The South Wales Peer Review Group: A Case Study in Collaboration Part 1

Identifying the challenges

An initial core group of participants representing England, Scotland, Wales and the Republic of Ireland, from both primary and secondary care, came together to outline a backbone of challenges which would make up the framework of discussions for the resumption of orthodontic services (Figure 1).

Much has been said of the unprecedented nature and speed at which the pandemic took hold around the world. Understandably, with no equivalent public health crisis involving communicable diseases affecting dentistry in recent memory, like other public sectors, the UK dental profession was caught largely unprepared and ill equipped for such a crisis. This meant that there was no ‘off the shelf’ template for how dentistry should respond. The framework mechanisms and policies required for an appropriate rapid response were absent and their absence will pose as much of a challenge for the resumption of activity as it did for suspension, perhaps more so.

A lot of uncertainty and anxiety comes from the absence of evidence demonstrating the degree to which operative dentistry is implicated in the transmission of disease within a community and, as such, its involvement in the R0 (the reproduction number, or the average number of secondary infections produced by 1 infected person). The impact of this backdrop of weak evidence, and its interpretation, is emphasized by the variations within the guidelines produced by several jurisdictions and professional bodies. We see differences in guidance between NHS Wales and NHS England, as well as Public Health authorities in Scotland, Wales, England and Northern Ireland which, by virtue of the nature of devolved power, are entitled to produce their own independent advice. Whilst there may well be co-ordination behind the scenes, the Chief Dental Officers continue to vary in their advice and management of the crisis, for instance approving the resumption of some services within primary care in England whilst simultaneously maintaining a Red Alert status in Wales. This can lead to confusion and frustration for both the members of the profession and the general public, especially when reported in the media.

Furthermore, there are challenges with regards to the sourcing and funding of quality Personal Protective Equipment (PPE) and the guidance on the level of enhanced equipment required for certain procedures. This, in turn, is associated with conflicting guidance on procedures which constitute an aerosol-generated risk and how these will be managed in primary and secondary care settings. Consideration for the generating of aerosols and the potential affect this has on disease transmission has implications on clinical activity and surgery layout, with open-plan polyclinics having to consider reconfiguring the clinical setting and alterations to patient scheduling. It was recognized that there is the potential for significant financial investment being undertaken for changes which may merely be transient and unnecessary in the longer term, but which may be essential for the transitional period during de-escalation.

The South Wales Peer Review Group (Figure 2)

The South Wales Peer Review Group (SWPRG) was founded on the basis of collaboration, co-operation and the creation of a safe space for the sharing of ideas. It was created on the principle that the sum of our collective contributions and innovations is stronger than our individual endeavours.

Still in its infancy, the concept is delivered through peer group sessions, where facilitated debate and discussion is used to break down complex and difficult challenges. This format has already been successfully utilized to discuss topics, including the consent process, work-life balance, complaints handling, interview techniques and, most recently, the session upon which this paper is based: Orthodontics: Beyond the Lockdown.

Organizations are now recognizing peer review to be an innovative and effective tool for the instigation of change, especially when used alongside clinical audit and professional development. As reflection and introspection become the favoured paradigms of learning, peer review can begin to take a more prominent role in service planning, problem solving, higher education teaching and crisis management. Studies by Clegg et al¹ and Peel² found that there was a complex negotiation between the reflective and active components of personal development that allows for individuals to engage more effectively with a given process. This effectively means that, when the reflective component is intrinsically built into the process, it makes for more engaging and productive outcomes. The study concluded that, at a structural level, issues that drive policy development are influenced by the relationship between reflection and action. This is intrinsically built into the peer review process.

A review of the literature by the Association of Dental Education in Europe (ADEE), commissioned by the GDC in 2019, made similar conclusions on the effectiveness of peer review.³ The review found that peer learning was more likely to lead to positive changes in practice and would enhance inter-professional and inter-practice communication. It concluded that peer learning facilitates sharing of best practice and promotes high standards of work through mutual understanding, which can be especially valuable for lone practitioners.

There are comparable studies in the UK which have identified similar benefits where critical examination of the workplace by peer review was effective in improving knowledge and impacted positively on clinical practice.^4,5 This has been mirrored by Health Education and Improvement Wales (HEIW) where it outlined how its Peer Review Programme (2018)⁶ was fundamental to its quality improvement drive in the devolved nation. The body of evidence is further supported by a systematic review carried out by Dadich,⁷ which concluded that peer review supports reflective practice and helps identify learning and improvement needs.

The General Dental Council's 2017 publication, Shifting the balance: a better, fairer system of dental regulation,⁸ advocates incorporating a significant peer review element into the development model, recognizing the potential for peer review to bring about sustainable change.

