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Scoring Element

Yes

No

Notes

Infection Control










  1. Sterilized items are allowed to dry before handling










  1. Disposable items are not reused










  1. 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.










  1. Instrument processing area is divided into a “Clean” and “Dirty” area or measures are taken to avoid contamination of clean instruments










  1. Instruments are debrided prior to sterilization










  1. Puncture resistant gloves are used for instrument processing










  1. Internal and external chemical indicators are used for each instrument package or load of unwrapped instruments










  1. Container or wrapping system is compatible with method of sterilization










  1. Unwrapped instruments are cleaned and dried prior to sterilization










  1. Chemical and biological monitors are used










  1. 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










  1. Wrapped instruments are marked for date of sterilization, sterilizer, and load










  1. Sterile packages are inspected before use, compromised packages are re-sterilized prior to use










  1. Sterile packages are stored in a closed or covered cabinet










  1. Cleaning and EPA-registered hospital disinfecting products are used correctly










  1. Liquid chemical sterilants/high-level disinfectants for disinfection of environmental surfaces are not used for environmental surfaces










  1. PPE, as appropriate, is used when cleaning and disinfecting environmental surfaces.










  1. Surface barriers are used on surfaces difficult to clean and changed between patients










  1. Contaminated environmental surfaces are appropriately cleaned










  1. 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










  1. Facility has an infected waste management plan












Scoring Element

Yes

No

Notes

Infection Control










  1. Contaminated non-sharp waste is stored in a puncture resistant, color coded bag










  1. Liquid waste is disposed of in a sanitary sewer system or in a manner in accordance with state regulations










  1. Water used for routine dental treatment meets EPA standards for drinking water










  1. Any device connected to a water system that enters the patient’s mouth is flushed for 20-30 seconds between patients










  1. Water lines are monitored according to manufacturer’s instructions










  1. Handpieces are removed, cleaned and sterilized between each patient










  1. Patients are not instructed to close lips around suction devices










  1. Gloves are worn when exposing radiographs and when handling contaminated packets










  1. Radiography film holders are disposed of, heat sterilized or disinfected appropriately between patients










  1. Aseptic procedures are used when transporting and developing films










  1. 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.










  1. Biopsy specimens are stored in a sterile, leakproof container labeled with the biohazard symbol










  1. Extracted teeth are handled as regulated medical waste unless returned to the patient










  1. Extracted teeth to be used for educational purposes are appropriately sterilized










  1. Appropriate PPE is used for all laboratory procedures










  1. Prostheses and impressions are sterilized before handled in the laboratory










  1. Facility conducts periodic infection control monitoring










  1. Practices not in compliance with infection control standards are addressed










Score



Scoring Element

Yes

No

Notes

Emergency Preparedness










  1. The program has a written fire/disaster emergency plan.










  1. 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.










  1. Emergency codes are accessible and prominently displayed in the clinic and reviewed with staff.










  1. Emergency phone numbers are prominently displayed in the clinic.










  1. An emergency kit is readily available, appropriate to Dental Clinic needs.










  1. If drugs are kept in the clinic, all dental staff knows its location and how to use the contents.










  1. The expiration dates of the drugs in the emergency kit are current.










  1. An oxygen tank with an appropriate valve, tubing, and mask is available. Dental staff is familiar with its location and use.










  1. The oxygen/nitrous oxide tank is checked routinely for leaks and function and this is documented.










  1. All dental staff is currently BLS certified, and documentation is maintained of BLS certification.










  1. A crash cart is available in the facility.










Score




Other Safety Considerations










  1. X-ray machines are inspected at the required 3-year intervals. Deficiencies are corrected in a timely manner










  1. Lead aprons are used on all patients receiving radiographs.










  1. The aprons are x-rayed annually to assure that no damage occurred to the lead lining during storage and/or use.










  1. Radiograph frequency adheres to ADA guidelines.










  1. Film positioners are used. Neither patient nor staff holds the film during exposure.










  1. Staff and other patients are protected from scatter radiation during film exposure.










  1. The agitator of the amalgamator functions under a protective cover.










  1. Amalgam scrap is stored in tightly closed containers










  1. Amalgam scrap is recycled properly.










  1. Medication and product recalls are documented.










  1. Expired drugs are removed from inventory in a timely manner.










Score


Scoring Element

Yes

No

Notes

  1. 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.










