Punjab Healthcare Commission: CG-09RM-Ed2

CG-09RM-Ed2
Punjab Healthcare Commission

Foreword
The Punjab Healthcare Commission (PHC) is an independent health regulatory body established under the PHC
Act 2010 promulgated by the provincial legislature. The primary objective of the PHC is to improve the quality
of healthcare in Punjab through the introduction of a culture of clinical governance and delivery of
standardized healthcare services at all healthcare establishments (HCEs), both public and private, for assuring
patient safety. Under its legal mandate, the PHC developed and enforced the Minimum Service Delivery
Standards (MSDS) for Category-I HCEs; i.e. hospitals having 50+ beds in 2012, followed by MSDS for Category-II
HCEs; i.e. hospitals having up to 50 beds.
In the year 2014, the Commission initiated developing MSDS for different kinds of Category-III HCEs offering
out-patient basis. This includes MSDS for Basic Health Units (BHUs) in the public sector and the clinics of general
practitioners/family physicians, dental clinics, clinical laboratories, radiological diagnostic centers, as well as for
homeopathic clinics and matabs providing services under the Unani Ayurvedic and Homeopathic Practitioners
Act 1965. The MSDS primarily focus on quality and safety of services and are based on the approved basic
framework which covers the ten functional areas of organizational management and patient care. These
include inter-alia, care of patients, management of medication, continuous quality improvement, information
management systems and infection control, etc., in accordance with the range and scope of services at the
particular type of HCE.
Accordingly, the MSDS for Dental Clinics mainly operated in the private sector, have been developed in line with
their scope of services and cater to the specialized practices at these HCEs. All relevant stakeholders, including
the Health Department and dental surgeons from all regions of Punjab, both from the public and private
sectors, were consulted during nalization of the MSDS which comprises of 23 standards and 69 indicators. The
document also provides the survey process, compliance requirements and scoring methodology at the end of
each area to facilitate implementation and assessment of compliance.
I would like to thank the PHC team, led by the Chief Executive Officer, who undertook the revision of earlier
version of MSDS in a thorough professional manner. My thanks are also due to the experts and stakeholders
who provided valuable inputs in compilation of this document. Although staying up to date with the regulatory
requirements requires constant vigilance and seems time-consuming, remaining current on the same is critical
as for safeguarding patients, care providers, the practices and the environment. The document in hand is the
2nd Edition of the MSDS for dental practices that has been reviewed and amended in the light of the
implementation experiences and incorporates other contemporary legal and operational developments.
Lastly, I am grateful to the fellow Commissioners on the PHC Board for their continuous guidance and support in
carrying forward the mandate of the Commission.
I sincerely hope that the nalization of this document would mark another step towards achieving the
mandated objectives of the PHC to improve the quality of healthcare service delivery in Punjab.
Prof. Dr. Attiya Mubarak Khalid

Chairperson
Punjab Healthcare Commission
MSDS Reference Manual Dental Clinics
Table of Contents
List of Acronyms and Abbreviations 5
1 Introduction 7
1.1 Development Methodology 10
1.2 Reference Manual MSDS Dental Clinics 10
2 Standards and Indicators 11

2.1 Responsibilities of Management (ROM) 12
Standard 1. ROM-1: The clinic is identi able as an entity and is easily accessible Indicators 13
Ind 1. The clinic is identi able with name and registration/license numbers on the sign board/s 13
Ind 2. The patient/client has easy access to the clinic 13
Ind 3. The dental clinic is registered/licensed with the PHC 14
Ind 4. Door plate/s clearly display name and quali cation/s of the dental surgeon 14
Ind 5. The staff on duty uses identity badge/s 15
Ind 6. Consultation hours are displayed 15
Standard 2. ROM-2: The manager and the healthcare service provider/s at the clinic is/are suitably 19
quali ed
Ind 7. The clinic manager is duly designated and has requisite quali cations 19
Ind 8. PMC Registration Certi cate of the dental surgeon is displayed 19
Standard 3. ROM-3: Clinic premises support the scope of work/services 22

Ind 9. The size/premises of the dental clinic is as per minimum requirement 22
Ind 10. The dental clinic has adequate facilities for the comfort of the patients 22
Ind 11. The dental clinic has adequate arrangements for the privacy of patients during consultation/ 23
examination/procedures
Standard 4. ROM-4: The responsibilities of the management are de ned 27

Ind 12. The dental clinic management intimates any change in scope or portrayal of services, the location 27
of the HCE or the service provider/s etc. to the PHC
Ind 13. The dental clinic management addresses social and community responsibilities 27
2.2 Facility Management and Safety (FMS) 30

