investigation of quality improvement strategies …

INVESTIGATION OF QUALITYIMPROVEMENT STRATEGIES WITHIN

EGYPTIAN DENTAL CLINICS

Mai S. Mabrouk*,§, Samir Y. Marzouk†,¶ and Heba M. A¯fy‡,||*Biomedical Engineering, Misr University for Science

and Technology (MUST University), Egypt†Department of Basic and Applied Science

Arab Academy of Science and Technology, Egypt‡Department of Bioelectronics Engineering

MTI University, Egypt§msm [email protected]

¶Samir [email protected]||[email protected]

Accepted 16 September 2018Published 18 December 2018

ABSTRACTThere is a demand to evaluate the quality of dental clinics for improving the healthcare of dentistry sector. The American

Dental Education Association (ADEA) presented the quality factors in a dental career which are technical skills, ethics,

expertise and cost in the light of the international criterions of dental instruments. There is the low possibility that is still

untapped in the aspect of the quality program for dental clinics because of lack of awareness, unapplied of total qualitymanagement (TQM) principles and fabrication of a mismatch between the patient needs and the services provided.

Therefore, this study described a framework of TQMapplication for Egyptian dental clinics in the view of clinical engineer

that based on random questionnaires from doctors, patients and quality control supervisors at di®erent medical entitiesunder study. All blinding data that obtained from statistical measurements are analyzed by Statistical Package for the

Social Science program (SPSS) to provide some recommendations that related to risk management, infection control and

thus reduce the spread of diseases in the clinics. The ¯ndings of this study elucidated the methodology of clinical

engineering in development the quality program among dental clinics through the design of clinic, equipmentmaintenanceand dissemination of quality standard guidelines. This work is considered as the ¯rst survey of dental clinics quality in

Egypt that will represent a preliminary step in the application of quality standards to promote the level of patient safety.

Keywords: Dental clinics; Total quality management; Quality questionnaires; Statistical package for the social science

program.

INTRODUCTION

Quality approach is widely applied for decades in

clinical researches for achieving the compliance, safety,

prevention, therapy, a®ordable cost, evaluation cycles,

accepted accreditation and patient monitoring in

healthcare delivery process.1 Therefore, Total Quality

Management (TQM) programs are an integral part of

clinical engineering ¯eld including quality of nursing,

physicians, drug discovery, hospital, clinic, laboratory,

administration, and medical equipment.2 It means that

§Corresponding author: Mai S. Mabrouk, Biomedical Engineering, Misr University for Science and Technology (MUST Univer-sity), Egypt. E-mail: msm [email protected]

Biomedical Engineering: Applications, Basis and Communications, Vol. 31, No. 1 (2019) 1950006 (13 pages)

DOI: 10.4015/S1016237219500066

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http://dx.doi.org/10.4015/S1016237219500066

TQM embodied the combination of all employees in the

production of quality program with practical frame

under groups of comprehensive procedures.3 It is im-

portant to study a direct relationship between patients'

satisfaction and medical quality services due to the ef-

fective role of patients in Clinical Quality Assurance

(CQA) schemes.4 In addition, quality service providers

and physicians in healthcare system are necessary to

perform the training programs for choosing the appro-

priate quality system that supported Continuous Qual-

ity Improvement (CQI) outcomes and quickly updated

the quality of present performance5 with taking into

consideration the standards guidelines from healthcare

regulations. It was found that there are many obstacles

of quality implementing within healthcare institutions

because of administrative restrictions, separation of risk

management into quality work, and absence of clinical

engineers' role who maintained the medical equipment

quality.6 There are ¯ve approaches actually for organi-

zation of healthcare quality7 such as Total Quality

Management/Continuous Quality Improvement (TQM/

CQI), Business Process Reengineering (BPR), Rapid

Cycle Change/Institute for Health Care Improvement

(IHI), Lean Thinking, and Six Sigma. TQM/CQI8 is

based on statistical methods, and \Plan-Do-Study-Act"

(PDSA) cycles for data aggregation and implementation

the gradual developments of quality principles while

BPR9 is based on redesign process by complete mod-

i¯cations in the organizational structure of quality.

