HIW Dental Practice Inspections - Rebecca Jewell Primary & Community Healthcare Manager, Healthcare Inspectorate Wales Ali Jahanfar, Peer Reviewer ...

HIW Dental Practice
     Inspections
                   Rebecca Jewell
Primary & Community Healthcare Manager, Healthcare
                 Inspectorate Wales
            Ali Jahanfar, Peer Reviewer

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About HIW
Who we are
HIW is the independent inspectorate and regulator of all healthcare in Wales
What we do
We review and inspect NHS and independent healthcare organisations in
Wales to provide independent assurance for patients, the public, the Welsh
Government and healthcare providers
Our purpose
To provide the public with independent and objective assurance of the quality,
safety and effectiveness of healthcare services, making recommendations to
healthcare organisations to promote improvements.

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Our values

•    Patient-centred: we place patients, service users and public experience at
     the heart of what we do
•    Openness and honesty: in the way we report and in all our dealings with
     stakeholders
•    Collaboration: building effective partnerships internally and externally
•    Professionalism: maintaining high standards of delivery and constantly
     seeking to improve
•    Proportionality: ensuring efficiency, effectiveness and proportionality in our
     approach

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Our outcomes

Provide assurance:
Provide independent assurance on the safety, quality and availability of
healthcare by effective regulation and reporting openly and clearly on our
inspections and investigations.
Promote improvement:
Encourage and support improvements in care through reporting and sharing
good practice and areas where action is required.
Strengthen the voice of patients:
Place patient experience at the heart of our inspection and investigation
processes.
Influence policy and standards:
Use our experience of service delivery to influence policy, standards and
practice.

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Our Work

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Give Clear Reassurance that:

1.This is not intended to be a ‘Gestapo’ type
  experience
2. Much more a discussion between professional
  colleagues
3. We are listening to your comments and
  experiences and acting upon them – where
  appropriate
4. We are refining our processes

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The Visit Workbook Components

•   1. Patient Experience
•   2. Management and Leadership
•   3. Written Documents
•   4. The Environment – internal and external
    premises
•   5. Standards (IRMER, Medical Emergencies and
    Waste
•   6. Decontamination Processes
•   7. Clinical Facilities
•   8. Patient Records
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The Inspection Team

            The Inspection Manager &
               The Clinical Reviewer

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HIW Dental Inspection Programme – the
 journey so far…

• Stakeholder Reference Group established including representatives from
  LHBs, WG, PHW, BDA, GDC and Deanery

• Methodology and reporting style developed

• Clinical Dental Lead (Dr Brent Weller) and Dental Reviewers appointed

• Pilot inspection undertaken to test HIW’s inspection processes

• 2014/15 inspection programme – 75 practices inspected

• 2015/16 inspection programme – 133 practices inspected
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Dental Inspection Programme – the
journey so far…
• Positive impact and engagement
• Findings used by Wales
Postgraduate Deanery, Public
Health
Wales and Welsh
Government
• First annual report
published in June 2015
• Second annual report to
be published summer 2016

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HIW Dental Inspection Programme – the process

BEFORE THE INSPECTION:

•   8 weeks notice by letter
•   ‘What to expect from an inspection’ guidance
•   List of documents for inspectors to view
•   Patient Questionnaires
•   Telephone call approximately one week before from inspector
•   www.hiw.org.uk/dental-services - workbook and guidance

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HIW Dental Inspection Programme – the process

THE DAY OF THE INSPECTION:

• Inspection team - HIW inspection manager + dentist
• One day on site
• Complete inspection workbook
   – Observe (eg decontamination process)
   – Talk (speak to patients and all staff)
   – Check (documentation and records)
• Immediate verbal feedback

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The role of the Peer Reviewer

   •The Peer reviewer inspects the following
   areas
    • Radiographic equipment & documentation
      • Including the Radiation Protection File,
      • The radiation equipment certification for each
        machine,
      • Quality assurance audits
      • Records of Radiation Protection Training (IRMER)

Radiography Issues

•   Registration of equipment
•   Age of equipment
•   Condition
•   Location relative to staff/patient positioning?
•   Local rules
•   Appointed persons?

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15

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Radiography Issues – Quality Assurance

•   QA 1,2,3 recording and auditing
•   Diagnostic reporting in patient notes
•   Film storage if ‘wet’ films
•   Data back up if digital
•   Start of day wedge testing?

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Daily Wedge Tests?

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The role of the Peer Reviewer

   •The Peer reviewer inspects the following areas
    • Resuscitation and First Aid
      • Practice resuscitation policy
      • Up to date training in CPR
      • Appointed first aider
      • Does the practice has adequate resuscitation
        equipment?
      • Are all emergency drugs within date?
      • Log book to show regular checks of emergency drugs
        and resuscitation equipment.
      • What systems are in place to ensure the security of
        drugs and prescription pads?

The role of the Peer Reviewer

•The Peer reviewer inspects the following areas
 • Decontamination of instruments and compliance with WHTM01-05
   • Daily maintenance programme including log books for checking each
     autoclave, start and end of day checks.
   • Pre-cleaning methods
     • Washer – disinfector
     • Ultrasonic bath
     • Manual cleaning
   • Instrument storage including transport between surgeries and
     decontamination room
   • Hand washing facilities available?
   • Designated contamination room available?
   • Decontamination training protocol with individual records
   • Routine audits of infection control requirements WHTM01-05
   • Inspection certificates for autoclaves

Cross Infection Control
•   Basic cleanliness issues
•   Work surfaces clear
•   Sealed surfaces
•   Sealed flooring

• Important to separate what is
  essential and what is
  advisable/desirable/ ‘Gold Standard’
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Clutter – worth commenting on but hardly a reportable
issue!

