Clinical governance is defined as “a system through which the health organisations are accountable for quality improvements of their services to meet the high standards of care by creating a suitable environment”.
The clinical governance is based on these fundamentals:
Risk management.
Confidentiality
Staff & Public involvement.
Complaints investigation.
Health promotion.
Practice manual.
Dissemination of good ideas.
Quality improvement.
Accountability.
Clinical effectiveness, audit, evidence based practice, and policy.
Risk management:
Risk management is quality control related discipline and insurance comprising activities designed the adverse effects of loss upon a healthcare organisation’s, physical, financial assets, and human through:
Claims control
Loss prevention and reduction
Identification of loss potential
Loss funding and risk financing
We have to try to establish what is actually likely to go wrong.
We have to analyse and control the risk – establish what can be done to reduce, minimise or eliminate it.
We have to calculate the cost of getting it right as opposed to the cost of getting it wrong.
Implementation of a risk management system: there are eight steps:
Identify key risk areas. review past incidents.
Identify key trigger events.
Implement an incident reporting system.
Investigate high risk events
Monitor and analyse reports for trends.
Implement changes if necessary.
Educate and feedback.
Consider a help from outside company with expertise in risk management.
Other sources of help may include:
The health authority
The local dental committee
The primary care group.
Confidentiality:
The principle of confidentiality is the basic to the practice in any healthcare setting. Patients attend for examination and treatment in the belief that the information that they give, will be kept secret. Health professionals are responsible to their patients with whom they are in a professional relationship, for the confidentiality of any information obtained.
The fundamental principle of confidentiality is that the health professionals must not use or disclose any confidential information obtained in the course of their work other than for the clinical care of the patient to whom that information relates.
Exceptions to the above are:
If the patient consents.
If it is in the patient’s own interest that information should be disclosed.
If the health professional has an overriding duty to society to disclose the information
If the disclosure is necessary to safeguard national security
If the disclosure is necessary to prevent a serious risk to public health.
Generally the consent is assumed for the necessary sharing of information with other professionals involved with the care of the patient for that episode of care and, where essential, for continuing care. Beyond this, informed consent must be obtained. The development of modern information technology and increased amount of multi-disciplinary teamwork in patient care, such as in undertaking clinical audit, make confidentiality difficult to uphold.
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You should tell patients whom you invite to participate in a survey in relation to audit about the standards of confidentiality. You should inform them about the extent to which their identity, contact details and information they give you is confidential to you, your work team or organisation. Be aware of your responsibilities under the Data Protection Act as to when you need to seek patient consent, (Department of Health 1998).
A written confidentiality policy document should be in place for the attention of all staff in the practice.
A named person should be responsible for the confidentiality policy document, this will include to monitor adherence to it and to deal with any potential or actual breaches of confidentiality. Temporary, voluntary or work experience students should all be informed of their obligations to maintain confidentiality.
Managers must ensure that paper and computer security is maintained.
The responsibilities of management, clerical, and administrative staff for confidentiality include:
Confidentiality training for all staff.
A clause about confidentiality in contracts of employment.
There should be a named person with whom any member of staff can discuss difficulties with confidentiality.
Physical difficulties such as lack of privacy at reception desks or being overheard answering the telephone should be reported and dealt with.
Clear rules about the handling of post marked “private”, “confidential”, or “personal” are in place.
The reasons for requests for information from patients should be explained. Only seeking the minimum of information required for the task.
Shredding confidential paper records must be in place.
Clear procedures for recording and storing information on paper or on computer must be in a policy document of the confidentiality in the practice. Safeguards against unauthorised access to either must be active.
Levels of access to data should be clearly stated.
Passwords to computer records kept confidential.
Terminal security must be arranged so that an unauthorised person is unable to use an unattended terminal to access data.
“firewall” security against unauthorised access to confidential data must be in place and active.
Consent:
Consent may be implied, oral, or written.
Example of Implied consent is when the patient opens his mouth to allow a dentist to do an examination may be assumed to have consented to that examination.
A note should be added to the patient’s records confirming the provision and nature of the consent when the patient consents orally.
Written consents are not normally essential or a guarantee but it gives a useful document if evidence is required months or years later.
Consent based on clear explanations is essential, especially in some situations such as implant placement, sedation and general anaesthesia.
Patients have the right to decide whether to undergo any dental intervention, even when refusal may result in harm to them.
The General Dental Council requires written consent for general anaesthesia and sedation procedures.
The patient must be given sufficient information to enable them to make an informed consent.
The amount of information should be given to the patient depends on a range of factors including the nature of the condition, risks and the patient’s wishes.
Patients may need more information about procedures with high risks or with serious personal, social, or professional implications.