  1. Appropriate measures have been taken to ensure patient safety and appropriate treatment. (eg- blood pressure, blood sugar, consultations when necessary).










  1. 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.










  1. Dental Progress Notes include:

    1. date of treatment

    2. signature of the provider(s)

    3. if signature is illegible, printed or stamped name of provider(s)

    4. degree of the provider(s)

    5. If the patient was seen as a dental emergency, the SOAP format was used










  1. Dental progress notes include a disposition (what the patient needs next) at the end of each visit.










  1. Informed consent contains risks, benefits, and alternate treatments, and in language the patient can understand.










  1. The informed consent form is signed by the dental provider and patient/parent/guardian.










  1. 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.










  1. All hard tissue findings (normal, pathology, or abnormalities) are recorded in the dental record.










  1. Documentation that radiographs have been read exists in the patient record. This may be either in the progress note or on the Exam Form.










  1. Evidence of soft tissue exam is present, either by listing of abnormalities or designation of “STN” (Soft Tissues Normal) or “WNL” (Within Normal Limits).










  1. Periodontal status (CPITN or PSR) and diagnosis for patients age 15 and older is noted on the dental exam.










  1. Orthodontic status (for patients ages 6 to 20) is noted on the dental exam sheet.










Score (% yes)




Scoring Element

Yes

No

Notes

  1. Written treatment plan exists for all patients receiving initial or recall dental exams.

    1. Treatment plan is easily understood

    2. Follows a logical sequence

    3. Is revised as needed, revisions are dated and initialed










  1. 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.










  1. The patient is placed in a recall program based on his/her individual risks and clinic resources, rather than arbitrary time intervals.










  1. Pre-operative x-rays are evident for appropriate procedures.










  1. Documentation of the behavior for all children under the age of 6 is documented.










  1. Behavior management techniques used and their level of effectiveness are documented.










  1. 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.










  1. The dental record contains an individualized dental disease prevention plan.










Score

Chart Review

Facility:_______________________ Provider: _____________



Record Number


CRITERIA
































Y-Yes Note: Threshold for

N- No success is 80%

NA- Not Applicable


































A. Every Visit (Total=__)

  1. Completed and Signed Medical History, Updated































  1. Precautions appropriate for PS































  1. Appropriate Codes































  1. Complete progress notes(SOAP for Emer)































  1. Disposition































  1. Informed consent contains risks, benefits, and alternate treatments, and in language the patient can understand.































  1. Informed consent is signed by provider and patient/parent/guardian.































  1. Pain Documentation































B. Exam and Treatment plan (Total=__)

  1. Hard tissue findings recorded































  1. X-rays read































  1. Soft tissue findings recorded































  1. Periodontal status and diagnosis































  1. Orthodontic status































  1. Treatment Plan Complete































  1. Notation of needed, unavailable services































  1. Follow up/ recall consistent with patient needs































  1. The dental record includes an individualized dental disease prevention plan.































C. Treatment Documentation

  1. 1)Pre-operative x-rays are evident for appropriate procedures.































  1. 2) Documentation of behavior is evident for all children under the age of 6.































  1. Behavior management techniques used ant their level of effectiveness is documented.































  1. 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 cumentation.


































Scoring Element

Yes

No

Notes

  1. The facility has a policy and procedure manual for dental department.










  1. The policy manual must include the following critical policies/procedures:

    1. Patient eligibility including determination of eligibility for services and CHS is in the P&P Manual.

    2. Scope of services is included in the P&P Manual.

    3. Standing orders for auxiliaries are included in the P&P Manual.

    4. The clinic has an appointment/broken appointment policy.

    5. The clinic has a pain management policy.

    6. The clinic has a behavioral management/restraint policy and procedure.

    7. Identifies procedures for which a separate informed consent is required.

    8. Identifies management of patients with medical issues such as hypertension, diabetes, etc.

    9. Identifies documentation guidelines (required documentation for clinical care).
































































  1. The Policy and Procedure Manual is updated annually.










  1. Staff has received an update on Policies and Procedures within the last year.










  1. The dental program operates under a written, readily available, working copy of a P&P Manual.










  1. The clinic has standard protocols for common services.










Additional Notes


Score




Scoring Element

Yes

No

Notes

  1. The clinic has a quality assurance and improvement plan. The clinic demonstrates local facility quality benchmarking against best practices, professional practice guidelines, overall health care goals, or performance measures.










