Primary Care Dental Services Clinical Governance Workbook.doc


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Primary Care Dental Services Clinical Governance Workbook.doc

  1. 1. Primary Care Dental Services Clinical Governance WorkbookTHEME 1 – Infection Control C1, C4, C10, C20, C21, D1, D12, D13RequirementsProcedures in accordance with BDA/DH Advice Sheet A12 (Infection Control in Dentistry) including: • Infection control policy • Inoculation injury policy and recording of Hepatitis B immunisation status of exposure prone staff • Staff induction programme to include infection control procedures and staff training • Audit of policy complianceInformationBDA/DH advice sheet A12 (Infection Control in Dentistry)GDC Standards for Dental Professionals 2005BDA Practice Compendium – model policiesCompliance with A12 ID WHO INDICATOR WRITTEN EVIDENCE ASSESSMENT VISIT Separate areas for reprocessing,  Training records on IC/induction  Practice Visit 1.1 ? identified clean / dirty areas in  Completion of self-assessment IC  IC Audit Tool surgeries audit tool Fully maintained and H&S compliant:  Hepatitis B immunisation status  Ultrasonic records 1.2 ?  Washer and dryer  Needlestick injury policy and  Autoclaves training records of staff • The practice self-assessment audit can be verified at practice visit. • Assessors should be able to readily access relevant IC training records. • Assessors should be able to access re-processing equipment maintenance and service records for past year and evidence ofGUIDANCE daily checks for previous quarter. • All staff should maintain up to date personal development portfolios, confirming IC practice induction and training, that could be viewed by assessors during visit.NHS PCC - Primary Care Dental Services Clinical Governance Workbook
  2. 2. THEME 2 – Child Protection C2, C6, C10Requirements  Identification and CRB checks for all staff  Child protection policy which is consistent with local and wider policies including any staff training requirementsInformationCRB website: guidanceLocal Safeguarding Children Board ProceduresChild protection and the Dental Team, book and due May 2006 COPDEND ID WHO INDICATOR WRITTEN EVIDENCE ASSESSMENT VISIT All staff are aware of PCT Child Child Protection policy and   Practice visit 2.1 ? Protection requirements and relevant training and induction  Self-reported procedures records for all staff. Practice policy on Child Protection  Comprehensive staff Human consistent with PCT Child Protection Resources records (identification, 2.2 ? Policy references and qualification checks)  All staff should respond positively and be familiar with Child Protection procedures and policies, assessors can confirm this during practice visit by speaking to staff.GUIDANCE  Induction/training records and personal CPD portfolios readily available to confirm.  Identity/CRB/references and qualification checks for all staff readily available in Human Resources records.NHS PCC - Primary Care Dental Services Clinical Governance Workbook
  3. 3. THEME 3 – Dental Radiography C1, C11, C24RequirementsProcedures and policies in accordance with the IRR(1999) and IR(ME)R(2000) including:  A quality assurance system  X-ray malfunction plan, including how to manage an unintended over-exposure  Records of staff training  X-ray equipment maintenance recordsInformationIRR 1999 and IR(ME)R 2000BDA advice sheet A11 (radiation in dentistry)NRPB guidance notes for dental practitioners ID WHO INDICATOR WRITTEN EVIDENCE ASSESSMENT VISIT All legal requirements with regard to  Staff training/induction records  Practice visits 3.1 ? radiological protection are satisfied  Maintenance and service records  DRO reports Fully maintained and H&S compliant x-  Evidence of regular audits to  Self-reported questionnaires 3.2 ? ray equipment in place ensure radiographs are of  Audit reports QA system and x-ray malfunction plan diagnostic value in place  Evidence of justification for 3.3 ? radiographs and reports on finding within clinical records  Assessors could confirm at practice visit that all legal requirements are met by viewing relevant documentation.  Assessors will have access to DRO reports and could confirm by viewing a sample of records that clinical justification forGUIDANCE radiographs and findings are recorded in clinical records.  Assessors could access staff training reads on dental radiography.NHS PCC - Primary Care Dental Services Clinical Governance Workbook