Standard 5. FMS-1: The dental clinic staff is aware of, and complies with, the relevant laws, rules, 31
regulations, bylaws and facility inspection requirements under the applicable
codes
Ind 14. The clinic management is conversant with the relevant laws and regulations 31
Ind 15. The clinic management regularly updates any amendments in the prevailing laws of the land 31
Ind 16. The management ensures implementation of relevant laws 32
Ind 17. There is a mechanism to regularly update licenses/registrations/certi cations 32
Ind 18. The staff has the knowledge about early detection and containment of re and non- re 32
emergencies
Ind 19. Arrangements to combat re and non- re emergencies are in place 33
Punjab Healthcare Commission 1
Standard 6. FMS-2: The clinic has a programme for management of dental and support services 39
2.3 equipment
Ind 20. The clinic plans has an equipment in accordance with its scope of services 39
Ind 21. Quali ed and trained personnel operate and maintain the equipment 39
Ind 22. Equipment is periodically inspected, serviced and calibrated to ensure its proper functioning 40
2.3 Human Resource Management (HRM) 45
Standard 7. HRM-1: There is documented personnel record of dental surgeon/s and staff 47
Ind 23. The Personnel record and credentials of all staff of the clinic are maintained 47
Standard 8. HRM-2: The employees joining the dental clinic/practice are oriented to the environment, 49
respective sections and their individual jobs
Ind 24. Each regular/part time employee trainee and voluntary worker is Ind 24. appropriately oriented to 49
the overall environment of the dental clinic/relevant section service and programme policies and
procedures
Ind 25. Each regular/part time employee is made aware of the job description 49
Ind 26. Performance evaluations are based on the JDs 50
Ind 27. Each regular/part time employee is made aware of his/her rights and responsibilities and patient 50
rights and responsibilities
2.4 Information Management System (IMS) 53

Standard 9. IMS-1: Patient clinical record is maintained at the dental clinic 54
Ind 28. Every patient's medical records has a unique identi er and particulars for identi cation 54
Ind 29. Only authorized person/s make entries in the record 54
Ind 30. Every record entry is dated, timed and signed 55
Ind 31. The record provides an up-to-date and chronological account of patient care 55
2.5 Quality Assurance (QA)/Quality Improvement (QI) 59
Standard 10. QA-1: The dental clinic has Quality Assurance / Improvement System in place 60
Ind 32. Service provision is as per portrayal 60
Ind 33. A quality improvement system is practiced 60
Standard 11. QA-2: The clinic identi es key indicators to monitor the inputs processes and outcomes 63
which are used as tools for continual improvement
Ind 34. Monitoring includes appropriate patient assessment 63
Ind 35. Monitoring includes safety and quality control programmes of the diagnostic services 63
Ind 36. Monitoring includes ALL invasive procedures and equipment 64
Ind 37. Monitoring includes use of anesthetics 64
Ind 38. Monitoring includes availability and content of the clinic records 65
Standard 12. QA-3: Sentinel events are assessed and managed 68

Ind 39. The clinic has enlisted the Sentinel Events to be analyzed and managed 68
2 CG-09RM-Ed2-141021
2.6 Assessment and Continuity of Care (ACC) 71

2.3
Standard 13. ACC-1: Portrayed service/s conform to the legal provisions 72
Ind 40. The services being provided at the clinic are displayed as per Code of Ethics 72
Ind 41. Specialized services being provided conform to the standards 72
Ind 42. The use and maintenance of specialized equipment conforms to the standards 73
Ind 43. Dental laboratory services, provided, conform to the respective requirements 73
Ind 44. Dental radiological diagnostic services, being provided, conform to the respective standards 74
Ind 45. Dental health education is provided as per guidelines 74
Ind 46. Preventive services are provided as per guidelines 75
2.7 Care of Patients (COP) 78
Standard 14. COP-1: The clinic has a well-established patient management system 79
Ind 47. The clinic has an established registration and guidance process 79
Ind 48 Standard/Ethical practice is evident from the patient record 79
Ind 49. The clinic has referral SOPs 80
Standard 15. COP-2: The clinic has essential arrangements for providing care to emergency cases 84
Ind 50. The clinic has essential arrangements to cater for emergency care 84
2.8 Management of Medication (MOM) 87
Standard 16. MOM-1: Prescribing practices conform to the standards 88

Ind 51. Standards for prescription writing are followed 88
Ind 52. Prescriptions are clear, legible, dated, timed, named/stamped and signed 88
Ind 53. Prescriptions are provided to the patients 88
Standard 17. MOM-2: Storage and dispensing/usage conforms to the guidelines 91

Ind 54. Medicines/disposables/dental materials are stored as per guidelines 91
Ind 55. Expiry dates are checked prior to administering, as applicable 91
Ind 56. Dispensing/utilization is by an authorized person 92
2.9 Patient Rights and Education (PRE) 95
Standard 18. PRE-1: There is a system for awareness/education of patients and others regarding the 96
Charter of Rights and Responsibilities for compliance
Ind 57. The Charter of Rights and Responsibilities are displayed and patients/families and staff are guided on it 96
Standard 19. PRE-2: There is a system for obtaining consent for treatment 98
Ind 58. The dental surgeon obtains consent from a patient before examination 98
Ind 59. The clinic has listed those situations where speci c informed consent is required from a patient or 98
family and the consent is taken accordingly
Standard 20. PRE-3: Patients and families have a right to information about expected costs 102
Ind 60. The patient/family is informed about the cost of treatment 102

