Page 1 1. INTRODUCTION Clinical Governance is a concept which brings together all the activities that demonstrate to our patients, the community, management and our peers that we hold ourselves responsible for providing safe, high quality health care. Clinical Governance has been defined as the systems by which the governing body, managers and clinicians share responsibility, and are held accountable, for patient or client care, minimising risks to consumers, and for continuously monitoring and improving the quality of clinical care. Australian Council on Healthcare Standard 1 The effective governance of clinical services involves the participation of all categories of personnel in a range of activities to ensure the quality and safety of clinical services. As Safety of Health Care is one of the dimensions of quality in health provisions, thus, the major aim of any health care should be the safe movement of patients through all parts of the system. Harm arising from care must be avoided and risk minimised in care delivery processes 2 . The safety of the patients in health care delivery is achieved through: • Accreditation audits • Audits – for example on Infection control, Dental Radiation safety, Mercury Hygiene and Safety in Dental Laboratory • Incident review • Complaints review. Auditing clinical practice against health and safety standards is a well-established process to identify risk, improve practice and gain assurance. The audit will demonstrate key quality factors and compliance with policy guidelines and procedures. To this end, the Oral Health Division, Ministry of Health Malaysia (MOH) has published various guidelines relating to health and safety in dental practice, namely Guidelines on Infection Control in Dental Practice (1 st edition 1996, 2 nd edition 2007), Guidelines on Radiation Safety in Dentistry (2006), Position Statement on Use of Dental Amalgam (2002), Manual on Compliance to Dental Mercury Hygiene (1 st edition, 2005) and Health and Safety in the Dental Laboratory (2002). The Division has also formulated compliance checklists to be used in inspection audits to track compliance with the guidelines in four areas pertaining to • Infection control • Use of dental amalgam and compliance to dental mercury hygiene • Radiation safety, and • Safety and health in dental laboratories. The aim is to use the checklists to audit key factors and procedures that enable identification of areas for improvement in terms of resources, infrastructure, and training needs for health and safety, and to identify ‘good’ practices that may be emulated in dental facilities of the MOH. These checklists are formulated based on the latest literature, with consideration of development and change of technology. 1 The Australian Council on Healthcare Standards (ACHS) - http://www.achs.org.au accessed 8 March 2010 2 Better Quality, Better Health Care: A Safety and Quality Improvement Framework for Victorian Health Services (2005)
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1. INTRODUCTION Clinical Governance is a concept which brings together all the activities that demonstrate to our patients, the community, management and our peers that we hold ourselves responsible for providing safe, high quality health care.
Clinical Governance has been defined as the systems by which the governing body, managers and clinicians share responsibility, and are held accountable, for patient or client care, minimising risks to consumers, and for continuously monitoring and improving the quality of clinical care.
Australian Council on Healthcare Standard1
The effective governance of clinical services involves the participation of all categories of personnel in a range of activities to ensure the quality and safety of clinical services. As Safety of Health Care is one of the dimensions of quality in health provisions, thus, the major aim of any health care should be the safe movement of patients through all parts of the system. Harm arising from care must be avoided and risk minimised in care delivery processes2. The safety of the patients in health care delivery is achieved through:
• Accreditation audits
• Audits – for example on Infection control, Dental Radiation safety, Mercury Hygiene and Safety in Dental Laboratory
• Incident review
• Complaints review. Auditing clinical practice against health and safety standards is a well-established process to identify risk, improve practice and gain assurance. The audit will demonstrate key quality factors and compliance with policy guidelines and procedures. To this end, the Oral Health Division, Ministry of Health Malaysia (MOH) has published various guidelines relating to health and safety in dental practice, namely Guidelines on Infection Control in Dental Practice (1st edition 1996, 2nd edition 2007), Guidelines on Radiation Safety in Dentistry (2006), Position Statement on Use of Dental Amalgam (2002), Manual on Compliance to Dental Mercury Hygiene (1st edition, 2005) and Health and Safety in the Dental Laboratory (2002). The Division has also formulated compliance checklists to be used in inspection audits to track compliance with the guidelines in four areas pertaining to
• Infection control
• Use of dental amalgam and compliance to dental mercury hygiene
• Radiation safety, and
• Safety and health in dental laboratories.