Rapid Cycle Change/IHI7 is based on less data and fast

modi¯cations during small guide schedules of quality

approach by the basic of PDSA cycles as applied to

TQM/CQI and BPR. This method should be useful in

clinical quality system, especially for risk management

that intended to decrease hazards to patients. The lean

thinking concept7 is based on patient behavior only and

neglected some factors concerning the healthcare quality

system. On the other hand, the Six Sigma10 is based on

creation an e®ective model of quality and more statis-

tical data as similar to PDSA cycles, although high cost

and complex implementation to patient care. According

to the international standards for laboratory produc-

tion, researchers realized importance TQM principles for

improving the clinical research laboratories by using

Quality and Project Management OpenLab (qPMO).11

Also, it found that the integrating of clinical scientists

and Quality experts represented as a wise and worth-

while investment when studied performance of care de-

livery within several hospitals at the United States and

England.12

One of the major entities for clinical quality man-

agement is dental clinics quality that needs more e®orts

to re°ect the strengths and weaknesses of dentistry

quality.13 According to dental education, Dental Qual-

ity Alliance (DQA) and the Commission on Dental

Accreditation (CODA)14 are essential agencies to par-

ticipate of dental quality improvement by using Elec-

tronic Health Record (HER) that used to analysis of

collected data as regarding to the healthcare delivery.15

Cher et al.16 discussed the quality speci¯cation in dif-

ferent locations for dental care at Taiwan and the pro-

posed results by SPSS17 con¯rmed that dental centers

provided a higher quality level than regional and district

hospitals. Hoover et al.18 focused on the infection con-

trol, and removable prosthodontics that responsible for

quality procedures to access to simple, worthy, and

measurable interventions. Goetz et al.19 applied the re-

peated evaluation of European Practice Assessment

(EPA) project to dental care units in Germany that

depended on technical, structural and organizational

factors for advanced dental quality. Another research

indicated the supporting factors for dental services

among female school students in Riyadh20 such as

quality, cost and location of dentist to students' homes.

Mindak21 revealed that patient vision is not enough for

evaluating dental quality services due to lack of infor-

mation on these specialized aspects and quality princi-

ples of health service. However, the role of dental nurse

in quality practices facilitated the dynamic communi-

cation between patient and dentist for Patient satisfac-

tion. Chang et al.22 suggested some quality factors for

controlling in Patient satisfaction and for classifying the

problems in dental care that based on Kano-type ques-

tionnaires. Recently, the quality of dental radiographic

exposures is applied to avoid patient exposure to un-

necessary radiation by using descriptive statistics.23 For

prosthodontics ¯eld, the studying of quality between

dentists and dental technicians controlled by evaluation

form including clarity and accuracy of instructions, pa-

tient information, type of prosthesis, choice of materials,

design and shade of the prosthesis and type of porcelain

glaze.24

In this paper, the contributions are based on deter-

mining the application of comprehensive quality stan-

dards and risk management in the dental clinics listed in

Cairo and Giza to identify the problems that prevent the

achievement of comprehensive quality standards and

proposals of respondents to overcome these problems. In

addition, we focused on studying to what extent the

criteria and indicators of overall quality management

and risk management are applied separately, how they

are measured in the dental clinics listed in the study and

what the in°uence of the equipment maintenance on the

level of service quality with regards to healthcare.

M. S. Mabrouk, S. Y. Marzouk & H. M. A¯fy

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Furthermore, the dimension of this study summarized in

three core points including theoretical, the practical, and

future implications. Theoretical aspect is related to the

performance of dental clinics through the historical de-

velopment, theories of quality and risk management

within the ¯eld of dentistry while practical aspect is

related to the achievement results that may be useful for

recognizing quality standards to achieve greater e®ec-

tiveness of dental clinics and their development in Cairo

governorate in speci¯c, as well as in other Egyptian

governorates in general. In order to preserve the contin-

uous dental care, future implications have a great impact

on the growth of quality through the workable recom-

mendations that suggested for developing the perfor-

mance of dental clinics in the Egyptian governorates.

MATERIALS AND METHODS

In this study, the quality of dental care examined risk

management and dental malpractices by using three

perspectives; patients, doctors, and individuals who are

responsible for quality control and risk management in

various medical institutions at Egypt. For manufactur-

ing of quality, patient acted as customers of the medical

services, doctors acted as medical service providers and

quality employees acted as the structure of quality im-

plementation. This proposed framework utilized the

descriptive statistic method25 to describe quality vari-

ables by using pie chart and histogram that based on the

construction of graphs, charts, and tables to calculate

various descriptive measurements such as averages,

variation, and percentiles. Also, data analyzed by the

parametric test that called ANOVA26 to the analysis of

variances, compare the study groups and determine the

signi¯cant values that based on demographic variables

using the SPSS statistical package.27

Data Generation

The data of the proposed framework collected from

brainstorming, interviews and designing questionnaires.

