Quality Assurance

QUALITY ASSURANCE ASSESSMENTS

Peer assessment - Preparing For Assessment

Dear Denturist:
You have been selected for assessment by the Quality Assurance Program….. You have received a letter from the College of Denturists of Ontario notifying you that you have been selected for a Quality Assurance Assessment. This letter often prompts a number of questions, the following section provides some answers!

How is the Assessor going to assess you? You work in a mixed array of clinical and non-clinical environments

Most professional members work from their own clinic, complete with reception area, office, laboratory and operatory. There are exceptions though where individuals are working in association with dentist(s), in nursing homes, in patient’s homes or a variety of environments. Does this exempt the professional member from being assessed at their principal location?

Absolutely not.

Where are you assessed?

The bulk of the assessment will be conducted in your principal location. If that means you spend most of your time in a dentist’s office, the assessor will arrange to meet you at this location and will conduct their assessment of the facility while maintaining a low profile. There is no reason for the office to close or refrain from conducting a full slate of appointments. The assessor will meet with you for a few minutes at the beginning of the assessment and then again at the end of the assessment, and may ask for directions or for files in the interim.

How this will impact the facility owner?

The facility owner, is obligated by the RHPA (1991) to make records and the facility that the Denturist uses in the course of their patient treatment available to the QA Assessor for the purpose of review. If there are areas identified where remedial actions need to be taken, the owner will be required to address the assigned actions to bring the facility to standard. If the owner is not willing to allow the QA Assessor access to the records and facility, their professional college will be notified and asked to intervene on behalf of the College of Denturists.

What if you practice in patients’ homes?

Admittedly there are not many professional members who work solely in patients’ homes, but if you do and are selected for assessment, the Assessor will arrange to meet you at your home, where they will review your patient records. You will be carrying your equipment to and from patient’s appointments in a medical bag, so the assessor will inspect this bag assuming it has been prepared to be take to a patient’s appointment. The Assessor will look for the method which ensures proper hygiene and asepsis, and will need to rule out the possibility of cross-contamination from one patient to the next.

In your home, the assessor will inspect the laboratory and the separate area designated for sterilization.

If you only conduct occasionalappointments in a non-clinical treatment throughout the year, the assessor will ask questions about the processes you follow and may wish to see how you would prepare your bag for a visit.

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How does this type of assessment compare to the Quality Assurance Program Manual?

Where the Standards and Premises Guidelines are clearly spelled out for the average clinic, standards such as lighting, treatment chairs, ventilation can be challenged in some non-clinical environments. The Quality Assurance committee recognizes that the maintenance of the clinical standard in this situation is out of your control, BUT, you are still responsible for the safety of your patients.

To this end the Quality Assurance Manual – Practice Assessment and Enhancement Section 2.6 – Premises has been revised as of the 42nd Meeting of Council (December 9th, 2005) when Council approved inclusion of a Universal Policy Statement that reads:

“The following standards and guidelines have been established to ensure the safe delivery of denture care. Denturists are encouraged to utilize accepted standards that will serve to protect their patients.

The College of Denturists of Ontario recognizes the need to make exceptions in circumstances where the treatment is provided outside their clinical environment e.g. home visits/nursing homes. It is expected that denturists will take measures and extra care to compensate for those standards that cannot be met because of location. Lack of adequate standards may place a practitioner at risk in the Courts if there are adverse results due to treatment rendered.

The College may also subject Denturists to a review if unsatisfactory results or patient complaints are received.”

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How does the Assessor discern which Practitioners work in non-clinical environments?

Assessment of Denturists providing Patient Appointments in a Non-Clinical Environment Questionnaire.

You will automatically receive this form with your letter notifying you that you have been selected for an Assessment. You are required to answer this questionnaire according to instructions, and return it by mail, to your Assessor, within 5 mailing days of your assessment appointment.

This questionnaire asks about the processes you follow in non-clinical environments. The questionnaire requires your signature, and on completion of the assessment the Assessor will also sign the form. This form is then retained in your file at the College of Denturists of Ontario, for reference.

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Your Certificate of Registration must be prominently displayed in your clinic!

It is a good idea to review this micro site periodically, whether you are preparing for an assessment, or personally reviewing your practice. If you have any questions in advance of an assessment, phone the College of Denturists of Ontario at 416.925.6331 or email qualityassurance@denturists-cdo.com

The Office Visit

Members should plan their schedule to allow for two 30-minute meetings with their assessors - at the start of the appointment (for a verbal review) and the end of the assessment (for the assessor to summarize their findings for the member). At this time, the assessor will also give the member the opportunity to clarify any information and discuss concerns the member may have about the preliminary report.

Self - Evaluation

Part of the assessment will be devoted to examining your self evaluation portfolio. Click here to download a blank self-evaluation form.

All activities such as seminars, workshops, conferences/AGM, correspondence courses and practice management seminars should be recorded. Completing and maintaining the portfolio each year will monitor individual goals, accomplishments and potential weaknesses. (A minimum of 10 hours is recommended per year).

