Term
| Is there a Master List of all critical and semi-critical Reusable Medical Equipment used in this area |
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Definition
| Yes - Dr. Patel has a comprehensive master list of all critical and semi-critical RME in his office in a binder labelled MASTER RME LIST - We also have all of our RME listed/broken down by coffin |
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Term
| Are there Standard Operating Procedures (SOPs) for all critical and semi-critical RME on the Master List? |
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Definition
| Yes - Available online from Milwaukee home site - Nursing --> RME --> By area (Dental) -- |
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Term
| Are there written SOPs for instrument handling readily accessible? |
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Definition
| Yes - We have a printed copy of SOPs at the front desk |
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Term
| Are there written competencies for all individuals who manage RME? |
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Definition
| Yes - Milwaukee has a copy, and we have up to date copies for each staff member located at our front desk - |
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Term
| Are competency sheets appropriately signed and updated as needed? |
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Definition
| Yes - This is done annually and if a competency is needed to be updated based on a change in the SOP, this competency is re-done and filed correctly into the records binder |
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Term
| Is there a list of all personnel who have demonstrated competency for processes used? |
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Definition
| Yes - There is a grid electronically kept, and a printed copy on the competency binder which shows all staff and dates of their completion of competencies |
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Term
| Do SOPs match all brands of equpment in current use in the service? |
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Definition
| Yes - all equipment has been inventoried by BioMed and Logistics and no other external or unapproved equipment is utilized within the dental clinic |
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Term
| Is hand hygiene performed before and after gloving? |
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Definition
| Yes - TMS for handwashing was mandated yearly by Dr. Patel - 15 seconds with soap and warm water - We also have the squirt hand sanitizer that is also used coming and and out of operatories (does not substitute for hand washing) |
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Term
| Are intraoral burs sterile and single patient use? |
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Definition
| Yes - We have all our sterile burs and diamonds in our sterile supply room - the only exception to single use are those items that are not yet manufactured as single/sterile use (ie. polishing and lab kits) |
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Term
| Are intraoral burs discarded into the sharps containers after use? |
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Definition
| Yes - All burs are considered one time use (sterile pack or otherwise) and are discarded into the sharps containers following use. |
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Term
| Are clean and dirty areas separate in the dental clinic? |
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Definition
| Yes - We have three distinct rooms in our clinic to keep all items separate. We have a dirty U, a sterile supply room, and a logistics supply room. All of these rooms are appropriately labelled |
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Term
| Is appropriate personal protective equipment used by dental service employees? |
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Definition
| Yes - All PPE is available for all staff members, and items such as barrier gowns are obtained through the linen service in the facility. |
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Term
| Are there (MSDS) sheets for chemicals in the clinic? |
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Definition
| Yes - Dr. Kaplan is the MSDS super-user (Milwaukee) - MSDS listings can be obtained online MSDS Drop down --> Location --> P{rimary Clinics --> Dental clinic -- (There quick link in each staff member's Z drive folder) and we also have a print out (done every 2 years) of all MSDS sheets at our front desk |
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Term
| Are all dirty instruments stored in a closed impervious container while holding for transport to SPS? |
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Definition
| Yes - each operatory has red bins approved by SPS for transfer of dirty RME to the dirty U - The dirty U has SPS approved transfer carts that SPS transfers to their department- This processes for this SOP and transfer is outlined in the SOP binder and Dental Infection Control Binder at the front desk |
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Term
| Are all instrument packages and cassettes marked with an expiration date? |
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Definition
| Green Bay VA dental clinic utilizes event sterilization, but the dates of these items being processed is noted, and staff are instructed to "take" items from oldest to newest - This is marked in the sterile RME room |
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Term
| Are packaged items free of rust and debris? |
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Definition
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Term
| Are sterile instruments stored in the operatory? |
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Definition
| No - All sterile items are retrieved from the sterile supply room specific to those items needed for that patient |
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Term
| Are all dental appliances, impressions, etc. disinfected prior to taking them to the dental laboratory? |
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Definition
| Yes - TBQ is our disinfectant (10 minutes) for these items prior for transfer - The policy for this is within the Dental Infection Control binder at the front desk |
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Term
| Are all dental appliances, impressions, etc, from the lab disinfected prior to taking them to the patient? |
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Definition
| Yes - TBQ is our disinfectant (10 minutes) for these items prior for transfer - The policy for this is within the Dental Infection Control binder at the front desk |
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Term
| Is the pumice station in the dental lab cleaned and disinfected daily if used? |
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Definition
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Term
| Are the rag wheels and pumice discarded at the end of the day? |
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Definition
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Term
| Alcohol hand rub available - not expired |
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Definition
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Term
| Appropriate hand soap available, not expired? |
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Definition
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Term
| Paper towels or other single-use towels available? |
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Definition
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Term
| Is personal protective equipment available? |
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Definition
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Term
| Is personal protective equipment appropriately stored? |
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Definition
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Term
| No contaminated PPE worn outside the operatory |
