From quality assurance to continuous quality improvement: why dental hygiene needs to change--continuous quality improvement ideas from the nursing profession.

ABSTRACT

Quality assurance is an ongoing concern for self-regulated health professions to ensure that the public is receiving quality, competent health care by its members. (1,2) In British Columbia, quality assurance mechanisms for dental hygienists consist of mandatory continuing competencies credits or mandatory continuing education. (1) It has been shown in the literature, however, that mandatory continuing education does not promote behavioural changes in health professionals. (3-6) The recent trend in health care has been from quality assurance, which focuses on ensuring individual compliance with clearly established standards, to continuous quality improvement, which uses specific approaches through people to improve practices. (11) This paper examines specific continuous quality improvement activities of the nursing profession, such as professional portfolios, personal profiles, and peer reviews and discusses the applicability of these tools for the dental hygiene profession. If the philosophy of a self-regulating profession is to empower its registrants to be responsible and accountable for their practices, then continuous quality improvement is beneficial for dental hygienists, the dental hygiene profession, and the public it serves.

Keywords: Quality assurance, health care; total quality management; dental hygienists; peer review; continuous quality improvement; professional portfolios; personal profiles

RESUME

L'assurance qualite est une preoccupation constante au sein des professions de la sante auto-reglementees qui veulent s'assurer que le public recoit des soins de sante satisfaisants et de qualite de la part de leurs membres. (1,2) En Colombie-britannique, les mecanismes d'assurance qualite pour les hygienistes dentaires se composent de programmes obligatoires d'unites de competences continues ou de formation continue. (1) Cependant, il a ete demontre dans la litterature que la formation continue obligatoire ne favorise pas les modifications du comportement chez les professionnels de la sante. (3-6) La recente tendance en soins de sante est de passer de l'assurance qualite, qui vise avant tout a assurer le respect individuel des normes clairement etablies, a l'amelioration continue de la qualite, qui utilise des approches specifiques aupres des personnes pour ameliorer les pratiques. (11) Ce document analyse des activites specifiques d'amelioration continue de la qualite pour la profession infirmiere, comme les portfolios professionnels, les curriculum vitae et les inspections professionnelles; il examine egalement l'applicabilite de ces outils a la profession d'hygieniste dentaire. Si la philosophie d'une profession auto-reglementee est d'amener ses membres a etre responsables et imputables de leurs pratiques, alors l'amelioration continue de la qualite est benefique pour les hygienistes dentaires, la profession d'hygieniste dentaire et le public desservi.

INTRODUCTION

Dental hygiene in British Columbia

DENTAL HYGIENISTS IN BRITISH COLUMBIA HAVE BEEN self-regulated since March 1, 1995, under the provincial Health Professions Act and the Dental Hygienists Regulation and Bylaws. (1) Self-regulation means the government considers the profession to have sufficient expertise to govern its own registrants appropriately. (1) However, with this privilege of self-regulation comes the responsibility of ensuring public safety. Self-regulated professions protect the public by having its registrants comply with quality assurance mechanisms, which are based on the established practice standards of the profession. (1,2) Quality assurance is an ongoing concern for self-regulated health professions to ensure that the public is receiving quality, competent health care by its members. (1,2) The College of Dental Hygienists of British Columbia's (CDHBC) concern for public safety is contained in its mission statement: "The mission of the College of Dental Hygienists of British Columbia is to protect the public by developing, advocating and regulating safe and ethical dental hygiene practice in British Columbia." (1)

The quality assurance mechanism of the CDHBC consists of mandatory continuing competencies credits (1) or mandatory continuing education. To qualify for re-registration, dental hygienists are required to complete 75 hours of continuing competencies within a three-year cycle, to pass a British Columbia Dental Hygiene Practice Examination or to successfully complete a refresher course approved by the CHBC Registration Committee. (1) Nonpractising dental hygienists are not required to maintain continuing competency credits but must show evidence of completing 75 continuing competency credits when reverting to practising registration. (1)

Although CDHBC uses mandatory continuing education for quality assurance purposes, the literature shows that this type of education does not promote behavioural changes in health professionals. (3-6) Critics of mandatory continuing education argue that registrants simply attend courses to fulfill requirements and that there are usually no measurable endpoints or evaluations to determine if the new knowledge finds it way into practice. (3,6,7)