  4. 4. NHS PCC - Primary Care Dental Services Clinical Governance Workbook
  5. 5. THEME 4 – Staff, Patient, Public and Environmental Safety C1, C4, C5, C20, C21, D12Requirements • Significant events analysis procedures and changes to procedures initiated as a result • Compliance with Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995 • Procedures to ensure all relevant safety alert bulletins are disseminated to staff and acted on • All medical devices are CE compliant, staff training for usage provided and incident reporting carried out • Medicines are appropriately sourced, purchased and stored including a medical emergencies drug kit • Compliance with Carriage of Dangerous Goods and Use of Transferable Pressure Equipment (Amendment) Regulations 2005 • Hazardous waste regulations 2005 and the management of waste amalgam/mercury • Health and Safety at Work Act 1974 • Management of Health and Safety at Work Regulations 1999 • Workplace (Health, Safety and Welfare) Regulations 1992 • Control of Substances Hazardous to Health Regulations 2002 • (Also see Infection Control, Child Protection and Dental Radiography)InformationSeven Steps to patient Safety – Advice Note 53 (amalgam separators)RIDDOR Regulations 1995Health and Safety (First Aid) Regulations 1981MHRA safety notices (bulletins are posted on BDA website: RegulationsDPF/BDA advice sheet B9 (Prescribing in general practice)GDC guidelinesMedicines Control Agency (MCA)Health and Safety at Work Act 1974BDA Advice sheet A3 (Health & Safety law for dental practice)CoSHH Regulations 2002BDA Advice sheet A5 (Risk assessment in dentistry)Management of Health and Safety at Work Regulations 1999BDA Advice sheet D14 (Violence at Work)Carriage of Dangerous Goods and Use of Transportable Pressure Equipment (Amendment) Regulations 2005 ID WHO INDICATOR WRITTEN EVIDENCE ASSESSMENT VISITNHS PCC - Primary Care Dental Services Clinical Governance Workbook
  6. 6. Practice meets all legal requirements  Significant event and incidence  Incident reports 4.1 ? for staff, patients, public and employee reporting policy and reports.  Practice Visit safety  Practice policy and procedures in All relevant H&S notices are displayed place for RIDDOR safety bulletins 4.2 ? and medical devices, hazardous All medicines and products used in waste, and use of pressure 4.3 ? clinical care are appropriately sourced, equipment, invoices and stock purchased and stored rotation records.  The practice should report significant event incidents in a consistent format a) Statement of problem or event/learning outcomes and action plan; or b) What happened? Why did it happen? Was insight demonstrated? Was change implemented?  The practice should involve team members and PCT if appropriate.GUIDANCE  Assessors could confirm practice policies and procedures and relevant documentation in place for RIDDOR safety bulletins and medical devices, hazardous waste, use of pressure equipment, and confirm that staff are familiar with and compliant with procedures and policies.  Assessors could confirm all medicines and clinical products are in date, stored appropriately and that all staff are aware and compliant with requirements.NHS PCC - Primary Care Dental Services Clinical Governance Workbook
  7. 7. THEME 5 – Evidence based Practice and ResearchRequirements  Relevant NICE Guidelines are followed  Clinical care is informed by other evidence-based guidelines  Existing care pathways and referral protocols are followed  Where appropriate, principles of research governance are appliedInformationNICE guidance12Faculty of Dental Surgery guidance Intercollegiate Guidance Networkhttp:/ referral protocols (where exist)Local research ethics committees ID WHO INDICATOR WRITTEN EVIDENCE ASSESSMENT VISIT 5.1 ? NICE guidelines are followed Clinical records justify recall   Clinical records/DRO reports intervals  Practice Visit Clinical staff are aware of and  Resources to assist patients  BSA on-line interrogation implement evidence-based guidelines contribute to and understand decisions on recall intervals. 