Quality indicators of dental health care in Serbia

Summary Health care has witnessed considerable progresses toward quality improvement over the past two decades. More precisely, there have been global efforts aimed to improve this aspect of health care along with experts and decision-makers reaching the consensus that quality is one of the most significant dimensions and features of health system. Quality health care implies highly efficient resource use in order to meet patient’s needs in terms of prevention and treatment. Quality health care is provided in a safe way while meeting patients’ expectations and avoiding unnecessary losses. The mission of continuous improvement in quality of care is to achieve safe and reliable health care through mutual efforts of all the key supporters of health system to protect patients’ interests. A systematic approach to measuring the process of care through quality indicators (QIs) poses the greatest challenge to continuous quality improvement in health care. Quality indicators are quantitative indicators used for monitoring and evaluating quality of patient care and treatment, continuous professional development (CPD), maintaining waiting lists, patients and staff satisfaction, and patient safety.


INTRODUCTION
Quality health care is of paramount importance for a health system. Continuous improvement in the quality of patient care and safety is an integral part of everyday activities of medical professionals, medical associates and anyone employed in the health system [1]. Striving for quality patient treatment and care with the aim of delivering the best possible outcome for the patient is as old as medical profession. Nonetheless, organized efforts to evaluate and improve quality of health care started to appear in the 20 th century. It was Avedis Donabedian who made a major contribution to this field at the time. Namely, in the late 1970s Avedis Donabedian introduced evaluation of medical care and patient expectations based on clearly defined standards.
Quality health care implies highly efficient resource use in order to meet patient's needs of prevention and treatment in a safe way while meeting patients' expectations and avoiding unnecessary losses [1]. The Health Insurance Act, which represents one of the basic sets of principles of health care in Serbia, states: "The principle of continuous quality improvement is exercised by the measures and activities that in accordance with the latest advances in medical science and practice, enhance the possibilities for positive outcome while reducing risks and other unintended consequences for health and well-being of individuals and the whole community" [2]. The fundamental components of continuous quality improvement (CQI) in health care are: patient-centeredness, process analysis, forming quality improvement teams, applying simple methods to analyze quality-related issues in sys-tematical way, implementing previously established plans and changes, data gathering, monitoring and evaluation.
A quality indicator is a quantitative indicator used to monitor and evaluate quality of patient care and treatment. It is also perceived as a support system for health care activities. Quality indicators include performance indicators of health care providers based on their type and range of services they offer. Furthermore, these include different indicators used to assess the performance of the Commission for Health Care Quality Improvement, but also those related to continuing professional development (CPD), maintaining waiting lists, patient safety, patient and staff satisfaction [3].
Each health institution in Serbia is obliged to collect data used for calculating quality indicators and then submit them annually to "Dr Milan Jovanovic Batut" Institute of Public Health of Serbia. This procedure is completed through the competent district institute.
The aim of this study was to introduce the basic quality indicators of health care in Serbia.

QUALITY INDICATORS IN DENTAL HEALTH CARE
Quality indicators in dental health care are monitored in health care institutions providing dental services, i.e. prevention and treatment. Accordingly, quality indicators are monitored in the following health care institutions: health centers, institutes for dentistry, institutes for student health care (within the Dental Care Department) and institutes for health care of workers.
There are ten defined quality indicators that are monitored in dental health care [3]: 1) Percentage of children who received topical application of concentrated fluoride at the age of 7; 2) Percentage of children who received topical application of concentrated fluoride at the age of 12; 3) Percentage of 7-year-old children with no tooth decay; 4) Percentage of 12-year-old children with no tooth decay; 5) DMFT in 12-year-old children; 6) Percentage of children in grade 7 of elementary school with diagnosed untreated orthodontic irregularities; 7) Percentage of children in grade 3 of secondary school with diagnosed untreated orthodontic irregularities; 8) Percentage of women who had a preventive checkup during pregnancy; 9) Percentage of patients aged 18 or above who have received conservative periodontal treatment; 10) Percentage of repeated interventions.
Dental health care quality indicators are in compliance with general and specific goals of the National Program for Preventive Dental Health Care [4].
According to the 2016 report on quality improvement in health care institutions, 38.3% of 7-year-old children and 37.6% of 12-year-old children had all healthy teeth, whereas the mean DMFT of 12-year-old children was 2.15. Approximately 90% of 7-year-old and 12-year-old children had received topical application of concentrated fluoride. Around one third (35.3%) of pregnant women had visited a dentist for preventive check-ups. However, there was high percentage of children with orthodontic irregularities -53.9% of grade 7 children (elementary school) and 49.9% of grade 3 children (secondary school). The proportion of patients 18 years old or above that had received conservative periodontal treatment was 15.9%. Finally, approximately one in twenty patients (4.18%) required repeated intervention [5].