The aim is to use the checklists to audit key factors and procedures that enable identification of areas for improvement in terms of resources, infrastructure, and training needs for health and safety, and to identify ‘good’ practices that may be emulated in dental facilities of the MOH. These checklists are formulated based on the latest literature, with consideration of development and change of technology.
1 The Australian Council on Healthcare Standards (ACHS) - http://www.achs.org.au accessed 8 March 2010 2 Better Quality, Better Health Care: A Safety and Quality Improvement Framework for Victorian Health Services (2005)
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2. OBJECTIVE OF THE COMPENDIUM This compendium aims to assist dental personnel in auditing compliance to health and safety processes contained in the various guidelines produced by the Oral Health Division, MOH. It is intended to clarify the use of checklists to monitor both clinical practices and the environment. This compendium also identifies the role and functions of members of inspection teams at state and district levels. It also aims to ensure that findings from inspection visits are properly recorded in a standardised way, then duly channeled and assessed to enable documentation of good, bad or questionable practices. It should also allow dental practitioners to self-assess their practice against the guidelines. This is one mechanism that will enable the oral health programme to identify areas for improvement in terms of financial support, improvements to infrastructure, procurement of equipment and materials as well as training needs that will enhance health and safety practices in the dental environment. For the time being, inspection visits will cover dental facilities of the MOH, with the intention that the use of the five checklists be later considered for incorporation into the quality system of the oral health programme of the MOH. 3. WHAT THE INSPECTION TEAM NEEDS TO DO (OBSERVE, CHECK & QUESTION) 3.1 The audit checklists are in five separate sections: 1. Management on Safety and Health 2. Infection Control in Dental Practice 3. Use of Dental Amalgam 4. Dental Radiation Safety 5. Health and Safety in Dental Laboratory Auditors are to record what is observed. When certain procedures are not carried out or performed during the visit, questions should be posed to dental personnel, and evidence checked to assess compliance. There are also aspects of the checklists that are not amenable to observation and these calls for questions and checking. However, there are also aspects of the inspection that calls for auditors to quietly observe without comment or question.
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3.2 State Safety and Health Teams There will be 1 state co-ordinator for occupational safety and health in each state, and this person shall be a dental officer appointed by the State Deputy Director of Health (Dental) [TPKN(G)]. Each audit team shall comprise the following personnel:
Dental Nurses
To audit
Management on Safety and Health Infection control Use of dental amalgam *Dental radiation safety
Dental Technologists Safety and health in dental laboratories *Dental radiation safety
Final membership of the audit team(s), however, shall be the prerogative of the TPKN(G), as shall be the number of audit teams to be established in each state. Larger states may need to establish more than one team.
*Not all dental clinics have dental laboratories. In clinics without laboratories, inspection
visits will only involve dental nurses, in which case, inspection for dental radiation safety
shall be undertaken by dental nurses.
3.2.1 Training of Trainers
Training of ‘trainers’ will be conducted in 2010. ‘One team of ‘trainers’ per state shall
undergo training, each team to comprise 3 members – the state co-ordinator, a
dental nurse and a dental technologist. This group shall serve as ‘trainers’ to train
other inspection team members. The TPKN(G) will identify the state co-ordinator and
dental team members to be trained as ‘trainers’ at national level.
The training session shall cover use of the manual and checklists for state co-ordinators, and for members of the team.
3.2.2 Managing and Planning Inspection Visits
Management of implementation of clinical inspections fall under the purview of the TPKN(G) and the state teams.
The TPKN(G) or state co-ordinator will determine the following:
1. The number of inspection teams to be formed in each state
2. The selection of inspection team members
3. The selection of dental facilities for inspection (to aim about 30% of total facilities
per year, inclusive of mobile dental teams)
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4. Arrangements for cross-auditing between states or between districts in each
state.
