Dental - Excel by cuiliqing

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									                                                                                        QUALITY ASSURANCE SURVEY
                                                        (Note: ☻= item for direct observation,   ►= item with special instructions )

 Standard 1 Staff Exhibit Professional Conduct
                                                                                   CORRECTIVE ACTION                        BY
               Survey ITEM                       Y N   PROBLEM                                                 BY WHOM
                                                                                      TO BE TAKEN                          WHEN
1.☻Staff follow a uniform policy & are
   well groomed.
2. All dental staff have a copy of their
  current job description.
3. All dental staff receive an annual
   Performance Appraisal.
4. Incident Reports are written if there is
   a problem & appropriate action taken.
5.☻Staff report for duty when scheduled
  & on time.
6. If staff are late or unable to report
   for work they contact Chief of Dental
   Division (DD) before 8am.
7. If Chief of DD is late or unable to report
  for work she/he contacts the DHS Director.
8. ►(Check at OPD)+A72
  The home phone # of Chief of DD is
  available at OPD for emergency after
  hours service (check at OPD).
9. There are adequate staff for an
   efficient & effective dental service.
10. Dental Clinic is open adequate hours
   to provide an effective service.
11. Chief of DD chairs a meeting for
    dental staff a minimum of monthly.
12. All dental staff attend the meeting.

13.☻Minutes of meetings are recorded.

                                                                            CORRECTIVE ACTION              BY
                Survey ITEM                       Y N             PROBLEM                       BY WHOM
                                                                               TO BE TAKEN                WHEN
14. Chief of DD discusses all unresolved
    DD problems with immediate supervisor
    on a regular basis.
15.☻Dentist(s) holds a current licence to
   practice as a dentist. (view licence)
16.☻Dental Nurse(s) holds a current
   licence to practice. (view licence)
17.☻Chief of DD maintains a Registry of
   Licenses of DD staff.

 Standard 2              Service Delivery is Efficient and Effective
                                                                            CORRECTIVE ACTION              BY
                Survey ITEM                       Y N             PROBLEM                       BY WHOM
                                                                               TO BE TAKEN                WHEN
 Dental Services
1. Preventative services are provided to
   children at the Dental Clinic.
  e.g. fissure sealant, fluoride, oral hygiene,
      distribution of toothbrushes/paste.
2. Restorative services are provided.
  e.g. cleaning & scaling, cavity filling,
      extractions, endodontic treatments &
3. Dental staff always attend Well Baby /
   Well Child Clinic (equiv) to apply
   fluoride treatment.
4. There is/are staff trained to model
   prescribed prosthetic appliances.
5. Design & final fitting for prosthetic
   appliances is performed by the Dentist/
   Dental Nurse.

                                                                CORRECTIVE ACTION              BY
               Survey ITEM                      Y N   PROBLEM                       BY WHOM
                                                                   TO BE TAKEN                WHEN
  Dental Surgery
6. Elective dental surgery for adults is
   performed in O.R. on scheduled days.
7. Children have extractions performed
   in O.R./E.R. on scheduled days.
8. Dentist consults with O.R./E.R. staff re
   dental surgery schedule.
9. Dentist informs Anesthetist re dental
   surgery and time.
10. Dentist writes the procedure on the
    whiteboard in the Holding Area in O.R./
11. The Consent for Anesthetic form is
    signed by the patient/parent/guardian,
    the witness & the Dentist at the same
    time - after Dentist has explained
    potential risks to all who signed.
  Higher Risk Dental Patients
12. Patients who have a medical condition
    recorded on the Dental Record have
    an assessment by an M.O. before
    dental treatment.
13. Following M.O. assessment, M.O.
    documents if patient is able to safely
    receive dental treatment.
14.►(ask staff the BP and sugar ranges
    & types of heart conditions)
   The following policies are observed:
   - Dental treatment is not given if patient
        BP > 140/90.
   - or blood sugar <60 or >200.
   - or patient has Rheumatic Heart
     Disease, Artificial Heart Valve or
    Pacemaker (without antibiotic coverage)

                                                                    CORRECTIVE ACTION              BY
                Survey ITEM                         Y N   PROBLEM                       BY WHOM
                                                                       TO BE TAKEN                WHEN
  Dental X-Rays
15. Only Dentist or Dental Nurse take
16. Patients wear a lead apron while X-ray
    is taken.
17. Regulation regarding pregnant
    women not having X-rays is observed.
18. Staff stand outside room when taking
19.☻After being read, the X-ray is placed in an
   envelope with patient name & is filed.

