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Clinic Policy Manual

Quality Assurance

Subject: Quality Assurance
Effective Date:   November 1993
Revision Dates:  
April 2002, January 2016


To develop a systematic and continuous protocol for assessing the patient care delivery system through the collection and analysis of reliable information.

General Policy

Quality assurance is an on-going evaluation system that focuses on patterns of behavior rather than on isolated instances of behavior.  Quality assurance is a mechanism for assessing the quality of care and implementing and evaluating changes in the patient care delivery system to maintain or improve the quality of care.  Each service area within the School of Dentistry must play an integral part in the quality assurance system.

The benefits to be derived from a systematic quality assurance program include the documentation of the effectiveness of the educational and patient care programs, the identification of the areas of the educational and patient care programs that could benefit from improvements, and the establishment of a mechanism for on-going identification of strengths and weaknesses that will support plans for development, revision, improvement, and expansion within the University of Washington School of Dentistry educational and patient care programs.


The dental school must conduct a formal system of continuous quality improvement for the patient care program that demonstrates evidence of:

  1. standards of care that are patient-centered, focused on comprehensive care and written in a format that facilitates assessment with measurable criteria;
  2. an ongoing review and analysis of compliance with the defined standards of care;
  3. an ongoing review of a representative sample of patients and patient records to assess the appropriateness, necessity and quality of the care provided;
  4. mechanisms to determine the cause(s) of treatment deficiencies; and
  5. Implementation of corrective measures as appropriate.


The dimensions of quality care have been defined to include structure, process, and outcomes of care.  The structural dimension of care includes such factors as facilities, equipment, organization, administration, and personnel.  The process of care refers to issues involved in the delivery of care such as diagnosis, sequence of care, appropriateness of care, and technical skill.  This dimension of assessment of care can be performed prior to treatment (prospective reviews), during treatment (concurrent reviews), and following treatment (retrospective reviews).  The outcomes of care refer to improvements in oral health, health, or other areas as a result of receiving dental care.

  • The elements of a quality assurance review in each of these dimensions must include the following:
  • selection of an aspect of oral health care to be evaluated
  • establishment of criteria and standards for quality oral health care which will be the basis for the assessment of quality
  • comparison of the care/service that has been provided with the established criteria
  • assessment of the quality based on the above comparison and the established standards
  • action on the results of the evaluation to provide positive reinforcement for quality care or implement modifications to address deficiencies
  • assure that actions result in maintenance or improvements in the quality of care

I. Structure

The Coordinated Quality Improvement Program (CQIP) consists of an Operations Committee which meets quarterly to review quality of patient care as reported through the Risk Master data base. This Committee reports to the Oversight Committee where policy and procedure recommendations aimed at quality improvement, and patient safety  are determined.

II. Process

The process evaluation of the quality assurance program is primarily built upon the dental record as the primary source of information on the care provided to the patient.  The process evaluation includes, but is not limited to, chart audits, infection control assessment, and competency/proficiency exams.

A. Office of Clinical Services

On a quarterly basis, as a part of the Patient Advocacy Program, the Patient Services Representatives will conduct chart audits that evaluate basic components of care delivery and documentation.

B. Departmental Reviews

In addition to the record audits assigned for comprehensive care, patients also receive a thorough exam following the completion of their care (see Appendix A) Any treatment deficiencies found at this examination will be referred back to the clinics for treatment.

C. Health and Safety Task Force

On an ongoing basis, the Health and Safety Task Force will direct the Safety Assistant to present documentation of compliance with infection control and safety policies by faculty, students, and staff.  The Health and Safety Task Force shall oversee compliance with Health and Safety regulations.

III.   Outcomes

A. Office of Clinical Services

The OCS will conduct patient satisfaction assessments on an annual basis.  The OCS will manage the compilation and dissemination of information gathered from the “Patient Satisfaction Survey”  (see Appendix B) and the “Patient Comment and Complaint Brochure” (Appendix C).

B. Departments of the School of Dentistry

Each department will develop and submit to the OCS a protocol for post-operative review of treatment by types of procedures to assess the appropriateness and necessity of the care provided by students and faculty.  On an annual basis, the departments will submit a report of the outcomes of the post-operative reviews.  The OCS will be responsible for producing fee waiver reports and disseminating this information to the departments.

The dissemination of the results of quality assessment activities is essential for the use of the data in quality maintenance and improvement.  Each department will be responsible for providing the results of quality assessment activities to the OCS.  The OCS will be responsible for the maintenance of a comprehensive file on the quality assessment activities of the School of Dentistry.  


Appendix A, Completed Treatment Review (PDF)

Appendix B, Patient Satisfaction Survey (PDF)

Appendix C, Patient Comment and Complaint Brochure (PDF)

Dean of UW SOD:

Joel Berg, Dean of the UW School of Dentistry
February 2, 2016