5.2 ?  CPD portfolios for all clinical include updates on evidence- based guidelines are implemented  Assessors can confirm compliance with NICE guidance recall intervals by surveying clinical records.  Clinical treatment plans reflect implementation of evidence-based guidance, e.g. child with active decay receives advice,GUIDANCE exposure to fluoride and restorative care as appropriate and consistent with evidence-based approach.  Compliance with referral protocols for e.g. IOTN and local referral protocols for dental specialties as they develop1 Guidance for third molars: Guidance for recall intervals: PCC - Primary Care Dental Services Clinical Governance Workbook
  8. 8. THEME 6 – Prevention and Public Health C22, C23, D13RequirementsAn evidence-based prevention policy for all oral diseases and conditions appropriate to the needs of the local population and consistent with local andnational priorities. This should include: • Links to any existing community based strategies • Tobacco use cessation • Alcohol consumption advice(Also see Infection Control, Patient, Public and Environmental Safety)InformationBDA/NHS/HAD: Helping smokers stop: A guide for the dental team (2004). Available at Basis of Oral Health Education (Levine and Stillman-Lowe, 2004)National/local oral health strategy ID WHO INDICATOR WRITTEN EVIDENCE ASSESSMENT VISIT All staff aware of PCT’s oral health Comprehensive preventive   Practice Visit needs assessment and evidence advice given and recorded in  Referrals to smoking cessation 6.1 ? based prevention policy outlined in clinical records and consistent service Choosing Better Oral Health with wider public health Evidence-based policy resources and messages preventive measures are readily  Smoking status recorded in 75% 6.2 ? accessible and utilised in the practice of clinical records  Records from practice based smoking cessation services.  All staff aware of preventive policy and key public health messages appropriate to the needs of PCT populationGUIDANCE  Assessors can confirm that appropriate, consistent advice and preventive care is given and recorded in clinical records  Assessors can confirm smoking status is recorded in clinical records and referral information is given as appropriate.NHS PCC - Primary Care Dental Services Clinical Governance Workbook
  9. 9. THEME 7 – Clinical records, patient privacy and confidentiality C9, C13, C20Requirements • Staff awareness of and compliance with Data Protection Act 1998 • Caldicott Guidelines 1997, Access to Health Records 1998 and Confidentiality Code of Practice 1998 are followed • Confidentiality policy satisfactory arrangements for confidential discussions with patients • Data protection policyInformationClinical Examination and Good Record Keeping: Good Practice Guidelines, FGDPGDC Standards for Dental Professionals 2005Professional indemnity insurers advice (DDU, DPS, MDDUS)BDA Advice Sheet B2 (Data protection)Data Protection Act 1998Caldicott guidelines Management: NHS code of ID WHO INDICATOR WRITTEN EVIDENCE ASSESSMENT VISIT Practice complies with all relevant  Confidentiality policy in place and  Practice visits 7.1 ? legislation training records confirm  PALS/Complaints Staff are familiar with and adhere to  Satisfactory DRO reports on 7.2 ? policy and guidelines clinical record keeping Patient privacy and confidentiality is  Clinical audit reports 7.3 ? respected Clinical records are stored and 7.4 ? completed appropriately  Assessors could confirm all clinical records are securely stored in a lockable filing system.GUIDANCE  Assessors could confirm that patient privacy and confidentiality is maintained in all practice settings by all practice staff in line with guidanceNHS PCC - Primary Care Dental Services Clinical Governance Workbook
  10. 10. NHS PCC - Primary Care Dental Services Clinical Governance Workbook