For example, a study by Bullock et al. in 1999 evaluated the effect of continuing education courses on dentists' practice. (8) Questionnaires were sent to dentists six weeks after they had attended a professional dental course or seminar to determine if there was any measurable impact on their practice. (8) It was determined that the most effective continuing education courses in dentistry were hands-on in nature and discussed common clinical topics. (8) This study, however, did not determine if the quality of dental care improved after the dentists had attended the continuing education courses. Bullock et al. also noted that large lecture-style formats tended to have the least amount of impact on dentists' practice. (8) Although this style of presentation is cost-effective and disseminates information to a large group, there is low participant involvement. (9) Passive learning does not result in behavioural changes because there is no self-reflection, identification of deficiency, or motivation to improve the identified deficiency. (9)

Although the CDHBC Registrants' Handbook states that it is the registrant's responsibility to choose specific learning activities that are relevant to his or her practice to maintain his or her competency, (1) there is no formal process for the registrant to assess his or her strengths and limitations. Quality assurance mechanisms only require confirmation that a registrant attended or performed a continuing competency activity; there is no assessment of the learning activity's outcome or its relevance to the registrant's practice. The limitations of quality assurance can be addressed, however, by the continuous quality improvement philosophy.

Quality assurance versus continuous quality improvement

There has been a shift in health care from quality assurance (QA) to continuous quality improvement (CQI), which uses specific approaches through people to improve practices that go beyond QA. (10) Table 1 highlights the key differences between QA and CQI.

The fundamental difference between QA and CQI is the focus. Quality assurance focuses on the individual and his or her performance; CQI focuses on the system or process of providing health care. (11) It is "a common myth that most quality problems can be blamed on individuals. Over 80% of quality problems are related to system problems, such as inefficiencies in work flow, information breakdowns, poorly designed or inefficient work processes, inadequate resources or a combination of these factors." (10) Only a small minority of health care providers are incompetent. (10) Therefore, a CQI approach aimed at enhancing systems through people seems reasonable for improving health care quality. (10)

This paper explores the nursing profession for CQI tools that can be used by dental hygienists. The nursing profession is similar to the dental hygiene profession in that both professions are self-regulating, (1,2) are predominately female, (12,13) and work in collaboration with other health professions in providing care to the public. Although nurses tend to work in large, government-run organizations (13) while dental hygienists tend to work in small, private sector businesses, (14) the CQI tools used by nurses can also be used by dental hygienists. Nurses use such tools as the professional portfolio, personal profile, and peer review. (2) The definition, purpose, benefits, and limitations of these mechanisms are examined, followed by a discussion about the need for change in dental hygiene.

CONTINUOUS QUALITY IMPROVEMENT TOOLS

Professional portfolios

Definition

A professional portfolio is a written account of an individual's process of learning and the outcomes of that learning. Brown defines the professional portfolio as follows: (15)

    A [professional portfolio] is a private collection of evidence which
  demonstrates the continuing acquisition of skills, knowledge,
  attitudes, understanding, and achievements. It is both retrospective
  and prospective, as well as reflecting the current stage of
  development and activity of the individual.

A portfolio is not a resume or curriculum vitae. (16) A resume or curriculum vitae lists the educational institutions attended, positions held, and other personal background information about the individual. (16) Although a portfolio may contain this information, the portfolio also contains evidence-based documentation of the individual's competencies and expertise, which has developed from these experiences. (16)

Rationale for using the professional portfolio

The portfolio is based on Knowles' four adult learning principles: (17) the adult learner is assumed to (1) be self-directed; (2) have a rich resource for learning based on his or her past experiences; (3) be open to learning in response to life's tasks and problems; and (4) be curious and self-motivated to grow and achieve. (17,18) Motivation alone, however, is not sufficient for producing behavioural changes. (9)

