Unit 5. Quality Assurance and Quality Improvement
Quality Assurance & Quality Improvement

Section 3. Measuring to Improve Quality

Methods of Measuring Clinical Quality

In general, there are three methods to ascertain clinical quality in dentistry:

  • Direct observation of patient care by a trained observer
  • Review of information in the dental record (chart review)
  • Quality metrics

When these are used to analyze the results in a process that improves care, it is considered proactive peer review. All three of these methods have advantages and drawbacks.


  • Can identify problems in technique that are not discernible through review of chart entries or X-rays.


  • Can be intrusive into clinic flow.
  • Requires consent of patient.
  • Time consuming—can take one or more days to get a reasonable sample of all of procedures performed in the clinic.
  • Almost completely health-professional focused, and can review only one health professional at a time.
  • Difficult to focus on a specific aspect of care unless appointments are manipulated to schedule only one type of patient.
  • Even if there is a problem with services provided by a health professional, that individual can attempt to hide the problem by practicing with extra care during the time when he/she is being observed.
  • The process is often disliked by health professionals, who correctly assert that their counterparts in private practice do not have to undergo such scrutiny in their practices once they have passed a board exam and received a license to practice.


  • Does not require presence of a patient.
  • Can easily be focused on one aspect of care by reviewing only charts of patients who received the services in question.
  • Can review all aspects of clinical practice by using a random sample of charts of all clinic users.
  • A large amount of data can be gathered in a relatively short amount of time.
  • Much data can be retrieved and recorded by clerical staff on log forms (e.g., presence or absence of signatures, updates of medical histories).
  • Can easily review services of all health professionals or focus on a single health professional.


  • Cannot identify problems in clinical technique that are not visible on radiographs.


  • Does not require presence of a patient.
  • Focuses on one aspect of care by only reviewing the charts of patients who received services in question.
  • If the metric reports are automated:
    • Data can be easily accessed at any time.
    • All charts can be reviewed for specific issue being addressed.
  • Results can be compared with all health centers using the same metric.
  • Multiple metrics can be used to develop a quality dashboard.
  • Removes subjectivity that is inherent in direct observation or chart audits.


  • Time consuming if reports are not automated, but less so than direct observation.
  • Limited to specific issue metric addresses.
  • Automated reports can be expensive to set up and require an electronic dental record and information technology input.

There is evidence that a relationship exists between the quality of clinical record keeping and the quality of care provided. Quarterly chart reviews can provide information to determine trends in quality of clinical care. If a clinic employs more than one dentist, chart review data can be used in aggregate to measure the overall quality of the clinic. Dentists are often more accepting of clinic-wide reviews than of dentist-focused reviews.

If ongoing monitoring reveals problems or trends, then aggregate data can be broken down by dentist to see if the trend is dentist-focused or clinic-wide. Problems present in the records of multiple dentists most likely represent problems with systems or procedures and should be analyzed from that standpoint. Problems or trends that point to a single dentist can be related to systems problems or to problems with the dentist’s skills.

Since direct observation is the most difficult to do, you might want to reserve it for times when clinical issues arise and a more focused review is required for a specific dentist. You can also use less direct methods like clinical photographs to obtain information that you may not get in a typical chart audit. As an example, you could have a new dentist or one that has had clinical issues take pictures of the first 10 endodontic access preps or crown preps that he or she does so they can be reviewed during administrative time.

Whichever method you use, it is ideal to have a document that describes how each question on the chart audit or each procedure being observed will be evaluated so your dentists know what is expected of them. Quality is best achieved when your dentists understand the quality that you expect. Review must be discussed with dentists and staff as part of your QI process. It is important to know that charts audits are limited in what practice details they can pick up. They are good for analyzing if the correct number of radiographs are being taken or if blood pressure checks are done at every exam, for example, but owing to the small number of charts audited they may not pick up on issues arising from incorrect clinical techniques or poor patient-management skills. It is critical to report back all results of every review to the dentists and discuss any improvements that are needed.