Scientific Justification of a System for Managing the Quality and Efficiency of Dental Care in Medical Institutions with Various Forms of Ownership in Market Conditions (on the Example of Khabarovsk Krai)

The dissertation is devoted to the development of a scientifically justified system for managing the quality and efficiency of dental care in medical institutions with various forms of ownership in market conditions, on the example of Khabarovsk Krai. The research includes a comprehensive analysis of the quality of ambulatory and inpatient dental care, an assessment of patient satisfaction, a study of the existing quality review system, and the identification of unresolved problems in the areas of standardization and management. Based on the conducted analysis, a promising model for managing the quality of dental care is justified, which includes an algorithm for managing processes of ensuring quality and experience in implementing total quality management (TQM) methods.

The essence and, over a long period of time, the current system of dental care for the population in the Russian Federation has a number of positive aspects (Leontyev V.K., 1999). These include a preventive orientation, the growth of specialization in individual areas, a well-developed network of dental offices, departments, and polyclinics, the organization of emergency care, a high level of its accessibility, and much more (Tillingast S., 19...).

At the same time, there are also a number of negative trends that have formed both in healthcare in general (Semenov V.Yu., 1989; Dyachenko V.G., 1996, 2003) and in dentistry in particular (Kntul I.S., Galonsky V.G., Gaidarova T.A., 2001; DMOOPS V.G., Goigoeza S.A., 2004). Above all, these are the low quality of dental care for the population, insufficient interest of medical workers in the final results of diagnosis and treatment quality for the patient, a high level of hospitalization in maxillofacial inpatient facilities, a low level of implementation of resource-saving technologies, and much more (Shchepni O.P., 1992; Kondratov A.I., 1994; Tagay N.D., 19...; Kunaki G.S., Morozova N.V., Alkinsky A.V., 1997; Leontyev V.K., Bezrukov V.M., 2000).

In territories with low population density (constituent entities of the Russian Federation in the Far Eastern Federal District), many of the aforementioned problems acquire a hypertrophied character, since the quality organization of dental care in these regions was formed without taking into account the types and volumes of this care for the population standardized for Russia, and not on the basis of the functioning of a network of dental institutions established over many years. Under these conditions, revising the system of organizing medical care of sufficient quality is a priority task (Leus P.A., 1991; 1995; Leontyev V.K., Shestakov V.T., Vorontin V.F., 2003; Chen M., Harmon R., Andersen R., 1997; Harding A., Preker A., Ed., 2000).

In Russia, there is a sufficient legislative base for improving dental care for the population. At the same time, there are no criteria for evaluating the activities of healthcare institutions of the dental profile, their subdivisions, an individual dentist, and a medical nurse (Kitae N., 1985; Loe N., 1995). In all healthcare institutions in Russia, in accordance with international requirements, including the requirements of the WHO, ensuring quality must be carried out systematically. But for this, many specialists in managing dental care in healthcare institutions of the non-commercial and commercial sectors, who in practice carry out quality assurance, lack the necessary modern knowledge on this issue (Dyachenko V.T., et al., 2001).

In many countries, original systems for ensuring quality in dentistry already exist. At the same time, a simple transfer of existing quality assurance systems to the healthcare sector will not achieve the goal, since it is necessary to take into account the specifics of the region, the economic situation of the healthcare system, and healthcare institutions of municipal formations (Tsimbalists A.V., Titov M.A., 1992; Tishin A.S., 2000; Meissen V., 1989; Mibdak M.G., 1996). Therefore, today there is a need to develop one's own concept that takes into account the conditions and needs of the service sector, which would provide for internal quality assurance with consideration of the aspect of voluntariness and a system of evaluation of various types of healthcare institutions of the dental profile. This concept should be based not on intra-institutional and inter-institutional control, punitive and "punitive" sanctions, but on forming in the staff of dental institutions moral and material incentives for processes that, in the final analysis, will lead to a permanent improvement in the quality of dental care (Shestoe V.T., 1991; Chavpetsov V.F., Perench N.B., Mikhailov S.M. and others, 1994; Shchepni O.P., 1996; Tsimbalists A.V., Gultai O.Ya., Golinsky Yu.G., 1999).

At present, measuring and rewarding quality have become a vital part of the efforts of healthcare institutions of the dental profile aimed at arming themselves in the Russian market system, where a high level of competition among producers of medical services is increasingly forming (Shchepni O.P., Lindenbroggen A.L., Goldberg V.P., Eviatkin R.M., Yakovleva T.S., 2000; Tariov A.L., Ware J.E., Orcentietd S., Nelson E.C., Perrin E., Zubkoff M., 1989; Thomas W., Nolw L., Lloyd P., 1990; Weber H., 1991; Vdlond L., Shubl J., 1995).

The government, employers, medical insurance payers, and consumers choose those healthcare institutions where high-quality dental services are produced, those that will be able to demonstrate this, and in the coming years will be in the greatest gain in the system of dental care for the population based on competition (Ulyanov E.S., 1997; Nyuniv V.O., M., Koch M.J., Nickusch U., Siaehle H.J., 1997; White E.L.P., 1991; WHO, 2000).