Although an individual may be successful in retaining new knowledge or skills, he or she may not apply that knowledge or skill to his or her practice. This sentiment is shared by Broad and Newstrom who believe the knowledge and skills gained by workers (well over 80% by some estimates) are not fully applied on the job. (9,19) Caffarella further states that the learning transfer of knowledge into practice needs to be encouraged by assisting people to reflect and plan for those changes. (9) The transfer of learning is also more likely to occur when people choose activities that will satisfy individual needs or particular environments. (6,9) The professional portfolio assists in the learning transfer by engaging the learner in critical thinking and self-reflection. Box 1 contains an example of a self-reflection worksheet. (20)

Purpose

The professional portfolio provides a method for health care practitioners to monitor their progress in meeting personal and professional goals. (16,20,21) The portfolio records significant elements in the practitioner's career and is therefore useful for career planning and personal profiles.

Contents

The actual contents of a professional portfolio will vary among health care practitioners because of variations in specialties, practice settings, job responsibilities, and personal and professional goals. (16) In general, portfolios should contain materials that demonstrate the practitioner's competencies and highlight his or her achievements. O'Halloran suggests the following four categories to include in the professional portfolio: (22)

1. Education: In this category, health care practitioners would include their resume or curriculum vitae, formal education credentials, licence or registration number, specialty certifications and titles, and any organizational awards received.

2. Performance: Job position descriptions, performance appraisals, reference letters, recommendations, and other evidence of meeting or exceeding job performance standards would be included in this category.

3. Community service and professional activities: In this section, membership in professional associations or organizations, involvement with committee work or professional boards, and volunteer services would be recorded.

4. Continuing education: Documentation of programs attended, professional journals read, and other learning activities are included in this category. The outcomes of the learning activities and their impact on the health care practitioner's practice are of special interest in this section. For the purposes of CQI, this section of the professional portfolio is the most important. Learning activities should be relevant to the practitioner's practice and should have an impact on the provision of care being provided to the clients. (20) A clear relationship between the learning activities and the claimed competencies needs to be established to provide evidence of the health care practitioner's knowledge and expertise. (16) An example of a professional portfolio entry is found in Box 2. (20)

Benefits

The professional portfolio provides the health care practitioner with many benefits, such as guiding the practitioner through the processes of critical thinking and self-reflection. (23) The reflective process of the portfolio encourages the health care practitioner to identify weak areas in his or her knowledge and skills; it also documents his or her strengths. (23,24) The professional portfolio encourages lifelong learning and professional development by emphasizing the importance of monitoring one's own learning needs. Portfolios are also beneficial to the profession because practitioners who are accountable and responsible for their own learning are the driving force behind professions that are seeking to grow through accountability, responsibility, and autonomy. (20,23)

Portfolios are also useful for supporting a health care practitioners' claims of competency. (20) Competency refers to the necessary knowledge and skills health care practitioners must have to perform a specific activity safely and according to the profession's Practice Standards. (1,2) To obtain the necessary knowledge or skills or both, health care practitioners may participate in workshops or other educational programs. This information is then documented in their portfolios as evidence in support of their claims of competency. In this regard, the portfolio is useful for professionals who are preparing for job interviews, annual job performance appraisals, job promotions, and career planning. (20)

The portfolio is a valuable tool for nurses applying to universities or colleges for post-RN formal education because these institutions' admission committees may grant credits for a nurse's prior learning and work experiences based on the information provided by the professional portfolio. (20) For dental hygienists seeking post-diploma education, the University of British Columbia will consider prior learning experiences for admission into the Bachelor of Dental Science in Dental Hygiene Program. (25) Although it is advantageous for applicants to know and offer relevant information in an interview, it can be difficult for some applicants to remember important information when they are under stress. A professional portfolio can assist the applicant by providing the interviewers with relevant, evidence-based information about the applicant's professional life.

Limitations

There are potential limitations associated with professional portfolios. One is that new practitioners may lack confidence when using a portfolio for the first time. (23,26) Scholes et al. in 2004 suggest that practitioners be given clear guidelines, a template with examples, support from more experienced practitioners, and feedback from the assessor to alleviate the practitioners' concerns. (26) Scholes et al. also state that the depth of reflection in the portfolio will change according to the stage in the health practitioner's professional career. (26) New practitioners should therefore think of their professional portfolios as works of art in progress.

