Data Indicators for Dental Clinic Efficiency and Effectiveness
Several data indicators are available to I/T/U programs for analyzing clinical efficiency and effectiveness. Most of these indicators are based on the Resource and Patient Management System-Dental Data System (RPMS-DDS) software that is available at most, but not all, I/T/U programs. For programs that use RPMS, it is possible to calculate numerous workload and access to care measures that when taken together provide an excellent overview of the efficiency and effectiveness of local programs.
A special data report has been developed within the RPMS-DDS to provide the specific data that are needed to calculate these workload indicators. This is the Basic Measures Report (BMR), which is a component of the Compiled Statistical Reports module (RCST). The RCST provides permanent retrospective reports for observing local program trends over time. While the RCST reports separate data for Indian patients and non-Indian patients, they do not separate workload totals by care provider or by reporting facility. Therefore, in service areas with multiple facilities, it is not possible to separate data for separate facilities or individual providers. Other reports, such as the Service Minute/Level of Care report (RSVC), provide separate data by dentist and by facility and can be used to make rough allocations of BMR data within the service area.
Note: As a compiled statistical report, the BMR has its data compiled automatically by RPMS Taskman on the 10th day following the end of each quarter. Therefore, if a program has fallen behind on data entry, some data might not be entered until after that quarter’s statistics have been compiled. That means, for example, that the number of broken appointments on the BMR might be lower than the number found on the Visits by Facility and Dentist Report (RDEN) for the same period of time, because the RDEN statistics are not compiled until the user runs the RDEN report.
Subnote: In some programs the RPMS site manager has made the decision to “turn off” the automatic compilation of RCST reports by Taskman. In that case, the dental program staff at that site should manually compile the RCST report on a quarterly basis, and the concern mentioned in the above note will not be an issue.
Other data indicators do not depend on the availability of RPMS-DDS data. This includes number of dentists, total number of dental staff, and number of dental operatories available in the program. Another important data element is patient population, which can be determined either with the RCST report or by non-RPMS means, such as tribal enrollment numbers.
These data indicators have been incorporated into two versions of a worksheet for applying the various indicators to specific dental programs, either via self-assessment or as part of a formal dental program review. Appendix V is the MS Word version of the “Efficiency and Effectiveness Data Indicators Worksheet.” Web link #2 is an Excel spreadsheet version of the worksheet that contains embedded formulas for automatic calculation of the indicator values. To gain access to the Excel spreadsheet, click on “Efficiency and Effectiveness Data Indicators Worksheet (Excel)” in the table of contents.
2. Dental Clinic Efficiency Indicators
Program Resources and Staffing Patterns:
Many of the clinical efficiency indicators require knowing the extent of resources that are available in a local program to provide services during the period being evaluated, as follows:
Annual patient population count
Number of dentists in full-time equivalents (FTEs)
Once these resources have been identified, calculations can be made for several indicators, as follows:
Patient Population to Dentist Ratio
Patient Population to Dental FTE Ratio
Data Elements: Facility Users Past 36 Months / # of Dentists
Facility Users Past 36 Months / # of Dental FTEs
These are rough but widely-accepted measures used by many federal, state, and local public health agencies to compare the health resources available in underserved areas. In order to provide adequate access to dental care for the population being served, an adequate number of dental providers and auxiliary staff must be available.
Recommendation: The IHS recommends a ratio of 1,200 patients per FTE dentist and 500 patients per FTE dental position.
Even though most I/T/U programs currently exceed the desired ratios, some by a substantial amount, these recommendations serve as guidelines for programs that are making plans to expand current dental clinics or build new facilities.
Number of Dental Operatories Available per Dentist
Data Elements: # of Clinic Operatories / # of Dentists
Recommendation: At least two dental operatories should be available per dentist, excluding operatories used primarily by a dental hygienist.
If the ratio of dental operatories to dentists is less than 2:1, the clinic is likely to experience bottlenecks in patient flow, because the dentists must routinely wait for an empty operatory before treating the next patient. A ratio of 2.5 to 3.0 operatories per dentist will enable the program to function at peak efficiency. If expanded functions (EF) restorative services are routinely provided in the clinic, 3.0 chairs should be available per dentist for the EF part of the program.
Number of Dental Assistants Available per Dentist
Data Elements: # of Dental Assistants / # of Dentists
Recommendation: At least two dental assistants should be available per dentist, with a ratio of three assistants being more appropriate for expanded functions restorative programs.