All collected data are analyzed using SPSS Version 20.0

and applied to the di®erent entities for providing 115

questionnaires form doctors, 325 from patients and 27

from quality and risk management sta® within clinics

and hospitals. Descriptive data reported from seven

entities that divided into public, private and university

clinics as illustrated in Table 1. This survey was con-

ducted to investigate the personal interviews with the

patients and doctors for gathering extensive feedback.

There was ample time to observe the health conditions

by volunteer patients with passion on a daily basis.

Observation method of patients was adopted during

their diagnosis and at the follow-up stage as well as while

being referred to di®erent clinics. Generally, we sum-

marized the analysis steps of proposed framework as

shown in Fig. 1.

Preparation of the Questionnaires

We selected three questionnaires for patients, doctors

and for quality and risk management sta® as shown in

Table 1. Number of Questionnaires Collected from MedicalFacilities.

DoctorQuestion-

naires

PatientQuestion-

naires

Quality and RiskManagement Sta®

Questionnaire

Clinic A 10 40 1

Clinic B 10 60 1Clinic C 10 55 1

Child Care Center in

Abbassia

30 40 5

15th of May Hospital 10 30 7

October 6 University

clinic

20 50 10

MUST Universityclinic

25 50 2

Total 115 325 27

Fig. 1 Block diagram of proposed framework.

Investigation of Quality Improvement Strategies within Egyptian Dental Clinics

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Tables 2–4. Initially, there are questions of personal

information concerning age and gender factors in

patient and doctor questionnaires but age, gender and

experience years in quality sta® questionnaire. The

questionnaire whichwas distributed to patients consisted

of ¯ve parts as shown in Table 2. In patient's perspective,

questions are classi¯ed as (1 to 3) for taking appoint-

ments, (4 to 6) about special facilities, (8 to 9) about skills

of sta® within the visit, (10 to 12) about special treatment

and (13 to 22) about infection control (IC).

The questionnaire which was distributed to doctors

consisted of ¯ve parts as shown in Table 3. In doctor's

perspective, questions are classi¯ed as (1 to 3) about the

quality of dental material and treatment, (4 to 5) about

the ¯ling system used in the clinics, (6 to 7) about ed-

ucation and clinical training, (8) about the maintenance

of special devices used in the clinics, and (9 to 27) about

special measurements taken to implement IC at the

clinics.

On the other hands, the questionnaire that was

designed for quality and risk management sta® consisted

of four sections. Each section discussed some quality

questions; Sec. 1 for quality assurance (QA), Sec. 2 for

patient satisfaction, Sec. 3 for ongoing improvement and

Sec. 4 for risk management as shown in Table 4.

Statistical Analysis

The goal of this study is analyzed of the collected data

from the three questionnaires that based on exploring

the statistical distribution of medical entities and per-

sonal information of respondents by statistical program

SPSS.

According to the patient questionnaire, the data

revealed that the largest number of samples collected

was from Clinic B and that the lowest number collected

was from the 15th of May Hospital as shown in Fig. 2.

According to doctor questionnaire, the samples showed

that the largest numbers of questionnaire samples were

compiled from the doctors at the Child Care Center in

Abbassia. The three private clinics (A–B–C) were equal

in the number of doctors and showed the lowest pro-

portion of samples collected shown in Fig. 3. According

to quality sta® questionnaire, it was clear from the

samples that most of those who participated in the

questionnaire were from the October 6 University and

then the 15th of May Hospital. The equal results in the

number of those who participated were in private clinics

shown in Fig. 4.

For statistical distribution from personal informa-

tion of respondents, the data of patient questionnaire

Table 2. Patient Questionnaire.

Yes I Don’t Know Comments

Appointments1 It was easy to take my first appointment.2 I received a reminder of each of my appointments.3 The appointment options that were given suited my schedule.

Facilities4 The office location and parking spaces were convenient.5 The reception area was neat and clean.6 The equipment was clean and presentable.7 The lighting in the office was sufficient.

Staff8 The dentist was professional and courteous.9 The dental assistant was professional and courteous.

Treatment10 Any questions I had were answered, given treatment alternatives.11 My dental treatment was completed efficiently and in a timely manner.12 The dental treatment was completed to my satisfaction.