Second, there is the limitation imposed by subjectivity. A portfolio may not represent a true picture of a practitioner's practice. (23) There is the possibility that practitioners believe that they are competent to do a task when they are not. (24) Practitioners may also believe they are competent because of the perception of others, but this is not sufficient evidence of competency. (24) True self-assessment is less likely to occur in those who are inexperienced because they are often unaware that they do not know. (27) The College of Registered Nurses and Nurse Practitioners of British Columbia (CRNBC) recognizes that portfolios are subjective and encourages registrants to seek peer feedback as a means of clarifying their limitations and identifying specific goals. (2)

Third, the use of a portfolio for assessing learning and competence is controversial because its reliability and validity are often difficult to measure objectively. (23,27) A measurement is said to be valid if it measures what it claims to measure and is reliable when the measurement is consistent. (28) But since portfolios are subjective and highly individualized, it is difficult to devise evaluation criteria that are valid and reliable. (28,29) Attempts have been made, however, to devise grading criteria for assessing portfolios in nursing education. (28) For example, Jasper in 1995 devised 10 criteria for grading a portfolio. (30) Each criterion was given a score from 0 to 10, ranging from "no or little evidence" to "evidence" of the criterion "being met in all its aspects." (30) These scores, however, were essentially subjective and their validity and reliability could only be judged if operational definitions of "little, etc." were provided. (28)

In another example, Hull and Redfern in 1996 used the following criteria for assessing portfolios for accreditation of prior or experiential learning for university credits: (31)

1. Depth and breadth: Are the learning activities isolated or do they encompass many different aspects of practice?

2. Authenticity: Can the person do or has done what is claimed?

3. Quality: Was the learning activity at the appropriate level to be considered for program exemption?

4. Currency: Does the person show evidence of keeping up-to-date with recent developments?

5. Acceptability: Does the evidence in the portfolio support the learning that is being claimed?

6. Sufficiency: Is there enough evidence to show sufficient proof of confidence?

Although these criteria give the assessors guidelines for assessing a portfolio, the assessment continues to be plagued by subjectivity. Webb et al. in 2003 explored the possibility of monitoring the rigour of student portfolio use on two levels, using a qualitative approach. (28) On the student level, they found that tripartite meetings between student, personal teacher, and mentor were effective. (28) In the meetings, students had an opportunity to demonstrate their communication, reflective, and analytical skills while discussing the contents of their portfolio. The mentor had an opportunity to provide the student with feedback and guidance on future learning needs, and the teacher could verify that the events took place. (28) In this situation, the assessors were able to gain more information about the student than what the portfolio alone provided. (28) This additional information was useful when the portfolio was graded. (28) On the overall monitoring level, Webb et al. suggested two calibrated examiners using detailed, objective criteria to grade the portfolios and audit trails, which are records of transactions that occurred, such that another person is able to reconstruct and examine the sequence of events. (28,32)

In spite of the controversies surrounding the validity and reliability of portfolios for assessing learning and competency, one must keep in mind the purpose of the portfolio. According to Jasper, the portfolio is a process, not an end product. It merely supplies the documents of the process rather than any measure of quality. (30) Snadden in 1999 continues by questioning whether we are trying to "measure the unmeasurable" and concludes by stating that "a mental shift is needed" to find a more holistic approach to assessment when dealing with portfolios. (33) According to Webb et al., this suggests that assessments of clinical skills and performance in practice settings should be assessed separately from the reflective aspects of the portfolio. (28) For professional regulatory bodies, a clear distinction will have to be made as to what is important in the vision and mission of that particular College. Is it QA or CQI? If it is QA, professional portfolios will not provide valid and reliable measures of a registrant's competency in clinical skills and performance in the practice setting. If it is CQI, then portfolios provide an important self-assessment component in the lifelong learning process and professional development of the registrant. According to the Health Regulatory Organizations of British Columbia, "quality care is more likely when quality improvement and control are emphasized over quality measurement." (10)