If there are fewer than 2.0 assistants available per dentist, the clinic is likely to experience difficulty in maintaining smooth patient flow. Having an insufficient number of dental assistants means that multiple operatories cannot be used efficiently, because the dentist will invariably find himself or herself working alone at times when it would be more efficient to have a chairside assistant. As with the number of dental operatories, clinics utilizing EF will typically need 3.0 EF assistants per dentist for the EF portion of the program.
Note: Combining the ratios from this recommendation and the preceding one results in an overall recommendation to provide at least two operatories and two assistants per dentist, exclusive of dental hygiene operatories. This also translates to a ratio of one assistant per operatory.
Workload Indicators Using RPMS Dental Data System:
The RPMS-DDS reports described earlier, especially the Basic Measures Report, can be used in conjunction with facility data, staffing data, and patient population to calculate several workload indicators, which are listed below.
Programs are encouraged to apply these workload indicators to their own local data and to track the indicators over time to identify changes in productivity within the program. However, for programs that have not tracked their own data in the past and programs that do track their own data but want to know how their productivity compares with that of other programs, rough productivity guidelines are available in this document. These guidelines are known as Reference Values.
Relative Value Units and Reference Values
Some of the workload measures are expressed in Relative Value Units (RVUs), which are a productivity measure that recently replaced a previous measure known as Service Minutes (SM). SMs were used by the IHS for more than 30 years, and nationwide IHS program and tribal program averages were calculated for each of these workload indicators. These nationwide averages were known as “Reference Values” and provided clinicians and program managers with a way to determine whether productivity at a program was high, low, or average compared to other programs.
The last time these nationwide averages were calculated for the IHS dental program dates back to fiscal year 1994. Obviously, the Reference Values have been in need of updating for many years. More recently, the conversion from SMs to RVUs dictates that the Reference Values now be expressed in the new RVU productivity units. Since 1994 the downsizing of IHS Headquarters and Area Offices and other factors have made the collection and calculation of national averages difficult, if not impossible. Because of the difficulty in obtaining nationwide averages, a decision was made to use Reference Values from a representative IHS Area for which these data were available. This Area consists of IHS, Tribal, and Urban Indian dental programs. Note: The one exception to using the representative Area for Reference Values is for the Annual Access to Dental Care indicator, which is based on the actual nationwide average for I/T/U programs.
Reference Values from the representative Area are not available for all of the workload indicators in this document, but they are available for the following measures:
Total Visits per Dentist
Total Visits per Operatory
RVUs per Patient Visit
RVUs per Dental FTE
RVUs per Dentist
RVUs per Operatory
RVUs per Patient
Reference Values are not included in the written descriptions of the workload indicators below, but they are included in the Data Indicator Worksheets that are included in this manual. The Excel spreadsheet that was used for calculating these Reference Values is included as Web link #3, which can be obtained by clicking on “Reference Value Calculations for Data Indicators (Excel)” in the table of contents.
Note #1: When Reference Values were last calculated from 1994 productivity data, separate levels were listed for IHS-managed programs and Tribal programs. At that time average productivity levels for IHS-managed programs were higher than for Tribal programs for many of the indicators, primarily because IHS programs were typically larger and more likely to utilize expanded functions dental assistants in their programs. However, in the representative IHS Area that is being used for the current Reference Values the relationship between productivity in IHS and Tribal programs has reversed, with the Tribal programs being more productive than the IHS programs. In this Area the Tribal programs tend to be larger than those in most other Areas, and due to the availability of expanded functions training programs within the Area, expanded functions are utilized by many of the Tribal programs in that Area. In an attempt to consolidate and simplify the Reference Values, only the overall averages for I/T/U programs are provided on the worksheets.
Note #2: Because of the widespread use of expanded functions in both IHS and Tribal programs in the representative Area, the Reference Value levels for many of the workload indicators might be difficult to achieve in programs that do not utilize expanded functions. In those programs, perhaps the best way to evaluate efficiency and productivity would be to monitor the workload indicators over time to determine an acceptable range of productivity levels. Ideally, all IHS Areas would collect these data and use them to develop Area-wide productivity expectations. This would be especially useful in Areas where most programs do not utilize expanded functions, which makes the Reference Values in this manual less applicable. As a starting point for developing efficiency/productivity expectations in Areas that do not typically utilize expanded functions, a “ballpark” estimate might be to use approximately 75 percent of the current Reference Values as initial benchmarks for workload indicators that are the most dependent on expanded functions, such as RVUs per dentist.
