Clinical Affairs and Quality Assurance
|Dr. Sharon Cooper||Chair (Full-time faculty elected by Faculty Assembly)||2014|
|Dr. Monica Fernandez||Full-time faculty elected by Faculty Assembly||2014|
|Dr. Stephen Howard||Full-time faculty elected by Faculty Assembly||2015|
|Dr. Theo Koutouzis||Full-time faculty elected by Faculty Assembly||2015|
|Dr. Geraldine Weinstein||Full-time faculty elected by Faculty Assembly||2016|
|Mr. Zachary Jin||Dental Student elected by students (sophomore)||2016|
|Ms. Nina Guba||Dental Student elected by students (junior)||2015|
|Ms. Valentina Espinosa||Dental Student elected by students (senior)||2014|
|Ms. Richelle Janiec||Ex officio: Director, Quality Assurance|
|Dr. Carol Stewart||Ex officio: Interim Associate Dean for Clinical Affairs|
|Dr. Luciana Shaddox||Ex officio: Patient Relations|
|Ms. Lori Primosch||Ex officio: Infection Control Subcommitee|
|Ms. Carrie Thurman||Support staff|
This committee consists of six full-time faculty, elected by the Faculty Assembly and three students (one each from the second, third and fourth year classes). The Associate Dean for Clinical Affairs and the Quality Assurance Director will serve as ex-officio members. The Committee elects the chairperson and vice chairperson from among the members. The vice chairperson will become chairperson upon completion of the chairperson’s term.
Standing Committee Charge
As stated in the Constitution and Bylaws, it is the responsibility of this committee to expedite operations in the student clinics, to determine optimal instrument requirements for students, to update the Clinic Procedure Manual, and to advise the Associate Dean for Clinical Affairs on clinic operatory utilization in all dental clinics. This committee also is responsible for addressing college-wide quality assurance issues and updating the Quality Assurance Manual in conjunction with the Quality Assurance Director.
Additional Charge from the Dean for 2013–2014
The Clinical Affairs and Quality Assurance Committee should align its work this year with the new strategic plan being created for 2012-2016 once it is ready. I am also requesting that the committee complete the following activities in the upcoming year:
- Identify and resolve patient access issues.
- Provide support for planning and implementation of a college-wide call center.
- Monitor and report current wait times for first appointments.
- Monitor and report on referrals through: UFHealth Web site, GatorAdvantage, and gatordental. Create a workflow process that illustrates how requests for information are handled.
- Monitor the patient load at the SOS Clinic and the number of patients denied access.
- Patient satisfaction.
- Continue to use the UF Survey Center to compile data and prepare presentations for the Focus Patient Satisfaction Survey.
- Develop process improvement projects for areas of concern identified in survey results.
- Work with the Easy Markit workgroup of the AxiUm Steering Committee to develop survey processes that can be incorporated into a daily satisfaction survey process.
- Comprehensive patient care. Analyze available data to track the number of patients screened, completed comprehensive treatment planning, disease control care, definitive care (as applies) and maintenance care, as well as the cycle times of each step of the process. Use data to drive improvement activities to reduce cycle time and ensure comprehensive patient care.
- Sedation policy. Work with the college’s Human Resources Office to jointly develop a college policy applicable to all clinical faculty including off-site and courtesy faculty, to ensure adequate credentialing and training for clinical faculty performing sedations. The policy should be linked to the overarching Clinical Privileges policy and maintained in the Clinic Manuals. It should:
- Outline conditions under which faculty can perform sedations or supervise the graduate student performing sedation.
- Define minimal initial and continuing education requirements associated with the privilege to perform sedation procedures in college clinics for our patients.
- Establish a mechanism for identifying in AxiUm, faculty who have attained the privilege to perform or supervise the performance of sedation services.
- Clinical Procedure Manual/Quality Assurance Manual.
- Complete major revision of manual, to include sections for Standards of Care, Infection Prevention and Quality Improvement
- Create a more user friendly format that is searchable. Also, the Clinical Affairs and Quality Assurance Committee should continually monitor existing and new policies and processes defined in the Clinical Procedural Manual and the Quality Assurance Manual.
- Infection control. Oversight of infection prevention processes for the clinical enterprise.
- Annually review onboarding processes to assure the criteria for admissions of student, staff, volunteers and patients meets with current regulations, policies and standards.
- Annually review training programs and revise as needed: BBP, OSHA and general safety.
