Albuquerque Area Dental Program Review Tool
Tribe-Service Unit/Date:
Reviewers: Dr. Tim Ricks, Area Dental Officer
Suzanne Marks, Dental Support Center Directors
Executive Summary / No recommendations for improvement / Some minor improvements recommended / Major improvements recommended / ScoreElements and ranked according to importance using industry and IHS standards.
1. Credentialing & Privileging
2. Patient Safety
(Combined score for a-d below)
a. Hazard Communications
b. Infection Control
c. Emergency Preparedness
d. Other Considerations
3. Documentation
4. Policies and Procedures
5. Quality Assurance & Improvement
6. Productivity & Efficiency
7. HP/DP
8. Employee Development
Top 3 program strengths
1.
2.
3.
Top 3 program recommendations
1.
2.
3.
Summary Narrative
I. Credentialing and Privileging
II. Patient Safety:
III. Documentation
IV. Policies and Procedures
V. Quality Improvement and Assurance
VI. HPDP
VII. Clinical Productivity
VIII. Employee Development
Recommendations Checklist
Category / Recommendation / Completion DateCredentialing & Privileging
Patient Safety
Documentation
Policies and Procedures
Quality Improvement and Assurance
HPDP
Category / Recommendation / Completion Date
Productivity & Efficiency
Employee Development
Scoring Element / Yes / No / Notes
a) All dentists in the facility have an active, unrestricted license to practice in their profession, with proof of licensure on record at the clinic.
b) All dentists in the facility have been credentialed in accordance with the clinic’s credentialing policies.
c) Credentialing files contain a NPDB query, a criminal background check, and verification of a DEA license, dental license, and dental degree(s).
d) Continuing education is updated in the credentialing file, or according to clinic policies.
e) All dentists in the facility have been granted privileges for the clinical procedures they perform by the facility’s governing body/health board; hygienists are either privileged or written scope of work. Providers that administer local anesthesia or nitrous oxide are privileged to do so.
f) Re-credentialing and re-privileging procedures are completed on all dentists at least every two years.
g) All dental assistants have been properly trained, certified, and current in the taking of radiographs and other services that they provide.
h) Peer reviews are used to evaluate providers prior to re-credentialing.
Hazard Communications
a) The program has a hazard communication program in the facility.
b) Staff understands and can use the MSDS book.
c) The program has an updated MSDS book, and a random sample of chemicals in the clinic shows no deficiencies.
d) Staff receives annual Hazard Communication training per OSHA regulations.
e) The program adheres to local environmental guidelines on the disposal of mercury.
f) Staff can demonstrate what to do in a hazard spill. The program has practiced or discussed a hazard spill at least once in the past year.
g) The program maintains incident reports on reportable events.
Scoring Element / Yes / No / Notes
Infection Control
a) Facility has a written, updated Infection Control Policy
b) Each employee has received training on infection control
c) Facility has a written policy of required vaccinations
d) Facility has a post-exposure management plan
e) Facility has a policy regarding work related illnesses and work restrictions
f) Facility has a policy for maintaining the confidentiality of employee medical records
g) Each employee has received, is in process of receiving or has documentation of declination of Hepatitis B vaccination
h) Standard precautions are used for all patients
i) Used sharps are placed in a puncture resistant container
j) Needles are recapped using either a one-handed scoop technique or a mechanical device designed for holding the needle cap
k) Hands are washed with soap and water or cleaned with an alcohol gel before and after each patient
l) Sterile gloves are used for appropriate procedures
m) Fingernails and/or jewelry do not impair the proper use of gloves
n) A surgical mask and eye protection with solid side shields or a face shield to protect mucous membranes of the eyes, nose, and mouth are worn during procedures likely to generate splashing or spattering of blood or other body fluids
o) Masks are changed between patients or if the mask becomes wet
p) Protective wear (gown, lab coat, uniform) is worn when skin or personal clothing is likely to become soiled
q) Protective clothing is removed before leaving work area
r) Gloves are worn when a potential exists for contacting blood, saliva, or mucous membrane
s) Gloves are changed if they become torn and between each patient
t) Patients are given protective eyewear when spatter is expected.
u) Patients are screened for latex sensitivity
v) The facility can provide a latex-free environment for patients with latex sensitivity
w) The facility has an emergency kit with latex free items
x) Critical and semi-critical items are heat sterilized before each use
Scoring Element / Yes / No / Notes
Infection Control
y) Sterilized items are allowed to dry before handling
z) Disposable items are not reused
aa) Noncritical patient-care items are barrier-protected or cleaned, or if visibly soiled, cleaned and disinfected after each use with an EPA-registered hospital disinfectant.