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Definition
| Yes - all dirty linen is discarded into the linen cart in the dirty U and absolutely no PPE is worn outside the operatories or into common clinical areas |
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Term
| Sterile/Clean & bulk supplies stored separately? |
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Definition
| Yes - Sterile items are in the sterile room. Clean and bulk items are held separately in the logistics stockroom |
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Term
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Definition
| 8 inches off floor, 18 inches from sprinklers, 2 inches from outside wall, bottom shelves are solid - Items are away from pipes, windows, sinks, and other areas where water condensation could contaminate supplies -- There is no storage under the sinks -- Storage carts and shelves are clean |
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Term
| All products properly labeled and dated? |
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Definition
| Yes - all items that are opened and consumable are dated when they are opened and are not kept beyond their expiration date or discarded after recommended time of use after opening (whichever comes first) |
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Term
| Instrument transport bins color coded or labeled? |
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Definition
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Term
| Door to dirty room labeled "biohazard" |
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Definition
| No - Dr. Patel has spoken to Mr. Deacy and submitted a work order for this door to be labelled. SPS is also aware this issue has been approached to be addressed. |
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Term
| No corrugated cardboard (except shipping boxes for lab cases which are only stored in lab) |
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Definition
| Correct - only cardboard boxes are within the lab and are used for shipping lab cases externally |
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Term
| Are all eye wash stations and/or showers available and checked routinely? |
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Definition
| Yes - SPS/Logistics/BioMed monitor the eyewash stations and have a log of when and who has checked to maintain compliance |
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Term
| Is there a fire and disaster plan for the service? |
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Definition
| Yes - posted throughout medical center, and also within the Emergency SOP binder at the front desk - These SOPs are also within each staff member's Z drive folder for easy reference |
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Term
| Does the fire/disaster plan include mercury or other chemical/biological exposures (including spills)? |
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Definition
| No - but these processes/plans are addressed in an SOP within the Emergency SOP binder at the front desk |
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Term
| Is there a process for managing scrap amalgam and other potential hazards? |
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Definition
| Yes - Amalgam waste policy is adhered to in clinic, and we have amalgam scrap container in Dirty U - We also in the Dirty U have a biohazard bin for biologicals, teeth, etc |
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Term
| Can staff communicate when hand hygiene is required? |
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Definition
| Yes - We have "just the facts" in dirty U for any questions/clarification |
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Term
| Are alcohol hand rubs located in each operatory? |
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Definition
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Term
| Can staff demonstrate/explain how to clena operatory between patients? |
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Definition
| Yes - We have a SOP for this |
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Term
| What cleaning/disinfecting solution is used to clena the operatory? Is a timer being used to assure that surfaces are being disinfected for the time specified by the manufacturer? |
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Definition
| Yes - We utilize Cavi-wipes to wipe down operatory surfaces per the SOP - Our disinfectant is TBQ, and this is used for 10 min with a timer that each operatory has |
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Term
| How to return items that are used to dirty room? |
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Definition
| Designated bins, no PPE in hallways, biohazard bags as needed |
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Term
| What is the process for bringing a prosthesis into and out of the dental lab? |
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Definition
| TBQ disinfection - 10 min with timer |
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Term
| Is there a stocking process to prevent outdated supplies? |
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Definition
| Yes - Rooms are re-stocked on a weekly basis - Large emphasis placed on not hoarding supplies or overstocking - Operatory sweep sheet protocol prevents any expired product from being in room - If supplies are/have expired, they are discarded -- We also do monthly supply audit sheets and submit to logistics |
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Term
| Is the room monitored for temperature and humidity? |
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Definition
| The SPS sterile room and the Logistic supply rooms are temperature tracked and Dr. Patel receives alerts if the temperature falls out of the designated ranges |
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Term
| Are medications stored in the service? How are they tracked? How are they stored? In secure locations? |
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Definition
| The only medications within the dental clinic are local anesthetic and peridex rinse. These are contained in a double lock narcotics lock box within each operatory. |
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Term
| Are all sterile packs kepts only in the central location? |
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Definition
| Yes. SPS sterile room which is lock entry.. |
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Term
| When are gloves required? |
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Definition
| In all instances when patient contact/interaction is being conducted |
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Term
| When is eye protection required? |
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Definition
| In all instances when patient contact/interaction is being conducted |
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Term
| What different types of PPE are used for different procedures? |
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Definition
| All types of PPE are available in the dental clinic for all procedures. |
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Term
| When and how to remove PPE? |
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Definition
| This process is noted in the Dental Infection Control manual found at the front desk. |
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Term
| How and to whom to report an infection control/safety problem? |
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Definition
| Notify Dr. Patel and with Dr. Patel file an ePER event report as necessary |
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Term
| Who are the infection control coordinators? |
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Definition
| Dr. Armin - Milwaukee/GB Section Chief of Infection Control |
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Term
| What is the process when a sharps injury occurs? |
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Definition