Infection control13 Did the doctor wear new gloves and a clean lab coat?14 Did the doctor use unsealed, new and sterilized tools?15 Did you find the unit clean?16 Did the doctor use a disposable cup?17 Did the doctor wash his hand after the treatment?18 Did the doctor throw used needles in the safety box?19 Did the doctor use new needles and syringes for your treatment?20 Did the doctor wear the eye protection glasses and mask throughout the

treatment?21 Did you see the nurse cleaning up before and after your treatment?22 Was the nurse wearing gloves and a mask while working with the doctor?


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displayed that the majority of female respondents were

between the ages of 15 and 30 years as shown in Fig. 5.

According to doctor questionnaire, the majority of fe-

male respondents were between the ages of 21 and 30

years as shown in Fig. 6. According to quality sta®

questionnaire, It was found that most of the quality

and risk management o±cers in the clinics were

females with ages between 30–40 years and that most

of them had less than 10 years' of experience as shown

in Fig. 7.

RESULTS

The experimental results divided into three sections that

related to three questionnaires and section for analysis

results by ANOVA test.

The Patient Questionnaire

The sample consisted of 325 questionnaires for a pa-

tient who visited the studied seven clinics for dental

Table 3. Doctor Questionnaire.

Yes No Comments

Quality of dental material and treatment1 Do you rate the quality after treatment?2 Do you work with high quality dental material?3 Do you distribute questionnaires to analyze patient satisfaction?

Filing system4 Do you use computers in filing and recording data?5 Do you use paper documents when filing data?

High degree education and clinic training6 Have you received clinic training?7 Have you completed any higher education other than the bachelor’s degree?

Equipment maintenance8 Is the equipment maintained?

Infection control (IC)9 Do you use one-hand needle recapping (scooping) in the clinics instead of two-hand

needle recapping?10 Is the hand hygiene protocol used in the clinic?11 Does the doctor receive infection-control training on initial assignment?12 Are needle sticks the only occupational risk factor independently associated with

hepatitis C infections?13 Is the use of personal protection equipment (PPE) such as gloves, masks, protective

eyewear or face shield and gowns necessary and practiced to prevent skin andmucous membrane exposures as well as protect against hepatitis B, hepatitis Cand HIV infections?

14 Is there a written infection control program to prevent or reduce the risk of diseasetransmission?

15 Is there a daily infection-control evaluation program to help insure that the policies,procedures, and practices are useful?

16 Have you been vaccinated against hepatitis B?17 Are you aware of latex allergy and the ways of preventing and treating it?18 Should the following items be thrown in a safety box or not disposable syringes,

needles, scalpel blades and other sharp items?19 Are artificial fingermails, hand, and nail jewelry prohibited and replaced with short

and smooth edged nails to help prevent glove tears and infection risks?20 Should disposable items such as mask and gloves be changed between patients?21 Do you wear sterile surgical gloves when performing oral surgical procedures?22 Are the critical and semi-critical dental instruments heat sterilized and packaged

before each use to avoid contamination?23 Are non-critical dental instruments (unit, saliva ejector, air-water syringe...)

cleaned and disinfected after each use and covered with barrier protection?24 Do you discharge water and air from any device that have entered the mouths of

patients and connect into the water system for 20 to 30 minutes?25 Do you wear gloves while taking radiographs and handling contaminated films

packets?26 Do you recommend that the patient use an antimicrobial mouth rinse before

starting dental procedure?27 Do the workers wear PPE while cleaning up the working area?


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treatment in Egypt and the participant questions are

22 that based on their satisfaction with dental treat-

ment as discussed in Table 2. Subsequently, the anal-

ysis of these questionnaires con¯rmed that most of the

patient responses were \yes" that indicated to a gen-

eral satisfaction for dental care in most clinics. It was

found that female patients (57.2%) are more interested

in dental treatment rather than male patients (42.8%).

The results showed that 162 of sampled patients

(49.8%) completed the dental treatment with the sat-

isfaction of the service they received as shown in

Table 5. The positive participant answers are pre-

sented as a percentage of sampled patients that re-

ferred to the quality rate of each service in di®erent

clinics as shown in Table 6. Also, these patient ques-

tionnaires re°ected the medical safety procedures in

clinics and infection control management to reduce the

spread of diseases.

The Doctor Questionnaire

The sample consisted of 115 questionnaires for a doctor

who worked in the studied seven clinics for dental treat-

ment in Egypt and the participant questions are 27 that

based on their evaluation of quality services after treat-

ment process as discussed in Table 3. It was worth noted

that most of the clinics did not rate the quality after

treatment process as shown in Table 7. This indicated

that if the patient did not complain to the clinic, the work

cannot be evaluated in terms of quality. The largest

number of doctor questionnaires was collected from the

Child Care Center in Abbassia. When the doctor ques-

tionnaires are collected, it was found that 33.9% of female

doctors did not rate the quality after treatment while as

21.33% of them rated the quality after treatment. As for

male doctors, it was found that 20% of them did not rate

the quality after treatment while as 18.26% rated the

quality after treatment. The statistical analysis of doctors

Table 4. Quality and Risk Management Sta® Questionnaire.


