Useful information. Useful information Provision of dental care in terms of health insurance
The article presents an analysis of the provision of dental care to the adult population in the city of Ufa according to the acts of examination of dental care for 2013, an assessment of the quality of medical care is given. Among the analyzed patient records, women accounted for 66.3%, men - 33.7%. Among the patients, the largest number was in the age groups 20–29 years old - 24.5%, 50–59 years old - 19.4% and 60–69 years old - 14.3%. Among those who applied for the treatment of carious teeth, women were 2.1 times more than men (68.2% versus 31.8%), for pulpitis, respectively, 2.8 times more (73.9% versus 26.1% ). The average number of insured cases for caries for each man is more than for a woman, this indicator by age groups it was distributed as follows: 7.0 insured events fell on the group of 40–49 years, 5.3 insured events - for 18–19 years and 3.7 cases - for the age of 20–29 years, respectively; for each woman - 5.3 insured events at the age of 18–19 years, 4.6 events at the age of 20–29 years and 4.3 events at the age of 30–39 years. Treatment defects accounted for 17.6% (155 out of 882). Of these, experts identified the following inconsistencies with the standards: treatment of a missing tooth (2.4%), lack of description of radiography (2.0%), lack of control radiography in the treatment of complicated forms of caries (6.8%), poor-quality obturation of root canals ( 8.1%), the absence of a document on the patient's informed consent to treatment (10.1%), duplication of records about the previous events (12.2%), etc.
insurance case
urban population
examination of the quality of medical care
dental care
1. Denisova E.I. On the problem of providing dental orthopedic care to elderly and senile people // Bulletin of the National Research Institute of Public Health of the Russian Academy of Medical Sciences. - 2012. - No. 1. - P.41–44.
2. Leontiev V.K. The quality of dental care: a systematic approach, management and regulation capabilities. 2013, article. Availableat: http://www.e-stomatology.ru/publication/.
4. ФЗ dated 29.11.2010 N 326-ФЗ (as amended on 12.03.2014). "On compulsory health insurance in Russian Federation».
5. Erk A.A., Sagin O.V., Suanov A.N., Bostanjyan G.M. Organization of quality control of dental care // Electronic scientific and educational bulletin "Health and education in the XXI century." - 2012. - No. 1. - P.8-14.
Dental care is a type of primary specialized medical care provided for diseases and injuries of teeth, jaws and other organs of the oral cavity and maxillofacial region. Strengthening the health of the population is impossible without organizing one of the most massive types of medical care, which is dentistry. The quality of medical care is a set of characteristics that reflect the timeliness of the provision of medical care, the correct choice of methods of prevention, diagnosis, treatment and rehabilitation in the provision of medical care, the degree of achievement of the planned result.
Improving the quality of dental care for the population is both a medical and no less significant social and economic problem. According to V.K. Leontyev (2013), it is precisely the improvement of the quality of the work of specialists, and not the increase in the number of patients admitted, that is the main reserve of the dentist's labor productivity. If the medical significance of improving the quality of dental treatment is generally understood - reducing the number of complications, improving the condition of the oral cavity, maintaining health, then the social and economic aspects of the problem are less well known. They consist in reducing the number of visits to the doctor, reducing the number of retreatments, increasing the productivity of the dentist, and reducing the economic cost per patient over a long period of time.
Domestic dentistry has come a long way in attempts to improve the quality of the work of doctors. At the same time, organizational and managerial measures were mainly used in the form of the introduction of various standards of treatment, quality indicators and, most importantly, control methods. Leontiev V.K. (2013) believes that the possibilities of this approach were limited, since control was usually of a departmental nature and was poorly effective, it was impossible to control the treatment of each patient. In addition, the quality of treatment, regardless of control, always lies within the effectiveness of the applied methods of treatment, which did not differ in modernity and novelty.
The introduction of health insurance led to the organization of non-departmental quality control of dental care by medical insurance organizations and territorial compulsory health insurance funds (MHI). It must be recognized that the assessment of social, medical and legal provisions established in dental practice on the present stage, dictates the need to create organizational structure, capable of improving the quality control mechanism of dental services both to prevent and resolve conflicts between patients and dental organizations.
Purpose of the study. Study of the quality of dental care in municipal dental clinics ah the city of Ufa.
Materials and methods. 882 cards of expert assessment of the quality of treatment in a polyclinic, filled in by experts from medical insurance companies, were copied. The expert assessment cards reflected the following information: gender, age of the patient, period of treatment, diagnosis, diagnostic and therapeutic measures, assessment of the quality of diagnosis and treatment.
Research results. Among the analyzed patient records, women accounted for 66.3%, men - 33.7%. Among the patients, the largest number was in the age groups 20-29 years old - 24.5%, 50-59 years old - 19.4% and 60-69 years old - 14.3%. Among those who applied for the treatment of carious teeth, women were 2.1 times more than men (68.2% versus 31.8%), for pulpitis, respectively, 2.8 times more (73.9% versus 26.1% ). Among women, the prevailing age group was 20-29 years (39.0%), 50-59 years (14.3% and 60-69 years (13.3%). The majority of men were in the age group 40-49 years (28, 6%), 20-29 years old (22.4%) and 50-59 years old (17.3%). Those who applied for complicated forms of caries, such as pulpitis and periodontitis, differed in age. more age groups 20-29 years old (25.3%), 50-59 years old (50-59%) and 60-69 years old (20.8%) respectively. (33.3%), 30-39 years old (29.4%) and 20-29 years old (19.6%). With regard to such a form of complicated caries as periodontitis, the proportion of the age group of 50-59 years among those who applied was 30 , 6%, at 30-39 years old - 23.6%, at 70-79 years old - 23.6% and 60-69 years old - 11.1%. Among women in the first place was the age group 60-69 years (25 , 4%), in second place, as in men, are two age groups - 20-29 and 40-49 years (23.8%, respectively), in third - 50-59 years (16.2%).
The study of the structure of appeals by diseases showed that caries was in the first place (36.5%), in the second - periodontitis (25.6%), in the third - pulpitis (23.5%) and in the fourth - periodontitis (14.4 %).
Each patient can apply for dental care not only once during the year. Most often, patients are afraid and postpone the visit to the dentist, thereby accumulating several diseases of the teeth and oral cavity.