Recordkeeping Activities

Use the following list to help identify opportunities for improvement with record keeping.

• My recordkeeping system allows for ready retrieval of an individual patient file.
• My records are legible.
• Am I using the proper dental/medical health card? Click here to see a sample of cards are available from DAO
• Each patient file clearly shows full name, address, date of birth and gender.
• The date of each visit or consultation is recorded including all financial records.
• My health records include the history, examination, assessment and prognosis for each patient.
• My health records include reasonable information on treatment and advice given, with appropriate consent.
• Each patient file contains a Privacy Policy form and the Health Consent form and a Treatment Plan form.

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Clinical and Lab Inspection

Clinic and lab inspection begins the moment the Quality Assurance Assessor arrives at your parking lot (if you have one). Ease of parking and accessibility to the clinic is evaluated. Signs and certificates must be displayed properly. Cleanliness and evidence of instrument cleaning and sterilization are assessed. A small area in the operatory or lab area must be set aside and dedicated solely to instrument sterilization. All sterilized instruments and equipment must be stored in sealed containers in a manner to minimize cross-contamination. All equipment in operatory and lab must be in working condition.

On assessment date regular clinic routine need not be interrupted. The Quality Assurance Assessor will work unobtrusively around patients and appointments.

Follow-up

Once the Assessor is finished the completed assessment form is sent to the College of Denturists of Ontario. A copy is sent to you for your records, and copies are sent to the QA Committee Chair and Chief Assessor. Provided there is nothing urgent or that could be viewed as a potential threat to your patients, the QA Committee meets monthly to review assessments.

If there is need for remedial, such as proof of a cuspidor or autoclave or evidence of asepsis, you will receive a letter advising you of such and a period of time in which the evidence of remedial action taken must be sent to the College. Otherwise, if everything is acceptable, you will receive a letter thanking you for your participation.

Contesting the Assessor’s findings?

You have 15 days from the receipt of the remedial notification to state your position in a letter. This letter will be kept in your file and your position will be reviewed.

If there is a Complaint or Discipline Action filed against you will the QA Assessment be referred to?

No. This is an internal process intended to maintain a minimum standard in the profession. In accordance with the Regulated Health Professionals Act, the results are confidential and may not be viewed by any other committee in the College of Denturists of Ontario.

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Recordkeeping

As part of the Quality Assurance assessment process, the QA Assessor will review your recordkeeping procedures. The QA Assessor will ask to see a sample selection of your records. There are a number of things they will be noting to ensure your practice is up to standards, so how can you prepare for this?

Reviewing your Quality Assurance Program manual will provide you with all of the information the QA Assessor is reporting on.

Where do I find the section on Recordkeeping?

To begin with, turn to section 2.2 Patient Management, on Page 7 of your manual. The first subsection addresses the Advise and Disclosure Standard, which you should know is: “Where an assessment is made; the following must be communicated:

1. Treatment plan; and
2. Prognosis, and when treatment is complete, post insertion education; and
3. Fees.

Referral Procedure

When a treatment plan cannot be completed without a referral, the procedure must be communicated to the patient and recorded in the patient file. All documentation received from other attending or consulting professional shall be maintained with the patient file.

Scope of Practice

Treatment provided shall at all times fall within the legislated parameters of professional and individual competency boundaries of the member/practitioner based upon personal skill, knowledge and training.”

This is your first indication of what a patient’s file should contain.

Subsection 2 states the Standard requires that records relating to a member’s practice should be kept in a manner consistent with the regulation (which follows on page 9 – 12 of the Quality Assurance Program Manual). You should review your manual for the precise wording of the Regulations, which essentially states:

1. Your clinic should maintain a daily appointment record
   
   The daily appointment record should state the name of each patient you examine or treat/render any service to.
2. Your clinic should keep a financial record for each patient
   
   The financial record must note charges made and payments received in respect of services and supplies provided to the patient.
3. Your clinic must have a patient health record for each patient

Each patient’s health record must include:

• the patient’s name, address and telephone number
• the date of each visit to your office
• the name and address of the primary care physician and any referring health professional
• the patient’s dental and relevant medical history
• reasonable information about every examination you’ve performed and about every clinical finding and assessment you’ve made regarding this patient
• reasonable information about every order you’ve made for examinations, tests, consultations and/or treatments to be performed by any other person
• every written report received on this patient with respect to examinations, tests, consultations and/or treatments performed by other health professionals
• reasonable information about every fee or other charge you’ve made to this patient
• reasonable information about a procedure commenced but not completed, including reasons for non-completion

If the only service you provide to a patient is a repair of a denture made by someone other than yourself, the patient’s record need only contain:

• the patient’s name, address and telephone number
• the date of each visit to your office
• the nature of the repair

Every part of the patient health record must have a reference identifying the patient or the patient health record. (This is to ensure that if a document is separated from the patient’s file, it can be returned to the appropriate file.) Each patient file must be retained for at least five years following the patient’s last visit.

