Biomedical Engineering: Applications, Basis and Communications, Vol. 31, No.

1 (2019) 1950006 (13 pages)

DOI: 10.4015/S1016237219500066

INVESTIGATION OF QUALITY
IMPROVEMENT STRATEGIES WITHIN
EGYPTIAN DENTAL CLINICS
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Mai S. Mabrouk*,§, Samir Y. Marzouk†,¶ and Heba M. A¯fy‡,||

*Biomedical Engineering, Misr University for Science
and Technology (MUST University), Egypt
Biomed. Eng. Appl. Basis Commun. 2019.31. Downloaded from www.worldscientific.com

†
Department of Basic and Applied Science
Arab Academy of Science and Technology, Egypt
‡
Department of Bioelectronics Engineering
MTI University, Egypt
§
msm eng@yahoo.com
¶
Samir marzouk2001@yahoo.com
||
hebaaffify@yahoo.com

Accepted 16 September 2018

Published 18 December 2018

ABSTRACT
There 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 quality
management (TQM) principles and fabrication of a mismatch between the patient needs and the services provided.
Therefore, this study described a framework of TQM application 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 entities
under 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, equipment maintenance
and 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 healthcare delivery process.1 Therefore, Total Quality

Quality approach is widely applied for decades in Management (TQM) programs are an integral part of
clinical researches for achieving the compliance, safety, clinical engineering ¯eld including quality of nursing,
prevention, therapy, a®ordable cost, evaluation cycles, physicians, drug discovery, hospital, clinic, laboratory,
accepted accreditation and patient monitoring in 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 eng@yahoo.com

1950006-1
 M. S. Mabrouk, S. Y. Marzouk & H. M. A¯fy
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
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the quality of present performance5 with taking into
consideration the standards guidelines from healthcare
regulations. It was found that there are many obstacles
Biomed. Eng. Appl. Basis Commun. 2019.31. Downloaded from www.worldscientific.com
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
1950006-2
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.
 Investigation of Quality Improvement Strategies within Egyptian Dental Clinics

Furthermore, the dimension of this study summarized in Table 1. Number of Questionnaires Collected from Medical
Facilities.
three core points including theoretical, the practical, and
future implications. Theoretical aspect is related to the Doctor Patient Quality and Risk
performance of dental clinics through the historical de- Question- Question- Management Sta®
naires naires Questionnaire
velopment, theories of quality and risk management
within the ¯eld of dentistry while practical aspect is Clinic A 10 40 1
Clinic B 10 60 1
related to the achievement results that may be useful for Clinic C 10 55 1
recognizing quality standards to achieve greater e®ec- Child Care Center in 30 40 5
tiveness of dental clinics and their development in Cairo Abbassia
15th of May Hospital 10 30 7
governorate in speci¯c, as well as in other Egyptian
October 6 University 20 50 10
governorates in general. In order to preserve the contin- clinic
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uous dental care, future implications have a great impact MUST University 25 50 2
on the growth of quality through the workable recom- clinic
Total 115 325 27
mendations that suggested for developing the perfor-
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mance of dental clinics in the Egyptian governorates.

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
MATERIALS AND METHODS
being referred to di®erent clinics. Generally, we sum-
In this study, the quality of dental care examined risk marized the analysis steps of proposed framework as
management and dental malpractices by using three shown in Fig. 1.
perspectives; patients, doctors, and individuals who are
responsible for quality control and risk management in
various medical institutions at Egypt. For manufactur- Preparation of the Questionnaires
ing of quality, patient acted as customers of the medical
We selected three questionnaires for patients, doctors
services, doctors acted as medical service providers and
and for quality and risk management sta® as shown in
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 Fig. 1 Block diagram of proposed framework.

1950006-3
 M. S. Mabrouk, S. Y. Marzouk & H. M. A¯fy

Table 2. Patient Questionnaire.

Yes I Don’t Know Comments

Appointments
1 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.
Facilities
4 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.
Staff
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8 The dentist was professional and courteous.

9 The dental assistant was professional and courteous.
Treatment
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10 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 control
13 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?

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

information concerning age and gender factors in
patient and doctor questionnaires but age, gender and
experience years in quality sta® questionnaire. The
questionnaire which was 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.
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

1950006-4
 Investigation of Quality Improvement Strategies within Egyptian Dental Clinics

Table 3. Doctor Questionnaire.

