How staff learn or why policies and procedures don’t seem to work

Nothing has frustrates me more than introducing a new process at work, or streamlining an existing process. Why haven’t staff followed my very comprehensive, written procedures!

Since starting SmartDentist I have gained a greater understanding of what Policies and Procedures are good at; how to make them better; and what they wont do for the practice.
The following hints and learnings aim to help others who have suffered similar frustration. Consider:

  1. What Policies and Procedures are good for
  2. What Policies and Procedures wont do
  3. Better printing of Policies and Procedures (SmartDentist)
  4. Great understanding about our staff and how people learn

What Policies and Procedures are Good for!

1. Making sure AHPRA doesn’t ‘get’ you! Yes you need an Infection Control Manual (made of policies and procedures) because the Dental Board requires one. In Q’LD you also need policies and procedures so you have an Infection Control Management Plan. Dentists don’t really learn about this aspect of practice management in University yet we are legally responsible for what happens in our dental practice reprocessing. Practitioners benefit by considering creating a set of policies as worthwhile learning tool. The procedures used by your DA might not be correct or efficient. (The way we were shown in the past is the greatest predictor of what we do in the present. ) A good set of policies can help a practitioner understand and streamline or update procedures. They are a great insurance policy guarding against the stress of the loss of a knowledgeable staff member.

2. Having a procedure where everyone does the same thing the same way. Not only is this a safety precaution but it means life actually becomes easier for everyone (saving time and money). Established policies can sit on the SmartDentist website (untouched) until a new staff member needs them as a teaching aid. It is very handy to have good written procedures in case a significant staff member leaves. These need to be refreshed every so often. DON’T expect staff to look at these policies once everything is running well.

3. Performance management. When there is a communication breakdown or dispute about staff actions there needs to be formal written procedures in place in order to evaluate future staff actions or performance. Staff cannot refuse to do something that is reasonable, part of their normal work or customary. In regards to infection control practices, a staff member can not engage in conduct that causes serious and imminent risk to the health and safety or a person or the reputation, viability or profitability of a business. Of course staff would need adequate counselling, education and help to undertake their performance tasks. (see below – How staff learn)

What policies and procedures wont do

  1. Policies wont work without work.
    Policies and procedures should be living documents of excellence /efficiency. Often people are just too busy doing the job they have been given to actually question the processes of the job. Give some time to considering if processes are necessary and are efficient. Not every policy needs changing, not every task needs explaining but some processes will need more complex explainations or reviewing. Each policy review is the opportunity to get rid of old fashion inefficiencies or streamlined procesess.
  2. Written policies and procedures wont save a practice from workplace disputes. Just because you have a policy in place doesn’t mean you can discipline someone for not following it. You need to educate, tell, do and find out why they aren’t doing something. Workplaces are gigantic relationship centres and relationships require work and tolerance and give and take.

Better printing of policies and procedures (SmartDentist)

In developing better policies it can be helpful to consider what you find useful in instruction manuals. Many people only use instruction manuals when they can’t work out how to use the system or object. Instruction manuals that include relevant pictures are easier to follow and instruction manuals written in short point form are easier to read.
Hence it has been found that most used policies /procedures are:

  • short
  • easy to read
  • and help staff when faced with an uncommon process or problem

Consider developing two different types of policies. One could be for practical use and one for legal requirements or complex justification (e.g. infection control policies).
We only print policies if they have instruction for unusual or stressful processes, or if constant reminders of their content need to be seen by staff.
[For example I have the following policies located at our reception: Start of Day Reception; Middle of Day Reception; End of Day Reception; Payments and Hicaps.
These are separate laminated, two-sided documents printed out from SmartDentist. I have found longer policies are best divided into 2 separate policies (if they need printing and laminating). When a policy is updated it is easier to simply change a single sheet of paper.

How to print more useful polices from SmartDentist
Each SmartDentist policy has a small icon next to the name which reduced the “guff” off the policy. It also has the date on the top of the policy.
(Guff = resources; links; National standards etc. When submitting for accreditation please include the “guff.”)
Using the icon to gain a shorter version of the policy will also print better lists and save paper.

How our staff learn

Most of our staff are kinesthetic learners. They learn by doing. Learning should follow the following sequence – Tell; Show; Do; Review…and do this over and over again.
Do you know that changing a habit generally takes two months? That is two months of constant persistent reinforcement – do and review; do and review.
We communicated changes via:
1. Staff communication book
2. Verbal communication
3. Emails from SmartDentist – using basic communication form or the policy communication.

Consequences :- If there are no consequences for not changing, learning will take longer and reinforcement will need to be more persistent and regular. What consequence can staff introduce to remind them of the need to make procedural changes?
Self-care: – Find a mentor or supporter to encourage and reminding you about 1) your own inability to change 2) about the great things the staff do everyday without instructions!


Tracking and Tracing – What is the difference?