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Why do I need to keep all of this information?

Consider your recordkeeping a snapshot of your patient. With accurate and complete records you are able to continue treatment regardless of the time lapsed between visits. Your records will indicate where treatment was required and your reasons for providing the treatment.

If you are required to report on your treatment of your patient, to another health professional, or if a complaint or claim is filed by your patient, your records will be called upon to support your reasoning. The better the documentation you maintain on each patient, the more proficiently you can move through this process. Conversely, if you do not have patient records to support your reasoning, the process will be slowed and your credibility may be called into question.

What if I do not have my own clinic, but work from a Dentist’s office?

The facility owner is obligated by the RHPA (1991) to make records and the facility that the Denturist uses in the course of their patient treatment available to the QA Assessor for the purpose of review. You will be required to make arrangements for the QA Assessor to have access to the facility and a sample of records relating to your patients.

The QA Assessment of the facility is not lengthy and should not interfere with the regular operations of the facility.

What if I do not have my own clinic, but work from locations such as home visits and nursing homes?

If you are working remotely, it is expected that you will have an area of your residence dedicated as a professional office. This area will include a secure file cabinet for your records.

If you are strictly working from a computer (either desktop or laptop), the computer must have password security and be connected to a printing device, so that a copy of records can be made. In addition to this, a backup of the electronic files must be kept and stored in a separate location.

Recordkeeping – what is a secure environment?

A concern is raised when the Quality Assurance Assessor notes that your filing cabinet is not secure, and/or that your electronic files are not password protected. According to PHIPA standards, the filing cabinets should either have a lock on cabinet, or should be in an area that can be locked. For example, if your filing cabinet is in the reception area, there should be a door separating this area that could be locked so that cleaning staff could not enter this area at night. This means someone in your office (you or a staff member) will be assigned with cleaning the area, independently of the cleaning staff.

Your computer needs to be configured so that the database, or file with patient records have restrictions on entry. Only people who require access to these records should be familiar with the password. It is recommended that you change the password regularly for additional security.

The computer screen must face away from the area where patients sit, so the patients cannot inadvertently view the screen. If, due to space restrictions, this is not possible, you should attach extensions onto your monitor which can be purchased at office supply stores.

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Tips on preparing for the assessment

Refer to Patient Management for an outline of what the Quality Assurance Assessor will review at their visit to your office.

Forms – do I have all of the Forms the Quality Assurance Assessor will ask for?

The Quality Assurance Assessor will ask for a copy of your Self Evaluation form. This is your “Curriculum Vitae”, your synopsis of what you have done to further yourself professionally. This listing includes your personal data, education, further education in the form of fellowships, professional history, professional membership and service involvement, volunteer work, awards and recognition, references and a log of continuing education from certification to the present.

A minimum of ten (10) hours per year of personal attendance to professional development forums (such as Perfecting Your Practise), courses, seminars, lectures or intensive technical reading is deemed to be appropriate.

The Quality Assurance Assessor will also ask for a copy of your office Privacy Policy form and the Health Consent form.

When you are advised of a pending Quality Assurance Assessment, you will receive a questionnaire about practising in locations other than a clinical environment. Make sure you complete this form for presentation to the Assessor.

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Storing supplies under the sink – why is this a problem?

Again, a concern is raised when the Quality Assurance Assessor notes that you store supplies, such as paper products, under your sink.

Because of the potential for moisture to accumulate and the opportunity then for mold to grow, it is recommended that supply products be stored in areas other than under the sink.

Logging Autoclave test results – what is an acceptable process?

The Quality Assurance Assessor will ask to see your log of autoclave/chemclave/dry heat sterilizer test results. Test should be conducted monthly and the results recorded in a log.

Test Kits can be purchased from your dental supplier. Each kit typically comes with 12 control strips, 24 test strips and 12 return envelopes. The typical process for each test is to place two (2) test strips in the sterilizer at a different location. Following the sterilization cycle, the strips are placed into a return envelope provided by the supplier and sent to the Laboratory for testing.

Biological indicator test strips are prepared from suspensions of Bacillus atrophaeus and Geobacillus stearothermophilus. These test strips can be used for monitoring autoclaves, chemiclaves and dry heat sterilizers.

Spore Test Results – what do they indicate?

A negative spore test (a test that has no growth) tells the operator that the process was adequate to kill the spores. A positive spore test (a test that shows growth) indicates a failed process and the load is not sterile.

Positive spore test results could be caused by; packs that are improperly prepared; the sterilizer is overloaded; the sterilizer does not work properly; or the process time is too short.

According to the Centre for Disease Control guidelines…. “if spores are not killed in routine spore tests, the sterilizer should be checked for proper use and function and the spore test repeated. If the spore test remains positive, use of the sterilizer should be discontinued until it is serviced."