Improving practice and patient care in OMFS
This page is aimed at OMF surgeons and other health care professionals interested in the QOMS project. A similar page for patients and members of the public interested in finding out more about QOMS is under construction.
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2020 and 2021 have so far been quite interesting and challenging and we hope that the rest of 2021 will see a return to "normal".
Over this period, BAOMS has run 3 COVID-19 service evaluations (dental infection and OMFS trauma), the results of which have been published online in BJOMS and collaborated in the COVIDTrach project, which has now published 2 reports. (See Publications).
The QOMS project team has been working on the next phase of the QOMS project. There are still opportunities for surgeons to have direct inputs into QOMS, simply contact the Project Manager Fabien Puglia or via the QOMS forum.
Escalating healthcare expenditure in the NHS is unsustainable, and service commissioners need to provide cost-effective surgical procedures that demonstrate clear health benefits in line with best evidence-based practice. Patients should expect, and demand, high quality care and the best possible surgical outcomes from oral and maxillofacial surgery (OMFS), but the specialty lags behind other surgical specialties in publication of clinical outcomes across the UK (McMahon et al. 2018, Ho et al. 2021).
In November 2018, the Getting It Right First Time (GIRFT) initiative published their first report for the oral and maxillofacial surgery. The report highlighted the lack of systematic clinical outcome measures in place, thus limiting opportunities for the specialty:
- To understand if care was being delivered in line with standards
- For providers to benchmark themselves against others
- To support continuous improvement.
Recommendation 5 of the GIRFT recommendations was to "Deliver an efficient and patient-focused outcomes audit programme for oral and maxillofacial surgery”.
BAOMS, under its 2018 President Mr Ian Martin, and with the support of Council, initiated a specialty-wide quality improvement and clinical effectiveness programme, the Quality and Outcomes in oral and Maxillofacial Surgery (QOMS). This reflected the President’s view that implementing systematic quality improvement in OMFS and ensuring effectiveness of care provided based upon appropriate metrics were key to the continued successful development of surgical care in the NHS and reflected the core culture of the Association.
QOMS is the quality improvement and clinical effectiveness programme for OMFS.
To meet the needs of the specialty, QOMS developed a series of registries to address issues around quality of care and improvement, and clinical effectiveness. The Subspecialty Interest Groups and the membership were consulted to decide on the procedures, conditions and the quality-of-care indicators to be included in QOMS.
Data collection and storage is managed by the Barts Cancer Research-UK Centre at Queen Mary University of London (BCC, QMUL), using the Research Electronic Data Capture software (REDCap).
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To set up and develop a sustainable quality management and clinical effectiveness programme that delivers continuous improvement in the care of patients undergoing OMFS, within all parts of the NHS and demonstrates health-related benefits to patients from selected core OMFS activities.
QOMS basically is composed of a series of clinical registries set up to collect data about OMFS practices in the UK and in time the Republic of Ireland. They were developed for either quality improvement (audits or service evaluations) or clinical effectiveness and surveillance (disease- and procedure-specific registries). QOMS exists in parallel to other already existing registries and quality improvement initiatives (see below).
Figure 1. Roles of clinical registries
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Data collected in QOMS will be used to compare OMFS units across the UK and identify and share best care practices. The project focuses on areas of the care process that impact on OMFS surgical teams.
Figure 2. Use of clinical registries for audit and quality improvement activities
QOMS wants to identify best performers against any given metric across the NHS, quality assure that data, and then generalise the care practices that underpin it by case studies, newsletters, presentations at conference, as well as BAOMS website content. Where performance falls significantly below the mean, and data checking confirms that to be the case, the Association intends to provide mentorship for change.
Figure 3 - Oral & dentoalveolar
Figure 4 - Trauma
Figure 5 - Oncology
Figure 6 – Reconstruction
Figure 7 - Non-melanoma skin cancers
Figure 8 – Orthognathic
The orthognathic component of QOMS is also interested in collecting patient reported outcome and experience measures (PROM / PREM) and is working with the British Orthodontic Society (BOS) to select and develop this tool.
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While audit activities mainly concentrate on the lower part of the clinical registry cycle, QOMS aims to also develop in time some disease- or procedure-specific registries. Those registries will be used to assess the long-term effects and the changes of current practices on care quality and patient’s outcomes and look at OMFS practice for which there is little or no strong available evidence and support the development of for high-quality, strong recommendations.