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that answered \No" for evaluation of quality services

after treatment process is summarized in Table 8.

The Quality and Risk Management

Staff Questionnaire

The sample consisted of 27 questionnaires for quality

sta® who worked in QA department for quality im-

provement in Egypt and the participant questions are

23 that based on the statistical program for quality

services and risk management schedules as discussed in

Table 4. The results appeared that 40.7% of the sam-

ples reported that they have a formal written QA

program and a committee, 25.9% reported that they

have a written QA program without a committee,

7.4% reported having a committee without a written

program, 3.7% reported that they have neither a

committee nor a written program, but have individual

or department responsibility and 22.2% of the ques-

tionnaires samples reported that they didn't have a

QA program as shown in Fig. 8 and Table 9. However,

the most clinics that do not have a QA program stated

to establish and integrate one in their system within

the upcoming 18 months. Practically, there has been a

recent interest in quality and still need to activate the

risk management departments in Egypt. Most of the

Fig. 2 Distribution of patient questionnaires in hospitals and units.

Fig. 3 Distribution of doctor questionnaires in hospitals and units.

Fig. 4 Distribution of quality sta® questionnaires in hospitals and

units.

Fig. 5 Analysis of patient questionnaires according to their personaldata.

Fig. 6 Analysis of doctor questionnaires according to their personal

data.

Fig. 7 Analysis of quality sta® questionnaires according to their

personal data.

Table 5. Patient Satisfaction for Dental Treatment.

Frequency PercentValid

PercentCumulativePercent

Valid No 81 24.9 24.9 24.9

Maybe 82 25.2 25.2 50.2Yes 162 49.8 49.8 100.0

Total 325 100.0 100.0


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Table 6. Patients Percent that Answered \Yes" for Dental Services.

Services

Percent of Patients

by Answered \Yes"

Dental treatment completed for their satisfaction, easy to book their ¯rst appointment 38.46

Dental treatment completed for their satisfaction, received e reminder of each of their appointments 21.84

Dental treatment completed for their satisfaction, appointment options were given suited their schedule 19.69

Dental treatment completed for their satisfaction, o±ce location and parking were convenient 25.84Dental treatment completed for their satisfaction, reception area was neat and clean 30.18

Dental treatment completed for their satisfaction, equipment was clean and presentable 41.5

Dental treatment completed for their satisfaction, lighting in the o±ce was su±cient 38.15Dental treatment completed for their satisfaction, dentist was professional and courteous 34.46

Dental treatment completed for their satisfaction, dentist assistant was professional and courteous 27.38

Dental treatment completed for their satisfaction, any questions they had were answered and they were

given treatment alternatives

34.15

Dental treatment completed for their satisfaction, dental treatment was completed e±ciently in a timely manner 32.61

Dental treatment completed for their satisfaction, doctor wears new gloves with a clean coat 42.76

Dental treatment completed for their satisfaction, doctor used unsealed new sterilized tools 48.92

Dental treatment completed for their satisfaction, unit was clean 32.30Dental treatment completed for their satisfaction, doctor used a disposable cup 41.53

Dental treatment completed for their satisfaction, doctor washed his hand after the treatment 29.23

Dental treatment completed for their satisfaction, doctor threw used needles and syringe in the safety box 41.84Dental treatment completed for their satisfaction, dentist wears, the eye protection and mask during

the treatment process

38.46

Dental treatment completed for their satisfaction, saw the nurse cleaning up before and after their treatment 24.61

Dental treatment completed for their satisfaction, saw the nurse wearing the gloves and mask whileworking with the doctor

25.84

Table 7. Evaluation of the Quality Rate After Treatment.

Frequency Percent Valid Percent Cumulative Percent

Valid No 62 53.9 53.9 53.9Yes 53 46.1 46.1 100.0

Total 115 100.0 100.0

Table 8. Doctors Percent that Answered \No" for Evaluation of Quality Services After Treatment.

