Quality management in dental care: patients' perspectives on communication. a qualitative study.

BACKGROUND AND AIM: Dental care usually faces the traditional doctor-patient relationship, according to which the doctor does not seek feedback and patients feel uncomfortable when being involved in the healthcare process. The current study aims at analyzing patients' attitudes and knowledge about dental care and asses the level of communication between them and their dentists.
METHODS: A series of telephone interviews (N=40) were applied to patients in the city of Cluj-Napoca in order to identify attitudes and knowledge about dental care. The interview guide was applied separately to each respondent and each interview was audio recorded with the verbal consent of the respondent. The data collected was assessed and we performed thematic analysis on the provided answers.
RESULTS: When asked about the dentist's attitude during the consultation, the respondents reported only positive attitudes. The majority of the respondents stated that the communication with their dentist was an efficient and professional one, focused on their dental problems. When asked if they understood the verbal and written information received from the dentist, the majority of respondents said they understood the information without any problems.
CONCLUSION: Identifying the patients' health literacy about dental services leads to better communication between dentist and patient, which is essential for establishing a quality management system in dentistry. Effective communication leads to a high level of patient involvement.

Introduction

Quality management aims at continuously improving health services through quality planning, quality control, quality assurance and quality increase [1]. To this aim, available resources must be considered and used effectively, focusing on the patients’ needs [2].

Dental Care usually faces the traditional doctor-patient relationship, according to which the doctor does not seek feedback and patients feel uncomfortable when being involved in the healthcare process [3].

A more balanced relationship between patients and doctors described in terms of information, usually leads to improved dental care services, therefore, better quality management [4].

For the benefit of both parties, patients and dentists, a well-defined structure of management has been proposed, according to which the medical staff needs to focus on details, to show concern for the patients’ problems, to develop a regular dialogue and to assist the patients’ needs [5]. Recommendations to increase patient satisfaction include the acquisition of communication skills, maintaining hygiene standards, providing quality services. For the implementation of the quality system, the focus is on meeting the needs and expectations of patients, a close relationship between doctors and patients, achieving standards and continuous improvement system [6].

Proper communication with the patient involves the following [7]:

The dentist must communicate effectively with patients - need to listen, give them enough time to process information and make decisions

The dentist should recognize and promote the patients’ rights and responsibilities to make decisions with respect to their health and care priorities

The dentist should provide patients the information they need in a way they can understand so they can make informed decisions

The dentist should provide patients with clear information regardless of the costs of services.

Recommendations to increase patient satisfaction include mainly the acquisition of communication skills. Communication skills are essential in maintaining a state of contentment and satisfaction with the services offered to patients [8]. Patient information is a prerequisite to maintain quality in dentistry, placed alongside professional competence in the category of the most important variables in choosing a dentist.

Investigations performed on quality care revealed continuous connections between the quality of care and patient satisfaction, highlighting the concepts of quality, information, involvement, process and communication as being crucial for customer appreciation. In an attempt to measure patient satisfaction, causal relationships have been identified between quality of services provided by medical personnel and dependability, empathy, courtesy and professionalism. Besides the attributes mentioned above, access and availability to resources were also identified as critical factors in measuring quality [9]. Further studies focused on customer satisfaction about dental office emphasized the persistence of the dentist-patient relationship and waiting time as the most important features when evaluating dental care practices.

The aim of the current study is to analyze the patients’ attitudes and knowledge about dental care and asses the level of communication between them and their dentists from a qualitative perspective. In order to fulfill our aim, the chosen methodology involved telephonic interviews taken with residents of the city of Cluj-Napoca.

Methodology

Semi-structured interviews were conducted at a local level, in Cluj-Napoca, considered the second largest city in Romania with a population of approximately 309,136 (National Institute of Statistics 2012). The study included 40 respondents who were asked to participate in the study and answer the questions by telephone. The first three respondents were randomly chosen from the local telephone book (Yellow Pages). Following this first step, the approach was based on the snowball methodology, requesting each respondent to provide contact details of potential future participants. The interviews were applied until we reached data saturation on the topic of patients’ attitudes and knowledge about patient-dentist communication. Data saturation occurred when the interviewer did no longer receive new information. Following the 40 interviews, the principal investigator reached a point in the analysis of data that requested no need for additional sampling as similar information was provided by each respondent.