Insured event - an event that has occurred (illness, injury, other state of health of the insured person, preventive measures), upon the occurrence of which the insured person is provided with insurance coverage for compulsory health insurance.
The average number of insured cases by caries diagnosis was approximately the same for men and women (3.0 and 3.2, respectively), but there were differences by age groups. Thus, the average number of insured cases for caries in men in the age group 40-49 years was 7.0 cases, in the age group 18-19 years old - 5.3 and in the age group 20-29 years old - 3.7 insured events. Among women, the distribution of insured events by caries fell on younger age groups: 5.3 insured events at the age of 18-19, 4.6 at the age of 20-29 and 4.3 at the age of 30-39.
In general, the average number of insured events for pulpitis was also the same for both men and women (1.5 insured events each), but there were also differences in age groups. Thus, 5.7 insured events fell on women aged 70-79 years, 2.5 cases - for the age of 60-69 years and 2.1 cases for the age of 20-29 years. For men, the average number of insured events is the highest at the age of 30-39 years - 2.5 cases, at the age of 40-49 years - 2.3 cases and at the age of 20-29 years - 2.1 cases.
The average number of insured events for periodontitis was 1.7 times more among men than women (2.2 and 1.3 insured events, respectively). The largest number of insured events for periodontitis in men was observed in the age group of 70-79 years (7.0 insured events), in second place were the age groups of 30-39 and 50-59 years (2.8 cases each), in third place - age group 60-69 years (2.0 cases). On average, every woman aged 60-69 had 2.8 insured event, at the age of 40-49 years - 2.6 cases and 70-79 years - 2.0 insured events (Table 1).
Table 1
Distribution of insured events by diagnosis depending on gender and age
Age groups |
Average number of insured events |
|||||
periodontitis |
||||||
80 years and older |
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Examination of the quality of medical care is carried out in order to identify violations in the provision of medical care, including assessing the timeliness of its provision, the correct choice of methods of prevention, diagnosis, treatment and rehabilitation, the degree of achievement of the planned result. Examination of the quality of medical care provided within the framework of compulsory health insurance programs is carried out in accordance with the legislation of the Russian Federation on compulsory health insurance.
The examination of the quality of medical care is carried out by experts from insurance medical organizations on the basis of the "Medical card of a dental patient" (f. 043 / y). The data of the examination carried out are entered by experts of insurance organizations into the "Card of expert evaluation of the quality of treatment in the polyclinic". The peer review card lists all patient visits for the year.
The analysis showed that the inconsistency of diagnostic measures with the standards of medical care was in 14.3% of cases (126 out of 882, respectively), which included: inconsistency in the treatment of caries in 36.5% of cases, in the treatment of pulpitis - 23.5%, in the treatment of periodontitis - 25.2%, in the treatment of periodontitis - 14.8% (Table 2).
table 2
Structure of inconsistency of diagnostic measures
Defects in filling out medical records of a dental patient were as follows: in the first place - no treatment outcome was noted (55.1%), in second place - the dental formula was not filled out (34.1%), in third place - the date of the patient's request for dental care was not indicated (12.7%), in the fifth place - the tooth that was treated was not indicated (7.0%), in the sixth - the number of visits was not noted (4.6%) and in the seventh place - the diagnosis was not indicated (2.4%) ... There were also such comments in the expert's conclusions as insufficient collection of anamnesis (22.4% of cases), lack of records of existing chronic diseases (18.5%), illegibility of records (12.2%), incorrect medical records (5, 1%) (Table 3).
Table 3
Defects in filling out medical records of a dental patient (in%)
Defects in filling out medical records |
Number of acts |
|
in% to the total |
||
No treatment outcome noted |
||
Dental formula not filled |
||
Date of appeal is not specified |
||
No tooth specified |
||
Number of visits not marked |
||
Diagnosis not specified |
Treatment defects accounted for 17.6% (155 out of 882). Of these, experts identified the following inconsistencies with the standards: treatment of a missing tooth (2.4%), lack of description of radiography (2.0%), lack of control radiography in the treatment of complicated forms of caries (6.8%), poor-quality obturation of root canals ( 8.1%), the absence of a document on the patient's informed consent to treatment (10.1%), duplication of records of previous events (12.2%), etc.
In the expert's conclusions, remarks were made about the overestimation of the number of UET, about insufficient information in the anamnesis of the disease with which the patient sought dental care, about existing concomitant chronic diseases. Insufficient or formal collection of anamnesis of the disease and chronic diseases does not allow to fully represent the complete situation about the disease, and can also aggravate or lengthen the treatment period, affect the choice of drugs with which it is necessary to conduct effective treatment.
Thus, the analysis of the cards of the expert assessment of the quality of treatment made it possible to identify the main contingent of the population who applies for dental care, defects in medical documentation, defects in medical and diagnostic measures, the level of qualifications of dentists in the provision of dental care.
Reviewers:
Akhmadullina Kh.M., Doctor of Medical Sciences, Professor, Director of the Institute of Psychology and Social Work of the Academy of VEGU, Ufa.
Khusnutdinova Z.A., Doctor of Medical Sciences, Professor, Head. Department of Health Protection and Life Safety of the Federal State Budgetary Educational Institution of Higher Professional Education "Bashkir State Pedagogical University named after M. Akmulla ", Ufa.
Bibliographic reference
Fazliakhmetova G.R. ABOUT THE QUALITY OF DENTAL MEDICAL CARE IN THE SYSTEM OF COMPULSORY HEALTH INSURANCE // Contemporary problems science and education. - 2014. - No. 4 .;URL: http://science-education.ru/ru/article/view?id=14060 (date of access: 02/01/2020). We bring to your attention the journals published by the "Academy of Natural Sciences"
There is an opinion that dental treatment is always paid for a citizen. In fact, there are clear obligations of the state to citizens in the field of health protection, including the provision of dental care. It is worth noting that free medical dental care is available to absolutely every insured person and there is no difference in which insurance company issued him a policy.
Each region of the Russian Federation has its own Territorial program of compulsory health insurance, formed in accordance with the requirements of the unified program of state guarantees.
Under the compulsory medical insurance policy, only emergency medical care is provided throughout the country. The provision of planned medical care is possible only on the territory of insurance - in the region of residence.
