(Plan | Do | Check | Act)
- Determine WHAT regulations/recommendations (R/R) apply to the procedure being assessed by reviewing the Bloodborne Pathogens Standard from OSHA1 and the infection control guidelines from the CDC.2
- Confirm that personnel performing the procedure have an understanding of WHY the specific R/R are needed and what the procedure is supposed to accomplish when performed correctly. Provide training if necessary.
- Analyze the R/R to determine how to comply, obtain what is needed to comply and state when it should be performed.
- Decide HOW to perform the procedure and write a Standard Operating Procedure (SOP) with total staff input.
- Perform the SOP.
- Directly observe performance of the SOP and document details.
- Receive feedback from those performing the SOP to identify any problems and obtain suggestions for improvements.
- Confirm that the SOP is providing compliance with the R/R.
- Make any necessary changes in the SOP to achieve process improvements and Quality Assurance.
- Periodically monitor performance to assure continuous compliance (consistency).
1OSHA. Bloodborne Pathogens. Accessed December 2019 at: osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030.
2CDC. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health; May 2016. Accessed December 2019 at: cdc.gov/oralhealth/infectioncontrol/guidelines/index.htm.
(Define | Measure | Analyze | Improve | Control)
- Identify WHAT specific procedure will be analyzed.
- Determine WHY the procedure is performed and what R/R apply.
- State what the procedure is supposed to achieve and when it is to be performed.
- Identify the SOP if available.
- Observe the procedure as currently performed.
- Document each step in detail, including what is done, what is used to perform the procedure and when it is performed.
- Have the office staff review and analyze the measurements.
- Compare with any current SOP.
- Identify root causes of any problems detected.
- Determine ways to eliminate the causes of the problems detected.
- Brainstorm with the team and select the final solutions that address the root causes.
- Perform trial runs using the improved procedure.
- Create the new final SOP.
- Institute the improved procedure.