Explanations should be given and the consent should be obtained by a knowledgeable practitioner and ideally by the practitioner carrying out the procedure.
It may be appropriate for the patient to bring a friend, relative, interpreter, etc.
So, we have to ensure that there is a consent form for any intrusive procedure or any other procedure where a documented record is essential or advisable. Information provided must or may include the following:
Details of diagnosis and prognosis if the medical or dental condition is left untreated.
The options for further investigation prior to treatment.
Options for management and treatment should be explained fully to the patient including the option not to treat.
Other treatment options such as pain relief should also be explained and documented.
Common and serious side effects must be fully documented and explained to the patient in a way that the patient can understand and digest.
All the questions raised by the patient should be answered and explained to the patient in a way that he/she can understand.
Benefits
The patient must be informed and documented in the consent form if the process is untested or for research purposes.
Ensure a system to allow the patient to be provided with time and a copy of the consent form. Ideally the patient should discuss the matter with family, friends, etc.
The consent form must be explained and interpreted to allow for understanding that serious harm does not mean that the patient would become upset or decide to refuse treatment.
A referral to the patient’s GP for a psychiatric or psycho geriatric review to assess competence if he or she is unsure whether the patient is competent.
Explanations may be enhanced by using other material such as brochures, diagnosis, photographs, etc.
A patient should be given time to consider the issue before finally consenting. Consent must not be given under duress, either from family or the dentist.
The patient must be made aware of any hazard which might cause his concern or to which significance would be attached. Any relevant information withheld from the patient should be recorded together with the reason for doing so.
No one can provide consent on behalf of an adult, even if the person lacks the capacity to make a decision for him or herself. Just because a patient is the subject of a compulsory treatment order under a section of the Mental Health Act (1983) (or the Mental Health Act (Scotland) 1984), this does not remove the need to obtain consent for procedures which are unrelated to the mental illness.
If a patient is not competent to make a decision, the practitioner may provide any investigation or treatment that he or she judges to be in the patient’s best interests.
Children under 16 may be able to consent to investigations or treatment if they understand the nature, purpose and possible consequences of the proposed treatment and the consequences of non-treatment. They must not duffer duress from family or friend.
Staff & Public involvement.
Staff Involvement
Clinical Staff Requirements and Development
General Dental Council registration.
Clinical staff supervision.
Continuing Professional Development requirements.
Complaints Handling.
Poor performance policy. (including “whistle blow” policy)
Patient information and involvement
Setting priorities for developing clinical governance:
We can use SMART acronym to help us:
S – specific
M – measurable
A – Achievable
R – relevant
T – time based.
Collect information from all members of the team and from the patients before you make any decisions on how to progress.
Complaints investigation.
Complaints
Methods of dealing with complaints are:
Inform your medical indemnity insurer and they will advise you on the best way to deal with it.
Managing complaints system within the practice is in place.
Member of staff to manage the complaints process is nominated and has this responsibility.
Complaints procedure timescale is known to the staff and the dentist.
Dentists or the complaints manager should try to meet any patient who complains to attempt to resolve the problem.
Details of the complaints procedure should be published in the practice leaflet.
Details of the complaints procedure should be displayed on a suitable notice in the waiting area.
Complaints manager should seek advice about complaints from medical indemnity provider.
Dentist should offer an apology if the situation warrants it.
Practice should have a policy for refunding payments if the situation warrants it.
Claims
The principle of law is:
A doctor is not negligent if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art….a doctor is not negligent…merely because there is a body of opinion that takes a contrary.
If we receive a solicitor letter the principle steps are:
Don’t panic
Do not respond to a solicitor’s letter directly, send it to your dental defence company and let them reply.
Collect together all relevant notes, correspondence, and investigations.
Do not deface, alter or destroy any of the notes or other records.
Practice manual
Infection Control
Recording of hepatitis B immunisation status.
Audit of policy compliance.
Child Protection:
Identification and CRB (Criminal Record Bauru) checks for all staff.
Child protection policy.
Evidence-Based Practice and Research
Principles of research governance should be applied where appropriate.
The definition of Evidence based practice is ” an approach to decision making in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option which suits that patient best.
Evidence based practice “EBP” is helping the clinician to maximize the use of best available evidence.
Practice review:
Arrangements should be in place for the practice team to develop their own checklist for reviewing the practice.
A system should be in place for reviewing the practice risk.
A system should be in place for patients to pass suggestions to the practice e.g through a suggestion box.
A system should be in place for staff to report near misses.
A nominated staff member should be available to identify, implement and co-ordinate any risk reduction procedures in the practice.