Standard 21. PRE-4: Patients and families have a right to refuse treatment and lodge a complaint 104
Ind 61. Patients and families have a right to refuse the treatment 104
Ind 62. Patients and families have a right to complaint and there is a mechanism to address the grievances 104
2.10 Infection Prevention & Control (IPC) 107
Standard 22. IPC-1: The clinic has a well-designed, comprehensive and coordinated infection 108
prevention and control system aimed at reducing/ eliminating risks to patients,
visitors and care providers
Ind 63. The infection prevention and control plan is documented which aims at preventing and reducing 108
risk of nosocomial/cross-infection
Ind 64. The clinic has designated staff and de ned responsibilities for infection control and waste 109
management activities
Ind 65. The clinic has appropriate consumables, collection and handling systems, equipment and facilities 109
for control of infection
Ind 66. ALL staff involved in the creation, handling and disposal of dental/clinical waste shall receive 110
regular training and ongoing education in the infection control and safe handling of waste
Standard 23. IPC-2: There are documented procedures for sterilization activities in the clinic 122
Ind 67. There is adequate space available for sterilization activities 122
Ind 68. Regular validation tests for sterilization are carried out and documented 122
Ind 69. There is an established procedure for recall in case of breakdown in the sterilization system 123
3 ANNEXURES 131
ANNEXURE. A: Health Related Legislation 132
ANNEXURE. B: Equipment History Sheet 134
ANNEXURE. C: Sample Equipment Service History Form 135
ANNEXURE. D: Equipment Log Book 136
ANNEXURE. E: Orientation Guideline 137
ANNEXURE. F: Statement of Ethics 139
ANNEXURE. G: Template of JD 140
ANNEXURE. H: PHC Charters 144
ANNEXURE. I: Weeding of Old Record 148
ANNEXURE. J: Sample Authorized Personnel List 149
ANNEXURE. K: Sample Client Satisfaction Form 150
ANNEXURE. L: HCE Performance Measuring Checklist for In-charge 151
ANNEXURE. M: Actions Taken for Improvement of Services 152
ANNEXURE. N: Specimen Authorization of Professionals to Administerthe Drugs/Medications 153
ANNEXURE. O: Consent Form 154
ANNEXURE. P: Complaints Management 155
ANNEXURE. Q-I: First Consultation - 8 Dec, 2015 158
ANNEXURE. Q-II: Second Consultation - 22 Dec, 2015 160
ANNEXURE. Q-III: Field TestMSDS/RM - March 30-31, 2018 162
ANNEXURE. R: Development Team 164
4 CG-09RM-Ed2-141021
List of Acronyms and Abbreviations

A&E Accident and Emergency
AAC Access, Assessment and Continuity of Care
ACR Annual Con dential Report
ADR Adverse Drug Reaction
BOC Board of Commissioners
BLS Basic Life Support
BTS Blood Transfusion Service
CMC Complaint Management Committee
CME Continued Medical Education
CNIC Computerized National Identity Card
CQI Continuous Quality Improvement
CSOs Civil Society Organizations
CT Computerized Tomography
DHIS District Health Information System
DoB Date of Birth
DRAP Drug Regulatory Authority of Pakistan
ED Emergency Department
EDL Essential Drug List
EMR Electronic Medical Record
EMS Emergency Medical Services
EmOC Emergency Obstetric Care
FMS Facility Management and Safety
FP Family Planning
HCE Healthcare Establishment (Dental Clinic/Surgery)
HCP Healthcare Provider
HIC Hospital Infection Control
HMIS Health Management Information System
ICC Infection Control Committee
ICT Information Communication Technology

List of Acronyms and Abbreviations
Information, Education and Communication Infection
IEC
Prevention & Control
IMS Information Management Systems
IPC Infection Prevention & Control
JD Job Description
Kcl Potassium Chloride
LASA Look-Alike, Sound-Alike
MIS Management Information System
MLC Medico-Legal Case
MLR Medico-Legal Report
MOM Management of Medication
MSDS Minimum Service Delivery Standards
NGO Non-Government Organization
OEM Original Equipment Manufacturer
OPIM Occupational exposure to Potentially infectious materials
PHC Punjab Healthcare Commission
PMC Pakistan Medical Commission
PMDC Pakistan Medical and Dental Council
PNC Pakistan Nursing Council
PPE Personal Protective Equipment
PRE Patient Rights and Education
QA Quality Assurance
QC Quality Control
QI Quality Improvement
RBS Random Blood Sugar
ROM Responsibilities of Management
SMPs Standard Medical Protocols
SOPs Standard Operating Procedures
TAC Technical Advisory Committee
WM Waste Management
6 CG-09RM-Ed2-141021
PART 1
INTRODUCTION