Do the terms “tracking”, “tracing”, “traceability” and “batch control identification” confuse you? You are not alone. Even the experts have trouble agreeing on what these terms mean. Because we use these terms in relation to reprocessing (sterilisation) of Reusable Medical Devices (RMD) in dentistry and medicine, it is very important that we have a clear idea about their purpose.

Where do the terms come from?
The terms tracking and tracing have logistical origins.
Tracking is a process where you know where any item is at any time.
Tracing is being able to tell the history of where an item has been.

Why does it matter?
1. In the event of a failure in your reprocessing system you need to know how to do a recall of instruments (tracking) or recall of patients who were exposed to those instrument (tracing).
2. In the event of a patient acquiring an infection only attributed to their healthcare experience/treatment (HAI) then it is important to be able to determine whether reprocessing of RMD (tracing) played a part in the HAI.
[3. Accreditation requires these processes are in place because they are important aspects of safety and quality systems.]

Why is the confusion with terms?

Dentists traditional are more familiar with the term “batch control number” or “batch control indentification (BCI)” (AS 4815:2006). Using BCI, RMD are linked to a sterilization cycle batch (tracking) and if the RMD are used, then traced to a patient.

In newer AS/NZS 4187:2014 and National Standards (used in accreditation) the term “Traceability” is used instead of “tracking and tracing” or Batch Control identification. This is because traceability is no longer just concerned to items going through a steriliser “batch“, but include any RMD’s reprocessed in high level chemical disinfection system. Batch Control Identification is just considered a version of “traceability”.

Unfortuately ADA Guidelines for Infection Control (Third Edition) 2015 says that traceability has no place in dental practice!

Don’t misinterpret this statement.

The ADA guidelines make that statement about “traceability” ONLY because the ADA guidelines authors took a very specific view/interpretation of the meaning of  “traceability”.  In fact the ADA Guidelines fully supports the use of BCI, which is the form of traceability required by the standards for general dental practice.
The version of  ‘Traceability‘ which is considered unnecessary by the ADA in dentistry involves high levels of instrument identification and high levels of tracing history. e.g. being able to trace individual instruments (laser or otherwise uniquely identified) each time they are used on patients and then each time they are reprocessed. Imagine the pointless data bloat if we traced the history of patient use and sterilisation cycles for each identifiable individual instrument, over a compulsory 7 year period. e.g. 10 instruments in your cons kit X 3 sterilisations per day X 3 patients treatment X 5 days per wk X 52 wks per year X each 7 years = 163800 individual records for one cons kit.

How traceable does traceability need to be?

“As a minimum, the traceability system shall be sufficient to enable the identification of a patient(s) where a nonconforming product has been used in an event that a recall is necessary.” [AS/NZS 4187:2014]
Procedures need to be in place to detect a nonconforming product before they are used on a patient.

A. What needs to be traced when we reprocess a RMD?

AS 4815:2006 AS 4187:2014 ADA Guidelines RACGP Standards!
Patient R R R O
Steriliser Batch R R R O
Semi-critical# RMD  R^
Critical# RMD R R* R O
R – Required
O- Optional but recommended
* Individually identifiable RMD if implantable and reprocessed
^ If undergoing high level chemical disinfection
# Semi-critical RMD are those that come into contact with mucous membranes or non-intact skin.
# Critical RMD are those that come into contact with the vascular system or sterile tissue and that shall be sterile at the time of use. e.g. surgical instruments.
! RACGP Standards for General Practice July 2017 (medical drs)

B. Where is the Traceability information recorded?
The Traceability system forms part of the release and quality assurance management of RMD. The system of traceability could vary depending on whether an electronic system or paper system is used.

Where to start

Any healthcare organisation who packages instruments can set up an extremely simple system for traceability and quality control.
A. Sterilisation log
All practices are required to keep a sterilisation log book. This can be a paper book; a paper log that is scanned into a computer; or an electronic logging system. The record requirements are the same in each case (see table). Each sterilisation load has a separate sterilisation load (or batch) number. This load number must be unique especially if you have more than one steriliser.
B. Recording information on the packaging of RMD’s
By recording the sterilisation cycle + date we have a link back to all the respective data on the sterilisation log for that cycle. The date helps us use the oldest pack first and if necessary an expiry date. The packaging staff member initals the pack so if the pack instruments are incorrect or nonconforming (not clean) then we can consult; educate and correct this process. The external chemical indicator allows the end user (dental practitioner) to check themselves as to whether the instruments went through the steriliser. The stage of examining and opening the package is a “release” phase in reprocessing and would be the responsibility of the operater or assistant.
(Est time to do this. 2 second with a self inking date and cycle stamp – cost $110 for 1000’s of prints)
C. Patient records
The steriliser cycle number is added into the patients records which will already include a date. This cycle information allows us to find the patient should a future recall of instruments from that particular sterilisation cycle occurs.
Time to do this: 2 seconds.