Under the new socio-economic conditions of knowledge and skills, an individual dentist alone is no longer sufficient to provide high-quality services. A dentist today works as part of a complex organizational structure that includes many specialists of various profiles. How well this structure is organized largely determines the effectiveness and efficacy of the treatment that the patient will receive, and, consequently, the achievement of the best possible result.

To improve quality, it is necessary to have an environment conducive to raising quality and tools for improving quality, including statistical and organizational ones. In order to obtain comprehensive information about the processes taking place in healthcare institutions of the dental profile, dentists, other medical workers, and technical staff must participate in the work.

At the same time, in the state sector of dentistry, outdated normative indicators for evaluating the quality of work of dentists and dental technicians still operate, which do not meet modern requirements and do not allow an objective assessment of the quality of work performed (Mikhailova Yu.V., 1994; Leus P.A., 1995; Mylnikova N.S., 1996; Leontyev V.K., Popov A.A., Shnilsenko Yu.V., 1999).

In the private sector of dentistry, the problem of ensuring the quality of treatment and the quality of manufacturing lip prostheses is given considerable importance. But at the same time, a significant individualization of criteria by which the quality of produced services is evaluated is noted. Most often, criteria for evaluating the quality of work of a dentist and the manufacturing of dental prostheses depend on the opinion of the institution's administration, while consumer opinions are taken into account only to a limited extent (Kntul I.S., Galonsky V.G., Gaidarova T.A., 2001).

A unified system for evaluating the quality of work of dentists and the quality of manufacturing dental prostheses, allowing a comprehensive assessment, taking into account world requirements, of this type of specialized medical care and providing objective indicators for making managerial decisions, has, in the opinion of most scientists and practicing dentists, not been developed (Vyalkov A.N., 1999).

The specifics of improving technological processes in dentistry have nothing in common with standards as they were understood by most dentists yesterday. In the modern understanding, all elements of improving the process of providing dental care are based on forming the process itself. All methods are designed, developed, and used for managing various pathophysiological states through influencing the treatment process.

In individual dental institutions, working indicators are determined and measured, but they are evaluated exclusively according to the understanding of their administrators, and not in terms of their compliance with the requests and expectations of consumers (thereby turning performance indicators as well) regarding work, structure, reliability, convenience, durability, service, aesthetics, and subjective perception of quality.

It is advisable to consider this problem from the standpoint of the corresponding objective assessment of treatment results, based on a comprehensive evaluation of all its elements (Leontyev V.K., 1997). However, it should be noted that the absence of a unified program for ensuring quality in dentistry, standardization, and other criteria corresponding to the levels of healthcare institutions complicates the conduct of effective both inter-institutional and intra-institutional quality review of medical care, as well as the management of these processes.

The goal of the research was to develop a system for managing the quality and efficiency of dental care for the population in medical institutions with various forms of ownership in market conditions (on the example of Khabarovsk Krai).

The tasks of the research included:

- studying the structure of the dental service and evaluating the efficiency of the dental service's work in new economic conditions;

- conducting a comprehensive analysis of the quality of ambulatory and inpatient dental care in Khabarovsk Krai;

- conducting a comprehensive analysis of patient satisfaction with the quality and accessibility of dental care;

- studying the existing quality review of dental care and determining the directions for its improvement;

- developing a system for managing the quality and efficiency of dental care for the population of the region in market conditions.

The scientific novelty of the research:

- for the first time, a comprehensive scientific analysis of the results of expert work in medical institutions of the dental profile with various forms of ownership was conducted;

- methodological requirements for the procedure of conducting quality review of dental care for the population of the region were developed;

- methodological approaches to developing a system for managing the quality and efficiency of dental care for the population in market conditions were justified.

Practical significance.

A system for managing the quality of dental care for the region of practical (applied) character was developed and implemented.

The results of the research were taken into account by the Ministry of Health of Khabarovsk Krai when forming the Comprehensive Program for Managing the Quality and Efficiency of Medical Care for the Population of the Krai for 2006-2010.

Methodological recommendations for organizing and planning quality review of dental care for the population were developed and implemented for the Khabarovsk Krai Fund of Mandatory Medical Insurance.

The results of the research are used in the educational process at the Department of Public Health of the Far Eastern State Medical University during the cycle of advanced training for healthcare organizers (Appendix b).

The main provisions put forward for defense:

- the organizational form of quality review of dental care for the population of Khabarovsk Krai is intra-institutional quality review, based on the analysis of the structure, technology, and results of activities of medical institutions of the dental profile;

- the main staff unit of the system for managing the quality of dental care is a dentist-therapist who has undergone special training in quality review and quality management in dentistry;

- the system for managing the quality and efficiency of dental care for the population of Khabarovsk Krai in market conditions is based on structural transformations of dental care and determines the organizational model for managing dental assistance at the regional and municipal level.