This means that if a citizen develops a disease of the oral cavity, salivary glands and jaw, he (she) has the right to receive the necessary dental care (in a polyclinic, a hospital) of a medical organization of the district, regional, and if there is medical evidence, and at the federal level to free of charge.
How to sign up?
To cure your teeth for free, you need to contact a dental clinic or the dental department of a hospital, health center ...
If a child needs help, then you should contact a children's dental clinic, often an adult and a department for children operate within the same clinic.
If you need inpatient treatment, you can go through it in the appropriate hospital. Also demon paid services on insurance policy Compulsory health insurance can also be obtained in some private clinics operating in the compulsory health insurance system.
As in a regular clinic, you need to attach to dentistry. To do this, apply with the compulsory medical insurance policy and passport to the registry of the clinic of your choice. In the future, when applying for dental medical care, it is possible to make an appointment with a doctor in all available ways: by phone, in the register of an appointment in a medical organization and, if technically feasible, electronic entry using the information and telecommunications network Internet.
Terms of assistance
It should be remembered that in accordance with the Territorial Program, when applying for dental care, emergency medical care must be provided immediately, the provision of primary health care in an emergency form is no more than 2 hours from the moment of contact.
The waiting period for reception by district doctors should not exceed 24 hours from the moment the patient contacts a medical organization.
The timing of consultations of specialist doctors in the provision of primary specialized medical and sanitary care in a planned form is no more than 14 (10 in Moscow) working days from the date of the patient's appeal to a medical organization.
The timing of diagnostic instrumental (X-ray examinations, ultrasound examinations) and laboratory examinations in the provision of primary health care should not exceed 14 (10 in Moscow) working days from the date of appointment.
The timing of computed tomography (including single-photon emission computed tomography), magnetic resonance imaging and angiography in the provision of primary health care should not exceed 30 (26 in Moscow) working days from the date of appointment.
What dental care is not covered by the Area Program?
Dental prosthetics are excluded from the program; this type of dental care is paid for at the expense of citizens' personal funds, except for the privileged category of the population, which is financed from the corresponding budget.
Unfortunately, there are cases of illegal denial of free dental care under the Territorial Program, or you are offered to pay for this assistance.
Often in insurance company there is a question, is it possible to put a photopolymer seal under the compulsory medical insurance policy? The fact is that each region has its own Territorial program of state guarantees, which includes a different range of medical services. In most regions, this type of seal is not included in the list. In the Moscow region there is such an opportunity, but the choice of filling material is carried out exclusively by a dentist with the obligatory informing the patient about the method of treatment. The choice of a method of treatment using materials from photopolymers is possible in the absence of contraindications (presence of gum inflammation, area of tooth decay, allergic reactions, etc.).
In Moscow, photopolymer material is not included in the list of services under the compulsory medical insurance policy. Types of filling material: cement, metal-containing filling, chemical-curing composite filling.
For more information, please contact your insurance representative by calling the contact center number 8-800-200-92-04.
What to do?
First, contact the administrator of the medical organization (chief physician, deputy chief physician, head of the department) with a request to explain the reason for the refusal or the requirement for payment. In most cases, the problem is resolved on the spot. If the administrator refuses to help, contact your medical insurance company (name, phone, address, e-mail address is available on your compulsory medical insurance policy). The employees of the insurance company will provide you with the necessary advice and, if necessary, take measures to solve the problem.
Types of dental care
Periodontics:
Specialized (dental) medical care is used in the treatment and prevention of diseases near dental tissues
Indications: bleeding or swelling of the gums, itching in the gums, the appearance of "pockets" between the tooth and the gum, teeth mobility.
Orthodontics:
Specialized (dental) medical care is provided to children in the treatment of dental pathology using removable equipment (orthodontic plates: no more than two plates in 6 months) using domestic materials, with the exception of the bracket system
The waiting time on an outpatient basis is no more than 14 working days
Indications: correction of congenital pathologies of the dentition (occlusion correction) in children
Dental Orthopedics:
Specialized (dental) medical care is not included in the basic compulsory medical insurance program and is not provided under compulsory health insurance
For dental prosthetics, preferential categories of the population have been established
Indications: dental pathology acquired during life (prosthetics and implantation of lost teeth, correction of deformed ones)
Removal of dental plaque (tartar above and below the gum):
The type of treatment in dentistry provided under the CHI program. Treatment and prophylaxis mechanically (the mechanical method of cleaning teeth consists in removing plaque and tartar using tools (hooks, curettes, etc.) and equipment (ultrasonic scalers, powder-jet systems) and manually simultaneously in the area of up to six teeth
The waiting time on an outpatient basis is no more than 14 working days
The indications for the implementation of the therapeutic measure are determined by the attending physician
Improving the quality of dental care for the population is both a medical and no less significant social and economic problem. If the medical significance of improving the quality of dental treatment is generally understood - reducing the number of complications, improving the condition of the oral cavity, maintaining health, then the social and economic aspects of the problem are less well known. They consist in reducing the number of visits to the doctor, reducing the number of retreatments, increasing the productivity of the dentist, and reducing the economic cost per patient over a long period of time. In our opinion, it is precisely the improvement of the quality of the work of specialists, and not the increase in the number of patient admissions, that is the main reserve of the dentist's labor productivity.
Soviet dentistry has come a long way in trying to improve the quality of the work of doctors. At the same time, organizational and managerial measures were mainly used in the form of the introduction of various treatment standards, quality indicators and, most importantly, control methods. The possibilities of this approach were limited, since control was usually of a departmental nature and was poorly effective, and it was impossible to control the treatment of each patient. In addition, the quality of treatment, regardless of control, always lies within the effectiveness of the applied methods of treatment, which did not differ in modernity and novelty.
Another factor in improving the quality of treatment - the introduction of new technologies, was used very little, since the domestic industry produced mainly outdated and low-quality equipment, materials and tools that did not allow the use of new effective technologies, and imported dental products were practically unavailable. The training and improvement of specialists was carried out in many respects formally, without the provision of jobs and modern technologies. As a result, despite the considerable efforts of the dental management, the results of the administrative impact on the quality of dental care were very insignificant and mainly depended on the conscience, skills and capabilities of specialists, their provision and organization of work.