8 CG-09RM-Ed2-141021
1. Introduction
The Government of Punjab promulgated the Punjab Healthcare Commission Act 2010 to establish the Punjab
Healthcare Commission (PHC) as a regulatory body with the prime objective to improve delivery of healthcare
services and ban quackery in Punjab in all its forms and manifestations and perform other functions
connected thereto. The PHC is legally mandated to regulate all healthcare establishments (HCEs) providing
services in public and private sectors through registration and enforcement of minimum service delivery
standards (MSDS) for all categories of healthcare services and to grant license to the HCEs on the basis of
implementation of these MSDS.1 To carry forward its mandate, the Commission prioritized its work regarding
development of MSDS for three recognized systems of treatment; allopathy, homeopathy and tibb. The PHC, in
the rst phase developed and enforced implementation of MSDS for Category-I HCEs i.e. above 50 bedded
hospitals followed by the MSDS for Category-II HCEs which generally cover all types of hospitals related to
allopathic system of treatment having less than 50 beds. Later, the PHC also completed the development of
MSDS for Category-III HCEs; including Homeopathic Clinics, Basic Health Units (BHUs), Matabs, Clinical
Laboratories, Radiological Diagnostic Centers and clinics of General Practitioners (GPs)/Family Physicians,
which have been approved and are being implemented. This was followed by nalizing the document in hand,
the MSDS for Dental Clinics covering small to large scale dental practices.
Setting service delivery standards and indicators for their assessment is an established international practice
for incessantly improving the quality of delivery of healthcare services across the health sector. The primary
objective of developing MSDS for dental practices is to set yard sticks for the clinics of dentists to become
eligible for grant of license by the PHC. These standards are primarily designed to regulate the premises for
streamlining the delivery of healthcare services at the dental clinics even at the lowest level. Issuance of
Certi cate of Registration to the Dentists/ Dental Practitioners to practice however, remains the responsibility
of the PMC in accordance with the provisions of the PMC which was previously the domain of the erstwhile
PMDC established under the PMDC Ordinance 1962 amended through the PMC (Amendment) Act 2012.
1- Refer to Sections 13, 14, and 20 of PHC Act 2010

1.1 Development Methodology
An outline for Draft MSDS was prepared by the PHC team by taking on board a core group of experts in
practicing dentistry at various scales. In addition, the professionals working at government healthcare facilities,
at clinical and management positions, members of faculty from dental colleges/universities, representatives of
the PMDC now PMC and the College of Physicians and Surgeons Pakistan, and members of various medical/
dental associations were also consulted.
The draft MSDS prepared by the CG&OS team was shared and thoroughly discussed with the entire technical
team of the PHC, including a skill mix of senior and mid-level practicing doctors, hospital managers, public
health professionals, pharmacists and quality assurance experts, for seeking their views. After incorporating
inputs of the PHC technical team, the draft was shared with the key stakeholders. After seeking comments of the
core group, a broad-based consultative workshop for stakeholders was organized, which was attended by
experts from the Health Department, senior dental surgeons working in the public sector hospitals, public and
private teaching institutions and independently working dental surgeons from across the province. The draft
was thoroughly reviewed and consensus based recommendations were incorporated. The draft reviewed by
the Subcommittee of the Technical Advisory Committee on Standardization and Accreditation, was presented
to the Board of Commissioners of the PHC for approval. The BOC reviewed the MSDS and accorded approval to
forward the same to the Government for formal approval and noti cation before implementation.
1.2 MSDS Reference Manual for Dental Clinics
The MSDS Reference Manual for Dental Clinics comprises of 23 basic standards and 69 associated indicators, out
of which 48 indicators require 100% compliance (ascribed red), while 21 (ascribed yellow) are acceptable even
with partial compliance at least to the extent of 80%. The following scoring scale shall be used by HCE staff for
self- assessment to ensure 100% implementation.
Lowest Shades of Level of Implementation Highest
0 1 2 3 4 5 6 7 8 9 10
An Implementation Assessment Scoring Matrix has been provided at the end of each set of standards and
indicators for self-assessment practice by the HCE Staff, whereas additional details are provided for the PHC
assessors. It is highly desirable to achieve 100% scoring in all areas as these standards only prescribe the lowest
acceptable benchmark of quality, which HCEs are expected to follow. The revised version of MSDS will yet, be a
dynamic document for subsequent improvement on the bases of implementation experience and other
developments in the eld.
10 CG-09RM-Ed2-141021
PART 2
STANDARDS & INDICATORS

2. STANDARDS AND INDICATORS
2.1 Responsibilities of Management (ROM)
These standards provide the structure to help the managers and care provider's effectively work together to
enhance organizational performance. Many dental clinics have grown from single man practices to more
complex businesses with a higher number of employees. Thus adding administrative duties to practitioners.
Therefore, dentists particularly the clinic owners need to have management skills besides expertise in dental
practices.
A dental clinic owner is inter-alia responsible for managing staff, coordinating marketing activities, practices
overseeing the budget, purchases, and managing patient's appointments, besides clinical activities. All these
tasks needs to be performed in an efficient yet pro table way to guarantee the success of the clinic.
To meet these obligations, leaders/managers, care providers/ practitioners must collaborate and work together
as a team to achieve a common objective. The leaders/managers are responsible to develop the mission, vision
and goals of the organization; encourage honest and open communication and address con icts of interest so
that good relationships can thrive which enable the achievement of the stated goals.
The standards related to the responsibilities of management entail creating a culture that fosters safety as a
priority, planning and providing services that meet patients' needs and ensuring availability of physical,
infrastructure and human resources necessary to provide care. The management is also responsible to engage
all managers and clinicians in performance improvement. The standards make clear that performing
management functions is the direct responsibility of all leaders and that a coherent working relationship
amongst different tiers enhances the quality of care provided to the patients. In the small scale practices
however, the management functions and responsibilities will be according to the scope of services provided at
the particular HCE.
12 CG-09RM-Ed2-141021
2. Standards and Indicators