Yes No Comments
Quality of dental material and treatment
1 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 system
4 Do you use computers in filing and recording data?
5 Do you use paper documents when filing data?
High degree education and clinic training
6 Have you received clinic training?
7 Have you completed any higher education other than the bachelor’s degree?
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Equipment maintenance
8 Is the equipment maintained?
Infection control (IC)
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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 and
mucous membrane exposures as well as protect against hepatitis B, hepatitis C
and HIV infections?
14 Is there a written infection control program to prevent or reduce the risk of disease
transmission?
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?

displayed that the majority of female respondents were RESULTS

between the ages of 15 and 30 years as shown in Fig. 5.
The experimental results divided into three sections that
According to doctor questionnaire, the majority of fe-
related to three questionnaires and section for analysis
male respondents were between the ages of 21 and 30
results by ANOVA test.
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
The Patient Questionnaire
females with ages between 30–40 years and that most
of them had less than 10 years' of experience as shown The sample consisted of 325 questionnaires for a pa-
in Fig. 7. tient who visited the studied seven clinics for dental

1950006-5
 M. S. Mabrouk, S. Y. Marzouk & H. M. A¯fy
Table 4. Quality and Risk Management Sta® Questionnaire.
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Biomed. Eng. Appl. Basis Commun. 2019.31. Downloaded from www.worldscientific.com
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.
1950006-6
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
 Investigation of Quality Improvement Strategies within Egyptian Dental Clinics

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

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

personal data.

that answered \No" for evaluation of quality services

after treatment process is summarized in Table 8.
Fig. 3 Distribution of doctor questionnaires in hospitals and units.

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-
Fig. 4 Distribution of quality sta® questionnaires in hospitals and
units. 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
Fig. 5 Analysis of patient questionnaires according to their personal to establish and integrate one in their system within
data. 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

Table 5. Patient Satisfaction for Dental Treatment.

Valid Cumulative
Frequency Percent Percent Percent
Valid No 81 24.9 24.9 24.9
Maybe 82 25.2 25.2 50.2
Yes 162 49.8 49.8 100.0
Fig. 6 Analysis of doctor questionnaires according to their personal
Total 325 100.0 100.0
data.

1950006-7
 M. S. Mabrouk, S. Y. Marzouk & H. M. A¯fy

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

Percent of Patients
Services 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 25.84
Dental 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 38.15
Dental 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 34.15
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given treatment alternatives

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
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Dental treatment completed for their satisfaction, doctor used unsealed new sterilized tools 48.92
Dental treatment completed for their satisfaction, unit was clean 32.30
Dental 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 41.84
Dental treatment completed for their satisfaction, dentist wears, the eye protection and mask during 38.46
the treatment process
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 while 25.84
working with the doctor

Table 7. Evaluation of the Quality Rate After Treatment.

Frequency Percent Valid Percent Cumulative Percent

Valid No 62 53.9 53.9 53.9
Yes 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.

Doctors Percent by
Services 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 52.17
Evaluation 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 60
Evaluation 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 with 65.22
the hepatitis C infection
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 61.74
and mucous membrane exposures
Evaluation of quality rate after treatment, written infection control program to prevent or reduce the risk of disease 59.14
transmission
Evaluation of quality rate after treatment, there a daily evaluation of infection control program to help insure the policy, 61.74
procedure, and practice
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 safety 52.18
box or disposable syringes

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 Investigation of Quality Improvement Strategies within Egyptian Dental Clinics

Table 8. (Continued )

Doctors Percent by
Services Answered \No"
Evaluation of quality rate after treatment, arti¯cial ¯ngernails, hand and nail jewelry should be prevented and 67.88
replaced with short and smooth edged nails to help prevent glove tear and increasing infection risk
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 38.26
Evaluation of quality rate after treatment, critical and semi critical dental instruments heat sterilized and packaged 53.05
before each use to avoid contamination
Evaluation of quality rate after treatment, non-critical dental instruments (unit, saliva ejector, air-water syringe...) 70.44
cleaned and disinfected after each use and covered with barrier protection
Evaluation of quality rate after treatment, discharge water and air from any device that have entered the 33.04
patient mouth and connect it to the water system for 20 to 30 minutes
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Evaluation of quality rate after treatment, wear gloves while taking radiographs and handling contaminated ¯lm packets 60
Evaluation 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 31.30
Biomed. Eng. Appl. Basis Commun. 2019.31. Downloaded from www.worldscientific.com

dental procedure
Evaluation of quality rate after treatment, quality of dental material and treatment 39.13
Evaluation 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

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
Fig. 8 Quality assurance program.
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 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 66.7
Committee, 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 77.8
No 6 22.2 22.2 100.0
Total 27 100.0 100.0

1950006-9
 M. S. Mabrouk, S. Y. Marzouk & H. M. A¯fy

Table 10. ANOVA Test of First Hypothesis. Dependent Variable: The dental treatment was
Sum of Mean
completed to my satisfaction.
Model Squares df Square F Sig. In third hypothesis, there is a relationship between
Regression 7.500 4 1.875 9.787 0.000(f) QA program and using computerized data tracking and
Residual 21.074 110 0.192 analysis for QA at Cairo and Giza. To verify the validity
Total 28.574 114 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-
whether the dental treatment was completed e±ciently ing and analysis for QA as shown in Tables 14 and 15.
in a timely manner or not as shown in the Tables 12 Then, ANOVA test is applied to three models from
and 13. doctor, patient and quality sta® in order to de¯ne the
by 156.222.104.118 on 09/20/20. Re-use and distribution is strictly not permitted, except for Open Access articles.