  1. Department regularly monitors quality of care (delivery of care) through internal activities (quality assurance).










  1. The program has conducted at least one patient satisfaction/customer service survey in the past year.










  1. Nitrous oxide/oxygen administration is monitored annually for exposed workers and for leaks.










  1. The dental clinic has conducted at least one quality improvement program in the past year, with documentation of evaluation (PDSA or similar).










  1. The dental program actively participates in the facility’s quality assurance/improvement program.










Additional Notes


Score




Scoring Element

Yes

No




Notes

  1. Clinical Productivity and Efficiency

Productivity










  1. The average number of patient visits in the year preceding the review is greater than 1,926 per dentist.










  1. More than 40% of registered users at the facility have utilized dental services in the past year (this is different than the GPRA user population).










  1. The average number of total services in the year preceding the review is greater than 7,000 per dentist.










  1. The average number of relative value units (RVUs) produced by the clinic in the year preceding the review is greater than 10,146 per dentist.










Efficiency & Effectiveness










  1. The clinic has a dentist to population ratio of 1:1200 or better.










  1. The dental clinic has a full time equivalent (FTE) staff to population ratio of 1:500 or better.










  1. Excluding chairs dedicated solely to dental hygienists, the dental clinic has an operatory to dentist ratio of 2:1 or better.










  1. The dental clinic has a dental assistant to dentist ratio of 2:1 or better.










  1. The dental clinic produces at least an average of 5.3 RVUs per patient visit or more.










  1. The dental clinic produces 2,697 RVUs per FTE staff or more.










  1. The dental clinic produces 3,467 RVUs per operatory or more.










  1. The dental clinic has a broken appointment rate of 23% or lower.










  1. 63% or higher of patients seen in the dental clinic have been treatment planned.










  1. 48% or higher of patients receiving exams (0145, 0150, 0120) have completed treatment.










  1. The clinic produces 10.9 RVUs per patient.










  1. The clinic produces 792 or more patient visits per operatory per year.










  1. The average dentist productivity is 8.68 or higher patient visits per dentist per day.










  1. 80% or higher of all services were Level I-III (basic) services for the past year.










  1. The clinic produces a minimum of 5 RVU’s per dentist and 3.5 RVUs per hygienist per hour.
















Scoring Element

Yes

No

Notes

  1. The dental program has overall HP/DP goals or has identified high priority areas.










  1. At least one HP/DP program has been conducted in the past year by dental staff utilizing the POARE (Problem, Objectives, Activities, Results, and Evaluation) or similar program planning model or similar model.










  1. The program regularly evaluates community-based prevention activities.










  1. There is evidence of sharing goals and results of HP/DP programs conducted with tribal leaders, facility administration, dental staff, and the community.










  1. Dental staff is aware of the clinic’s HP/DP goals and current project(s).










  1. The dental program is actively collaborating with non-dental staff (in the facility) on an HP/DP project.










  1. An ongoing fluoride program is established at the community level, involving non-health care partners. This includes water fluoridation or topical fluorides (i.e., fluoride varnish) and collaborative partners may include Head Start, schools, or the water resource department.










  1. The program has built collaborations within the community and facility (i.e., medical, Head Start, daycare, schools, WIC, etc.).










  1. The dental program achieved its access to care GPRA goal in the last reporting year.










  1. The dental program achieved its dental sealant GPRA goal in the last reporting year.










  1. The dental program achieved its fluoride GPRA goal in the last reporting year.










Score

Scoring Element

Yes

No

Notes

  1. The dental program has performance plans/individual development plans for all dental staff.










  1. The dental program provides evidence of regular dental staff meetings.










  1. All dental staff is given opportunities for continuing education during the year.










  1. Staff has received HIPAA and Privacy Act training in the past year.










  1. All licensed or certified dental staff has met continuing education requirements in the past year.










Score

Sample Employee Training Tracking Form

Employee Name___________________ Position _______________


ANNUAL

(Year)


Year

Year

Year

Year

CPR CERT















RADIOLOGY CERT
















SAFETY















INFECTION

CONTROL















M.S.D.S.















MED EMERGENCY
















BLOOD BORNE PATHOGENS

















(List others)



















































































Comments:

Sample Facility Review Tracking Form




Frequency






















QA REPORT






















PROGRAM REVIEW























INFECTION CONTROL





















RADIOLOGY CERTIFICATION

























Comments:

SECTION E: COMMUNITY HEALTH
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