The evidence has clearly demonstrated the increasing importance of ‘Peer Review’, not only in driving change in our learning but also, as seen in these current circumstances, in planning service design strategies.

Networking and connecting

A study by Lillis⁹ investigated peer group learning within clusters of general medical practitioners and reported that learning opportunities were considerably enhanced when the participants had a wider range of experience and expertise. So it was therefore the intention of SWPRG to collaborate with individuals who could offer a myriad of insights into the challenges faced. The group comprised the following contributors (Figure 3):

The group was assembled in a way that would ensure a diverse geographic spread of ideas and perspectives. The combination of academics and clinicians was deliberate, as was the selection of individuals from primary and secondary care. The desire to assemble a heterogeneous cohort of contributors was driven by the need to ensure a multi-dimensional perspective as, quite clearly, many of the challenges that exist in primary care may not exist in secondary care, and vice versa. Similarly, there are real educational challenges in the university training centres and District General Hospitals which were important to factor in, as well as variations across the various health authorities in the devolved nations.

Participants were contacted and learning objectives distributed a week before the meeting date to allow for individual preparation. Various participants were given key areas to discuss, particularly to shed light on how different parts of the UK and Ireland responded to the pandemic.

The meeting was commenced with a short introduction and networking session. The participants understood that the session was not only an opportunity to share ideas and initiatives, but also an opportunity to network with colleagues with whom further collaborations may be formed in future. Each participant was introduced on an individualized slide with job title, geographic region and email address, which allowed for a rapport to be built amongst the group and enhanced the potential for consensus building and positive engagement.

Brainstorming through technology

The main pillar of this peer review session was the use of technology to facilitate innovation and collaboration. The digital tools used included:

Zoom ^®10 – Video conferencing software.

Miro ^®11 – Interactive collaboration software.

Survey Monkey ^®12 – Online feedback platform (Figure 4).

Microsoft Teams ^®13 – Collaborative publication platform.

Video conferencing and Zoom® networking have become regular features of life during lockdown, whether it involved virtual patient consultations, families connecting with each other or meetings conducted from home. Zoom® reported a 50% increase in its use by the end of April as it became apparent that such platforms offer an opportunity of bringing people together during social restrictions.¹⁴ However, impersonal interactions with a computer screen potentially removes the ability to gauge non-verbal and social cues, making it difficult to have multilateral dynamic conversations. Conversations often become bi-directional, with the facilitator inviting individual participation in turn. However, despite this shortcoming, if not for such virtual platforms it would have been incredibly challenging for a group spanning the United Kingdom and Ireland to come together spontaneously to discuss topics in such a way, even during normal times. Consent was obtained for the recording of the session that was then distributed to the group to aid reflection and as an effective record for quality assurance.

The main component of the meeting comprised an interactive brainstorming session using the digital mind map tool, Miro®. The platform allowed for discussions and ideas to be documented visually whilst following a flow of topics around a central theme. This essentially constituted a novel way of recording meeting minutes interactively while tracking the thought process of the group and capturing the ideas as they are shared and developed. Mind Mapping utilized in this way captures those whose thinking is based around visual/spatial learning, often referred to as kinesthetic thinking in neuroscience. It also frees up participants from note-taking, allowing them to fully engage in the process. Further, as previous authors have described, peer review is intrinsically reflective in nature. Watching how the mind map evolves and grows with the contribution of the participants aids the reflective process and enhances the benefits of the session.

Reflection

As previously established, reflection makes up a core component of peer review. Following the meeting, the use of Survey Monkey®, an online survey platform, allowed the participants' response to questions regarding retrospective reflection to be quantified.

These questions were scored with the responses plotted for each question. Participants scored highly for all aspects of the session, and on its impact on shaping their respective workplace and provision of orthodontic services moving forward. Furthermore, it was felt that the Zoom® platform was an effective vehicle and that adequate time was allocated to contribute to the discussions. The Mind Mapping tool, Miro®, was also well received, with participants finding it easy to follow.

Finally, the use of Microsoft Teams® was used to collaborate in the process of writing this two-part article. A section of the team was delegated to outline the structure of the article and map out the direction with which to document the events of the session. Another team was tasked with the role of writing and referencing the article; with a third and final team coming together to proofread, and quality assure the final article.

There are potential challenges in collaborations such as this but, through the use of readily available digital technology, and with a clear and unified goal, the process can be extremely rewarding and effective at building professional relationships and creating models for future initiatives.

In Part 2 of this article, how the various considerations were assessed, how the Mind Map evolved and what outcomes were agreed will be explained; all of which will be applicable to orthodontic practitioners in the months to come, as the transition out of the acute phase of the pandemic is made.