A fourth potential limitation is that practitioners may censor entries in the portfolio if there is lack of confidentiality. In a punitive environment, registrants may be afraid that the contents of a portfolio could be used against them during inquiry or disciplinary action. (23) According to a 2005 article by Asadoorian and Locker about dental hygienists in Ontario who use the professional portfolio system, only 11.6% of the respondents selected learning activities to "address a professional weakness." (6) Most of the respondents chose learning activities based on "personal interest" and "convenience." (6) Although Asadoorian and Locker speculate that the respondents chose learning activities with which they were comfortable, there is also the possibility that the respondents were afraid to identify any true professional weakness. In Ontario, dental hygienists are required to submit their entire portfolio for auditing purposes. (34) Although it is important for regulatory bodies to enforce the use of professional portfolios (if this is one of their registration requirements) by randomly auditing its registrants to check for compliance, (2,24) it is equally important that regulatory bodies establish confidentiality guidelines and a supportive environment to gain registrants' trust. The College of Dental Hygienists of Ontario (CDHO) has attempted to protect the registrants' confidentiality by having a firewall between the quality assurance and inquiry departments, but this does not appear to be enough to gain the registrants' trust. (34)

A better way for regulatory bodies to protect the public and encourage honest self-appraisals and pro-active, relevant learning of its registrants is to require the submission of a personal profile. This idea was taken from CRNBC, which uses the personal profile for auditing its registrants to assess the quality of their practices. (2)

Personal profiles

Definition

According to Brown, a profile differs from a portfolio in that it is a collection of evidence selected by the owner from his or her portfolio for a particular purpose and audience. (15) A profile is a "snapshot" of what a health care practitioner has accomplished and his or her present situation. (20) A profile is a public document; a portfolio is not. (20)

Purpose

Personal profiles are useful in situations where information is needed about the competencies and expertise of a practitioner and this information will be viewed by others. (16) For example, if a nurse was applying for a job promotion or job interview, he or she could select documentation from the portfolio to put into the personal profile, which would demonstrate his or her competencies and expertise for that job. (16) Personal profiles are especially useful for auditing purposes by regulatory bodies. For example, the CRNBC respects the confidentiality of its registrants by requesting registrants to submit a practice review, (2) which is a profile of the registrants' learning activities.

Benefits

The key benefit of the personal profile is that it maintains the privacy of the professional portfolio. (16,20) Any limitations or deficiencies identified by the practitioner of the portfolio are never publicized. Therefore the practitioner does not have to fear retribution from the professional regulatory body, his or her employers, or feel embarrassed among his or her colleagues. The profile liberates the practitioner to do honest self-appraisals and contributes to a safe and supportive learning environment.

The other benefit of the profile is that a practitioner can select the best and most appropriate information from the portfolio to show to others. (16,20) It is a great marketing tool for the health care professional as it provides the evidence needed to corroborate his or her claims of competency and expertise. (16,20)

Limitations

The only limitation of personal profiles is that new or inexperienced nurses may not have as much information or the same type of experience as more experienced nurses. However, the target audience generally takes this into consideration when viewing their profiles.

As with any self-assessment tool, the personal profile is only as effective as the person using it. (9) To obtain optimum benefits from the professional portfolio and the personal profile, the health care practitioner must be honest in his or her self-reflection process. Yet, as described earlier, some practitioners may be unaware of their weak areas. (24) Peer review is a valuable tool for helping practitioners to identify their strengths and weaknesses and is a necessary component of the professional portfolio. (2)

Peer review

Definition

"Peer review is a process for checking the work performed by one's equals (peers) to ensure it meets specific criteria." (35) A peer is defined as someone who is similar to you in terms of education, experience, and occupational status. (36) As peers are acquainted with the requirements and demands of particular positions, they are able to quickly identify each other's errors, speeding up the time it takes for mistakes to be identified and corrected. (35,36)

Purpose

Peer review may be a formal or informal process, depending on its purpose. Organizations use formal peer reviews for job performance appraisals. (36) A formal peer review is a written evaluation that follows the established guidelines and criteria of an organization to assess the health professional's standard of care. (36)

In contrast, informal peer reviews are discussions between colleagues on a specific subject to gain additional insight into one's practice. (2,36) The willingness of the participants to be open and frank in their discussion results in an enriching learning experience for both parties. (37,38) Since the informal peer review is more applicable to dental hygienists as a learning tool, it will be discussed in further detail.