- Monitor waterline test results, and resolve issues as needed.
- Monitor Clinic Surveillance outcomes for trends and resolve concerns as needed.
This year, the committee should institute an infection control surveillance protocol to be included in the new Clinic Manual. The surveillance should be conducted in each dental center or dental practice on a once per semester basis. The data collected from the surveillance reports should be utilized to improve processes and incorporated into ongoing training with clinical staff.
- Quality Improvement. Ensure that all QA processes are instituted, working effectively and institutionalized across the college.The committee should continue to verify that an adequate quantity and quality of post-treatment assessments are conducted.In addition to careful collection and review of all QA data, it is essential that all QA analyses (clinical occurrence forms, post-treatment assessments, chart audits and reviews, patient satisfaction data, etc.) be used to drive meaningful change resulting in improvement. The effect of changes should then be assessed using continuous monitoring of the data. Framing the monitoring and action plans with the Plan-Do-Check (PDCA) model, the college’s model for outcomes assessment and evaluation, will ensure meaningful and effective improvements. This year, I would like a comprehensive quality report with a thorough analysis of quality measures and corrective actions/process improvements provided to me and to the Faculty Advisory Board.
- Radiology quality improvement project.
- Internal referral process improvement (improve loop of assignment and follow-up)
- Update overdue conditions in preparation for enforcement
- Work toward tying training compliance to patient record access (HIPAA gen awareness, confidentiality statement, BBP, MEU/IMEP and Clinic Safety)
- Show PDCA outcomes of the implementation of the Post Treatment Assessment (PTA) processes, improve the recall PTA process.
- Review reports from other sub-committees regarding opportunities to improve quality (PSS, Infx Prev, etc.)
Work with Faculty, Staff and Student Training or Calibration to communicate process improvements
- Review data from unexpected outcomes reported using COF (clinic occurrence form), as trends develop, and create appropriate workgroups to formulate process improvements and training materials as applies. Report details to CAQAC.
- Faculty calibration. The committee should continue to examine relevant topics for calibration sessions and continue to improve clinical documentation in the college. Efforts should be made to increase clinical faculty participation in the sessions. Attendance reporting should be provided to the Associate Dean for Clinical Affairs to be monitored for clinic privileges.
- Clinical revenue and chair utilization. Monitor chair utilization on a monthly basis and identify opportunities to improve efficiency including improved work flow. Also, the committee should review clinic expenses to identify opportunities to reduce expenses.
- Dental materials. Monitor the development of new dental materials and equipment for possible introduction into the clinics.
- Referral of action items. Refer all committee action items to the Faculty Advisory Board (FAB) on an ongoing basis for FAB’s review, discussion and subsequent action, as needed.
This year, each standing faculty committee will be charged with reviewing relevant outcome measures from the college strategic plan. The measures which should be reviewed by the Clinical Affairs and Quality Assurance Committee include:
- Number of patient visits by department/location/Care Groups
- DMD chair utilization, productivity by procedure codes and clinical revenue by department/location/Care Group
- Patient satisfaction by department/clinic location
- Number of patient complaints by quarter and fiscal year, analyzed by department and clinic
- Trends in the number of patient treatment plans completed by assigned student dentist
Again, the committee should evaluate performance on these measures and when appropriate, action plans for improvement should be instituted using the Plan-Do-Check-Act (PDCA) cycle.
Individual Faculty Member Responsibilities
Members of this committee are expected to attend a monthly meeting of the full committee lasting 1¼ hours. The full committee meeting is held on the 1st Thursday of each month at lunch time.
Additionally, all members are assigned to at least one subcommittee through which much of the work of the committee is carried out. Subcommittees are expected to meet at least once per month for about 1 hour. These meetings are also usually held over the lunch hour. In addition, separate workgroups and project assignments may be required.
Select members of the full committee may also serve on the Clinical Affairs and Quality Assurance subcommittee which meets on the 2nd Thursday of each month.
Time commitment: Minimum of 3 hours per month.
Schedule of Meetings
Clinical Affairs and Quality Assurance meetings are held from 12:00 to 1:30 p.m. unless otherwise noted.
|December 4, 2013||D4-16||N/A||View||N/A|
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|Patient Satisfaction Survey Report (2006–2010)||View|
|Patient Satisfaction Survey Report by Clinic (2006–2010)||View|
|Patient Satisfaction Survey Results (2010)||View|
|Clinical Procedure Manual||View|