The environment:
The surgery should be thoroughly inspected by a team of staff including one or more of the dentists, the practice manager, a dental nurse and one or more senior receptionists.
Record Keeping
Quality of records is more important than quantity.
The patient record keeping provides all privileged parties with the history and details of patient assessment and communication between dentist and patient, as well as specific treatment recommendations, alternatives, risks, and care provided. The patient record keeping is an important legal document in third party relationships. Poor or inadequate documentation of patient care consistently is reported as a major contributing factor in unfavourable legal judgments against dentists (American Academy of Paediatric Dentistry 2006).
An electronic patient record is becoming more commonplace (Atkinson et al 2002, & Heid et al 2002).
General Charting:
Initial patient record:
Components of a patient record:
Components
Medical history
This should include systems review which includes cardiac, respiratory, haematological, diabetes, hepatitis, epilepsy, gastrointestinal, and mental impairment. Medications which they are include regular medications, recent medication, and allergies. Medical history should include any history of hospitalization. This includes age and cause of admission, operations, and general anaesthesia.
Dental history
Past history: e.g. regular or irregular attendee, previous experiences, experience of local anaesthesia, and previous co-operation levels
Home care: e.g. oral hygiene habits and dietary habits.
Reason for attendance.
Clinical assessment
Diagnosis
Treatment recommendations
Progress notes
When applicable the patient record should include
Radiographic assessment
Caries risk assessment
Informal consent documentation
Orthodontic records
Laboratory orders
Test results
Sedation / general anaesthesia records
Referrals record
Additional ancillary records.
Medical history update:
The history should be consulted and updated at each recall visit.
Dental history
Chief complaint
Previous dental experience
Date of last dental visit/radiographs
Oral hygiene practices
Fluoride use/exposure history
Dietary habits & oral habits
Previous orofacial trauma
Temporomandibular joint history
Social development
Family history
Comprehensive Clinical Examination:
General health assessment
Pain assessment
Temporomandibular joint assessment
Extra oral examination
Intra oral examination: this includes soft tissues, periodontal tissues, oral hygiene assessment, occlusion assessment, and caries risk assessment.
Radiographic assessment is important to aid the diagnosis of dental caries, to detect bony and dental pathology, and to detect abnormalities in dental development.
Examination of a limited nature:
Treatment recommendations and informed consent:
Progress notes
Orthodontic treatment
Correspondence, consultations, and ancillary documents
Principles of treatment planning: includes management of pain, and long term treatment planning.
Caries risk assessment: from this assessment appropriate decisions regarding prevention, restorative care, extractions, and long-term recall protocols can be made.
Preventive care: the provision of preventive dental care is possibly the most important aspect of treatment planning for the patient.
Restorative care: having established the co-operation of the patient it is important to make realistic decisions concerning restorative care. This involves carefull consideration of the advisability of restoring an individual tooth.
Aesthetic consideration:
Recall visits: completion of the initial course of treatment is merely the start of a long-term relationship with the patient. Reassessment and recall are essential to the treatment planning process. Ongoing prevention, such as the use of fissure sealants or fluoride supplements, requires monitoring as does general and orofacial growth consideration must be given to the existing caries risk factors and awareness that these may change.
Clinical audit
It is the method used by “health professionals to assess, evaluate, and improve the care of patients in a systematic way, to enhance their health and quality of life”, (Irven, 1991).
The steps of the audit cycle represented in figure 1 are:
Select topic & objectives
Re-audit
Audit Cycle
Review standards
review literature for criteria
Make action plan
Set standards
Feed back findings
Design Audit
Analyse data
Collect Data
Fig. 1: Steps in audit cycle.
Select the Topic:
Set criteria:
Set Standards:
Data collection:
What information we wish to collect.
Define Sample: this can be limited by time, funds, staff skills etc.
Data analysis:
Feed back the findings
Draw up the collection plan:
Implementation
Re-audit:
AUDIT TOPIC
Quality of Clinical Record-Keeping
Background: Why is this audit worth doing?
A permanent, faithful and accurate contemporaneous record is required for the appropriate management of patients by clinical dental teams and may be required for medico-legal and clinical governance reasons.
CRITERIA AND STANDARDS
All patients’ records must:
A Have clear identifying details.
B Be legible.
C Be dated and filed chronologically.
D Have clinician’s signature with his/her printed name and designation.
E Have clear history, diagnosis and treatment plan for the patient.
F Only use approved abbreviations.
G Have cancellation and failure to attend recorded.
H Retain the original record if any alterations are made.
100% Compliance with criteria was set as the gold standard for the audit.
Assess local practice (DATA COLLECTED)
Clear identifying details. (1, 2, 3)
1 means clinical record does not have clear identifying details.