For this stage of the research we developed a semi-structured interview guide that addressed the patients’ perspectives on patient-dentist communication. Each interview was conducted based on this guide. Question were developed and coded according to major topics of interests that were identified according to literature review (Table 1). We asked our respondents to answer the questions by recalling the last visit they had had to the dentist. The interview guide was applied separately to each respondent and each interview was audio recorded with the consent of the respondent. If the respondent refused to be audio recorded, notes were taken during the interview application.

Table I

Interview guide: topics covered

Patient – dentist relationship: general description

Dentist’s attitude towards the patient

Patient – dentist communication: general description

Informed decision regarding the dental treatment

Dentist’s willingness to offer information

Patient’s degree of feeling comfortable regarding his/her communication with the dentist

Written/oral dental information

Data collected after conducting the interviews was transcribed and coded. Following the main themes in Table I, data were coded and arranged into topics which were grouped for analysis. Qualitative analysis (content analysis of the interviews) was performed in order to test the hypothesis using the NVivo 9 software.

Besides the specific questions related to the topic of patient-dentist communication, we were also interested in basic socio-demographic information: gender, marital status, family monthly income, highest level of education and occupational status.

Results

Socio-demographic characteristics of the sample

Most respondents were female (55%) and single (53%). When asked about their family monthly income, 58% stated that they earn more than 1500 RON/month (1 euro ~ 4.44 RON). The majority of the respondents registered a high level of education (high school N=15; university N=16) and 18 out of the total of 40 were employed.

Attitude

When asked about the dentst’s attitude during the consultation, the respondents reported only positive attitudes. The respondents mainly referred to their doctor as being friendly, professional and respectful. Dentists were described as being polite, cooperative and open to patients’ questions, furthermore, having a positive and understanding attitude. Moreover, respondents said that their dentist spent time explaining them the procedures they were about to apply, but also spent time in getting to know their patients. None of the respondents declared problems communicating with their dentist due to the dentist’s attitude.

Attention

All of the respondents declared they were treated with respect by their dentist. When asked if their dentist gave them individual attention, the majority of the respondents said yes. Two respondents said that it was because they were the only ones in the procedure room. Another respondent said that they did not get the dentist’s full attention because the dentist attended to other things, while they were waiting in the procedure room. Moreover, another respondent said they did not get individual attention because they had not been the dentist’s patient for a long time, and that they had only been to that particular dentist for two consultations.

Communication with the dentists

The majority of the respondents stated that the communication with their dentist was an efficient and professional one, focused on their dental problems. The respondents also said that their dentist was polite, sincere and open to discussions. Three respondents said that the dentist gave them details about the treatment, presented a full treatment plan, and the costs associated with that treatment. One respondent declared that receiving all the details about the procedure helped lower the level of anxiety and fear.

One respondent said she felt comfortable to call her dentist at any time if any problem occurs, while another respondent said that communication with his dentist was not very efficient, but they also said that this could be solved by going more often to consultations. The respondent also declared that even though they went for a specific problem, the dentist only performed a consultation and pointed the issues that should be attended.

Treatment

Dentists explained every step and procedure, as well as the methods and the potential risks. All this information helped the patients make an informed decision. One respondent also said that the dentist prepared him emotionally before the procedure, while another declared that the dentist presented the instruments that were to be used in the procedure. Another respondent said the dentist presented a comprehensive treatment option, from a financial and quality point of view, which helped at making an informed decision about the procedure. Moreover, another respondent said the dentist adjusted the language so that he would understand the procedures.

One respondent said the dentist did not explain the treatment options, and that dentists should take time to explain to their patients the steps and procedures that are to be employed. He argued that patients have no knowledge of dental procedures and dentists should always tell their patients what their dental problems are and how to resolve them. Two other respondents stated that even though the treatment options were not presented, they did not ask for more information. However, the treatment procedures were thoroughly explained.