Benefits of informal peer review

Peer review is a valuable component of the professional portfolio because it enhances the self-reflective process by providing different perspectives of the learning experience. (2)

In Europe, peer review is widely accepted as a suitable method for quality improvement in medical practice. (39,40) Studies have shown that health care practitioners experienced changes in their performance by being involved in peer reviews with colleagues. (37,40,41) Although there were reservations and fears initially, these were quickly dispelled and the health care practitioners embraced the peer review method. (37,41)

In dental hygiene, peer review can occur in study clubs. Although most dental hygienists work in private dental practice and are frequently the only dental hygienist in the office, (14) they can voluntarily join a study club. Study clubs consist of a minimum of five dental hygienists who come together for clinical or non-clinical educational study for the purpose of maintaining or increasing their competence. (1) Peer review is possible in a study club because there is often an opportunity to share experiences with one or two members of the group on an informal basis. Only another dental hygienist can understand what a dental hygienist is experiencing; this understanding facilitates a genuine rapport between the dental hygienists. Since the study club provides a safe, supportive environment, it facilitates open communication and enhances personal growth for each member of the group. CDHBC believes that study clubs are valuable venues for continuing dental hygiene competence and professional development. (1)

Limitations of peer review

Occasionally, peers may deliberately give generous assessments in anticipation of receiving reciprocal treatment (24) or give harsher reviews than management. (42) The reluctance to provide honest feedback is a critical problem in peer review. (36) Honest feedback is more likely to occur when there are established standards for quality of care. Peers are encouraged to use their professional practice standards to assess a colleague's job performance rather than their own personal standards or feelings. (36)

The professional portfolio, personal profile, and peer review are effective CQI tools that dental hygienists can use to improve the quality of their practices. CQI is effective for encouraging professional growth and higher standards of care, but does this mean that it is necessary for dental hygiene to adopt CQI?

QA TO CQI: WHY IS CHANGE NECESSARY?

The ability to change and adapt is key to growth. Dental hygiene is a growing profession; (43) maintaining the status quo, such as the passive quality assurance system, places the profession at risk for stagnation. (44) Although change is uncomfortable, it is both possible and necessary. Health care is rapidly changing and so must the provision of health care. (6,44) Not only are there rapid advances in science and technology, consumers learn about and are demanding these innovative health care services. Dental hygienists have a responsibility to meet this need by continuing to learn and improve their practices to provide the best possible care to clients. (1) Under the current QA philosophy, dental hygienists could maintain competency (and their right to registration) simply by attending courses. (1) Yet this philosophy does not necessarily improve the practitioner's practice. Dental hygiene needs to shift from QA to CQI to meet the health care demands of the public it serves. CQI is effective in improving dental hygiene practice because it empowers and supports health care practitioners to make wise choices about their learning activities, selecting activities that will have the greatest impact on their professional practice and careers. Dental hygienists have individual characteristics, experiences, attitudes, and values that will influence their learning choices as well as the impact those learning choices will have on their practices. (9) CQI allows dental hygienists to select their personal path to improvement; QA dictates what must be done to meet the requirements of the regulatory body. (11) By empowering and supporting dental hygienists, the CQI philosophy allows the dental hygiene profession to grow through its most valuable asset, its people.

CONCLUSION

To meet the growing needs of the public and the dental hygiene profession, dental hygienists must change their current passive role in quality assurance to the more accountable and responsible role in continuous quality improvement. Continuous quality improvement tools such as professional portfolios, personal profiles, and peer reviews are useful for dental hygienists who want to improve their dental hygiene practice. The CQI philosophy mirrors the goal of self-regulating professions by empowering its members to be responsible and accountable for their professional careers. Not only will this protect the public today, it will enhance the quality of health care for the future.

  If you want one year of prosperity, grow grain.
  If you want ten years of prosperity, grow trees.
  If you want one hundred years of prosperity, grow people. (45)
  --Ancient Chinese Proverb

The author would like to thank Dr. Maura MacPhee, Professor with the School of Nursing, University of British Columbia, for her assistance with manuscript.