Note #3: For senior IHS and Tribal staff who are familiar with productivity measures in terms of SM but who are not yet accustomed to using RVUs, there is a way to make a rough estimate of RVU values in terms of the old SMs. In many programs, especially those that focus on basic services rather than specialty services, RVU production is approximately 10 percent of SM production.
For ease of use, the terms used to describe the workload indicator data elements are expressed in the exact wording found in the Basic Measures Report.
Visits per Dentist
Data Elements: Dental Visits Past 12 Months / # of Dentists
This indicator measures the average number of patient visits per dentist for the period being evaluated. Because most programs track the number of dental visits, this measure is also likely to be available even in programs that do not have access to RPMS data. In that case it becomes an important measure, because it might be the only workload indicator that the program can easily obtain.
Visits per Operatory
Data Elements: Dental Visits Past 12 Months / # of Operatories
This indicator provides a general measure of how efficiently resources are being utilized to provide access to care. The number of dental operatories serves as a stable common denominator across all programs. Indicator values reflect the effects of local appointment policies, broken appointment management, and other patient flow and efficiency issues.
Relative Value Units per Patient Visit
Data Elements: Relative Value Units / Dental Visits Past 12 Months
This indicator measures how much dental treatment was provided per visit, on average.
Relative Value Units per Dental FTE
Data Elements: Relative Value Units / # of Dental FTEs
This indicator measures productivity per dental employee, without regard to the employees’ positions. Programs that utilize expanded functions tend to have higher RVU/FTE values, so this measure is most useful when comparing like programs with regard to EF usage.
Relative Value Units per Dentist
Data Elements: Relative Value Units / # of Dentists
This indicator measures dental team productivity without regard to the number and type of auxiliary staff available. If programs with dental hygienists are compared with programs without hygienists, it is most meaningful if the RVUs provided by hygienists are excluded from the calculation. This is not as easy to do as it might seem, because the RPMS-DDS software reports all dental hygiene services under a dentist’s name, with the hygienist listed as an auxiliary provider.
Relative Value Units per Operatory
Data Elements: Relative Value Units / # of Dental Operatories
This indicator provides a common denominator for comparing productivity across all programs.
3. Dental Program Effectiveness and Access to Dental Care Indicators
An important aspect of dental program effectiveness is the level of access to dental care, or the ability of patients to obtain needed dental treatment when they request it. In general the goal is to provide at least the same level of dental access to AI/AN communities as is available to most communities in the United States. These goals are based upon the assumption that most individuals will be better able to maintain good oral health if they are able to see a dentist regularly, e.g., at least once per year.
Any calculation of dental access requires as accurate an estimate of the user population as possible. The RPMS-DDS Basic Measures Report provides data on “Facility Users Past 36 Months,” which traditionally has been a widely-accepted measure of user population. This measure represents an unduplicated count of patients who had at least one appointment in any portion of the medical facility during the past three years. If programs prefer to use other measures of patient population, they have the option to use them.
Access to Care Indicators Using RPMS Dental Data System:
Proportion of Population Served Annually (Annual Access to Dental Care)
Data Elements: Dental Users Past 12 Mo. / Facility Users Past 36 Mo. X 100
This indicator measures population penetration or utilization rate, which is the proportion of the community or population base that has gained access to dental services during the preceding year. Annual access to dental care has been a Government Performance and Results Act of 1993 (GPRA) objective for the IHS dental program for many years. Typically only Indian user counts are included in both the numerator and denominator of this indicator in order to measure access for AI/AN people.
Proportion of Patients Treatment Planned
Data Elements: Patients Treatment Planned / Dental Users Past 12 Mo. X 100
This indicator measures the proportion of patients who receive a treatment plan annually, based on a count of routine exam codes (0150 + 0120).
Proportion of Patients Completed
Data Elements: Pts. Planned Tx. Completed / Pts. Tx. Planned X 100
This indicator measures the proportion of patients who have received an exam/treatment plan who actually had at least their basic (Levels I to III) treatment completed (code 9990). This measure is reliable only if programs routinely use the 9990 code when a patient is completed.
Relative Value Units per Patient
Data Elements: Relative Value Units / Dental Users Past 12 Months
This indicator measures how much dental treatment was provided per patient, on average. In programs where comprehensive care is the rule, the number of RVUs per patient will obviously be higher than in programs where treatment is limited primarily to emergency care and basic care.
Dental Clinic Efficiency 2007