Predictors: (Constant), Treatment, My dental relation between variables as shown in Table 16. The
treatment was completed e±ciently and in a timely statistical analysis exposed the fact that there is a neg-
manner. Any questions I had were answered. \I was ative relationship between QC program and using
Biomed. Eng. Appl. Basis Commun. 2019.31. Downloaded from www.worldscientific.com

given treatment alternatives". computerized data tracking for QC. While a positive

Table 11. Coe±cients of First Hypothesis.

Unstandardized Standardized
Coe±cients 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 0.006
Is 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 Standardized
Coe±cients Coe±cients
Model B Std. Error Beta t Sig.
(Constant) 5.21E-015 0.000 0.000 1.000
Treatment 3.000 0.000 1.558 412509426.372 0.000
My dental treatment was completed e±ciently and 1.000 0.000 1.074 290322293.720 0.000
in a timely manner.
Any questions I had were answered. I was given 1.000 0.000 1.045 287650637.258 0.000
treatment alternatives

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

1950006-10
 Investigation of Quality Improvement Strategies within Egyptian Dental Clinics

Table 15. Coe±cients of Third Hypothesis.

Unstandardized Standardized
Coe±cients Coe±cients
Model B Std. Error Beta t Sig.
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.

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Pearson Correlation
Type of Respondents Hypothesis Correlation Sig. Result
Biomed. Eng. Appl. Basis Commun. 2019.31. Downloaded from www.worldscientific.com

Doctor Relation between maintenance of the equipment and quality There is a relation 0.002 Signi¯cant
assessment after treatment
Patient Relation between patient satisfaction and the dental treatment was There is a relation 0.000 Signi¯cant
completed e±ciently and in a timely manner
Quality Relation between quality assurance program and using computerized There is no relation 0.000(a) Signi¯cant
data tracking and analysis for quality assurance

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.

1950006-11
 M. S. Mabrouk, S. Y. Marzouk & H. M. A¯fy

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

the culture of quality among medical organiza-
The quality adoption in dentistry accredited as defen-
tions and healthcare institutions.
sive medicine for enhancing patient dental care as well as
(iv) Factors and policies that supported the culture of
the preservation of dentists form wrong practices and
quality should be identi¯ed and incorporated into
healthcare deterioration. This study encouraged the
the quality improvement process.
activation of clinical engineer interference in the quality
(v) Senior management and leaders at the Ministry of
framework of dental clinics at Egypt to follow the
Health should display their commitment to the
equipment maintenance. This study stated the demand
quality improvement process by turning their
for attention in building a quality database using the
letters about quality into practical actions.
clinic computer for easy access to information that
(vi) Senior management and leaders at the Ministry of
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needed and determination of training employees to use

Health should invest for developing employees by
it. The e±ciency of the quali¯ed medical team signi¯ed
ongoing training and capacity building activities,
an essential change in quality improvement process and
as well as focused on developing practical methods
Biomed. Eng. Appl. Basis Commun. 2019.31. Downloaded from www.worldscientific.com

thus in the dissemination of quality culture. The redis-

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.
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.
REFERENCES
1. Rashid WE, Juso® HK, Service quality in health care
setting, Int J Health Care Qual Assur 22:471, 2009.
2. Zarei A, Arab M, Froushani AR, Rashidian A, Mahmoud
Ghazi Tabatabaei S, Service quality of private hospitals:
The Iranian Patients' perspective, BMC Health Services
Res 12:31, 2012.
3. Abdulaziz A, Abumelha M, Almaleh A, Total quality
management implementation challenges, Int J Computer
Systems 2:558, 2015.
4. Kalaja R, Myshketa R, Scalera F, Service quality assess-
ment in health care sector: The case of Durres public
hospital, Procedia-Soc Behav Sci 235:557, 2016.
5. Bailie R, Bailie J, Larkins S, Broughton E, Editorial:
Continuous quality improvement (CQi) advancing
understanding of design, application, impact, and evalu-
ation of CQi approaches, Front Public Health 5:306, 2017.
6. Al-Shdaifat EA, Implementation of total quality management
in hospitals, J Taibah Univ Med Sci 10:461, 2015.
7. Powell AE, Rushmer RK, Davies HT, A systematic nar-
rative review of quality improvement models in health
care, Glasgow: Quality Improvement Scotland (NHS
QIS), 2009.
8. Deming WE, Quality control and continuous improvement.
In: Goodwin CB, Gri±th DB, eds. Supervisor's survival kit.
Upper Saddle River, NJ: Prentice-Hall, 97, 2009.