bb) Instrument processing area is divided into a “Clean” and “Dirty” area or measures are taken to avoid contamination of clean instruments
cc) Instruments are debrided prior to sterilization
dd) Puncture resistant gloves are used for instrument processing
ee) Internal and external chemical indicators are used for each instrument package or load of unwrapped instruments
ff) Container or wrapping system is compatible with method of sterilization
gg) Unwrapped instruments are cleaned and dried prior to sterilization
hh) Chemical and biological monitors are used
ii) In the case of a positive spore test: problem is corrected, and another spore test is run to confirm sterilization effectiveness. All affected instruments are re-sterilized
jj) Wrapped instruments are marked for date of sterilization, sterilizer, and load
kk) Sterile packages are inspected before use, compromised packages are re-sterilized prior to use
ll) Sterile packages are stored in a closed or covered cabinet
mm) Cleaning and EPA-registered hospital disinfecting products are used correctly
nn) Liquid chemical sterilants/high-level disinfectants for disinfection of environmental surfaces are not used for environmental surfaces
oo) PPE, as appropriate, is used when cleaning and disinfecting environmental surfaces.
pp) Surface barriers are used on surfaces difficult to clean and changed between patients
qq) Contaminated environmental surfaces are appropriately cleaned
rr) Spills of blood or other potentially infectious materials are cleaned and decontaminated with an EPA-registered hospital disinfectant with low- (i.e., HBV and HIV label claims) to intermediate-level (i.e., tuberculocidal claim) activity
ss) Facility has an infected waste management plan
Scoring Element / Yes / No / Notes
Infection Control
tt) Contaminated non-sharp waste is stored in a puncture resistant, color coded bag
uu) Liquid waste is disposed of in a sanitary sewer system or in a manner in accordance with state regulations
vv) Water used for routine dental treatment meets EPA standards for drinking water
ww) Any device connected to a water system that enters the patient’s mouth is flushed for 20-30 seconds between patients
xx) Water lines are monitored according to manufacturer’s instructions
yy) Handpieces are removed, cleaned and sterilized between each patient
zz) Patients are not instructed to close lips around suction devices
aaa) Gloves are worn when exposing radiographs and when handling contaminated packets
bbb) Radiography film holders are disposed of, heat sterilized or disinfected appropriately between patients
ccc) Aseptic procedures are used when transporting and developing films
ddd) Dispensing medication from multi-dose vials: a) sterile needles and syringe are used for each patient and b) vials are kept out of patient care areas.
eee) Biopsy specimens are stored in a sterile, leakproof container labeled with the biohazard symbol
fff) Extracted teeth are handled as regulated medical waste unless returned to the patient
ggg) Extracted teeth to be used for educational purposes are appropriately sterilized
hhh) Appropriate PPE is used for all laboratory procedures
iii) Prostheses and impressions are sterilized before handled in the laboratory
jjj) Facility conducts periodic infection control monitoring
kkk) Practices not in compliance with infection control standards are addressed
Score
Scoring Element / Yes / No / Notes
Emergency Preparedness
a) The program has a written fire/disaster emergency plan.
b) The program has a written medical emergency plan for the dental clinic, and staff has participated in at least 1 medical emergency drill in the past year in dental.
c) Emergency codes are accessible and prominently displayed in the clinic and reviewed with staff.
d) Emergency phone numbers are prominently displayed in the clinic.
e) An emergency kit is readily available, appropriate to Dental Clinic needs.
f) If drugs are kept in the clinic, all dental staff knows its location and how to use the contents.
g) The expiration dates of the drugs in the emergency kit are current.
h) An oxygen tank with an appropriate valve, tubing, and mask is available. Dental staff is familiar with its location and use.
i) The oxygen/nitrous oxide tank is checked routinely for leaks and function and this is documented.
j) All dental staff is currently BLS certified, and documentation is maintained of BLS certification.
k) A crash cart is available in the facility.
