Integrating Adverse Outcome Metrics Into Quality Assurance Strategies for Improved Patient Outcomes

The Commission of Dental Accreditation (CODA) Standard 5-3 dictates that dental schools must conduct a formal system of continuous quality improvement and demonstrate a “mechanism to determine the cause(s) of treatment deficiencies and…implementation of corrective measures as appropriate” [1]. The core purpose of this standard has been central to the creation of the Adverse Outcomes model developed at the University of Illinois Chicago, College of Dentistry (UIC-COD). In a healthcare setting, adverse events refer to undesirable and unintended outcomes of patient management rather than the underlying condition [2, 3]. The UIC-COD defines “adverse outcomes” as unintended outcomes of routine care that necessitate the repetition of a procedure or an alternative treatment plan. In an educational context, adverse outcomes are not uncommon when care is provided by trainees, which often go unreported in the literature. Formal systems for documenting treatment deficiencies, causes, and corrective measures may help institutions set benchmarks, standardize operating procedures, and enhance training for students and faculty alike [4]. In 2019, UIC-COD created an innovative workflow within the electronic health record (axiUm, Exan, Coquitlam, BC, Canada) to formally document adverse outcomes. The process begins chairside when the student provider and attending faculty identify a deficiency in a recently completed procedure (within 2 years) and attach a completed adverse outcome form to the original procedure code in axiUm (Figure 1). The UIC Quality Assurance Committee regularly runs reports, consolidating the data from the forms and displaying results graphically, with a detailed list of the various deficiencies (Figure 2). Data from this form can be used to identify patient care trends, which can then be further investigated and addressed through adjustments in student education, faculty calibration, lab communication, dental material choices, or clinical care philosophies. Two workflows for all-ceramic, single-unit crowns in the UIC-COD predoctoral program were recently investigated. The study was exempted by the UIC Institutional Review Board (#STUDY2024-1431). The query aimed to investigate the rate of in-house fabricated (IHF) digitally scanned all-ceramic crown adverse outcomes as compared to commercial lab fabricated (CLF) and the associated causes over a time span of 5 years (August 16, 2019–August 15, 2024). Descriptive analysis revealed a comparable adverse outcome frequency of approximately 2.7% (Figure 3). The result has helped validate the in-house digital workflow within the curriculum. Since poor marginal adaptation following cementation was found to be the leading cause of failure, the program can now consider strengthening efforts in student training, faculty and lab technician calibration, and dental cement choices for improved patient care outcomes. The outcomes of this innovative workflow have proven to be valuable from a quality improvement standpoint. Successful implementation necessitated student and faculty training, clinic director oversight, and the initial effort of developing and creating the custom forms and reports. The adverse outcome system for documenting treatment deficiencies, causes, and corrective measures has helped UIC-COD set benchmarks, standardize operating procedures, focus calibration efforts, and enhance student education. The authors would like to thank Nish Shivnani and Ed Early, former and current Directors of Health Informatics Technology, respectively, at the UIC-COD.

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