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Rethinking and tidying needed

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Less Clutter

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Wipe clean keyboard

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Cross Infection Control

•   AUTOCLAVE ISSUES
•   Type B, N or S?
•   (B- pre-wrapped and storage 12 months)
•   (N- post wrapped and storage 12 months)
•   (S- see manufacturer’s guidance)
•   Type B may be best but not compulsory

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Autoclaves

• Location
• Use of a ‘Sterilising room’ / CSSD
• Autoclaves still in surgeries?

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Clear Labelling and Expiry Dates

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We All Make Mistakes!!

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Pre- Autoclave Cleaning Process

•   Pre soaking?
•   PPE
•   Ultrasonic cleaning
•   Manual cleaning
•   Visual Inspection – good light + magnification
•   Use of washer-disinfectors?

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Clear Visual Inspection

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Hand Cleaning and Instructions

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Post Sterilisation Storage

• Where?

• How long?

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Storage away from surgery - labelled

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Autoclaving of Ultrasonic Tips AND Handpieces

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The role of the Peer Reviewer

•The Peer reviewer inspects the following areas
 • Handling, storage and disposal or clinical and non-clinical
   waste
   • Contracts in place for clinical waste, amalgam waste, sharps,
     non-clinical waste
   • Where is the clinical waste stored?
   • Is the clinical waste stored securely?
   • What happens to unused medicine?
   • Extracted teeth with/without amalgam
   • Domestic waste such as black bags
   • Amalgam separators installed?

Waste Storage

•   Clinical waste
•   Contaminated
•   Teeth
•   Amalgam waste
•   Amalgam capsules
•   Lockable storage?

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Sharps

•   Management
•   Needle resheathing? Or not?
•   Holders
•   Sharps containers and location

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The role of the Peer Reviewer

•The Peer reviewer inspects the following areas
 • Clinical Facilities
   • Dental Surgeries
     • Dental unit and cabinetry in good condition?
     • Is the surgery clean?
   • X-ray equipment
     • Local rules visible
     • Film holding kit available
   • Dental Equipment and Instruments
     • Sufficient number of fast, slow and straight handpieces
     • Ultrasonic scaler and tips
     • Surgical kit
     • Filling mixer
     • Disposable or single use items.
     • Regular serving of compressor

Audit

•   Recording of audits
•   Which are being done?
•   Which are essential
•   NB some contain confidential data that we do
    not need to view

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CPD Records

•   Should be recorded
•   And available on the day to view
•   Staff training and updates
•   CPR Training – when and who?
•   Defibrillator - Compulsory or not?

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BPEs and Periodontal Care

• Ensure that
• 1. BPEs are being recorded and updated
• 2. Treatments prescribed match the BPE score

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The role of the Peer Reviewer

•The Peer reviewer inspects the following areas
 • Patient records
   • Previous dental history
   • Social history including alcohol and tobacco use
   • Smoking cessation advice offered?
   • Reason for attendance
   • Symptoms
   • Initial medical history signed and dated by patient.
   • Updated medical history for each course of treatment
   • Full Base charting
                                         • Treatment provided
   • Baseline BPE recorded
                                         • Recall recorded
   • Oral cancer screening               • Radiograph justification
   • Treatment planning evidence         • Clinical findings noted
   • Treatment options recorded          • Quality grade noted (QA1, 2 or 3)
   • Informed consent                    • Referrals recorded

Medical History

• Initial
• Updated?

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Batch Numbers and Expiry Dates

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HIW Dental Inspection Programme – the process
AFTER THE INSPECTION:
•   Immediate Assurance letter within 2 days (if necessary)
•   Draft report for factual accuracy check within 3 weeks
•   3 domains:
      – Quality of patient experience
      – Delivery of safe and effective care
      – Quality of management and leadership
•   Respond to Improvement Plan within 2 weeks
•   Report translated and published on HIW website 3 months after date of
    inspection

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Typical Issues

• Radiation – IRR 1999 and IR(ME)R 2000
• Decontamination – WHTM01-05
• Patient records –medical histories; justification and clinical
  findings from radiographs
• No mechanism for patient feedback
• No evidence of indemnity insurance
• CPR training out of date
• No hepatitis B vaccination records
• Out of date drugs/equipment
• Staff appraisals

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Issues That Have Warranted the
‘Immediate Assurance’ Process

• Lack of IRMER training
• X-ray equipment lacking certification –
  registration and servicing
• Ultrasonic scaler handpieces and 3-in-1 tips not
  sterilised after each use. (This has arisen at 3
  inspections.)
• Inappropriate PAT testing
• Medications out of date
• No CPR training records

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• Endodontic files being re-used
• Lack of audit (in compliance with WHTM 01-05)
• No maintenance certificates for autoclaves
  (twice)
• Infection control issues
• Breach of Care Standards Act 2000 – private
  practice not registered with HIW & use of class 4
  laser unregistered
• Poor clinical practice (GDC?)

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Issues Leading to Recommendations in
Reports

• Complaints procedure either not clearly
  displayed or compliant with ‘Putting Things
  Right’
• Patient’s views not sought e.g. by
  questionnaires etc
• X-ray justification not recorded &/or quality of
  images not recorded
• X-rays not reported upon
• Practices unaware of their DBS obligations
• Corporates and shared practice managers
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Other Comments

• Inspection workbook is now published on the
  HIW website to assist practices to prepare in
  advance of inspections
• We have occasionally found disparity between
  the QAS returns and the actual inspections!!

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Thank you

Any questions or suggestions?

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