3.2.3 Terms of Reference of Members of the Team
State Co-ordinators
1. Assist in determining number of teams to be established for the state
2. Assist in appointing inspection team members for the state
3. Oversee selection of dental facilities, data collection and data entry
4. Oversee/undertake data analysis
5. Prepare report/feedback to auditees
6. Compile reports/feedbacks from auditees
7. Oversee undertaking of remedial measures
8. Prepare state report for national level
9. Ensure state reports are sent in November of current year
10. Ensure that health and safety aspects are on the agenda of state meetings
Trainers
1. Undertake echo training on various aspects of inspections for health and safety
- Use of checklists to collect data
- Compilation and data entry
- Data analysis
- Preparation of feedback to auditee
- Preparation of report for state and national level
2. Undertake inspections themselves
3. Render support to other inspection teams.
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3.3 Work Flow
Management of Safety and Health Inspection in Dental Facilities
TPKN(G) - State Deputy Director of Health (Dental) KPP - Principal Assistant Director
NO. ACTIVITY
RESPONSIBILITY
1. Appoint state co-coordinator State Deputy Director of Health (Dental) [TPKN(G)]
2. Appoint safety and health inspection team members
- Dental officers* - Dental Nurses Grade U32 and above (infection control
and use of dental amalgam) - Dental Technologist Grade U32 and above (dental
laboratory and dental radiation)
TPKN(G) / KPP or State Co-ordinator
3. Select dental facilities for annual visits
Inspection Team
4. Schedule the date(s) for inspection(s)
5. Inform the selected clinics
6. Inspect the clinic(s)
7. Collect data
8. Enter data into database
9. Analyse data
Inspection Team / State Co-ordinator
10. Prepare report
11. Give feedback(s) to auditee
12. Compile feedback from auditee and send to state co-ordinator
Personnel-in-charge of dental facility
13. a. If comply, close audit
Inspection Team / State Co-ordinator
b. If does not comply, go back to step 4 and arrange for re-inspection / compliance audit
14. Compile state report for annual state report
15. Send (only soft-copy email) report to the Oral Health Division, MOH
• November of the current year
State Co-ordinator
*option left to TPKN(G)
The role and function of state co-ordinators and inspection team members are shown above.
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4. WHAT THE NATIONAL WORKGROUP NEEDS TO DO
The national level committee will
1. Review the training modules every 5 years based on the latest literature and technology
advances
2. Develop the data entry files to standardize collection of data for analysis and evaluation.
3. Compile an annual national report on all occupational safety and health activities of
inspection teams across the country, to include recommendations for improvements and
Name of Clinic ....................……….....................................................................
Date of Inspection
Contact person ......………………………….........................................................
Contact number Tel: ......……....................... Fax :....................................
e-mail ........................................
Type of facility 1. Dental Clinic 2. Non-hospital-based Specialist Dental Clinic 3. Specialist Dental Clinic in Hospital 4. School Clinic/School Dental Center 5. Mobile Dental Clinic 6. Mobile Dental Team 7. Dental Laboratory
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Basic Instructions to Auditors Auditors are to record what is observed. When certain procedures are not carried out or performed during the visit, questions should be asked of dental personnel, and evidence checked for compliance or otherwise. There are aspects of the checklists that are not amenable to observation and call for questions and checking. However, there are also aspects of the inspection in which auditors should quietly observe without comment or question.
1. Tick or write in the relevant columns 2. If not applicable, please indicate ‘NA’ 3. If no handling of such procedures are undertaken, please inquire from the officer-in-charge
(PIC). If the PIC is not available, please pose questions to the next-in-line. Note who you interviewed under ‘comments’.
4. Observe as much as you can. 5. Auditors are advised to make enquiries into the clinic programme prior to the visit. 6. If the facility has more than one workplace, please check all.