| Inform Dr. Patel immediately and send patient/employee to primary care on first floor. |
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Term
| Can staff explain the process for how the clinical inspections and chart reviews are conducted? Who conducts them? |
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Definition
| Yes - The Green Bay VA Dental staff is aware of different inspecting bodies (SPS, JCAHO, VISN, QC, EOG, OIG, etc) that inspect the clinic. Chart reviews are arranged and managed by Dr. O'Brien and Dr. Patel |
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Term
| Review provider panels and ask staff to explain: How are patients assigned? Are some providers' schedules booked out further than others? |
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Definition
| Currently, Dr. Patel is the only dentist at the clinic. The patients for the hygienists are assigned as equally as possible. |
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Term
| All Employee Survey? Is staff genearlly satisfied with their jobs and working conditions? |
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Definition
| Yes - The All Employee Survey is completed by the dental staff annually - |
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Term
| Can the staff demontstrate patient identification correctly? |
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Definition
| Yes - Full name/DOB or Full name/SSN -- The GB Dental clinic utilizes Full Name/DOB as a standardized process prior to patient care |
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Term
| Can staff demonstate tooth marking for extraction? |
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Definition
| Yes - However, Dr. Patel will complete the site identification for the procedures with the patients. |
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Term
| Can staff demonstrate the time out procedure? |
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Definition
| Yes - The time out procedure is done AT LEAST once per procedure. |
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Term
| Can staff demonstrate medication reconciliation? |
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Definition
| Yes - Staff is standarized in completing a medical reconciliation at the start of every appointment and all medications per interview or print out are cross checked with the CPRS record |
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Term
| Can staff demonstrate the procedure for booking future appointments? |
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Definition
| Yes - All staff have had the training to make appointments, however, this practice is completed only by the MSA. |
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Term
| Are staff members involved in Dental or facility committees? |
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Definition
| Yes - Dr. Patel represents the dental clinic in all facility and dental committees |
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Term
| Can staff explain the consult procedure and how they are booked? |
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Definition
| Yes - The staff is aware of the "consult package" and different types of consults that are available for the medical center to use. Staff is aware and knowledgeable about follow up and imaging consults. |
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Term
| Is the dental infection control policy readily accessible? |
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Definition
| Yes - available at the front desk in a binder and within all staff members' personal Z drive policies/protocols folder |
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Term
| What is the process for recapping dental needles? |
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Definition
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Term
| Are all medications, syringes, etc, on the procedure tray labelled? |
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Definition
| Yes - as soon as a medication or syringe is loaded or out to be used, it is labelled as to what it is. Items/liquids that are consumable and have an expiration date are always labeled when opened. |
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Term
| Are sharps containers locked? |
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Definition
| Yes - Dr. Patel and facilities management have the keys for the sharps boxes. |
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Term
| Are sharps boxes unobstructed/not overfilled? |
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Definition
| Yes - If sharps boxes appear to start becoming full, Dr. Patel is informed and facilities is contacted to exchange the box out |
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Term
| Are open bottles of saline/sterile water dated/discarded at the end of the day? |
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Definition
| Yes - They are labelled when opened and discarded at the end of the day |
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Term
| Is the area clean and well maintained? Are there open work orders for clinic improvements? |
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Definition
| Yes - the clinic undergoes housekeeping daily. Dr. Patel has an updated log of open work consults, pending. |
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Term
| Are floors clean and well maintained? |
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Definition
| Yes - housekeeping department. Dental clinic does not have cleaning supplies for use within the clinic. If an issue arises, housekeeping is contacted. |
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Term
| Are appropriate cleaning products being used? |
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Definition
| Yes - all cleaning products used are approved by the facility and used by the contracting housekeeping agency |
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Term
| Are surfaces clean and uncluttered? |
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Definition
| Yes - no personal effects in operatories and clinic spaces are all standardized |
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Term
| Is upholstered furniture clean and intact? |
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Definition
| Yes - maintained by facilities and housekeeping |
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Term
| Is trash placed in appropriate waste containers? |
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Definition
| Yes - maintained by facilities and housekeeping |
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Term
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Definition
| Yes - maintained by facilities and housekeeping |
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Term
| Are ceiling tiles in place and free of stains? |
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Definition
| Yes - maintained by facilities and housekeeping |
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Term
| Are food, drugs, and specimens not stored in the same refrigerator? |
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Definition
| Yes - staff are aware that the BioMed provided refrigerators are only used for dental materials and that no food/drinks should ever be in the same place as temperature controlled materials |
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Term
| Are all refrigerators for patient care items monitored for temperature? Review logs and review plan for when temperature does not meet appropriate parameter? |
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Definition
| Yes - Dr. Patel receives temp-track information for the BioMed refrigerator |
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Term
| Are the refrigerators clean? |
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Definition
| Yes - Weekly cleaned by staff |
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Term
| Are the microwaves clean? |
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Definition
| Yes - Weekly cleaned by staff |
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