In the conditions of market relations, the problem of the quality of dental care remains central in the treatment-and-prophylactic section of the specialty. Most importantly, there is an increasing understanding in the dental community of the possibilities not only to influence the quality of dental care for the population, but also to manage it, as well as regulate various aspects of this problem. This understanding comes gradually, through realizing the role of professional management of the specialty, within which 60-80% of the opportunities for active influence and regulation of the quality of dental care are located, and only a smaller part of such opportunities are available in the sector of administrative management of dentistry, and this part is closely intertwined with professional problems. dentistry. At the same time, it is necessary to take into account a number of peculiarities of dentistry in Russia that affect the quality of dental care for the population (Fig. 2).
These include:
1. Lack of general dentists;
2. Availability of large state dental clinics with differentiated admission by specialty;
3. Lack of a unified plan for the treatment of patients at the dentist as a system;
4. Impersonal responsibility for the end result of treatment;
5. Weak system of postgraduate training of dentists;
6. Lack of experience in market relations;
7. Lack of a firm state policy in health care.
In the problem of regulating and managing the quality of dental care, we see two main aspects of the systematic approach (Fig. 3):
I. Levels at which the formation and regulation of the quality of dental care takes place;
II. The main problems (directions) on which the quality of dental care depends;
Let's consider the first aspect of the problem under study.
As it follows from it, 4 levels can be distinguished in the formation of management and responsibility for the quality of dental care (Fig. 4).
I. State level
The main task and purpose of quality management at this level is the creation of a legislative, regulatory and policy framework (Fig. 5) that determines administrative, economic, financial, social and legal aspects health care, the formation, responsibility and implementation of the quality of medical care in general and dentistry in particular. At least the following sections should be defined here:
1. State legislation on health care and the compliance of the country's dental service with these documents;
2. Compliance of dental facilities and technologies with state sanitary-hygienic and technological SANPins and rules;
3. Federal state algorithms, standards of treatment, prevention, etc .;
4. Compliance of dental personnel with state educational standards, the nomenclature of personnel - the requirements of their function and training;
5. System of postgraduate training of specialists;
6. Types of dental organizations and their equipment tables;
7. The system of state examination of the quality of dental care.
The state level of the formation of the quality of dental care is created by issuing a number of laws on health care, adopting concepts for the development of health care, a mechanism for implementing these laws, adopting by-laws and directive documents on their basis, etc. departments, regional authorities, etc.
Role state level in the formation of the quality of medical care is decisive and important. Depending on the thoughtfulness, quality, compliance of these documents with the development trends of the state and society, their acceptance or rejection by civil society, their vitality or non-perception, the possibility of the development of the medical sphere or its stagnation depend.
Over the past 15 years, we have seen a lot of both positive and negative impact of legislation and policy documents on the development of health care and the quality of medical care. Such important and significant facts for the formation of civil society as the adoption and understanding of the law or its rejection, participation in its implementation by society or negativism and indifference, etc., depend on legislation and directive documents. Let's take a few examples from the area of healthcare legislation. The main thing in them is that all the government documents adopted on health care have left the medical community indifferent and only a small part of it is aware of them. In our opinion, this happens because the documents do not solve the most serious health problems:
- the leading link in health care remained absolutely disenfranchised medical institutions, wholly at the mercy of officials, the position of doctors remained disenfranchised;
- new forms of medical organizations have not been introduced;
- the possibility or impossibility of privatization and corporatization in healthcare has not been clearly defined for a long period;
- the role of professional associations in health care management and self-government in general has not been defined;
- the problem of professional responsibility and professional risks has not been resolved;
- the frankly weak system of compulsory health insurance is not being improved;
- anti-corruption measures have not been taken;
- the administrative reform in health care is not effective, which led to further growth bureaucracy and a decrease in the competence of management, etc .;
A number of state laws and orders, both positive and negative, are also directly related to dentistry.
So, the order of the Ministry of Health of the USSR No. 50, the order of the Ministry of Health of the Russian Federation No. 312, No. 289 and some others made it possible to significantly improve the quality of dental care for the population, its volume, efficiency and profitability.
At the same time, such facts as the existence of contradictions between the Civil and Budget Code of the Russian Federation in the issue of the use of funds earned for paid services by state medical institutions and the refusal to consider and settle these contradictions led to the fact that all funds earned by state dental institutions are withdrawn to the budget. and are partially returned to these institutions, but already in the form of specific budget items, which does not allow them to be used in the interests of the institution and its staff. This problem has not yet been resolved.
As before, the MHIF is waging a war against planning, accounting and reporting on UET in dentistry, trying to return the specialty to the notorious "visits", without even delving into why dentistry and the relevant legislation have unambiguously approved the conventional units of labor intensity as a single form of accounting, reporting, planning and financing in dentistry, which allowed us to make a revolutionary step in the development of our specialty.
Thus, it can be stated that without new progressive legislation on health care and new directives that adapt health care to market conditions, placing the role and payment of a doctor depending on the quality of his work, it is impossible to seriously improve the quality of medical care in general and dentistry in particular.
Due to the fact that over the past 15 years, health officials have not been able to do this, and there have been no serious attempts, there is little hope for this, given that the quality of the work of the Ministry of Health and its officials has been constantly deteriorating over the past time, and competence has been falling. Against the background of the recent scandals, faith in the Ministry of Healthcare has disappeared not only among professionals, but also among the population. Perhaps that is why the national projects put forward by the President's Office were received with some optimism, which made it possible to hope for their effectiveness. However, these projects lack a systematic approach, which does not allow reforming healthcare with their help.
In the last order of the Ministry of Health of the Russian Federation No. 11-9 / 10 / 2-5718 of December 25, 2012, there are a number of positive changes, in particular, in the planning and accounting of dental care, a return to UET is defined, but at the same time it is recommended to use the UET conversion factor in visits, although such an indicator is not scientifically substantiated and unnecessary. However, it is further permitted (cit.) "When paying for dental care on an outpatient basis, the system of payment for UET can be applied." But almost all dental care is outpatient! According to the order, tariffs should be determined on the basis of standards, which is disastrous for dentistry, since the average per capita standard for all medical care (not only dental) is set at 3.0-3.6 thousand rubles, which actually excludes the conduct of modern dental treatment. Therefore, there are serious concerns that such funding will not improve the quality of dental care.