Figure 9. Use of clinical registries for clinical effectiveness, disease- and procedure-specific registries
With the launch of the 2nd phase of QOMS in spring 2021, the project team will focus their attention towards developing those registries. At the onset of QOMS, the following themes were proposed:
- Salivary gland cancer
- Patient-specific mandibular implants
- Benign tumours of the jaws
In a first instance, the team will focus on writing up the protocols for those registries to highlight their aims and how they will be run.
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- The QOMS project team is also working with the Saving-Faces-run Head And Neck Audit (HANA) to minimise data entry across the subspecialties of oncology and reconstruction and the BAPRAS-run UK National Flap Registry (UKNFR), which published its first report in 2019.
- The Temporomandibular Joint (TMJ) Replacement Registry already exists and is administered independently of QOMS by Dendrite Clinical System Ltd. We hope that we will be able to include some reporting based on the content of this registry into QOMS.
- Third molar audit developed by Saving Faces and led by Geoff Chiu.
- The National Clinical Improvement Programme (NCIP) from NHS digital and The Getting It Right First Time (GIRFT) initiative in England. Both initiatives are using data from the NHS Health Episode Statistics (HES) database. Efforts are underway for HES data to be utilised for comparative purposes, hence accurate numbers and good quality data will be essential in providing information for the next phase of the BAOMS QOMS initiative. GIRFT is currently working on their 2nd data deep dive into HES data to assess quality of clinical coding and care. We are working with GIRFT to validate case ascertainment for QOMS. NCIP has been working since 2018 on ways to use HES data to drive quality improvement across a variety of surgical specialties. For Head and Neck oncology and reconstruction, they collaborated with Reza Nouraei, an ENT surgeon at Southampton, to develop an algorithm to extract identify and clinical data form HES. They have created in parallel a portal where surgeons can visualise their data for a set of indicators. NCIP is currently trying to pilot their systems in different hospitals in England. NCIP is also working on expanding their work onto other areas of OMF practice.
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QOMS is overseen by the BAOMS Council and the QOMS Steering Committee. The QOMS team is led by the BAOMS QOMS Clinical Lead, Mr Michael Ho, and deputy lead, Mr David Tighe. The QOMS Project manager, Dr Fabien Puglia, is responsible for the day-to-day activities of the project.
The project team also include:
- The Information Governance Group (IGG), which deals with all information governance issues. The IGG includes Mr Michael Ho, Mr Jeremy McMahon (Caldicott Guardian), Dr Marisa Mason (National Confidential Enquiry into Patient Outcome and Death NCEPOD) and Dr Fabien Puglia.
- The Audit and Registry working groups:
- Oncology-Reconstruction and Skin cancer: Mr Panayiotis Kyzas and Mr Conor Bowe
- Trauma and Oral and dentoalveolar surgery: Mr Geoff Chiu and Mr Basim Dawoud
- Orthognathic surgery: Professor Ashraf Ayoub, Mr Moorthy Halsnad, Ms Christine Lwin, and Mr Alexander Hills
- Salivary gland cancers: Mr Damian Broderick
- Trainee representative: Ms Harmony Ubhi
- A Patient and Public Involvement group made up by patients and lay members to represent the opinions and voices of patients from different subspecialties.
- QOMS is also supported by members of Saving Faces: Professor Iain Hutchison, Dr Fran Ridout and Ms Sharon Cheung.
Meet the team section (under construction)
Figure 10. Structure of the QOMS project
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Following the initial audit pilot (December 2019 - March 2020) in 6 OMFS units in England and the feedback we received, QOMS underwent further refinement (for more details, read Ho et al. (2021) BJOMS).
- Questionnaires have been revised by the new Audit Groups and SSIGs to improve their content, structure and flow.
- To ease the burden of the data collection process, where it was possible, we are seeking support to collect patient data without consent. QOMS has been granted support for Confidentiality Advisory Group (CAG) section 251 in England and Wales. We are preparing a similar application to the Public Benefit and Privacy Panel for Health and Social Care (PBPP) in Scotland. However, as it stands, data collection will be anonymous in the Scotland and Northern Ireland. There is no equivalent regulatory body in Northern Ireland (and the Republic of Ireland).
- Appointment of Data Coordinators in OMFS units to support and improve data collection. This is a 3-year pilot to demonstrate the value of encouraging NHS Trusts and Health Boards to support this process in the long term (see below for more details).
The new phase of QOMS will be open to every OMFS unit and/or surgeon in the UK (subject to local information governance approval) and will effectively be the initiation of the definitive QOMS data collection process. Some funding from BAOMS is being provided to 10 OMFS units to employ a dedicated data co-ordinator to effectively support high-quality and comprehensive data collection.