PATIENT SATISFACTION WITH DENTAL HEALTH CARE SERVICE
Patient/user satisfaction is perceived as a general attitude of individuals towards their own experience with a health care system. Taking patient satisfaction into consideration is a measure that reflects the system's responsiveness to people's non-medical expectations. Thus, the patient's perception is critical for the quality of care [5].
National surveys of patient satisfaction conducted by means of questionnaires represent the most convenient way of collecting data from a large number of people. These are carried out in institutions providing primary, secondary and tertiary care. Such analyses enable us to assess patient satisfaction among different patient populations based on their gender, age and type/department of health institution. The replicability of such research facilitates the process of monitoring any changes that occur within health care system over time. As for Serbia, this measure was first introduced in 2010 and has been used ever since.
To assess dental health care, these surveys are conducted in institutions providing primary care within departments of pediatric dentistry. The questionnaire consists of 19 questions divided into several sections. The person who brings a child for a dental check-up is asked to fill in the questionnaire. The first four questions refer to parents'/ guardians' socio-demographic characteristics (gender, age, education, and financial status). The remaining questions relate to dental care provided to the child (chosen dentist, criteria for choosing/replacing the chosen dentist, the number of visits to public/private dentists within the past year and waiting times). A set of questions covers health education, i.e. the importance of regular check-ups, application of fluoride, maintaining proper oral hygiene, balanced diet and orthodontic irregularities). Certain questions refer to working times, getting check-up on weekends, accessibility of care for children with special needs, accessibility of care in emergencies, the time between check-ups, helpfulness of receptionists and keeping a book of complaints. Finally, the last section evaluates the characteristics of chosen pediatric dentists such as providing clear explanations of procedures, allocating sufficient amount of time to discuss the patient's issues, being well-aware of the child's problems and conditions. This section also gathers information on cooperation among medical staff and dental charges (exempt from charges, participation fee, full price) [6].
The proportion of patients who were satisfied (satisfied and very satisfied) with pediatric dental health care in 2016 was 83.2% with the average mark of 4.08 (range: 1-5) [5,7].

PATIENT SATISFACTION WITH HEALTH CARE
These indicators refer to the number of complaints and are given in the Report on the Number of Complaints for the reporting year [5]. The Law on Patients' Rights terminated the Patient Ombudsman in December 2013. As a result, each health care institution has appointed an advisor whose duty is to protect patients' rights. That person is not employee of health care institution to avoid conflict of interest.
The patient who believes that he/she has been denied medical care or that their social right to health care has been denied by a health professional/associate is entitled to make a complaint [8]. A complaint can be made about the quality of health care, conduct of health professionals/ associates, fee processing, organization of medical institution, waiting times, reimbursement of medical costs, patient rights, etc.

JOB SATISFACTION AMONG EMPLOYEES IN PUBLIC HEALTH INSTITUTIONS
Job satisfaction among employees in public health care institutions in Serbia has been measured since 2006. Job satisfaction is defined as subjective perception of an employee regarding their personal fulfilment derived from work and the impact of their contribution on the institution.
Work motivation is one of the essential prerequisites for efficient work performance and is tightly connected to achieving positive results both at individual and institutional level. From a manager's point of view, motivation translates into employees being completely involved, committed and dedicated to themselves, their skills and capacities, and the job they perform while feeling fulfilled and content [9]. Salaries and remuneration packages can often enhance employees' feelings of accomplishment in the workplace. Reward schemes can include either individual or group compensation. However, apart from financial incentives, reward schemes should comprise nonfinancial incentives, as well. These are numerous and refer to appreciating one's need to further develop by acknowledging their professional competencies, including them in goal-setting and decision-making, allowing them to define and perform tasks and duties independently, enabling them to cooperate with other institutions, offering flexible working hours and providing them with continuing professional development, etc.
Work-related stress is one of the major causes of occupational diseases and sick leave not only in Europe, but also across the world. According to the 2010 Report published by the European Commission (EC) and the International Labour Organization (ILO), stress is second most frequent health problem among employees in the European Union [10]. Owing to the fact that patients trust medical practitioners with their lives and health, medical profession is among the most stressful professions. This inevitably results in medical practitioners being exposed to highly specific stressors. There are a variety of occupational stressors in health care. Many recent studies on morbidity from psychosomatic and mental disorders have shown that stressors such as contact with patients and their families, decision-making, working shifts, including night shifts and long working hours, contribute to emotional exhaustion among medical practitioners [11,12]. Managers in health care institutions and departments should be responsible for identifying stress hotspots, as well as the employees who might be experiencing high levels of stress. Even though it is the management's duty to ensure that stress is addressed at the organizational level, each person should take any necessary measures to prevent stress at the individual level.
A universal questionnaire is used to investigate job satisfaction among health professionals in Serbia, regardless of their positions. The questionnaire consists of 23 questions designed to assess employees' attitudes towards equipment, interpersonal relations, time management, professional development, remuneration, their superiors, cooperation with colleagues, patients, stress exposure, work pressure and plans to change jobs. The final part of the questionnaire is concerned with employees' suggestions, complaints and proposals for improving quality of care and increasing job satisfaction [13].