II. Professional level of influence.
This section of the impact on the quality of dental care (Fig. 6) includes a lot of factors that depend on the professional management and professional work of dentists:
1. Recommendations and implementation of the principles and technologies of evidence-based medicine in prevention and treatment;
2. Attestation, certification and accreditation of dental institutions and personnel (assessment of the knowledge of specialists, the level of organization and management);
3. Independent dental expertise;
4. The system of non-state postgraduate education (conferences, congresses, master classes, competitions, etc.);
5. Standards of the Dental Association;
6. Programs for training personnel at all levels;
7. Development of corporate ethics and professional attitude towards quality treatment and prevention;
8. Demand and control over the fundamental availability of a treatment plan and its implementation for each patient;
9. Introduction of a system of guarantees for treatment;
10. Evaluation, testing and recommendations of any types of dental equipment, instruments, materials;
11. Writing textbooks, manuals, monographs, recommendations, manuals;
12. Determination of the quality of dental care for any purpose, etc .;
Analyzing the list of tasks for maintaining and improving the quality of dental care at a professional level, it can be stated that the bulk of the work on the quality of care is solved by professionals, but these decisions should always be within the existing legislation and directive documents. The main methods for solving problems of the quality of dental care at a professional level are as follows:
- decisions of congresses, conferences, symposia, etc .;
- participation in the work of administrative management bodies (commissions, task verification, etc.);
- fulfilling the tasks of policymakers;
- carrying out various types of non-state training of specialists;
- preparation, correction, development of training programs, textbooks, training materials, etc.
- delegation of the solution of a number of problems (attestation, certification, preparation of some directive documents, etc.) to professionals;
All the difficulties and troubles of improving the quality of dental care at a professional level boil down to the fact that for state dental organizations, professional decisions and recommendations in our country should come in the form of directive documents of administrative health authorities. However, the latter, due to many reasons (bureaucracy, lack of understanding of professional problems, personal relationships, irresponsibility, and much more), either do not accept professional recommendations, or issue them in a distorted form (often with a great delay), or ignore them, making major mistakes in work and thus hinders the development of the quality of medical and dental care. Recently, the violation of the normal interaction of representatives of state and professional levels of quality assurance of medical care is increasingly happening due to the incompetence of the highest level of healthcare management, their non-recognition of the need to work with professionals, disregard of medical public organizations and the opinions of specialists, etc.
This is especially evident in the numerous failures of various programs and acts (administrative reforms, pension reform, drug provision, the work of the MHIF, the lack of real health care reform, etc.). The most surprising thing is that all these failures do not lead to either administrative or personnel conclusions and everything remains the same.
Therefore, it is not surprising that some good initiatives to improve health care are now coming from the President's office in the form of well-funded national projects. But this approach does not have a systemic solution and does not fundamentally transform our healthcare.
III. The institutional level of the formation of the quality of dental care
It includes the following activities: (Fig. 7)
1. Creation of conditions (medical, organizational, managerial, psychological, etc.) for the influx and admission of patients;
2. Technological support for patient reception;
3. Organizational and managerial support for patient admission;
4. Staffing of patient reception;
5. Information support for patient admission;
6. Creation of economic and financial mechanisms work of institutions in accordance with budgetary, market, insurance and other working conditions;
7. Creation of an incentive system for high-quality work of specialists, for mastering new technologies, for increasing the flow and admission of patients in all departments of the clinic;
8. Demanding a treatment plan for each patient and monitoring its implementation;
9. Availability of a system of responsibility for each patient, first of all - personal;
10. Evaluation of the quality of work of specialists and taking measures to improve it, to train personnel, etc.
A great advantage of the institutional management and regulation of the quality of dental care is the huge role of the chief physician, staff selected and trained in good traditions in providing quality dental care to the population. Today, the corps of chief doctors of dental institutions is one of the main treasures of our specialty, sincerely interested in the quality of dental care and doing a lot for this.
However, the limits of the capabilities of the dental organization of institutions and their leadership are within the framework of the existing imperfect legislation, the absence of many necessary directive documents or ignoring of the existing ones by the administrative leadership (MHIF, higher organizations, etc.), the lack of budget funding, complete dependence on the higher management, often indifferent and incompetent. , suppression of many initiatives, etc. etc. All this takes place in the conditions of high quality requirements on the part of the administrative bodies of health care while ignoring or not fulfilling their direct responsibilities as representatives of the owner in health care to maintain a decent level of funding, provision and development of subordinate organizations and professional level of management. In this situation, the institutional level of dentistry cannot develop or its development is extremely difficult, and the work of specialists does not inspire optimism in the possibility of improvement.
All this gives rise to a gray and black market for dental services in public institutions, since specialists cannot adequately live on the budget and legislation provided. wages... In turn, the gray and black market for dental services in institutions leads to a decrease in the quality of work, irresponsibility, mutual responsibility and other troubles that impede the normal development of our specialty.
IV. The medical level of the formation of the quality of dental care
It includes the following measures (Fig. 8):
1. Execution of algorithms (standards) of prevention and treatment;
2. Information support for treatment and patient consent to treatment;
3. Professional attitude towards high-quality treatment and prevention;
4. Good technological preparation, readiness and ability for continuous self-education and improvement;
5. The relationship between remuneration and the quality of medical and preventive work, decent remuneration for personnel.
The medical level of quality of dental care is characterized by the fact that it intersects the advantages and disadvantages of all previous levels of management and quality assurance of dental care - federal, professional and institutional. Any disadvantages of higher levels inevitably affect the main performer of dental care for the population - the quality of the dentist's work. If the available solutions do not provide a direct relationship between the quality of dental care and a decent salary for specialists, then one cannot expect a high quality of work at a doctor's appointment. Inevitably, one of the options for the specialist's additional earnings to a level that ensures a decent life for him and his family arises, which is usually expressed in the emergence in the institution of a gray or black system of remuneration and mutual responsibility for such an approach. In a gray economy, it is very difficult to ensure and monitor compliance with all the principles of quality treatment, starting from the psychological environment and ending with the ethical principles of such a technique.
We in Russia now live approximately in the situation described above. Who is to blame for this? The most wrong thing is to find the culprit in the performer of dental care - the dentist. Is he to blame for the fact that he is not able to provide a decent life for his family on official earnings in government agency? Is it his fault that the state dental institution is not provided on the budget with the necessary technologies, equipment, materials?