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by Pauline Imai, CDA, Dip DH, RDH, BDSc, MSc student, Faculty of Dentistry, University of British Columbia

Box 1. Self-reflection worksheet (20)

Imagine that you are applying for a new job. In the interview, the prospective employer asks you, "Why are you the best person for this job?" To answer this question confidently, you need to know your strengths as well as your weaknesses.

Summarize your          Summarize your
strengths               weaknesses

Knowledge for practice  Knowledge for practice
Practice skills         Practice skills
Personal qualities      Personal qualities
Values                  Values
Other                   Other

What do you do well? I have excellent clinical, communication, and organizational skills. In your opinion, what do you need to do to improve your weak areas to make you a better candidate for the job? I need to improve the success rate of my inferior alveolar blocks and will be attending a hands-on workshop to achieve this.

Box 2. An example of a professional portfolio entry (20)

Workplace

Where were you working when the learning activity took place?

Name of organization: Dr. Smith, private dental practice

Brief description of your work/role: clinical dental hygienist

Nature of my learning activity

Date: January 7, 2006

Briefly describe the learning activity; for example, attending a course: Attended a hands-on workshop for local anesthetic techniques

State how many hours this took: 6

Description of the learning activity

For example, why did you do choose this learning activity? When and where did you do the learning activity? What type of learning activity was it? What did you expected to gain from it?

I was only 50% successful with the mandibular inferior alveolar block. Therefore, I attended a hands-on workshop at the UBC dental clinic for local anesthetic techniques. The instructors demonstrated the landmarks, penetration site, and depth and angle of penetration. I then had the opportunity to try the block on a colleague under the supervision of an instructor.

I hoped to learn why I have been unsuccessful and how to correct my technique.

Outcome of the learning activity

Give a personal view of how the learning informed and influenced your work.

What effect has this learning had on the way you work or intend to work in the future? Do you have any plans or ideas for follow-up learning?

I know what I was doing wrong and how to correct it. I'm more confident when I see patients who require local anesthetic in the mandible and am able to successfully anesthetize them. I will no longer hesitate to take hands-on workshops because I know it will be beneficial to me in a practical sense. I also realize that I am not the only one who has problems with administering local anesthetic and I don't have to feel ashamed. I also realize that avoiding or denying a weakness hampers my ability to provide quality dental hygiene care for my clients.

The way in which this learning activity has influenced my work is by ...

I can successfully anesthetize clients and provide better dental hygiene care for these clients than in the past.

Table 1. Key differences between quality assurance and continuous
quality improvement (CQI) (11)

                Quality assurance (QA)

Definition      The establishment of practice standards by a regulatory
                body, by which the professional services provided by the
                health care professional are assessed and corrected, if
                the services do not meet the established standards.
Focus           The individual health care professional's performance,
                i.e., what does the professional do or not do? What
                mistakes did he or she make?
Purpose         To correct the outliers or "the bad apples."
Outcomes        Punitive actions against the "deficient" health care
                professionals.
Impact on       The individual must follow the by-laws and regulations
the individual  set out by the regulatory body. Whether one chooses
health care     appropriate learning activities to enhance one's
practitioner    practice is not as important as fulfilling the
                requirements of the regulatory body.

                Continuous quality improvement (CQI)

Definition      "A structured system for creating organization-wide
                participation in planning and implementing a
                continuous improvement process to meet and exceed the
                consumers' needs." (11)
Focus           The performance of the system or process, i.e., how can
                one make the system or process better to meet or exceed
                the consumers' needs?
Purpose         To use the expertise of the health care professionals,
                who are the experts in the practice setting, to identify
                systems that work or don't work.
Outcomes        Acknowledgment of the health care professional as the
                organization's best asset for improving the process of
                delivering health care and encouragement of professional
                growth.
Impact on       Health care practitioners are encouraged to think
the individual  critically and analytically to improve their practice.
health care     Only they are aware of their weak areas and are
practitioner    therefore the best ones to decide on a realistic action
                plan to improve these areas. It is more important to
                choose learning activities that are relevant rather
                than fulfilling an arbitrary number of activities.