, for the staff. Once the efficiency equilibrium has been reached, no improvement is possible without changing the system. For example, if marginal integrity has been stabilized at roughly one problem for every 200 patients and returned claims are approximately one in every 50, further assessment and adjustment will never improve it. What about finding that the case-acceptance rate is 75 percent when you want 80 percent? Improvements by rejection or rework are not possible. The 25 percent level of unaccepted plans is inherent in the system, and the only permanent solution is to change the system (the next highest level of learning).

There are two kinds of practice-management consultants or institutes. One aims for fundamental change in the dental practice. This is a one-time alteration, usually bringing in a standard model that somebody believes is best for most dentists. This promotes changes in office effectiveness. The more common style of practice-management consultation aims to improve efficiency. Offices that have built-in waste and disorganization normally are self-selected for participation. Methods are put in place that reduce those inefficiencies. The normal pattern is for fairly prompt, noticeable changes as the inefficiencies are driven to an equilibrium point for that particular office system. When equilibrium is reached, no further improvement is possible, although some variation remains. Then the dentist loses interest. This pattern of quick results, followed by a plateau, is common in all of business consulting and is a result as much of selecting inefficient practices as it is of providing insightful intervention.

What is needed is a type of practice consultation that shows dentists how they can continue to make improvements in their own practices. Outcomes-based practice is one such model.

In the next article, we will turn our attention to Level 2 Learning — continuous practice improvement under the control of the dentist, who uses outcomes (relationships among goals, experiences, and assessment) to respond by changing the system, rather than reacting to its imperfections or conforming to its ineffectiveness.