                Survey ITEM                               PROBLEM   CORRECTIVE ACTION   BY WHOM    BY
                                                    Y N
                                                                       TO BE TAKEN                WHEN
20.►(Ask staff to recite)
   Shelf life for instruments or gauze
   sterilized in pouches is (ask) - 4 months.
21.►(Ask staff to recite)
   Shelf life for gauze sterilized in sterilizing
    wrap is (ask) - 1 month.

22. Only the Dentist writes prescriptions.
23.►(ask pharmacy)
   All prescriptions are written with the
   required information (ask the
24.►(ask pharmacy)
   Controlled drugs are written on a
   Controlled Drug Prescription Form
   with all required information (ask
25. Dentist counsels patients on medication
    use & compliance when prescribing
  Dental Records
26.☻There is an accurate computer
   Registry of all dental patients:-
   1. Dental Clinic patients.
   2. School children visited in School
      Dental Health Program (6-12 yrs).
   3. Pre-school children (6 mths-5 yrs)
   4. Antenatal patients.
27.☻Every patient who visits the Dental
   Clinic has a Dental Record with all
   patient information & signed by
28.☻The provider records the service(s) on
    the Dental Record immediately
    following the service.

                                                                  CORRECTIVE ACTION              BY
               Survey ITEM                        Y N   PROBLEM                       BY WHOM
                                                                     TO BE TAKEN                WHEN
29.☻Dental records are filed in an
   organized manner.
30. All dental records are filed away at the
    end of each day.
31.☻There is an Appointment Book for
    planned appointments.
32.☻Appointment Cards are written for
   patients giving date & time of
  Dental Fee Schedule
33☻There is a current dental fee
   on display for patients to read.
34. Chief of DD plans & organizes dental
    education sessions annually for all
    dental staff.
35.☻There are pamphlets/booklets
   available on dental hygiene which
   are distributed to the community.
36.►(Ask 4 dental patients)
   If they wer satisfied with the Dental Clinic
   service they received.
  2. __________________________
  3. __________________________
  4. __________________________

 Standard 3 Supplies and Equipment are Adequate and Functional
                                                                 CORRECTIVE ACTION              BY
               Survey ITEM                       Y N   PROBLEM                       BY WHOM
                                                                    TO BE TAKEN                WHEN
1. Since last survey, there are always
   adequate supplies for preventative
   services, including instruments.
2. Since lst survey, there are always
   adequate supplies for restorative
   services, including instruments.
3. Since last survey, there are always
   adequate supplies for prosthetics.
4. Since last survey,there are always
   adequate supplies for School Dental
   Program visits.
5. Supplies are ordered from Medical
   Supply Dept on the scheduled days
6. Supplies are delivered by Medical
   Supply Dept on the same day as ordered.
7. All dental equipment is functional.
8. There is a functional X-ray viewer
   in the Dental Clinic.
9. Dental clinic has its own autoclave.
10. Autoclave is adequate & is functional.
11. There are always adequate supplies
    for sterilizing - e.g. pouches, 2 x 2
    gauze squares.
12. There are always required Dental unit
     forms available (printed or photocopied).
13. Dental forms are designed to record all
    required information & are user friendly.
14.☻Dental unit computer(s) is used for work
    purposes only.
15. Dental unit computer(s) & other office
    equipment are functional.