2.1 Responsibilities of Management (ROM)
Standard 1. ROM-1: The clinic is identi able as an entity and is easily accessible
Indicators (1-6):
The clinic is identi able with name and registration/license numbers on
Ind 1.
the sign board/s
Survey Process:
The indicator requires that any one accessing the dental clinic is able to identify it by the name of the clinic and
the service provider clearly written on the sign board, with the PMC registration number and the PHC
registration/license number i.e. “Clinic ABC-PMC Registration Number. 0000” and “PHC Registration
/License Number 0000”2. Surveyors are required to assess that the clinic board is appropriately placed,
prominently visible and patients are able to know before entering into the clinic that they are accessing a clinic
of quali ed dental practitioner/(s) registered/ licensed with the PHC and the practitioner duly registered with
the PMC.
Compliance Requirements:
i. Sign board of the HCE available, visible and placed appropriately with the following clearly written:
a. Name of the clinic
b. Name of service provider/s
c. PMC Registration Number
d. PHC Registration/License number
Scoring:
If the sign board clearly identi es the clinic as above, then score as fully met.
If there is no sign board or there are non-conformities to the above, then score as not met.
Ind 2. The patient/client has easy access to the clinic
Survey Process:
Observe that access to the dental clinic for patients/relatives, particularly for disabled/elderly persons, is easy. In
case the entry/exit is not on a level ground, it should have steps and ramps/slopes for a wheel chair/stretcher
etc. and the ramps/slopes should be non-slippery. The entry/exit of the clinic and the washroom door/s (if
applicable) are wide enough to allow easy passage for a wheel chair.
i. Non slippery steps and/or,
ii. Non slippery ramp/slope for wheel chair and/or,
iii. Facilitation for patient access,
iv. Entry and exit of clinic and washroom doors (if applicable) are wide enough to allow easy passage of
wheel chairs.
2- The requirement to display PMC/PHC Registration number on the main sign board is relaxed for initial one year during which the Registration Number should be displayed at a prominent place inside the
clinic.

Scoring:
If the access to the dental clinic is easy as de ned above, then score as fully met.
If the entry/exit of clinic are not on ground oor, and it has steps but no ramps for the wheel
chair/stretcher as de ned above, but facilitation is provided to the patients, then score as partially met.
If the entry/exit of the clinic are not on a level ground, the steps are narrow and steep and there is no
ramp or other facilitation, then score as not met.
Ind 3. The dental clinic is registered/licensed with the PHC
Survey Process:
The surveyor is required to verify Registration Certi cate and the License issued under the PHC Act 2010 or an
evidence of having applied for the License. PHC Registration Certi cate/License is to be displayed at a
prominent place inside the dental clinic.
i. PHC Registration Certi cate/License is available and displayed inside the clinic OR
ii. In case is yet in the process of acquiring license or if the license is expired, there is evidence of initiating
the process of obataining registration or renewal.
Scoring:
If the dental clinic has a Registration Certi cate/License from PHC and it is displayed as described above,
then score as fully met.
OR if the dental clinic has; i. registration Certi cate of the PHC which is displayed and ii. evidence of
having applied for the grant of License or renewal, from the PHC. Thereof also score as fully met.
If the dental clinic has no certi cation as above, then score as not met.
Ind 4. Door plate/s clearly display name and quali cation/s of the dental surgeon
Survey Process:
Observe the placement of the door plate/s displaying quali cation/s and having text in accordance with PMC/
PMDC Code of Ethics of Practice for Medical and Dental Practitioners3 prescribed under the PMC Act 2020/
PMDC Ordinance 1962 and the PMC (Amendment) Act 2012 as amended from time to time.
i. Door plate/s xed with name and quali cation/s
ii. Door plate/s text according to the PMC/ PMDC Code of Ethics for the Medical and Dental Practitioners
iii. Door plate/s size is according to the PMC/ PMDC Code of Ethics (not exceeding 4x10 inches)
Note: PMC Code of Ethics prohibits suffixing of any degree/diploma with the name of practitioners which
are not registered with PMC
Scoring:
If the door plate/s is/are as above, then score as fully met.
If the door plate/s is/are present but full information is not displayed as above, then score as partially met.
If the door plate/s does/do not exist, or it displays super uous information then score as not met.
3- Provision 7 (1) No person shall practice modern system of medicine or surgery unless that person is a doctor or dentist having registered quali cation and valid registration with PMC, 8 (1) refers to display
of valid registration of PMC at the clinic and writing of registration number on prescriptions, Certi cate and money receipts to patients and 8 (2) prohibits suffixing of degrees/diplomas with their names
which are not registered with PMC.
14 CG-09RM-Ed2-141021
Ind 5. The staff on duty uses identity badge/s ⁴
Survey Process:
The essence of the indicator is to ascertain that every employee of the dental clinic⁵ who is on duty and
providing services can be identi ed by means of an identity badge, having clearly written name/designation
and specialty/discipline, where applicable.
i. Identity badge/s issued to staff by the administrator/in-charge of the dental clinic
ii. Staff on duty is identi ed with badges
iii. Badge/s have clearly written name/designation/discipline
Scoring:
If the staff is using identi cation badge/s as above, then score as fully met.
If the identi cation badge/s are not in use or there are non-conformities to the above, then score as not met.
Ind 6. Consultation hours are displayed
Survey Process:
The dental clinic should function only when the dental surgeon is physically available to provide consultation/
services as per consultation hours prominently displayed outside and inside the clinic.
i. Consultation/Practice hours are displayed inside and outside the clinic
ii. Dental surgeon/s is/are physically present during consultation/practice hours
Scoring:
If the timings/consultation/practice hours are displayed and followed, then score as fully met.
If the timings/consultation/practice hours are NOT displayed or not followed, then score as not met.
Guidelines
Identi cation of the Dental Clinic
It is essential for every dental clinic to be clearly identi ed by its name, specialty, registration of the care
provider with the PMC and status of registration/license of the HCE from PHC to depict its status of being a
legitimate healthcare establishment/service provider while excluding those who are not
quali ed/authorized to practice independently.
Dental clinics are required to install appropriate boards taking into consideration safety measures and
ful lling the regulations/by laws of municipal authorities:
i. Size of the board in relation to the dental clinic building
ii. Location and tting strength of the board in view of the wind pressure
iii. Clear visibility from the approach road
4- Means a full identity card with photo and signatures of the staff and issued under the signatures of the administrator/in-charge of dental clinic.
5- For female staff, like dental nurse, female dental assistant or receptionist etc, who may not like their names/photos to be displayed, a modi ed system having designation only may be devised.