COMMISSION FOR HEALTH CARE QUALITY IMPROVEMENT REPORT
Comprehensive report on the work of the Commission for Health Care Quality Improvement is an indicator of quality of the Commission's performance which offers a comprehensive overview of all activities and measures implemented in the reporting year with the aim of improving quality of care and functioning of the health care institution [5].
Initial part of report focuses on different domains of quality of the Commission's performance (annual evaluation of professional performance and an integrated plan for continuous quality improvement within the health care institution, number of assessments without prior notice, number of patient complaints, etc.). The second part of the report is concerned with indicators of patient satisfaction associated with quality of care. The report also contains statistics of patient satisfaction and staff satisfaction, along with the analysis of collected data. The final part of the report summarizes the overall performance with regard to the Integrated Plan for Continuous Quality Improvement in Health Care.

PATIENT SAFETY
Patient safety is universally defined as "identification, analysis and correction of risky events in order to increase the levels of safety in health care and minimize patient-related risks. " [1]. Thus, patient-related incidents are considered to be cumulative consequences of the cause rather than individual mistakes. The principle of safety requires health care system that prioritizes patient safety and minimizes any risks during the provision of diagnostics or therapeutic treatment.
Due to the fact that one in ten patients experiences iatrogenic harm, the World Health Organization (WHO) has published an advocacy material in order to reduce the number of such incidents in the world. The WHO guidelines refer to drug nomenclature, patient identification, handover communication and the importance of hand hygiene.
Agency for Accreditation of Health Care Institutions in Serbia (AZUS) plays a prominent role in establishing the patient-safety system in Serbia. Ever since the AZUS Patient Safety Strategy was first introduced in 2010, health care institutions and facilities in Serbia have been obliged to adhere to its principles. The strategy sets out five key goals related to patient safety. These include safe surgical procedures, infection prevention and control, medication safety, personalized care and treatment, and eliminating/ minimalizing adverse events [14,15,16].

CONTINUING PROFESSIONAL DEVELOPMENT (CPD)
Continuing Professional Development of health professionals and associates, which is one of the obligatory require-ments for obtaining a license to practice, directly correlates with enhanced quality and efficiency in health care.

Quality indicators of CPD at institutional level are [5]: 1) Formulating plans for CPD of all employees;
2) The number of workshops, courses and seminars organized by the institution; 3) Percentage of employees for whom the institution covered the costs of attending course, seminar, congress or symposium relevant to their field at least once; 4) The number of CPD courses accredited by the Serbian Health Council that are organized/held by medical professionals employed in the institution.

CONCLUSION
"Quality is the responsibility of everyone. " This is commonly quoted slogan in health care which purpose is to reiterate that quality improvement is not what only individuals; specialized commissions, health care institutions and facilities are accountable for. Instead, it should lay the foundation for the provision of health care in its broadest sense. The process of quality improvement is gradual. Besides, it is equivalent to the process that we encounter in medical practice. The cause of poor quality is first identified by means of health care quality indicators. The next step is to carry out trials on the interventions that could help enhance it. Quality in dental health care should provide the patient with a proper treatment while minimizing risks as much as possible. Dental health care professionals and patients alike are obliged to cooperate with the aim of assuring high quality dental health care.