Score
Other Safety Considerations
a) X-ray machines are inspected at the required 3-year intervals. Deficiencies are corrected in a timely manner
b) Lead aprons are used on all patients receiving radiographs.
c) The aprons are x-rayed annually to assure that no damage occurred to the lead lining during storage and/or use.
d) Radiograph frequency adheres to ADA guidelines.
e) Film positioners are used. Neither patient nor staff holds the film during exposure.
f) Staff and other patients are protected from scatter radiation during film exposure.
g) The agitator of the amalgamator functions under a protective cover.
h) Amalgam scrap is stored in tightly closed containers
i) Amalgam scrap is recycled properly.
j) Medication and product recalls are documented.
k) Expired drugs are removed from inventory in a timely manner.
Score
Scoring Element / Yes / No / Notes
a) A health questionnaire completed by the patient and signed by the provider within the past 12 months is present and documentation exists that it was reviewed at each visit with the changes or the phrase “no changes” recorded. Medical alerts are highlighted.
b) Appropriate measures have been taken to ensure patient safety and appropriate treatment. (eg- blood pressure, blood sugar, consultations when necessary).
c) Appropriate ADA codes are recorded (including tooth number, surface, or pocket depths when appropriate) and documentation exists in the progress note to justify all codes.
d) Dental Progress Notes include:
a. date of treatment
b. signature of the provider(s)
c. if signature is illegible, printed or stamped name of provider(s)
d. degree of the provider(s)
e. If the patient was seen as a dental emergency, the SOAP format was used
e) Dental progress notes include a disposition (what the patient needs next) at the end of each visit.
f) Informed consent contains risks, benefits, and alternate treatments, and in language the patient can understand.
g) The informed consent form is signed by the dental provider and patient/parent/guardian.
h) Pain documentation is included on the progress note. Documentation is consistent with the facility policies. If pain is indicated, additional information on the management, treatment, or referral for tx is included.
i) All hard tissue findings (normal, pathology, or abnormalities) are recorded in the dental record.
j) Documentation that radiographs have been read exists in the patient record. This may be either in the progress note or on the Exam Form.
k) Evidence of soft tissue exam is present, either by listing of abnormalities or designation of “STN” (Soft Tissues Normal) or “WNL” (Within Normal Limits).
l) Periodontal status (CPITN or PSR) and diagnosis for patients age 15 and older is noted on the dental exam.
m) Orthodontic status (for patients ages 6 to 20) is noted on the dental exam sheet.
Score (% yes)
Scoring Element / Yes / No / Notes
n) Written treatment plan exists for all patients receiving initial or recall dental exams.
a. Treatment plan is easily understood
b. Follows a logical sequence
c. Is revised as needed, revisions are dated and initialed
o) If a full scope of services is not available at the facility, a chart notation is made that the patient has been informed of his/her need for treatment at another facility.
p) The patient is placed in a recall program based on his/her individual risks and clinic resources, rather than arbitrary time intervals.
q) Pre-operative x-rays are evident for appropriate procedures.
r) Documentation of the behavior for all children under the age of 6 is documented.
s) Behavior management techniques used and their level of effectiveness are documented.
t) When definitive periodontal therapy is planned for patients with CPITN/PSR of 2 “4’s”, a periodontal work-up is conducted. This includes probing pocket depths, furca involvement, mobility, and occlusal features, with documentation.
u) The dental record contains an individualized dental disease prevention plan.
Score
Chart Review
Facility:______Provider: ______
Record Number
CRITERIAA. Every Visit (Total=__)
1) Completed and Signed Medical History, Updated
2) Precautions appropriate for PS
3) Appropriate Codes
4) Complete progress notes(SOAP for Emer)
5) Disposition
6) Informed consent contains risks, benefits, and alternate treatments, and in language the patient can understand.
7) Informed consent is signed by provider and patient/parent/guardian.
8) Pain Documentation
B. Exam and Treatment plan (Total=__)
1) Hard tissue findings recorded
2) X-rays read
3) Soft tissue findings recorded
4) Periodontal status and diagnosis
5) Orthodontic status
6) Treatment Plan Complete
7) Notation of needed, unavailable services
8) Follow up/ recall consistent with patient needs
9) The dental record includes an individualized dental disease prevention plan.
C. Treatment Documentation
1) 1)Pre-operative x-rays are evident for appropriate procedures.
2) 2) Documentation of behavior is evident for all children under the age of 6.
3) Behavior management techniques used ant their level of effectiveness is documented.
4) When definitive periodontal therapy is planned for patients with CPITN/PSR of 2 quadrants of “4” or more, a periodontal workup is conducted. This includes probing pocket depths, furca involvement, mobility, and occlusal features with documentation.