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348 - 52 - Samir 70
348 - 52 - Samir 70
INVESTIGATION OF QUALITY
IMPROVEMENT STRATEGIES WITHIN
EGYPTIAN DENTAL CLINICS
by 156.222.104.118 on 09/20/20. Re-use and distribution is strictly not permitted, except for Open Access articles.
†
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
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.
§
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 to re°ect the strengths and weaknesses of dentistry
production of quality program with practical frame quality.13 According to dental education, Dental Qual-
under groups of comprehensive procedures.3 It is im- ity Alliance (DQA) and the Commission on Dental
portant to study a direct relationship between patients' Accreditation (CODA)14 are essential agencies to par-
satisfaction and medical quality services due to the ef- ticipate of dental quality improvement by using Elec-
fective role of patients in Clinical Quality Assurance tronic Health Record (HER) that used to analysis of
(CQA) schemes.4 In addition, quality service providers collected data as regarding to the healthcare delivery.15
and physicians in healthcare system are necessary to Cher et al.16 discussed the quality speci¯cation in dif-
perform the training programs for choosing the appro- ferent locations for dental care at Taiwan and the pro-
priate quality system that supported Continuous Qual- posed results by SPSS17 con¯rmed that dental centers
ity Improvement (CQI) outcomes and quickly updated provided a higher quality level than regional and district
by 156.222.104.118 on 09/20/20. Re-use and distribution is strictly not permitted, except for Open Access articles.
the quality of present performance5 with taking into hospitals. Hoover et al.18 focused on the infection con-
consideration the standards guidelines from healthcare trol, and removable prosthodontics that responsible for
regulations. It was found that there are many obstacles quality procedures to access to simple, worthy, and
Biomed. Eng. Appl. Basis Commun. 2019.31. Downloaded from www.worldscientific.com
of quality implementing within healthcare institutions measurable interventions. Goetz et al.19 applied the re-
because of administrative restrictions, separation of risk peated evaluation of European Practice Assessment
management into quality work, and absence of clinical (EPA) project to dental care units in Germany that
engineers' role who maintained the medical equipment depended on technical, structural and organizational
quality.6 There are ¯ve approaches actually for organi- factors for advanced dental quality. Another research
zation of healthcare quality7 such as Total Quality indicated the supporting factors for dental services
Management/Continuous Quality Improvement (TQM/ among female school students in Riyadh20 such as
CQI), Business Process Reengineering (BPR), Rapid quality, cost and location of dentist to students' homes.
Cycle Change/Institute for Health Care Improvement Mindak21 revealed that patient vision is not enough for
(IHI), Lean Thinking, and Six Sigma. TQM/CQI8 is evaluating dental quality services due to lack of infor-
based on statistical methods, and \Plan-Do-Study-Act" mation on these specialized aspects and quality princi-
(PDSA) cycles for data aggregation and implementation ples of health service. However, the role of dental nurse
the gradual developments of quality principles while in quality practices facilitated the dynamic communi-
BPR9 is based on redesign process by complete mod- cation between patient and dentist for Patient satisfac-
i¯cations in the organizational structure of quality. tion. Chang et al.22 suggested some quality factors for
Rapid Cycle Change/IHI7 is based on less data and fast controlling in Patient satisfaction and for classifying the
modi¯cations during small guide schedules of quality problems in dental care that based on Kano-type ques-
approach by the basic of PDSA cycles as applied to tionnaires. Recently, the quality of dental radiographic
TQM/CQI and BPR. This method should be useful in exposures is applied to avoid patient exposure to un-
clinical quality system, especially for risk management necessary radiation by using descriptive statistics.23 For
that intended to decrease hazards to patients. The lean prosthodontics ¯eld, the studying of quality between
thinking concept7 is based on patient behavior only and dentists and dental technicians controlled by evaluation
neglected some factors concerning the healthcare quality form including clarity and accuracy of instructions, pa-
system. On the other hand, the Six Sigma10 is based on tient information, type of prosthesis, choice of materials,
creation an e®ective model of quality and more statis- design and shade of the prosthesis and type of porcelain
tical data as similar to PDSA cycles, although high cost glaze.24
and complex implementation to patient care. According In this paper, the contributions are based on deter-
to the international standards for laboratory produc- mining the application of comprehensive quality stan-
tion, researchers realized importance TQM principles for dards and risk management in the dental clinics listed in
improving the clinical research laboratories by using Cairo and Giza to identify the problems that prevent the
Quality and Project Management OpenLab (qPMO).11 achievement of comprehensive quality standards and
Also, it found that the integrating of clinical scientists proposals of respondents to overcome these problems. In
and Quality experts represented as a wise and worth- addition, we focused on studying to what extent the
while investment when studied performance of care de- criteria and indicators of overall quality management
livery within several hospitals at the United States and and risk management are applied separately, how they
England.12 are measured in the dental clinics listed in the study and
One of the major entities for clinical quality man- what the in°uence of the equipment maintenance on the
agement is dental clinics quality that needs more e®orts level of service quality with regards to healthcare.
1950006-2
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
by 156.222.104.118 on 09/20/20. Re-use and distribution is strictly not permitted, except for Open Access articles.
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-
Biomed. Eng. Appl. Basis Commun. 2019.31. Downloaded from www.worldscientific.com
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
1950006-4
Investigation of Quality Improvement Strategies within Egyptian Dental Clinics
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?
by 156.222.104.118 on 09/20/20. Re-use and distribution is strictly not permitted, except for Open Access articles.
