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Key Components to a Comprehensive IPAC Plan: Are You Ready for a Public Health Inspection?

Updated: Sep 13, 2021

February 4, 2020

by Susan McGuire, Professional Consultant & Trainer, Certified WHMIS Trainer, CDA Level II, OSAP Member, AGD/PACE approved provider

Are you compliant with the current regulated IPAC protocols in your clinic?

By now, every dentist should be acutely aware that changes are necessary to traditional IPAC processes. All clinics must now follow the latest protocols created by the Provincial Infectious Diseases Advisory Committee (PIDAC) and the RCDSO Standards of Practice for Infection Prevention and Control. These protocols are in place to prevent cross-contamination and the spread of infectious diseases in health care settings. Required Infection Control steps must be followed, and they must be completed in a specific order. Staff should be universally trained on IPAC protocols to ensure that everyone is consistently completing all required steps.

Public Health and inspectors are mandated to protect the public from harm. Dental offices should be prepared for a possible Public Health in-office inspection as no office is immune to an inspection. An inspection can be triggered by a direct complaint from a patient [either valid or imagined] or because a patient who acquired a reportable infectious disease has had to provide Public Health with all, if any, health care locations that they have visited.

During an inspection, all aspects of the IPAC requirements in an office, from hand washing to sterilized instrument storage will be reviewed. Documentation is a major area where most offices are deficient. Inspectors will need to see evidence of compliant IPAC processes.

For this reason, let’s focus on the documentation requirement offices must meet.

The documents an inspector will be looking for in the office clinic setting are:

1. Complete records of reprocessing passes, including:

  • cycle parameters pass

  • spore test results

  • indicator pass

  • air removal test pass

  • process challenge device (PCD) pass

2. Proper labelling of pouches or cassettes including:

  • Date

  • Cycle number

  • Sterilizer

  • Contents (if not visible)

  • Initials of the user that created the pack

3. Maintenance log sheets for sterilization equipment 4. MIFU manuals for all clinical equipment 5. MIFU for instrument cleaning and reprocessing of all patient care items 6. MIFU for all disinfecting solutions, PPE, and other cleaners used for clinical equipment 7. Safety Data Sheets for all hazardous materials 8. Records of water quality testing of the clinical dental waterlines 9. IPAC manual with office policies and procedures 10. Current training records and updates completed by staff

These documents should be readily available. It is usually the first thing the inspector will ask for when he or she arrives. All staff members who have a role in IPAC should know where the manuals are and can demonstrate that they know how to use them, in carrying out IPAC responsibilities.

Being compliant with these new requirements will cost money and time to implement. However, the office can minimize costs and save time by putting comprehensive protocols into place and training staff to follow these diligently. Trying to take the approach of “baby steps” will leave gaps in your processes. The best advice is to embrace these changes and put a comprehensive plan into place immediately.

Investigating available automated “workflow” systems that help minimize the burden of completing all of the required reports manually, is recommended. An automated system that eliminates manual entries or manual collection of data for storage can save a significant amount of staff time. However, more importantly, it can significantly reduce human error or omissions, and generate reports that are easily produced for inspection if required. These automated processes and reports will give an inspector confidence that the office is diligent and compliant, and that the patients are not at risk.

Investment in these systems is a budgetary concern, and each system is different. Before investing in one system, careful evaluation should be taken to ensure it meets the needs and goals of the clinic.

For most offices the major goals are:

  1. Reducing staff time related to the increased documentation burden

  2. Decreasing the risk of accidentally delivering improperly sterilized instruments to the patient

  3. Creating comprehensive reports so that the office can easily demonstrate compliance to an inspector when needed

Some questions to ask about any computerized data collection system are:

  • How much time is the system saving? Systems vary significantly depending on how much data is collected electronically and how much still must be keyed in manually.

  • How easy is it to retrieve the necessary data an inspector will require? Is it readily available and backed up?

  • Is all data digital and easily obtained, or is the system limited to labelling packages?

  • Are reports created automatically by the system or manually by the staff?

  • Will the system assist staff during the sterilization process to ensure that all necessary steps are preformed to ensure quality control and avoidance of human error?

  • Does the system validate the data or simply accept what a staff member has entered?

In Conclusion, PIDAC has mandated specific IPAC protocols to be followed by all health care clinics. The accountability and increased risk that has been placed on dental offices, by these changes in requirements in the last few years is significant. However, the effects of these changes can be minimized by the use of comprehensive IPAC protocols, automation of manual processes and adequate staff training. Following all of these steps will protect the health and safety of you, your patients and your staff.

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