Services

Doctors Percent by

Answered \No"

Evaluation of quality rate after treatment, work with high quality dental material 36.52

Evaluation of quality rate after treatment, distributions of questionnaire to analyze patient satisfaction 40

Evaluation of quality rate after treatment, using computer in ¯lling and recording data 52.17Evaluation of quality rate after treatment, using ¯lling made of paper 33.04

Evaluation of quality rate after treatment, received the clinic training 43.47

Evaluation of quality rate after treatment, continued higher education other than the bachelor's degree 41.73

Evaluation of quality rate after treatment, equipment maintained 60Evaluation of quality rate after treatment, use one-hand needle recapping 63.48

Evaluation of quality rate after treatment, the hand hygiene protocol used in the clinic 66.94

Evaluation of quality rate after treatment, receiving infection-control training on initial assignment 55.66

Evaluation of quality rate after treatment, needle is the only occupational risk factor independently associated withthe hepatitis C infection

65.22

Evaluation of quality rate after treatment, using of personal protection equipment (PPE) such as gloves, masks,

protective eyewear or face shield and gowns are necessary intended to prevent skin, hepatitis B, hepatitis C, HIV

and mucous membrane exposures

61.74

Evaluation of quality rate after treatment, written infection control program to prevent or reduce the risk of disease

transmission

59.14

Evaluation of quality rate after treatment, there a daily evaluation of infection control program to help insure the policy,procedure, and practice

61.74

Evaluation of quality rate after treatment, received a vaccine of hepatitis B 55.66

Evaluation of quality rate after treatment, aware of the latex allergy and the ways of prevention and treatments 28.69

Evaluation of quality rate after treatment, items such as needles, scalpel blades and other sharp items thrown in safetybox or disposable syringes

52.18


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clinics do not use computerized data tracking and

analysis for risk management. It noticed that the

younger quality management sta® are more concerned

with maintaining quality and females are becoming

more interested in the quality program.

ANOVA Test

This framework focused on recognizing the statistical

decision making not subjective decision making and

knowing if the research hypotheses are relevant or not.

Therefore, we classi¯ed elements of quality services to

the above three models for measuring the validity of the

hypothesis of research. There are di®erences of statisti-

cal signi¯cance by signi¯cant >0:5.

In ¯rst hypothesis, there is a relationship between the

maintenance of the device and quality evaluation after

treatment in clinics at Cairo and Giza. To verify the

validity of the ¯rst hypothesis, ANOVA Test and coef-

¯cients have been used to know if there is a relation

between the dependent variable and whether the devices

were maintained or not as shown in Tables 10 and 11.

Predictors: (Constant):

Do you use computer in ¯lling and recording data? Is the

equipment maintained; Is the hand hygiene protocol

used in the clinic? Have you continued higher education

other than the bachelor's degree?

Dependent Variable: Do you rate the quality after

treatment?

In second hypothesis, there is a relationship between

patient satisfaction and the dental treatment that

completed e±ciently in a timely manner at Cairo and

Giza. To verify the validity of the second hypothesis,

ANOVA test and coe±cients have been used to know if

there is a relation between the dependent variable and

Table 8. (Continued )

Services

Doctors Percent by

Answered \No"

Evaluation of quality rate after treatment, arti¯cial ¯ngernails, hand and nail jewelry should be prevented and

replaced with short and smooth edged nails to help prevent glove tear and increasing infection risk

67.88

Evaluation of quality rate after treatment, disposable item (mask, gloves) be changed between patients 52.18

Evaluation of quality rate after treatment, wear the sterile surgeons gloves when performing oral surgical procedure 38.26Evaluation of quality rate after treatment, critical and semi critical dental instruments heat sterilized and packaged

before each use to avoid contamination

53.05

Evaluation of quality rate after treatment, non-critical dental instruments (unit, saliva ejector, air-water syringe...)cleaned and disinfected after each use and covered with barrier protection

70.44

Evaluation of quality rate after treatment, discharge water and air from any device that have entered the

patient mouth and connect it to the water system for 20 to 30 minutes

33.04

Evaluation of quality rate after treatment, wear gloves while taking radiographs and handling contaminated ¯lm packets 60Evaluation of quality rate after treatment, workers wear PPE while cleaning up the working area 36.52

Evaluation of quality rate after treatment, recommend the patient to use antimicrobial mouth rinse before starting

dental procedure

31.30

Evaluation of quality rate after treatment, quality of dental material and treatment 39.13Evaluation of quality rate after treatment, ¯lling system 34.78

Evaluation of quality rate after treatment, high degree education and clinic training 33.04

Evaluation of quality rate after treatment, infection control 66.95

Fig. 8 Quality assurance program.

Table 9. Analysis of the Data on Quality Assurance.