The dental clinic/practice will be open and functional only during the presence of the dental surgeon/
dentist. In order to ensure this, the consultation/practice hours of the dental surgeon must be prominently
displayed outside and inside the clinic, so that visitors have clear information about the timings of
availability of the dental surgeon. The only exception may be opening for a limited time before and after
practice hours for performing cleaning and sterilization procedures noting appointments at reception or
any other maintenance activities.
Those dental clinics where more than one dental surgeon provides services, the timings in terms of their
days and hours must be clearly mentioned. If a practitioner provides services at more than one clinic, his/her
name and authorised quali cation with working hours and days must be displayed accordingly.
In case a consultant dental surgeon is just on call to provide services as required, his/her name and
quali cation/s are to be displayed with the words 'ON CALL'.
Location and Accessibility

There is a tendency of encroachment on the in/out gates of the clinics/HCEs by shops, taxis, rickshaws and
other vendors which hinders the traffic ow and passage of the patients. Such situations need intervention
by the management of the dental clinic to coordinate with concerned authorities for remedial actions. The
management of the dental clinic is required to facilitate access to the clinic for disabled and elderly patients
through ramps/slopes for the movement of stretchers/wheel chairs, etc. The ramps should not be steep or
slippery.
Registration and Licensing

Only the dental practitioners registered with the PMC/PMDC are authorized by law to provide care to the
patient independently. The registration with the PMC has to be renewed and updated as per the prescribed
regulation. Registration and licensing of the HCEs/clinics are two separate procedures and it is mandatory
for every dentist/dental surgeon to get his/her clinics registered with the PHC in terms of Section 13 of the
PHC Act 2010 and licensed in terms of Section 14, 15 and 16 of the Act.
The HCEs have to apply for registration/license on a prescribed form along with necessary documents. In
response to this application, PHC will issue a Registration Certi cate/Provisional License, which has to be
displayed in the dental clinic at a prominent place and its copy must be available in the clinic's record.
No dental clinic can provide dental services without being registered/licensed with PHC and the
Registration/License Certi cate prominently displayed at the place of practice.
16 CG-09RM-Ed2-141021
Staff Identity
Identi cation of the staff on duty at the dental clinic is essential because
i. Patients/relatives have a right to know as to who is providing care to the patient
ii. For seeking follow up of treatment
iii. To provide feedback regarding quality of care
Authority for Issuing Identity Badges

The identity badge/s should provide correct and standardized information regarding particulars of the
person to whom the card is issued to avoid impersonation.
The manager/administrator of the dental clinic is responsible to nalize the specimen and to sign the
identity badge which has also to be signed by the holder/employee. The sample format of the card provided
below may be followed/adapted:
Clinic Name
Employee No:_______________________
Name:_____________________ Designation: _____________
Date Of Issue: ______________ Employee Sig: ____________