2 means clinical record have moderately (fairly) clear identifying details.
3 means clinical records have very clear identifying details.
Be legible
means records are not legible
means records are fairly legible
means records are very legible
Be dated and filed chronologically.
Means records are not dated and not filed chronologically
Means records are not always dated and filed chronologically
Means records are always dated and filed chronologically.
Have clinician’s signature with his/her printed name and designation.
Means records do not have clinician’s signature or names.
Means records some times have clinician’s signature and names
Means records always have clinician’s signature and printed names.
Have clear history, diagnosis and treatment plan for the patient.
Means clinical records do not have clear history, diagnosis and treatment plan for the patient
Means clinical records sometimes have clear history, diagnosis and treatment plan for the patient.
Means clinical records always have clear history, diagnosis and treatment plan for the patient.
Only use approved abbreviations.
Means clinical records do not have approved abbreviations.
Means clinical records sometimes have approved abbreviations
Means clinical records always have approved abbreviations.
Have cancellation and failure to attend recorded.
Means clinical records do not have cancellation and failure to attend recorded.
Means clinical records sometimes have cancellation and failure to attend recorded.
Means clinical records always have cancellation and failure to attend recorded.
Retain the original record if any alterations are made.
Means clinical records do not retain the original records if any alterations are made.
Means clinical records only occasionally retain the original records if any alterations are made.
Means clinical records always retain the original records if any alterations are made.
Table
A
B
C
D
E
F
G
H
Total
1
3
3
3
3
2
2
3
3
6
2
3
3
3
3
3
3
3
3
8
3
3
3
3
3
3
3
3
3
8
4
3
3
3
3
3
3
3
3
8
5
3
3
3
3
3
3
3
3
8
6
3
3
3
3
3
2
3
3
7
7
3
3
3
3
3
2
3
3
7
8
3
3
3
3
3
2
3
3
7
9
3
3
3
3
3
1
3
3
7
10
3
3
3
3
3
3
3
3
8
11
3
3
3
3
2
3
3
3
8
12
3
3
3
3
2
3
3
3
8
13
3
3
3
3
2
3
3
3
7
14
3
3
3
3
1
2
3
3
6
15
3
3
3
3
2
2
3
3
6
16
3
3
3
3
1
2
3
3
6
17
3
3
3
3
3
3
3
3
8
18
3
3
3
3
3
3
3
3
8
19
3
3
3
3
3
3
3
3
8
20
3
3
3
3
2
2
3
3
6
21
3
3
3
3
2
2
3
3
6
22
3
3
3
3
2
2
3
3
6
23
3
3
3
3
3
3
3
3
8
24
3
3
3
3
3
3
3
3
8
25
3
3
3
3
3
3
3
3
8
26
3
3
3
3
3
3
3
3
8
27
3
3
3
3
3
3
3
3
8
28
3
3
3
3
3
3
3
3
8
29
3
3
3
3
3
3
3
3
8
30
3
3
3
3
3
3
3
3
8
31
3
3
3
3
3
3
3
3
8
32
3
3
3
3
2
1
3
3
6
33
3
3
3
3
3
3
3
3
8
34
3
3
3
3
2
1
3
3
6
35
3
3
3
3
3
3
3
3
8
36
3
3
3
3
3
3
3
3
8
37
3
3
3
3
3
3
3
3
8
38
3
3
3
3
2
2
3
3
6
39
3
3
3
3
3
3
3
3
8
40
3
3
3
3
3
3
3
3
8
41
3
3
3
3
3
3
3
3
8
42
3
3
3
3
2
2
3
3
6
43
3
3
3
3
1
2
3
3
6
44
3
3
3
3
1
2
3
3
6
45
3
3
3
3
3
3
3
3
8
46
3
3
3
3
3
3
3
3
8
47
3
3
3
3
3
3
3
3
8
48
3
3
3
3
3
3
3
3
8
49
3
3
3
3
3
3
3
3
8
50
3
3
3
3
3
3
3
3
8
Total
50
50
50
50
34
33
50
50
32
Data are collected and analysed:
25 clinical records per clinician assessed.
Clinician A records was given the numbers from 1 to 25.
Clinician B records was given the numbers from 26 to 50.
RESULTS (FINDINGS)
Compare findings with standards
Only 32 out of 50 records met the gold standard
64% of records are meeting the above gold standards.
Clinician A has 15 records out of 25 records met the gold standards (60%)
Clinician B has 17 records out of 25 records met the gold standards (68%)
Change
Improvement will be considered and implemented that all records must have clear history, diagnosis and treatment plan for the patients, and only approved abbreviations to be used.
Digital input to be considered for all dental records have clear legible printed records.
Re-audit annually.
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