Frequency Percent Valid Percent Cumulative Percent

Valid Formal written program and committee: Yes 11 40.7 40.7 40.7

Written program, no committee: Yes 7 25.9 25.9 66.7Committee, no written program: Yes 2 7.4 7.4 74.1

No committee, no written program,

but individual or department responsibility: Yes 1 3.7 3.7 77.8No 6 22.2 22.2 100.0

Total 27 100.0 100.0


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whether the dental treatment was completed e±ciently

in a timely manner or not as shown in the Tables 12

and 13.

Predictors: (Constant), Treatment, My dental

treatment was completed e±ciently and in a timely

manner. Any questions I had were answered. \I was

given treatment alternatives".

Dependent Variable: The dental treatment was

completed to my satisfaction.

In third hypothesis, there is a relationship between

QA program and using computerized data tracking and

analysis for QA at Cairo and Giza. To verify the validity

of the third hypothesis, ANOVA test and coe±cients

have been used to know if there is a relation between the

dependent variable and using computerized data track-

ing and analysis for QA as shown in Tables 14 and 15.

Then, ANOVA test is applied to three models from

doctor, patient and quality sta® in order to de¯ne the

relation between variables as shown in Table 16. The

statistical analysis exposed the fact that there is a neg-

ative relationship between QC program and using

computerized data tracking for QC. While a positive

Table 10. ANOVA Test of First Hypothesis.

Model

Sum of

Squares df

Mean

Square F Sig.

Regression 7.500 4 1.875 9.787 0.000(f)

Residual 21.074 110 0.192

Total 28.574 114

Table 11. Coe±cients of First Hypothesis.

Unstandardized

Coe±cients

Standardized

Coe±cients

Model B Std. Error Beta t Sig.

(Constant) 0.350 0.102 3.444 0.001

Do you used computer in ¯lling and recording data? 0.380 0.135 0.270 2.817 0.006Is the equipment maintained? 0.321 0.099 0.277 3.245 0.002

Is the hand hygiene protocol used in the clinic? �0.359 0.104 �0.305 �3.445 0.001

Have you Containing higher education than the bachelor degree? 0.242 0.101 0.233 2.393 0.018

Table 12. ANOVA Test of Second Hypothesis.

Model Sum of Squares df Mean Square F Sig.

Regression 222.812 3 74.271 57447258055122200.000 0.000(c)Residual 0.000 321 0.000

Total 222.812 324

Table 13. Coe±cients of Second Hypothesis.

Unstandardized

Coe±cients

Standardized

Coe±cients


(Constant) 5.21E-015 0.000 0.000 1.000

Treatment 3.000 0.000 1.558 412509426.372 0.000My dental treatment was completed e±ciently and

in a timely manner.

�1.000 0.000 �1.074 �290322293.720 0.000

Any questions I had were answered. I was given

treatment alternatives

�1.000 0.000 �1.045 �287650637.258 0.000

Table 14. ANOVA Test of Third Hypothesis.

Model Sum of Squares. df Mean Square F Sig.

1 Regression 35.686 1 35.686 28.935 0.000(a)Residual 30.833 25 1.233

Total 66.519 26


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relationship between QC after treatment process and

equipment maintenance is revealed during interviewers

with 115 doctors and also a positive relationship be-

tween patient satisfaction and dental treatment e±-

ciently is employed during interviewers with 325

patients.

DISCUSSION

Although, there has been a wide range of quality

endeavors in healthcare system, the implementation of

quality in dental care domain is extremely limited in

perception the mission of clinical engineer and using of

traditional questionnaires that examined the technical

standards of quality service at Egypt. Quality manage-

ment system in dentistry is ordinarily su®ered from

traditional doctor-patient relationship that uncovered

the principles of equipment maintenance, criteria of in-

fection control, patient satisfaction, and disregard of

doctor view for the quality scheme.28 Currently, patient

satisfaction is serious representative for improving the

instrument quality system in di®erent dental clinics by

comparing with items of Dental Satisfaction Question-

naire (DSQ) that based on attitude, cost, convenience,

pain management, quality, and patients' perceived need

for prevention of oral disease.29 The majority of dental

quality researches designed for guiding the policymakers

to patients' health literacy that leads to enhance dental

centers setting.30

Therefore, this proposed framework emphasized that

the adequate communication between dentist, patient and

quality sta® occurred by using three questionnaires for

quality assessment of dental clinics in Egypt. We selected

some factors for respondents like age, gender and years of

experience when involved in the quality process by sup-

plying their answers. This study was conducted to reach a

methodology for improving quality in Egypt and results

were obtained by using the SPSS program, especially

ANOVA Test. The strength of our study was that it car-

ried satisfaction questionnaires of all elements that par-

ticipated in dental care. As a proposed method outcome,

the expectations of patients are not enough for compre-

hensive quality metrics. The optimal quality is visualized

following the development of dental questionnaires

through study the feedback from doctors and quality sta®

as well as patients' feedback to elaborate the causes of

malpractices for providing higher quality services.