  11. 11. THEME 8 – Staff Involvement and Development (for all staff) C5, C8, C10, C11, C21, C24, D7, D12Requirements • Employment policies – appropriate job descriptions for all posts • Appraisal, personal development plans and links to mentoring schemes • Appropriate staff training undertaken and records of staff training maintained (e.g. customer training, equal opportunities, dealing with complaints and patient feedback) • Records of practice meetings and evidence of staff involvement • Protected time for staff meetings and clinical governance • Confidential process for staff to raise concerns about performance • Links to a local Practitioner Advice and Support Scheme (Pass) or similar • Evidence of regular basic life support training • Evidence that staff opinion is sought about practice matters (e.g. staff surveys, practice meetings)InformationGDC – Standards for Dental Professionals 2005NHS(GDS) Complain6ts Regulations 2004BDA Advice sheet B10 (Handling Complaints) Advice sheet E10 (CPD, clinical governance, audit and peer review)Postgraduate Dental OfficePersonal Development Plans for Dentists (Amar Rughani et al)CPD – A guide for the Dental Team (BDA)BDA advice sheet D12 (staff recruitment) Advice sheet D13 (Discrimination)Equal Opportunities Commission ID WHO INDICATOR WRITTEN EVIDENCE ASSESSMENT VISITNHS PCC - Primary Care Dental Services Clinical Governance Workbook
  12. 12. The practice has a written procedure  Employment procedure manual  Practice visits manual that includes staff employment available  Self-assessment 8.1 ? policies including equal opportunities,  Comprehensive HR and Training  Occupational health and PASS bullying and harassment, sickness and records for all staff includes up- referrals absence, to which staff have access to-date job description and The practice has up-to-date mandatory training record, i.e. 8.2 ? comprehensive HR and training BLS records for all staff  Personal portfolios include Practice holds well attended meetings evidence of appraisal and 8.3 ? objective setting where all staff contribute Practice protects for clinical  Minutes of regular practice 8.4 ? meetings and staff feedback governance Practice team regularly test collapse  Policy on raising concerns at 8.5 ? work with identified links to PASS procedure against clock  The procedures manual should contain dated copies, which are made available to staff of the policies relating to theirGUIDANCE employment.  Assessors should confirm with employed staff that they are aware of the content of the manual and its whereaboutsNHS PCC - Primary Care Dental Services Clinical Governance Workbook
  13. 13. THEME 9 – Clinical staff Requirements and Developments C4, C5, C10, C11Requirements(Items listed under Staff Involvement and Development also apply)All GDC requirements are met including: • GDC registration/enrolment where appropriate • Supervision of clinical staff • Continuing Professional Development requirements • Handling of complaintsDealing with poor performance (including “whistle blowing” policy)InformationGDC – Standards for Dental Professionals 2005Principles of Patient Consent 2005BDA Advice sheet B10 (Handling Complaints) ID WHO INDICATOR WRITTEN EVIDENCE ASSESSMENT VISIT All staff appropriately qualified and  GDC registration/enrolment and  Practice visit 9.1 ? registered qualification records are held for  DRO reports Practice supports appropriate CPD for all staff in comprehensive Human  PALS/complaints 9.2 ? all staff Resources record  PASS Any learning outcomes for complaints  Up-to-date CPD portfolio in place 9.3 ? for all staff effect change No poor performance is un-addressed  Complaint policy/procedures in place.  Reports available demonstrating 9.4 ? how learning outcomes have effected change  Policy on raising concerns at work in place  Assessors could access Human Resources records and CPD portfoliosGUIDANCE  Complaints procedures and reports readily available  Assessor could confirm staff aware of raising concerns policy and procedureNHS PCC - Primary Care Dental Services Clinical Governance Workbook