Application for this funding opened to every OMFS units nationwide at the end of 2020. Unit selection was based on a competitive process: track record in engagement with quality improvement, national audit and academic outcomes. Successful applications required the committed engagement from all local OMF surgeons and the hospitals’ medical directors.
The data co-ordinator job is a part-time position and its funding supported by a pump-priming grant for 3 years. The individual appointed will work closely with the local QOMS clinical lead and other surgeons to collect and update data for the project. Behind that 3-year initial funding, BAOMS hopes:
- To have demonstrated the importance and value of the QOMS programme and
- That OMFS departments will be able to secure local funding from their NHS Trusts and Health Boards to continue data collection or to start taking part inQOMS.
For interested units, the data co-ordinator job description is available here (if not logged in already, you will need to login to the Members' area first to view this document, under Members>Further Resources>QOMS documents).
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QOMS is open to every unit in the UK. The following units are already taking part:
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QOMS Short Introduction for Clinicians
This video gives a quick overview of QOMS, the quality improvement and clinical effectiveness programme initiated by the British Association of Oral and Maxillofacial Surgeons for the specialty (BAOMS).
QOMS Introduction for Clinicians
This video describes briefly the Quality and Outcomes in Oral and Maxillofacial Surgery, QOMS. QOMS is the quality improvement and clinical effectiveness programme initiated by the British Association of Oral and Maxillofacial Surgeons for the specialty (BAOMS).
The QOMS experience in Glasgow
This video is an extract of the webinar held by the QOMS Team in November 2020.
Webinar links to videos:
The webinars held in 2020 and 2021 for OMF surgeons were given by the BAOMS QOMS team to introduce QOMS to a wider audience, present the 2nd phase of the project and offer an opportunity to participants to ask questions directly to the team. Both webinars also included a short presentation by Jeremy McMahon showing how QOMS could be used to assess performance of clinical care locally and direct future quality improvement work.
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- McMahon J, Puglia F, Martin I, et al. Measuring health-related benefit and quality of care in oral and maxillofacial surgery: British Association of Oral and Maxillofacial Surgeons Outcomes Project. British Journal of Oral and Maxillofacial Surgery 2018;56:439–43. doi:10.1016/j.bjoms.2018.05.016
- Ho MW, Nugent M, Puglia F, et al. Results of flap reconstruction: categorisation to reflect outcomes and process in the management of head and neck defects. British Journal of Oral and Maxillofacial Surgery 2019;:S0266435619303213. doi:10.1016/j.bjoms.2019.08.005
- Ho MW, Puglia F, Tighe D et al. BAOMS QOMS (Quality and Outcomes in Oral and Maxillofacial Surgery): a specialty-wide quality improvement initiative, progress since conception. British Journal of Oral and Maxillofacial Surgery 2021 DOI: https://doi.org/10.1016/j.bjoms.2020.12.023 (accepted)
- Ho MW, Puglia F, Tighe D et al. BAOMS QOMS: findings from the pilot phase and lessons learned in the feasibility evaluation of a national quality improvement initiative. British Journal of Oral and Maxillofacial Surgery 2021 DOI: https://doi.org/10.1016/j.bjoms.2021.02.015 (accepted)
- COVIDTrach collaborative. COVIDTrach; the outcomes of mechanically ventilated COVID-19 patients undergoing tracheostomy in the UK: Interim Report. Br J Surg. 2020 Nov;107(12):e583-e584. doi: 10.1002/bjs.12020. Epub 2020 Sep 17. PMID: 32940347.
- Hamilton N, Schilder A, Jacob T, et al. COVIDTrach; a prospective cohort study of mechanically ventilated COVID-19 patients undergoing tracheostomy in the UK. medRxiv 2020;:2020.10.20.20216085. doi:10.1101/2020.10.20.20216085
- Puglia FA, Hills A, Dawoud B, et al. Management of oral and maxillofacial trauma during the first wave of the COVID-19 pandemic in the United Kingdom. British Journal of Oral and Maxillofacial Surgery 2021;:S0266435621000140. doi:10.1016/j.bjoms.2020.12.021
- Puglia FA, Ubhi H, Dawoud B, et al. The management of odontogenic cervicofacial infections presenting to Oral and Maxillofacial Units during the first wave of the COVID-19 pandemic in the United Kingdom. British Journal of Oral and Maxillofacial Surgery 2021;:S0266435621000012. doi:10.1016/j.bjoms.2020.12.017
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If you have any questions or thoughts you’d like to share with us, please contact Fabien Puglia, QOMS Project Manager. For updates, follow us on social media:
Useful documents:
Important links:
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Last updated: April 2021