This study exhibited the future recommendations as

the following:

(i) The senior management at the Ministry of Health

should work in a well-planned and a structured

manner to develop the information in a database

system that would be available to all healthcare

institutions, and to provide a training for

employees to use e®ectively the database.

(ii) The roles of senior management and leaders

should be activated for participating in quality

improvement.

Table 15. Coe±cients of Third Hypothesis.

Unstandardized

Coe±cients

Standardized

Coe±cients


1 (Constant) 6.095 0.718 8.488 0.000

Group −0.696 0.129 �0.732 �5.379 0.000

Table 16. Hypothesis of the Research for Three Models.

Pearson Correlation

Type of Respondents Hypothesis Correlation Sig. Result

Doctor Relation between maintenance of the equipment and quality

assessment after treatment

There is a relation 0.002 Signi¯cant

Patient Relation between patient satisfaction and the dental treatment was

completed e±ciently and in a timely manner

There is a relation 0.000 Signi¯cant

Quality Relation between quality assurance program and using computerized

data tracking and analysis for quality assurance

There is no relation 0.000(a) Signi¯cant


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(iii) A strategic plan should be carried out to spread

the culture of quality among medical organiza-

tions and healthcare institutions.

(iv) Factors and policies that supported the culture of

quality should be identi¯ed and incorporated into

the quality improvement process.

(v) Senior management and leaders at the Ministry of

Health should display their commitment to the

quality improvement process by turning their

letters about quality into practical actions.

(vi) Senior management and leaders at the Ministry of

Health should invest for developing employees by

ongoing training and capacity building activities,

as well as focused on developing practical methods

to measure progress after training in order to o®er

the organization's needs.

(vii) Quality improvement should be viewed as a

strategic goal and individuals who work towards

achieving it should have practical knowledge and

experience for committing to the implementation

of the process.

(viii) Renovating medical equipment and using high-

quality dental materials and supplies to ¯t the

healthcare services around the world should be

facilitated the providence of high quality that

re°ected on the provided health service.

(ix) Maintaining the halls and paints of the waiting

areas for patients, doctor's o±ces and reception

should be carried out in order to create a suitable

medical environment since the shape of the build-

ing and equipment determined the social level of

patients within the facility.

(x) Paying attention to the out¯t, name tags and

overall look for both doctors and nursing sta®

a®ected the quality of provided service.

(xi) Enhancing the trust between patients and

employees through training in hospitals and cen-

ters for reassuring the patients to make them feel

comfortable through training.

(xii) The health establishment should raise the level of

personal attention to patients through continuous

attention from the doctors, nursing and the sta®.

The patient needs better information and the

working hours should be commensurate with the

patients' needs.

Finally, it is important to improve the quality assess-

ment procedures in dental clinics by collecting further

data, using more accurate statistical methods, moni-

toring the quality of company that is dealing with the

provision of raw materials and incorporating manage-

ment risk into future quality researches.

CONCLUSIONS

The quality adoption in dentistry accredited as defen-

sive medicine for enhancing patient dental care as well as

the preservation of dentists form wrong practices and

healthcare deterioration. This study encouraged the

activation of clinical engineer interference in the quality

framework of dental clinics at Egypt to follow the

equipment maintenance. This study stated the demand

for attention in building a quality database using the

clinic computer for easy access to information that

needed and determination of training employees to use

it. The e±ciency of the quali¯ed medical team signi¯ed

an essential change in quality improvement process and

thus in the dissemination of quality culture. The redis-

tribution of dentists in proportion to the proximity of

housing and increasing the incentives within the public

clinics that associated with the Ministry of Health would

make a worthwhile contribution to interest their work

time. According to the declaration of respondents, the

attention should also be paid to patients' queries and

reduced waiting time through the use of a reservation

system or a ticket for appointments to prevent over-

lapping appointments. However, clinical quality criteri-

ons are likely to change with requirements of clinical

entities and new treatment methodology in order to

continue the quality improvement in future.

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investigation of quality improvement strategies …

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