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Annual Appraisal

The effectiveness of the Dental Department's CQI Program will be evaluated annually by the [appropriate individual(s)]. This annual reappraisal of the CQI Program will include evaluation of the organization, including the scope, effectiveness, objectiveness, comprehensives of the current activities, and community input from tribal sources or patient satisfaction surveys. The results of this evaluation will be reported to the [appropriate individual].


Confidentiality

All QI records shall be maintained in accordance with the Privacy Act, Freedom of Information Act, and other local confidentiality policies as applicable.



D.2 RISK MANAGEMENT/PROGRAM MONITORING
[Insert facility’s Policy Header Information]
PURPOSE

The purpose of this Risk Management plan is to continuously improve the quality of dental program and reduce risk that may be introduced through dental care provided at [facility].

PROCEDURE



Program Elements

[Appropriate individual] will coordinate risk management with [administration or appropriate individual e.g. safety officer]. Incident and accident reports will be completed and processed as per Facility policy. Valid patient and employee complaints will be referred to the appropriate staff for appropriate management.

A program review and infection control review will be conducted annually. Results will be submitted to [appropriate individual]. Deficiencies will be address in a staff meeting, through continuing education, or other appropriate means.

See Attachment * for program review tools or forms.

Tracking

[CE coordinator or appropriate individual] will ensure appropriate certifications such as CPR, radiology, CE, and other mandatory certifications are maintained by dental staff. Additionally, dental staff is responsible for maintaining facility required training such as Electrical Safety, Fire Safety, Infection Control, MSDS, Blood Borne Pathogens, and Hazard Communications training as per facility safety guidelines

[Frequency as required by the facility] quality assurance activity report will be submitted to the [appropriate individual].

Nashville Area Dental Program Review Tool

Nashville Area Dental Officer & USET Dental Support Center


Tribe/Date:

Reviewer:


Executive Summary

No recommendations for improvement

Some minor improvements recommended

Major improvements recommended

Score

Elements and ranked according to importance using industry and IHS standards.




1. Credentialing & Privileging













2. Patient Safety

(Combined score for a-d below)



 

 

 




  1. Hazard Communications













  1. Infection Control













  1. Emergency Preparedness













  1. 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







Top 3 program recommendations






Summary Narrative



  1. Credentialing and Privileging

  2. Patient Safety:

  3. Documentation

  4. Policies and Procedures

  5. Quality Improvement and Assurance

  6. HPDP

  7. Clinical Productivity

  8. Employee Development

Recommendations Checklist

Category

Recommendation

Completion Date

Credentialing & 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

  1. All dentists in the facility have an active, unrestricted license to practice in their profession, with proof of licensure on record at the clinic.










  1. All dentists in the facility have been credentialed in accordance with the clinic’s credentialing policies.










  1. Credentialing files contain a NPDB query, a criminal background check, and verification of a DEA license, dental license, and dental degree(s).










  1. Continuing education is updated in the credentialing file, or according to clinic policies.










  1. 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.










  1. Re-credentialing and re-privileging procedures are completed on all dentists at least every two years.










  1. All dental assistants have been properly trained, certified, and current in the taking of radiographs and other services that they provide.










  1. Peer reviews are used to evaluate providers prior to re-credentialing.
















Hazard Communications










  1. The program has a hazard communication program in the facility.










  1. Staff understands and can use the MSDS book.










  1. The program has an updated MSDS book, and a random sample of chemicals in the clinic shows no deficiencies.










  1. Staff receives annual Hazard Communication training per OSHA regulations.










  1. The program adheres to local environmental guidelines on the disposal of mercury.










  1. 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.










  1. The program maintains incident reports on reportable events.










Score



Scoring Element

Yes

No

Notes

Infection Control










  1. Facility has a written, updated Infection Control Policy










  1. Each employee has received training on infection control










  1. Facility has a written policy of required vaccinations










  1. Facility has a post-exposure management plan










  1. Facility has a policy regarding work related illnesses and work restrictions










  1. Facility has a policy for maintaining the confidentiality of employee medical records










  1. Each employee has received, is in process of receiving or has documentation of declination of Hepatitis B vaccination










  1. Standard precautions are used for all patients










  1. Used sharps are placed in a puncture resistant container










  1. Needles are recapped using either a one-handed scoop technique or a mechanical device designed for holding the needle cap










  1. Hands are washed with soap and water or cleaned with an alcohol gel before and after each patient










  1. Sterile gloves are used for appropriate procedures










  1. Fingernails and/or jewelry do not impair the proper use of gloves










  1. 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










  1. Masks are changed between patients or if the mask becomes wet










  1. Protective wear (gown, lab coat, uniform) is worn when skin or personal clothing is likely to become soiled










  1. Protective clothing is removed before leaving work area










  1. Gloves are worn when a potential exists for contacting blood, saliva, or mucous membrane










  1. Gloves are changed if they become torn and between each patient










  1. Patients are given protective eyewear when spatter is expected.










  1. Patients are screened for latex sensitivity










  1. The facility can provide a latex-free environment for patients with latex sensitivity










  1. The facility has an emergency kit with latex free items










  1. Critical and semi-critical items are heat sterilized before each use









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