  14. 14. THEME 10 – Patient Information and Involvement C3, C7, C13, C14, C16, C17, C18, C19, C21, D2, D3, D5, D8, D9, D10Requirements • Patients’ and carers’ views on services are sought and acted upon • Patients have opportunities to ask questions and provided with sufficient information to make informed decisions about their care • Patient information leaflets are available in languages appropriate to the local population • Well-publicised complaints system that is supportive of patients • Other patient feedback methods are available (e.g. suggestion boxes) • Evidence that practice have acted on findings of patient feedback • Information for patients on how to access NHS care in and out of hoursInformationGDC – Standards for Dental Professionals 2005GDC – Principles of Patient Consent 2005Local patient and public involvement (PPI) strategy (where exist)BDA Practice CompendiumBDA Clinical Governance toolkitGDS/PDS Regulations draft 2006-06-15 BDA Advice Sheet B10 Handling Complaints advice sheets B1 (Ethics in dentistry)BDA advice sheet A6 (Marketing in dentistry)PCT access action plans and NHS DirectNational Clinical Governance support team ID WHO INDICATOR WRITTEN EVIDENCE ASSESSMENT VISIT Patient aware of how to make  Practice information leaflet  Practice 10.1 ? comments or complaints through a  Reports of patient satisfaction  PPI – mystery ‘patient’ shopper number of options  Surveys available and reports on  PALS/complaints Practice leaflet freely available changes implemented  Patient treatment plans and 10.2 ? consents available  Resources available to inform treatment choices  Assessors could check practice leaflet against requirements as set out in Schedule 3 of the dental contractGUIDANCE  Assessors could check treatment plans, consents and resources available to explain different treatment options and procedures, e.g. photographs, modelsNHS PCC - Primary Care Dental Services Clinical Governance Workbook
  15. 15. THEME 11 – Fair and Accessible Care C7, C13, C18, C19, C21, D11Requirements(Items listed under Patient Information and Involvement may also apply) • Compliance with the Race Relations (Amendment) Act 2000 and Human Rights Act 1998 • Access to interpreting services • All reasonable efforts made to comply with the Disability Discrimination Act 1995Emergency/urgent appointments available during the Practice CompendiumBDA Advice Sheet D13 (Discrimination) information at Rights CommissionRoyal Association for disability and rehabilitationLocal PCT Opportunities ID WHO INDICATOR WRITTEN EVIDENCE ASSESSMENT VISIT Active engagement with PCT to  DDA audit and report of  Practice Visit 11.1 ? support PCT to address inequalities in reasonable changes implemented  PPI/PALS mystery ‘patient’ access to NHS dental care  Day book illustrates emergency shopper No patient refused treatment for any slots  PALS/complaints 11.2 ? reason detailed in Clause 28 of the  Contact details of interpreting  Interrogation of BSA data dental contract service available and how to Reasonable effort to meet DDA access known by staff 11.3 ? compliance  Assessors could confirm booking/acceptance procedures with reception staff against contract requirementsGUIDANCE  Assessors could view day sheets/appointment books for previous quarterNHS PCC - Primary Care Dental Services Clinical Governance Workbook
  16. 16. THEME 12 – Clinical Audit and Peer Review C5, D1, D3, D4, D5Requirements • All staff involved in identifying priorities for and involved in clinical audit or peer review • Evidence of compliance with any locally agreed requirements for clinical audit or peer review • Evidence that changes have been made where necessary, as a result of clinical audit or peer reviewInformationLocal audit/peer review panel or other local arrangementDental Practice Advisor (DPA)/PCT Tutor/Audit FacilitatorPostgraduate Dental Office ID WHO INDICATOR WRITTEN EVIDENCE ASSESSMENT VISIT Practice protects time for clinical audit  Clinical audit reports and  Practice Visit and learning outcomes are documented learning outcomes  Copies of audit reports 12.1 ? communicated to all staff and PCT  Minutes of Peer Review meetings submitted to PCT together with improvements  CPD portfolio implemented as a result  Assessors could confirm that documented learning outcomes reported to PCT as a result of clinical audit have beenGUIDANCE implemented through survey of clinical records or observing procedures against reports available.NHS PCC - Primary Care Dental Services Clinical Governance Workbook