Signature
Valid Upto: _______________ Issuing Authority:_________

Assessment Scoring Matrix
Standard 1. ROM-1: The clinic is identi able as an entity and easily accessible
Indicators 1-6 Max. Weightage Grading

Score Score
The clinic is identi able with name and registration/
Ind 1. 10 100%
license numbers on the sign board/s
Ind 2. The patient/client has easy access to the clinic 10 80%
Ind 3. The dental clinic is registered/licensed with the PHC 10 100%
Door plate/s clearly display name and quali cation/s of

Ind 4. 10 80%
the Dental Surgeon
Ind 5. The staff on duty uses identity badge/s 10 100%
Ind 6. Consultation hours are displayed 10 100%
Total 60
Detailed remarks regarding non-compliance, partial compliance and assessors own impression:
Assessor Coordinator
Name:__________________________________ Name:__________________________________
Signature:_______________________________ Signature:_______________________________
Date:___________________________________ Date:___________________________________
18 CG-09RM-Ed2-141021
Standard 2. ROM-2: The manager and the healthcare service provider/s at

the clinic is/are suitably quali ed⁶
Indicators (7-8):
Ind 7. The clinic manager is duly designated and has requisite quali cations
Survey Process:
Review the roles and responsibilities of the individual/s managing the dental clinic and/or providing clinical
services and assess if their credentials match the assigned role/portrayed services⁷.
i. Clinical services are managed/supervised by a dental practitioner registered with the PMC
ii. Support services are managed by a dental practitioner or any other designated person
iii. Evidence of staff credentials (quali cation, experience, training, etc.) is available
Scoring:
Score fully met, unless the survey team identi es signi cant de ciencies in the credentials.
Ind 8. PMC Registration Certi cate of the dental surgeon is displayed
Survey Process:
A photo copy of the valid Registration Certi cate issued by the PMC to the dental surgeon is displayed at a
prominent place and the original is made available when demanded by the inspection team. The validity of the
PMC registration certi cate can be veri ed from the PMC, if so needed.
i. Photocopy or original valid PMC Registration is displayed inside the clinic
ii. Evidence of initiating renewal process of registration (if applicable) is provided
Scoring:
If copy of the valid PMC Registration Certi cate is prominently displayed in the clinic or the original is
available when demanded by the inspection team, then score as fully met.
If copy of the PMC Registration Certi cate is displayed in the clinic, but is expired, and there is evidence
of having applied for its renewal, then score as partially met.
If copy of the Registration Certi cate is not available at the clinic or it is expired and the process for
renewal has not been initiated, then score as not met.
6- The practitioner/care provider has to be quali ed and registered as per the PMDC Ordinance 1962 and the PMDC (Amendment) Act 2012 or as amended from time to time.
7- The dentist registered with the PMC can be the owner/manager of the practice/clinic himself/herself. In case the clinic is owned by a person other than the dental surgeon himself/herself, then the technical
management shall lie with the dental surgeon who should not allow anyone else to practice in his/her absence, while general administrative issues may be handled by the owner/administrator/manager as the
case may be.

Guidelines
Quali cations of a Clinic Manager
Keeping in view the nature of specialized clinical services, the individual who provides healthcare services
at the clinic should be a quali ed BDS doctor, currently registered with the PMC. In case of a single- man
clinic, the doctor himself/herself shall be considered as the person in-charge, owner or manager of the
clinic, for overall administration, coordination and functioning of the dental clinic, unless some other
person is hired as manager for handling non-technical matters. For the polyclinics and large scale practices,
an additional quali cation in healthcare for the managers would be preferable.
In case the clinic is owned by a non-doctor, the owner shall only manage the general administrative matters,
while all technical matters related to provision of dental care shall be the responsibility of the quali ed
doctor.
In case the clinic is owned/run by more than one practitioner, the person in charge has to be designated,
clearly de ning the following responsibilities as in-charge/manager of the clinic:
i. Provision of services at the clinic according to the PMC rules, regulations and Code of Ethics,
ensuring that only admissible dental services are portrayed and provided at the clinic.
ii. Regular maintenance and repair of physical infrastructure and putting in place the building safety
requirements.
iii. Maintain high standards of general hygiene and a positive approach to patient handling and
facilitation by the support staff.
iv. Maintain discipline amongst the staff and displaying the practice hours.
v. Ensure that medication is dispensed according to standard procedures.
vi. Ensure that all records are maintained with required information and are periodically reviewed and
kept in safe custody with declared responsibility.
vii. Arrange requisite facilities and trained staff to deal with emergency care and referrals.
viii. Establish a complaints redressing system.
ix. Ensure compliance of SOPs on infection control, etc.
x. Maintain all the equipment of the clinic in functioning order.
xi. Responsibility for all kinds of nancial requirements of the clinic.
xii. Responsibility for the training of the staff, like dental assistants, receptionists, etc.
xiii. Ensure that the PMC registration of the dentist/s providing services is valid and copies, along with
the PHC Registration Certi cate are displayed in the clinic and the original certi cates are produced
when asked by the surveyors.
xiv. Ensure that there is a process for renewal of PMC registration/PHC License on regular basis, the
process for renewal is initiated well before expiry and the receipt of application is kept in the record.
20 CG-09RM-Ed2-141021
Standard 2. ROM-2: The manager and the healthcare service provider/s at the clinic is/
are suitably quali ed

