The University of Texas
Dental Branch at Houston A Part of The University of Texas Health Science Center at Houston

The Quality Assurance & Risk Management Program at UTDB

PROGRAM COMPONENTS:

• Quality Assurance Indices Review (QAIR)
  • The QAIR utilizes indices designated by departments as critical elements in assessing the Standard of Care. Annually, each department chair, the QA Director and other designated faculty review a sampling of patient records that pertain to the specific disciplines within the department. These records are assessed against the Standards of Care for the department's discipline(s).
• Clinical Reviews
  • During the course of treatment, comprehensive care patients receive periodic evaluations and appropriate periodontal and preventive maintenance. Pre-doctoral dental students are required to recall completed patients until graduation.
  • Ongoing Monitoring of Care at each clinical appointment by attending clinical faculty.
  • Oral Maintenance and Prevention Clinic provides an additional, formal opportunity to assess the outcomes of patient care when patients are evaluated for reassignment to another student.
  • Post Treatment Review is a formal review of completed patient treatment at the time a treatment plan is completed.
• Record Reviews
  • Pre-doctoral (DDS) Record Reviews are formally conducted during the Spring semester of the 3rd year, the Fall semester of the 4th year and immediately prior to graduation; at treatment plan approval (by the student's Practice Leader; and at each clinical appointment (by attending clinical faculty)
  • Dental Hygiene (DH) Record Reviews are conducted by the Dental Hygiene Facilitators at "Case Complete" and other random record reviews are performed on a regular basis by DH faculty
  • Postdoctoral Record Reviews are conducted by each program as part of their compliance with individual program accreditation standards, by faculty and residents at each clinical appointment, and at the completion of the treatment plan
  • Urgent Care Clinic Record Reviews are conducted on a random basis annually by the Urgent Care Director and the QA&RM Director. Additionally, attending faculty in the Urgent Care Clinic review records with the students at each clinical appointment.
  • Ad Hoc Record Reviews Ad hoc record reviews are conducted on the request of the Clinical Affairs Committee, on the request of the Associate Dean of Patient Care, and at the discretion of the QA Director based upon information gathered or received from clinical personnel, or from personal observations or encounters.
• Patient Services Reports
  • Patient Satisfaction Surveys are conducted twice each year in all UTDB clinics, and survey cards are always available at the entrances to the clinic areas for patient input.
  • Patient Relations Reports are a compilation of comments entered into the EPR by Patient Care Coordinators & staff. This report is generated monthly and reviewed by the Associate Dean for Patient Care and the QA&RM Director. Comments which require review and possible action are identified and investigated by the QA&RM Director.
  • Remake Reports are generated from deficiencies in treatment outcomes reported at case complete, found through audits, found by OMP Clinic, or found after reassignment to another student.
  • Refund Requests are on a monthly basis.
• Clinic Incident Reports
  • Clinic Incident Forms are used whenever a faculty, student or staff member identifies a potential QA&RM issue that needs to be addressed.
  • Medical Incident Reports are initiated in any instance where a UTDB nurse is called. These types of reports typically include needle stick or instrument injuries, swallowing of items, or other medical emergencies.
• Automatic QA&RM Reviews
  • Automatic QA&RM Reviews are initiated in the case of extremes in adverse clinical outcomes. Events that may trigger an automatic review include: extraction of the wrong tooth, restorative preparation of the wrong tooth, hospitalization of a patient directly from a UTDB clinic, a Code "Blue" emergency, a personal or legal complaint filed by a patient, or any other event considered to be a significant variance from a standard of care.
• Ad Hoc QA&RM Reviews
  • Ad Hoc QA&RM Reviews are on an as-needed basis initiated by informal faculty, student, resident, or staff reports to the Associate Dean or the QA&RM Director. Examples of events which would trigger an ad hoc review include: a medical consult was not followed by appropriate documentation in the EPR, a record review component that falls below a 90% score, more than three remakes annually of a specific procedure that is attributable to a specific faculty member, or when a Patient Satisfaction Survey item falls below a 90% satisfaction score. Individual Departments or Clinic Programs may also request an ad hoc review.