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Oral Health Division Ministry of Health Malaysia
Checklist for Management of Safety and Health in Dental Practice
Q – question staff, O – observe, C – check evidence (documents etc)
No. Checklist Q/O/C
Tick (����) the relevant Comments Yes No
A. GOVERNANCE
1. Statement on safety and health available (OHSA, sec 16)
Q/C
2. Active Safety and Health Committee (OHSA, 30)
Q/C
3. Mechanism of reporting of accident, danger events, job poisoning and job disease and investigation (OHSA, VIII, Sec 32(i) available ie reporting, investigation, review.
Q/C
4. Programme for maintenance of equipment and facility available (OHSA, Sec 15(2)(a)
Q/C
B. SAFETY ARRANGEMENT
1. Lay out plan and equipment (related to safety) arrangement
Q/C
2. Signage and notice board for information and warning signs
Q/C
3. Electrical source with safety features
e.g. extension wire and socket
C. HEALTH MANAGEMENT
1. Personnel medical surveillance e.g. immunization of personnel
Q/C
Total
General comments, recommendation or area for improvement
Guidance: Q – question staff, O – observe, C – check evidence (documents etc)
No. Checklist
Q/O/C
Tick (����) the relevant Comments Yes No
A. GOVERNANCE
1. Document Position statement on the use of dental amalgam Q/C
B. FACILITIES
1. Good Ventilation O
2. Air conditioning filter maintained as scheduled Q/C
3. Using Bulk mercury and alloy C
C. WASTE AMALGAM STORAGE
1. Non fragile container C
D. HANDLING
1. All dental staff wearing personnel protective appliances Q/O
2. Instruments free from waste amalgam before sterilizing Q/C
E. DISPOSABLE WASTE AMALGAM
1. Waste Amalgam collected from amalgam trap in the spittoon and separator at suction unit
Q/C
For items 2-4, please choose one of the options below: b. Domestic bin c. Clinical waste bin d. Storage as waste amalgam e. Others (please write in the column comment)
2. Waste Amalgam disposed into ............ C
3. Extracted teeth with amalgam restoration dispose into........ C
4. Contaminated clinical waste with Amalgam including amalgam capsule disposed into.............
C
TOTAL
General comments, recommendation or area for improvement
Nama Klinik ....................III.....................................................................
Tarikh Lawatan
Pegawai untuk dihubungi ......IIIIIIIIII.........................................................
Nombor untuk dihubungi Telefon: ......II....................... Faks ....................................
e-mel ........................................
Jenis fasiliti 8. Klinik Pergigian 9. Non Hospital Based Klinik Pakar Pergigian 10. Klinik Pakar Pergigian di Hospital 11. Klinik / Pusat Pergigian Sekolah 12. Klinik Pergigian Bergerak 13. Pasukan Pergigian Bergerak 14. Makmal Pergigian
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Bahagian Kesihatan Pergigian Kementerian Kesihatan Malaysia
Senarai Semak Audit Pengurusan Keselamatan Dan Kesihatan Di Fasiliti Pergigian
Q- Soal staf, O- perhati, C –periksa (dokumen dll)
Bil.
Senarai semak Q/O/C
Tanda (√) yang
berkenaan
Catatan
Ya Tidak
A. PENGURUSAN 1. Ada penyataan dasar keselamatan dan kesihatan (OSHA, Seksyen 16) Q/C
2. Jawatankuasa Keselamatan dan Kesihatan Pekerjaan Aktif, JKKP (OHSA, 30)
Q/C
3. Laporan/pemberitahuan mengenai kemalangan, kejadian berbahaya, keracunan pekerjaan dan penyakit pekerjaan dan siasatan [OHSA, Bahagian VIII, Seksyen 32(i)]
4. Terdapat program penyelenggaraan peralatan dan fasiliti [OHSA, Seksyen 15(2)(a)]
Q/C
B. KESELAMATAN
1. Pelan menunjukkan susun atur peralatan (peralatan keselamatan) Q/C
2. Ada signage dan papan tanda makluman dan amaran
3. Sumber elektrik dengan ciri keselamatan Q/C
C. Kesihatan
1. Pengawasan perubatan anggota eg. Ada diuruskan imunisasi personel Q/C