All respondents stated their dentist paid attention to them every time. Moreover, in general, the respondents said they were comfortable to communicate with their dentist.

One respondent felt he could communicate easily about any kind of subject with his dentist because he trusted him. Another respondent said he felt comfortable communicating with his dentist because he could address him informally. The personality of the dentist was also a factor in communicating easily with the dentist.

One respondent said that even though she felt comfortable to ask questions, she did not, because she believed the dentist would not have time to explain everything. Additionally, a respondent stated that even though he felt comfortable communicating with the dentist, this communication could be improved if the dentist were younger, or if the dentist had more patience. Another respondent said she would feel more comfortable communicating with the dentist if she was not afraid of him. One respondent said he felt uncomfortable communicating with the dentist because it was his first experience with that particular dentist.

Symptoms

The respondents stated they had no problems in explaining their symptoms to their dentists. However, one respondent said this also depended on the symptoms, while another said this was because the problem was not very serious. Moreover, a respondent stated that her inability to explain her problem determined the dentist to perform additional radiographs in order to determine what the problem was.

Verbal and written information

When asked if they understood the verbal and written information received from the dentist, the respondents said they understood the information without any problems. Some respondents said they understood the verbal information and there was no need for written information, while others said his dentist explained everything verbally, after which he wrote it down. One respondent stated that even though it is easy to understand the information, it would be helpful if the dentist did not use many specialized terms. Another respondent declared that he understands fairly well the information if the dentist explains it, otherwise he would not. Moreover, another respondent said the verbal information is easier to understand than the written one.

Discussion

In many countries implementing a quality management has been a priority, providing examples of good practice. Switzerland provides perhaps the best model through Frenkenklinik, a dental clinic that uses the EFQM (European Foundation for Quality Management) in dental care [6].

In Romania, the health care reform has led to a process of promoting quality in dentistry in order to achieve European standards. However, quality plays a marginal role in the Romanian health system, as is indicated by the health reform law [10]. The quality seen by dental professionals relates to patients’ expectations regarding health services, therefore, it is essential to identify patients’ perceptions regarding the quality of dental care.

The present study aims at assessing the current situation on the topic of patient-dentist communication on the local level and provide us with an overview related to this subject. As regards limitations, the sample cannot be defined as a representative one, but taking into account that this is a qualitative study, the number of respondents is suitable, as we conducted the research until reaching data saturation. Another limitation is given by the snow-ball approach methodology that translates into the enrollment of similar subjects. Moreover, we need to be aware of the respondents’ subjectivity when providing their answers.

Our study confirmed that asking for patients’ feedback plays an important role. Identifying the patients’ health literacy about dental services leads to better communication between dentist and patient, which is essential for establishing a quality management system in dentistry. Still, the current legislative framework provides limited information regarding the way quality management should be implemented. Future recommendations include improvement of communication skills and a greater involvement of the patients in the decision process.

Our results are congruent to recent research studies and stress the importance of improving the patient-dentist relationship. A similar qualitative study revealed the fact that empathy and good rapport of patients with their oral health providers strengthen their relationship. The results were based on in-depth qualitative interviews conducted with 20 uninsured or underinsured dental patients and were analyzed using content analysis [11]. Another study that explored the views of patients on the meaning of quality in dentistry in England identified good interpersonal communication, politeness and being put at ease as being the most important factors that elicited positive responses [12]. Furthermore, recent studies assessed the importance of the patient’s involvement in the process of quality management. A pilot study based in the United Kingdom showed that patients were least satisfied with opportunities to ask questions within their consultation and furthermore, wished for a higher level of involvement in decision-making. The results of the same study also suggested differences in patients’ perceived satisfaction with communication according to the dentists’ experience and gender [13].

Conclusion

According to our analysis, communication between patient and dentist is an efficient and professional one. When asked about the attitude of the dentist during the consultation, the respondents reported only positive attitudes. Moreover, our interview content analysis revealed the fact that dentists are focused on their patients’ dental problems and engage in positive relationships with their patients by providing useful and comprehensive information regarding their dental issues. When asked if they understood the verbal and written information received from the dentist, the majority of respondents said they understood the information without any problems.