To improve the quality of dental care, the entire health care system needs to be reformed, and this requires serious government decisions regarding the financing and economics of health care, the forms of organization of medical institutions, a harmonious change in health care management, changing the status of a doctor, and granting more rights. medical organizations, their leaders, and, finally, - a profound change in the role and position of the doctor in health care, this root, main figure, without improving the position of which any other measures are meaningless.
In the second part of the work, we will touch on the characteristics of the main areas that determine the quality of dental care for the population (Fig. 9).
In the context of the transition to market relations, the ways of influencing the quality of dentists' work are changing and improving significantly. In this case, one can distinguish:
1) the influence of market mechanisms;
2) introduction of modern effective treatment technologies;
3) administrative and managerial methods;
4) the use of subjective factors.
1. The introduction of market relations should affect the quality of the work of dentists in the most direct way. It should be assumed that this factor will be the most important turning point in improving its quality. A number of mechanisms should work here: (Fig. 10)
a) Competition for medical services. This factor appears when a medical service becomes a commodity that can and should be bought. In this case, the buyer - the patient of the dentist - tries to acquire the most acceptable dental care for him in terms of price, quality, convenience, and guarantees. Therefore, there will be competition between dentists and dental institutions, a struggle for the dental services market. At the same time, the main indicators of the struggle for the market should be the factors of the cost of dental care, the quality of treatment and its comfort. These factors will inevitably entail the desire to improve the quality of dental services by influencing all the components that affect it - the qualifications of specialists, modern technologies, wages, etc. Therefore, the emergence of market relations actually automatically entails the desire to improve dental care by specialists and dental institutions. Those who manage to achieve this will survive in the market, acquire and retain patients, and improve their developmental opportunities. The quality of treatment will become one of the selection factors in the competition in the market.
b) The choice of a doctor, institution, form of dental care by patients will become the main methods that will be used by patients, enterprises, insurance companies to receive highly qualified and comfortable dental care. The same factors should determine the salaries of specialists, the formation and development of dental institutions that will be able to adapt to market relations, as well as the most convenient and beneficial forms of dental care for the population. In the conditions described, there will be no place for unsatisfactory dental care, its poor organization, overpriced with inadequate quality of services. Poorly trained dentists will find themselves without patients if they fail to improve the quality of their work.
The result of the free choice of a doctor will inevitably be an increase in the quality of his work, a sharp differentiation in payment, the emergence of classy clinics, the desire to master new technologies, the migration of specialists, an increased demand for training in new technologies, the desire to update equipment, repair, reorganize clinics.
2. The desire to use new effective technologies for treatment and prevention should become one of the most important factors in improving the quality of dental care (Fig. 11). In the last 30 years, a deep technological breakthrough has been made in dentistry, especially in the field of cariesology and prevention, which allows to dramatically increase the effectiveness of dental care for the population. Unfortunately, insufficient attention, poor funding, ideological barriers, and subjectivity contributed to the serious lag of Soviet dentistry behind the world technological level of advances in the prevention and treatment of dental diseases. The domestic industry had no interest in the production of modern materials, equipment, tools, the primitive system of their distribution through Medtekhnika could not provide a choice to a specialist. The institutes not only did not teach, but did not even mention in the textbooks the presence of other, more modern and advanced technologies.
The transition to market relations has dramatically changed the situation. Any dental products have appeared on the emerging market of dental products, specialists have the opportunity to purchase the most modern materials, equipment, tools. At the same time, the material capacities of dentists and institutions have also increased, although not adequately for prices. The dental community quickly came to understand that it is unacceptable, having learned about new technological possibilities, to remain within the framework of previous ideas. There was a desire for training, the use of new technologies, their acquisition, for which it turned out to be necessary to find new sources of funding, forms of work, economic approaches... Not everyone is able to overcome the difficulties that exist here, especially in the absence of support from the regional leadership, chief physicians, and healthcare management. An important aspect is the psychological side of the problem. Neither the leadership of the regions, nor the leadership of health care, nor the population can yet understand and get used to the fact that the transition to new technologies of treatment and prevention is inevitably associated with a new and very high price that must be paid for them, and it is practically possible to take this money either from the state or from the patient. The state, as you know, currently does not have such capabilities. Health care spending has not increased. Therefore, almost the only source of additional funding for dentistry is money from the population, enterprises, organizations that want to pay for high-quality dental care. Unfortunately, neither the existing legislation, nor the Ministry of Health of Russia have taken any steps to introduce the new relations emerging between health care and the population into the generally accepted and, most importantly, legal channel. It is necessary to understand that there is no other way out. Now, neither dentists nor the population will ever give up either new technologies or the opportunities they provide.
Separately, we should focus on the problem of teaching new technologies. The current system of postgraduate education does not meet the needs of dentists, since in most clinics they are not provided with a workplace, there is no necessary equipment, materials, tools, and teachers themselves often do not own modern technologies. Now, in fact, the former system of postgraduate education has collapsed. But in its place there are still no new state structures capable of meeting the needs of practice. At the same time, the problem of education is naturally invaded by the owners of dental products enterprises and their distributors. They are ready to create and create the necessary Training Centers for specialists, but they have neither experience nor qualified specialists. Probably, hybrids are already emerging on the basis of disintegrating postgraduate departments and companies interested in selling technologies that will be able to create efficiently operating postgraduate training centers.
3. Administrative and managerial measures have always been and will be one of the important ways to improve the quality of the work of specialists (Fig. 12). The main one should be the introduction of professional (industry, medico-economic, state) algorithms and standards for the work of dentists. Standards should ensure the quality of the work of dentists of all specialties, while fulfilling several functions. The content of the standard is to describe certain technological methods of diagnosis and treatment that a specialist must apply for effective examination and treatment of a patient. At the same time, the standard, in addition to the medical one, should contain a legal aspect - the rights and obligations of a doctor and a patient in their relationship during treatment, as well as an economic aspect - the possibility of assessing the cost of technological methods of diagnostics and treatment made by medical personnel.