1950006-12
 Investigation of Quality Improvement Strategies within Egyptian Dental Clinics
9. Khodambashi S, Business process re-engineering applica-
tion in health care in a relation to health information
systems, Procedia Technol 9:949, 2013.
10. Bandyopadhyay JK, Coppens K, Six sigma approach to
health care quality and productivity management, Int J
Prod Qual Manag 5:V1, 2005.
11. Bongiovanni A, Colotti G, Liguori GL, Di Carlo M,
Lacerra FADG, Mascia A, Cira¯ci AM, Barra A, Lanati
A, Kisslinger A, Applying quality and project manage-
ment methodologies in biomedical research laboratories:
A public research network's case study, Accred Qual
Assur 20:203, 2015.
12. Tsai TC, Jha AK, Gawande AA, Huckman RS, Bloom N,
by 156.222.104.118 on 09/20/20. Re-use and distribution is strictly not permitted, except for Open Access articles.
Sadun R, Hospital board and management practices are
strongly related to hospital performance on clinical qual-
ity metrics, Health A®airs 34:1304, 2015.
Biomed. Eng. Appl. Basis Commun. 2019.31. Downloaded from www.worldscientific.com
13. Parkinson JW, Zeller GG, Clinical performance measures
and quality improvement system considerations for dental
education, J Dent Education 81:347, 2017.
14. Commission on Dental Accreditation. Evaluation and
operational policies and procedures manual. 2016. At:
www.ada.org//media/CODA/Files/eopp.pdf?la=en.
15. McGlynn EA, Six challenges in measuring the quality of
health care, Health A®airs 16:7, 1997.
16. Cher T-L, Lin C-P, Huang C-S, Clinical dental care in
hospital dental departments in Taiwan: Results from the
2008 national survey, J Dent Sciences 9:371, 2014.
17. Levesque R, SPSS Programming and Data Management:
A Guide for SPSS and SAS Users, 4th edn., Chicago,
Illinois: SPSS Inc, 2007.
18. Hoover TE, Kirk J, Fredekind RE, Clinical quality as-
surance surveillance and targeted interventions: Manag-
ing unfavorable trends in a dental school clinic, J Dent
Education 71:746, 2007.
19. Goetz K, Campbell SM, Broge B, Brodowski M, Wensing
M, Szecsenyi J, E®ectiveness of a quality management
1950006-13
program in dental care practices, BMC Oral Health 14:1,
2014.
20. Al- Hussyeen AJA, Factors a®ecting utilization of dental
health services and satisfaction among adolescent females
in Riyadh City, The Saudi Dent J 22:19, 2010.
21. Mindak MT, Service quality in dentistry: The role of the
dental nurse, Br Dent J 181:363, 1996.
22. Chang W-J, Chang Y-H, Patient satisfaction analysis:
Identifying key drivers and enhancing service quality of
dental care, J Dent Sciences 8:239, 2013.
23. Nenad MW, Halupa C, Spolarich AE, Gurenlian JR, A
dental radiography checklist as a tool for quality im-
provement, J Dent Hyg 90:386, 2016.
24. Tulbah H, AlHamdan E, AlQahtani A, AlShahrani A,
AlShaye M, Quality of communication between dentists
and dental laboratory technicians for ¯xed prosthodontics
in Riyadh, Saudi Arabia, Saudi Dent J 29:111, 2017.
25. Holmes D, Mergen AE, Using descriptive statistics in
statistical process control, Northeast Decision Sciences
Institute Annual Meeting, Renaissance HarborPlace
Hotel, Baltimore MD: 566, 2007.
26. Seong MG, Park, Jang KA, Choi JO, Analysis of factors
a®ecting the patient's service satisfaction in Kimhae
Dental Hospital, J Dent Hygiene Science 8:215,2008.
27. Statistical package for social sciences, version 20, http://
spss-64bits.en.softonic.com.
28. Timofe MP, Albu S, Quality management in dental care:
Patients' perspectives on communication. a qualitative
study, Clujul Med 89:287, 2016.
29. Luo JYN, Liu PP, Wong MCM, Patients' satisfaction
with dental care: A qualitative study to develop a satis-
faction instrument, BMC Oral Health 18:2, 2018.
30. Ali DA, Patient satisfaction in dental healthcare centers,
Eur J Dent 10:309, 2016.