ment of a separate organization and process for accrediting or certifying clinics in dental schools may be advisable at some point. That process would best be structured as part of a more comprehensive effort to assess and ensure the quality of dental care including community-based and hospital-affiliated services.
The path toward certification for outpatient care programs has not been a smooth one in either medicine or dentistry, and the design and implementation of quality assurance and improvement programs for ambulatory care encounter particular problems. Difficulties include the number and diversity of ambulatory care settings and services, their traditionally fragmented and incomplete data systems, and the relative scarcity of agreed-upon quality indicators, especially outcomes measures (IOM, 1990e). Improvements in data systems and outcome measures should be priorities for dental school clinics regardless of how external review programs are structured.
To the extent that the health care system of the future is based on organizations that integrate different types and settings of care, most academic health centers will need to develop a more coherent relationship among their constituent patient care units. Where a center can call upon its dental school, it may be able to develop an advantage over competitors without dental programs if the school's patient care activities become more patient oriented and able to attract patients independently or through referrals. Not only could the school offer services, it could be a productive source of referrals for other parts of the academic health center. Thus, academic health centers may indeed welcome participation by dental educators in reorganizing patient care activities to make them more competitive. Where such participation does not exist or is limited, dental school deans and faculty should take the initiative in exploring closer relationships.
Dental schools that are not part of an academic health center could, in principle, seek integration or involvement with other institutions. Whether they would be attractive partners absent some preexisting connection probably would depend on how attractive patient care within the dental school could be made.
Dental schools' perceptions of their patient care mission are still evolving, as are their strategies for fulfilling this mission. The