Equipment maintenance
8 Is the equipment maintained?
Infection control (IC)
Biomed. Eng. Appl. Basis Commun. 2019.31. Downloaded from www.worldscientific.com
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?
1950006-5
M. S. Mabrouk, S. Y. Marzouk & H. M. A¯fy
treatment in Egypt and the participant questions are The Doctor Questionnaire
22 that based on their satisfaction with dental treat-
The sample consisted of 115 questionnaires for a doctor
ment as discussed in Table 2. Subsequently, the anal-
who worked in the studied seven clinics for dental treat-
ysis of these questionnaires con¯rmed that most of the ment in Egypt and the participant questions are 27 that
patient responses were \yes" that indicated to a gen- based on their evaluation of quality services after treat-
eral satisfaction for dental care in most clinics. It was ment process as discussed in Table 3. It was worth noted
found that female patients (57.2%) are more interested that most of the clinics did not rate the quality after
in dental treatment rather than male patients (42.8%). treatment process as shown in Table 7. This indicated
The results showed that 162 of sampled patients that if the patient did not complain to the clinic, the work
(49.8%) completed the dental treatment with the sat- cannot be evaluated in terms of quality. The largest
isfaction of the service they received as shown in number of doctor questionnaires was collected from the
Table 5. The positive participant answers are pre- Child Care Center in Abbassia. When the doctor ques-
sented as a percentage of sampled patients that re- tionnaires are collected, it was found that 33.9% of female
ferred to the quality rate of each service in di®erent doctors did not rate the quality after treatment while as
clinics as shown in Table 6. Also, these patient ques- 21.33% of them rated the quality after treatment. As for
tionnaires re°ected the medical safety procedures in male doctors, it was found that 20% of them did not rate
clinics and infection control management to reduce the the quality after treatment while as 18.26% rated the
spread of diseases. quality after treatment. The statistical analysis of doctors
1950006-6
Investigation of Quality Improvement Strategies within Egyptian Dental Clinics
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
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
by 156.222.104.118 on 09/20/20. Re-use and distribution is strictly not permitted, except for Open Access articles.
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 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
1950006-8
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
by 156.222.104.118 on 09/20/20. Re-use and distribution is strictly not permitted, except for Open Access articles.
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 the above three models for measuring the validity of the
analysis for risk management. It noticed that the hypothesis of research. There are di®erences of statisti-
younger quality management sta® are more concerned cal signi¯cance by signi¯cant > 0:5.
with maintaining quality and females are becoming In ¯rst hypothesis, there is a relationship between the
more interested in the quality program. 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-
ANOVA Test ¯cients have been used to know if there is a relation
between the dependent variable and whether the devices
This framework focused on recognizing the statistical
were maintained or not as shown in Tables 10 and 11.
decision making not subjective decision making and
knowing if the research hypotheses are relevant or not. Predictors: (Constant):
Therefore, we classi¯ed elements of quality services to 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,
Fig. 8 Quality assurance program.
ANOVA test and coe±cients have been used to know if
there is a relation between the dependent variable and
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
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
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
1950006-10
Investigation of Quality Improvement Strategies within Egyptian Dental Clinics
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
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 Therefore, this proposed framework emphasized that
equipment maintenance is revealed during interviewers the adequate communication between dentist, patient and
with 115 doctors and also a positive relationship be- quality sta® occurred by using three questionnaires for
tween patient satisfaction and dental treatment e±- quality assessment of dental clinics in Egypt. We selected
ciently is employed during interviewers with 325 some factors for respondents like age, gender and years of
patients. 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
DISCUSSION ANOVA Test. The strength of our study was that it car-
Although, there has been a wide range of quality ried satisfaction questionnaires of all elements that par-
endeavors in healthcare system, the implementation of ticipated in dental care. As a proposed method outcome,
quality in dental care domain is extremely limited in the expectations of patients are not enough for compre-
perception the mission of clinical engineer and using of hensive quality metrics. The optimal quality is visualized
traditional questionnaires that examined the technical following the development of dental questionnaires
standards of quality service at Egypt. Quality manage- through study the feedback from doctors and quality sta®
ment system in dentistry is ordinarily su®ered from as well as patients' feedback to elaborate the causes of
traditional doctor-patient relationship that uncovered
malpractices for providing higher quality services.
the principles of equipment maintenance, criteria of in-
This study exhibited the future recommendations as
fection control, patient satisfaction, and disregard of
the following:
doctor view for the quality scheme.28 Currently, patient
satisfaction is serious representative for improving the (i) The senior management at the Ministry of Health
instrument quality system in di®erent dental clinics by should work in a well-planned and a structured
comparing with items of Dental Satisfaction Question- manner to develop the information in a database
naire (DSQ) that based on attitude, cost, convenience, system that would be available to all healthcare
pain management, quality, and patients' perceived need institutions, and to provide a training for
for prevention of oral disease.29 The majority of dental employees to use e®ectively the database.
quality researches designed for guiding the policymakers (ii) The roles of senior management and leaders
to patients' health literacy that leads to enhance dental should be activated for participating in quality
centers setting.30 improvement.
1950006-11
M. S. Mabrouk, S. Y. Marzouk & H. M. A¯fy
1950006-12
Investigation of Quality Improvement Strategies within Egyptian Dental Clinics
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1950006-13