Packages of RMD Steriliser Log Patient Record
Cycle Number Cycle Number (unique) Cycle Number
Date processed Date processed Date of use
Packing person Load and release person/s
Contents * if not obvious due to packaging Contents of load: RMD name or set and number
Chemical indicator Parameters printout
Functional tests e.g. Bowie Dick/Helix

Traceability can be simple or complex. You can trace each load or only critical instruments. The best, quickest and easiest system is one that is consistent for all instruments and staff at the practice.

Guidelines for Infection Control 2015 Australian Dental Association
RACGP Standards for General Practice Jul 2017

dental equipment needs sterilising



Oasis software Banking reconciliation

Lining up your daily bank feed with daily practice payments is an easy task if you understand the basics. Bank reconciliation should be done each day so errors are picked up and investigated straight away. With bank feeds via MYOB or XERO this should be a quick task which takes no more than 2 minutes.
Regular reconciliation makes end of month calculations a simple quick task.

1. Send all your income to the one bank account and set up another account for payments. This makes it clean and easy to see. (If this is not your current practice then set up the second account for payments and leave your income coming into your existing account.)

2. Print off a bank statement and look at the entries. Become familiar with how and when you are paid. The following relates to NAB but will be similar for any bank. These are the credit entries in my online bank transaction area in NAB:
2.1 Deposits – this is our total of cash + cheques together. If these are banked daily life is easier. (Banking of cash and cheques is done the day following the payment.)
2.2 Eftpos – this is banked daily via our hicaps terminal which settles at 8.45 pm each night and is banked on the day they are processed at our practice (Practices can manually select to “settle” if they want a different time.). Note: refunds are not processed until the following day and are separate to credits.
2.3 Hicaps – this is banked the day AFTER they are claimed by our practice. If a reversal is made then this is included in that days’ claims. Claims made after about 9pm may not appear until the day after.
2.4 DVA – Vet Affairs are claimed online by our staff and are paid in 1-2 days usually. The bank entry will have the provider number in the bank entry. The totals are somewhat unpredictable but always just for a single dentists. Once paid the statements can be accessed from the HPOS or PRODA accounts.
2.5 CDBS – This is paid per practitioner and will be paid 2 hrs to 2 days. Usually the next day. The bank entry will have the provider number in the bank entry. Payment or refusal reports are available at HPOS or PRODA accounts.

3. Oasis software – Closing off of banking
Closing off of banking is a process undertaken by reception. It clears off that part of banking and payments which is considered correct and “finished with”.

[Learn how to “keep” and “release” banking in Oasis – you can do this for individual transactions and for whole pages of transactions. You can also set a default for each type of banking. Learn how to only view certain types of banking in Oasis e.g. find only cash and cheques.]

3.1 Deposits – Cash and cheques are “released” and closed off each end of day (Oasis task). The money and cheques are put in a deposit slip/envelope and our petty cash is counted to make sure no errors have occurred. A deposit slip is printed.
The deposits are checked the next morning and then taken to the bank and deposited with a teller. This is done via tellers because we got tired of disputed amounts when we placed money in “night banking”. Our staff need to be accurate when they are standing with a teller! Daily banking helps with reconciling Oasis and the bank. If you banked less frequently you would NOT close this off until you were ready to bank it.
3.2 Eftpos – This is closed off with Cash and Cheques at the end of the day. If a reversal has occurred during the day this MUST be released and closed off separately. Staff are NOT permitted to do a reversal except on the day it occurred. e.g. they can not have the HICAPS password.
3.3 HICAPS – This is closed off the next day. (first thing before we start with patients). Staff go onto the HICAPS website and print off the relevant days transactions and compare it to our HICAPS total and if it is the same the HICAPS is released and closed off.
3.4 DVA – any invoices to Veteran Affairs are held in the Marked Payment area of the Veterans Affairs account in Oasis. As the payment appears on the bank feed the payment is marked off as a DirectDebit. This direct debit can then be closed off as a distinct payment.
3.5 CBDS – These payments appear in the Oasis banking screen for Eclaims but are always placed on KEEP until they appear in our bank feeds as paid. As long as CDBS payments are NOT released from Oasis they can be altered. e.g. if they don’t get paid we can alter then and then they do not appear as incorrect on individual dentists monthly summaries.
As CDBS payments appear on our bank feeds they are “released” and closed off. Closed off totals must match a bank feed entry. i.e. Dr X get paid $240 from CDBS in one bank entry and Dr X gets paid $47 in another bank entry. Each of the bank entry totals are closed off separately so $240 is closed off, then $47 is closed off. This way we can relate each bank entry with a Oasis close off.

After the HICAPS close off each morning staff also print off the Daily Oasis Bank summary for the previous day and this is used for bank reconciliation. Except for Cash and Cheques (totaled together), each figure is entered as a separate sales amount in MYOB and it will be matched with a separate bank feed entry.  (takes about 2 minutes. Remember to put them in as Paid Sales or the bank feed in MYOB wont find them)