 Standard 4 Facility and Practices Prevent Spread of Infections
                                                                  CORRECTIVE ACTION              BY
               Survey ITEM                      Y N   PROBLEM                         BY WHOM
                                                                     TO BE TAKEN                WHEN
1☻There is liquid soap & paper towels at
  every sink.
2. Hands are washed before putting on
   gloves & as soon as gloves are taken off.
3. Gloves are put on for every dental
4. Gloves are taken off before answering the
5.☻Masks are worn for every dental
6.☻Gloves & masks are placed in the
  contaminated waste after use.
7. ►(Ask staff to recite)
   Staff know how to correctly clean up a
   blood spill
8. ►(Ask staff to recite)
   Staff know what to do if they receive a
   needle stick injury
9. All staff are screened for TB annually &
   have Hep B coverage.
10☻Chief of DD maintains a registry of
   dental staff TB & Hep B coverage.
11.☻No food or drink is consumed in
   clinical areas.
12.☻Betel nut is not chewed in clinical areas

13☻There are 3 bins - 1 for clean trash,
   1 for contaminated waste (with red
   plastic bag) & 1 for soiled linen &
   cleaning rags etc.(with plastic bag)

                                                                CORRECTIVE ACTION              BY
               Survey ITEM                      Y N   PROBLEM                       BY WHOM
                                                                   TO BE TAKEN                WHEN
14. Soiled linen is sent to the Laundry every
    every day.
15. There are adequate supplies of cleaning
    agents & rags.
16☻There is a written cleaning schedule
   for all areas of the Dental Clinic & the
   schedule is followed.
17.☻The following areas are clean &
          - Chief of DD office
          - Dental Clinic office
          - Waiting Room
          - Bulletin Board
          - Sterilizing Room
          - Storeroom
          - Dental Laboratory
          - Operatory 1
          - Operatory 2
          - Operatory 3
          - Cupboards
          - Refrigerator
18.☻Janitors sweep & mop floors, clean
   the restroom & empty clean &
   contaminated waste bins daily.
19.☻There is functional fire equipment in the
20The fire equipment is checked/serviced
   by Maintenance Dept every 6 months.

                                                                  CORRECTIVE ACTION              BY
               Survey ITEM                        Y N   PROBLEM                       BY WHOM
                                                                     TO BE TAKEN                WHEN
  Sterilization of Instruments
21. Dental Nurse / Assistant sterilizes
    instruments daily.
22. The correct sterilizing procedures are
  (a) After use, instruments are soaked
       in detergent & cleaned with a brush.
  (b) Instruments are rinsed & soaked in
       an instruments disinfectant before
       rinsing, drying & packing.
  (c) Instruments are packed in individual
      sterilizing pouches.
☻(d) Date is marked on pouches.
  (e) Instruments are sterilized in
       autoclave at 250 o - 270 o C for 25-35
       minutes until pouch indicator
       changes color.
☻(f) Sterilized instruments are placed in
      drawers after sterilizing.
23. If gauze needs to be sterilized (ask staff)
    - it is placed in pouches or wrapped in
      sterilizing wrap before sterilizing.

                                                                          CORRECTIVE ACTION                  BY
              Survey ITEM                      Y N      PROBLEM                               BY WHOM
                                                                             TO BE TAKEN                    WHEN
24.☻There is a sharps container in each
25.☻Sharps are emptied by dental staff into
   the incinerator when container is ¾ full.
26.☻Instruments are kept in cupboards/
   drawers when not in use.
27. The air-con unit is functional.

28. Air-con is serviced by Maintenance
    Dept at least every 6 months.
29.☻Lights, ventilation & plumbing are
    adequate & functional.
30. ☻There are no rats, mice, ants,
 cockroaches or termites in the clinic
31. ☻Walls have clean paint (without
    stains, dirty hand marks, grafitti)

                                  Number of "YES" answers =       %   =                       x 100     `

                                  Number of questions     =

                                                                              =           %
                           Date of Survey:
                       Name of Surveyor:


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