The standards should be used to assess the quality of diagnosis and treatment by comparing the actions performed by the physician to the standard. They should also be used in all conflict situations arising between patients and a doctor, a doctor and an administration, a doctor and an insurance company, a court, etc. Problems of pricing, profitability, and economic relations should be resolved on the basis of the standard.
The standards should cover all areas of work of specialists - training and retraining of personnel, equipment and condition of workplaces, offices and clinics, the quality of dental products. Non-compliance of these indicators with the standard should automatically lead to a ban on work at a given workplace, office, clinic, for specific technologies, for a specific specialist until all shortcomings are eliminated and the work is brought in accordance with the standard. Almost the entire world uses the standard as the main mechanism for ensuring the quality of medical care. Now the main problem for solving this issue is the drafting of standards. This is a large and painstaking work that can only be performed by qualified specialists (usually within the framework of the Dental Association), associated with significant material costs. Such a labor of compiling federal standards is now underway MGMSU and StAR within its own funds.
At the same time, one must also see the shortcomings of the standards. Each patient and his illness is individual, personified. Therefore, the standards do not take into account the characteristics of patients, diseases and their treatment. In the standards, the main part should be their algorithmicization - the medical and technological focus of treatment. Blind adherence to standards can deprive a doctor of creativity, an individual approach, which, in the end, can harm both the patient and the doctor himself. Therefore, the main role of standards should be defined as the etiopathogenetic orientation of treatment, and the choice of technology should always remain with the doctor, within the limits of his knowledge and capabilities, the characteristics of the patient and his illness, as well as the patient's consent to treatment.
Life shows that only administrative and organizational measures, the emergence of market relations, the introduction of new technologies and training are not enough to improve the quality of dental care for the population. It is not uncommon for patients to receive substandard dental care in well-organized clinics with modern equipment and technologies operating on the basis of market relations. The most striking thing is that it is often provided by highly qualified doctors who know how to work well, have the relevant knowledge and experience.
What's the matter? Not less, and in some cases - the decisive role is played by the subjective, human factor (Fig. 13). We call it conditionally - the professional installation of specialists. We are talking about the conviction of a specialist in the need for highly qualified treatment of patients always, all, regardless of rank, condition of teeth and oral cavity, payment and other factors. At the same time, the professional attitude of the dentist should arise under the influence of two factors - the internal conviction of the specialist and external influences. The internal conviction of a dentist in the need for high-quality treatment arises as a result of his education as a specialist - training, communication with patients, empathy, understanding the needs and aspirations of the patient. This inner conviction should result in a constant desire to help the patient as much as possible, not to calm down until the maximum possible dental care is provided to him, and the necessary treatment results are achieved. This quality should make him turn to the help of other specialists, to consultations, even to transfer the patient to another doctor, if he cannot achieve the necessary results. It is this conviction that should first of all underlie the need for training and improvement of a specialist. Soviet dentistry, despite all the imperfection of its technologies, organization, etc., always had many such specialists who, working without appropriate opportunities, achieved brilliant success. But at the same time, one cannot but say that there was no proper education of specialists in the above spirit, which is explained by many reasons that we do not discuss here.
Along with the inner conviction of a specialist about the need for only high-quality work, there is also an important problem in this problem. external factor... It consists, first of all, in corporate thinking - what will his colleagues say about the work of a specialist, how will they evaluate his work, his skill, his qualifications. The role of this factor increases dramatically when there are many highly qualified specialists in the team who support the clinic's image. In the conditions of market relations, the role of this factor also increases sharply, since the opinion of patients, salary problems, etc. are actively added to the solution of this problem. the organization of specialists for the quality work of their colleague inevitably increases dramatically, as does their mutual responsibility.
Thus, the provision of ways to improve the quality of dentists' work in the new conditions of the transition to market relations takes on a new meaning and new directions. In many ways, it will now be determined by market and professional factors. Their influence must be taken into account in the planning of the entire work of the dental service.
In conclusion, it is necessary to touch upon a number of issues, without a correct and targeted approach to which it is impossible to solve the problems of the quality of dental care.
1. The statement of the problem should relate to improving the quality of dental care for the population and contain the whole set of solutions to it both by levels (state, regional, etc.) and by directions (administrative, economic, market, etc.), those. it must be systemic;
2. To improve the quality of dental care, there should be a plan for this work, which includes the solution of all issues (in time) on which the quality of dental care depends, taking into account the importance of each section;
3. The easiest, simplest, and ineffective solution lies in the substitution of the concept of regulation and the organization of improving the quality of dental care by its control. Quality control, examination of the quality of dental care are the least significant and most ineffective measures in the range of measures to improve the quality of dental care. By themselves, they are ineffective and, basically, are necessary for solving the problems of conflict management. But now in our country, unfortunately, there is a great desire everywhere to control, make expertise, punish and lead. This, naturally, is ten times easier than taking even the simplest measures to improve the quality of dental care. Of course, “keep out and forbid” is easier than actually preparing and implementing effective quality measures. If you look at reality in the eye, now only the heads of a number of dental institutions, dentists are engaged in improving the quality of dental care, undergoing training and improving their work, completing various postgraduate courses where there are opportunities for learning new technologies.
In other governing and directing institutions, expert councils are created, experts are appointed, training in quality examination is carried out, etc. Unfortunately, there are no tips, orders, directives on specific measures aimed at improving the quality of dental care for the population, either in the Ministry of Health and Social Development, or in the Agencies under it, or in the Central Research Institute of Information Technologies. Separate, but serious steps in this direction were made only in StAR, which for a number of years purposefully and regularly taught new methods of anesthesiology in dentistry, restoration and treatment of teeth, endodontics, etc. All this was done by the efforts of the dental community, without state plans and funds at a high professional level.
Therefore, it is necessary to create joint groups of officials and professionals who would train Required documents and activities that can make a real difference to the quality of dental care.
4. It is impossible to achieve an improvement in the quality of dental care without the allocation of additional funds for staff training, the purchase of equipment and materials, revision and adoption of a number of laws, regulations, directive documents, without changing the status of dental organizations and the position of dentists. It is at the solution of these problems that the work of all links of state and professional management of health care and dentistry should be directed.
I would like to touch upon the criteria for the quality of dental care (materials by V.D. Wagner).
The following main provisions are highlighted:
1. Safety of assistance;
2. Clinical effectiveness;
3. Cost-effectiveness;
4. Timeliness of assistance;
5. Equality of all patients in receiving dental care;
6. Active participation of the patient in receiving dental care (contract, informed consent)
As follows from this list, comparing it with the levels and areas that ensure the quality of dental care, the above criteria in their positive form can only be achieved as a result of long-term work in all areas and at all levels that determine and regulate the quality of dental care for the population (Fig. fourteen). Without such work, it is impossible to achieve positive criteria for dental care. In this regard, the examination of dental care helps only to determine the level of quality of dental care that a particular region, institution, doctor has managed to achieve, to determine what further goals and objectives are, to identify weaknesses and mistakes, as well as the necessary measures to eliminate them. ...
Finally, the level of quality of dental care in practice looks like the effectiveness of the entire system of dental care and is determined by a large number of indicators, starting and ending with the availability of the opportunity to receive any type of dental treatment and prevention.
Thus, the management and regulation of the quality of dental care is a multilevel and multidirectional process that requires serious analysis and integration of the existing state of care and information about it, an objective picture of the situation, deep research and creativity in order to take real and effective measures to improve it. It should be based on a systematic approach and long-term comprehensive purposeful work.
Administration of St. Petersburg
HEALTH COMMITTEE
ORDER
Organization of outpatient dental care
in the compulsory health insurance system
_________________________
Document with changes made:
by order of the St. Petersburg Healthcare Committee of September 22, 2006 N 389-r.
In pursuance of the order of the Governor of St. Petersburg dated 16.10.2000 N 1090-r "On the territorial program of state guarantees for providing citizens of the Russian Federation with free medical care in St. Petersburg" and in order to provide residents of St. Petersburg with guaranteed volumes of free dental care:
1. To approve:
1.1. "Form of materials, consumable instruments and medicines for the provision of outpatient dental care in accordance with the Territorial program of compulsory medical insurance of citizens of the Russian Federation in St. Petersburg" (Appendix N 1).
1.2. "The volume of outpatient dental care for the adult population in accordance with the Territorial program of compulsory medical insurance of citizens of the Russian Federation in St. Petersburg" (Appendix No. 2).
1.3. "The volume of outpatient dental care for children in accordance with the Territorial program of compulsory medical insurance of citizens of the Russian Federation in St. Petersburg" (Appendix No. 3).
2. To consider as invalid the order of the Health Committee of 30.06.1995 N 381 "On the organization of the dental service under the conditions of the Law on Compulsory Health Insurance", the order of the Health Committee of 14.10.1996 N 429 "On amendments and additions to the order of the Health Committee N 381 of June 30, 1995 ", paragraph 3 and Appendix N 1 of the order of the Health Committee of 01/09/2001 N 2-r" On the introduction of dental and oncological care in the compulsory health insurance system. "
3. Control over the execution of the order shall be entrusted to the Deputy Chairman of the Committee for the Organization of Medical Aid to the Population, V.Ye. Zholobov.
And about. Chairman of the Committee
on health
A.I.Frolova
Appendix 1 to the order. LOST POWER
Appendix N 1
at the disposal of the Committee
on health
dated 06.02.2001 N 28-r
Form of materials, consumables and
medicines for outpatient
dental care in accordance with the Territorial
compulsory health insurance program
Russian citizens in St. Petersburg
___________________________________________
Appendix 1 has ceased to be in force on the basis of
Health Committee orders
St. Petersburg dated September 22, 2006 N 389-r -
see previous edition
___________________________________________
Appendix 2 to the order. The volume of outpatient dental care for the adult population in accordance with the Territorial program of compulsory medical insurance of citizens of the Russian Federation in St. Petersburg
Appendix N 2
at the disposal of the Committee
on health
dated 06.02.2001 N 28-r
1. Dental care.
Reception of the dentist is therapeutic and diagnostic.
Treatment of caries, pulpitis, periodontitis.
Removing a permanent seal.
Trepanning of the tooth crown.
Therapeutic treatment of a tooth with a root fracture.
Treatment of periodontal diseases.
Removal of dental plaque.
Oral hygiene training.
Oral hygiene control.
Determination of hygiene indices.
Selective teeth grinding.
Coating teeth with varnish.
Opening of the abscess with an intraoral rupture.
Exposure of the crown of the impacted tooth.
Postoperative dressing in the oral cavity.
Stopping bleeding.
Surgical treatment of wounds with sutures.
Operations on the soft tissues of the oral cavity.
Extraction of teeth.
Orthodontic treatment using an inclined plate, Angle's arch, sling.
Appendix 3 to the order. The volume of outpatient dental care for children in accordance with the Territorial program of compulsory medical insurance of citizens of the Russian Federation in St. Petersburg
Appendix N 3
at the disposal of the Committee
on health
dated 06.02.2001 N 28-r
1. Dental care.
Reception of the dentist is preventive and medico-social.
Reception of the dentist is dispensary, medical, diagnostic.
Dentist consultation.
Home visit to the dentist by car.
Treatment of non-carious lesions of dental hard tissues, caries, pulpitis, periodontitis.
Treatment for traumatic tooth damage.
Treatment of diseases of the oral mucosa.
Removing the stone.
Remineralizing therapy.
Professional hygiene of all teeth.
Oral hygiene monitoring using indicators.
Drawing up a prevention plan.
Opening the abscess with an intraoral incision.
Treatment of alveolitis with hole curettage.
Exposure of the crown of the impacted tooth.
Postoperative dressing.
Stopping bleeding.
Surgical debridement with sutures.
Excision of the "hood" with pericoronitis.
Treatment of diseases of the salivary glands.
Operation on the soft tissues of the oral cavity.
Extraction of teeth.
Reduction of dislocation, subluxation of the temporomandibular joint.
Application, infiltration, conduction anesthesia.
Intravenous anesthesia, mask.
Prevention of facial skeletal anomalies, functional treatment.
Apparatus orthodontic treatment with the use of the Angle arch, the Klampt apparatus, a widening and vestibular plate, a plate with a support for the tongue, with an inclined plane.
The imposition of a sling.
Silvering of carious cavities.
2. Help from support services.
X-ray examinations.
Physiotherapy treatment according to medical indications (according to the referral of the attending physician).
Document revision taking into account
changes and additions
prepared by legal
bureau "KODEKS"