Score Score
The clinic manager is duly designated and has requisite
Ind 7. 10 100%
quali cations
PMC Registration Certi cate of the dental surgeon is

Ind 8. 10 80%
displayed
Total 20
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________

Standard 3. ROM-3: Clinic premises support the scope of work/services
Indicators (9-11):
Ind 9. The size/premises of the dental clinic is as per minimum requirement
Survey Process:
Observe that the dental clinic has the minimum required space for reception, a sitting/ waiting for patients⁸,
consultation/procedures on a dental chair (dental unit), an X-ray unit (portable/stand mounted or separately
installed/mounted on wall), autoclave and cabinets for instruments and for the dental materials used during
the procedures.
i. Premises has allocated space for the following:
a. Reception desk
b. Sitting arrangement for at least three patients at one given time
c. Dental chair with essential components and support systems (dental unit) for consultation and
procedures
d. Dental X-ray unit mobile or separately installed (as the case may be)
e. Autoclave
f. Labelled cabinet/s and drawer/s for instruments
g. Labelled cabinet for essential dental materials
Scoring:
If the dental clinic ful lls the requirements as described above, then score as fully met.
If the premises of the dental clinic is as above, but there is no reception desk then score as partially met.
If the premises of the dental clinic is not as above or the sitting arrangement is not sufficient to even
accommodate three patients at a time, then score as not met.
Ind 10. The dental clinic has adequate facilities for the comfort of the patients
Survey Process:
The surveyors should observe the presence of the following during a visit to a dental clinic.
i. Sitting arrangement/ waiting area
ii. Alternate arrangements of electricity, having at least a backup time of one hour for keeping all the
essential equipment operational and at least three emergency lights
iii. Appropriate waste containers in the consultation/procedure room as well as the patients' waiting
area and places where technicians work
iv. Proper ventilation/air conditioning
v. Clean drinking water
vi. Mosquito and y proo ng (wire gauze)⁹
vii. Toilet (available/accessible)
8- Comfortable sitting means arrangement for at least three to ve patients sitting with comfortable posture at one given time, depending on the size of the practice.
9- Essential to safeguard against diseases transmitted through mosquitos e.g. malaria, dengue, etc. and other infectious diseases spread by ies.
22 CG-09RM-Ed2-141021
Scoring:
If the dental clinic has all the seven facilities ( i to vii) mentioned above, then score as fully met.
If the dental clinic has rst six facilities (i to vi) mentioned above, then score as partially met.
If the dental clinic lacks any one of the rst six facilities listed above, then score as not met.
The dental clinic has adequate arrangements for the privacy of patients
Ind 11.
during consultation/examination/procedures
Survey Process:
Observe if arrangements for patient's privacy during consultation/examination, as applicable, are available and
privacy is respected ⁰ .
i. Arrangements for patient's privacy as per the PMC Code of Ethics:
a. Curtain
b. Cabin/Wooden partition
ii. Evidence that privacy is respected as per the PMC Code of Ethics.
Scoring:
If the Dental Clinic has arrangements for patients' privacy as de ned above and evidence that the
privacy is respected, then score as fully met.
If privacy arrangement is not available in the Dental Clinic, then score as not met.
Guidelines
The Premises
The size and premises of the dental clinic are important for proper delivery of proper healthcare. The clinic
should be designed keeping in mind the comfort of both patients and care providers. Dental clinics are
recommended to have sufficient space designed to cater for basic needs as follows:
i. Patient reception and waiting area for three to ve patients sitting in a comfortable posture at one
given time. The waiting area/room needs to be appropriately furnished with chairs, settee/s, sofa/s
or benches, depending upon affordability and the number of clients to accommodate at least three
to ve patients and attendants at a given time, allowing movement without hindrance. The furniture
should be comfortable and should preferably also have a center-table and magazine rack
depending on the available space and budget. The waiting area can also have a pin-board for
posting articles, appointments or general information for patients.
ii. Approximately 80 sq. ft. space to accommodate a dentist, patient and one to two attendants for
initial consultation and nal prescription writing after performing procedure separately or as part of
the dental procedure room.
iii. In dental procedure room/s, it is ideal to have one dental chair in one room. However, if separate
rooms for more than one dental chair are not available then two chairs may be xed in one larger
room with a mobile screen/ xed partition between the two for performing minor procedures only.
For difficult procedures and where surgery is performed, only one patient shall be managed at one
time. There should be sufficient space around each dental chair for free movement of the dentist and
the assistant/s. There should be sufficient space to accommodate purpose built cabinets/drawers for
10- Privacy of all patients during history taking/examination is important and cannot be ignored. Female patients and minors are not examined alone by the male practitioners. In such an event, the accompanying
attendant, preferably a female, should be requested to remain present. The PMC Code of Ethics for Medical and Dental Practitioners and PHC Charters for Patients and others are relevant.

sterilized instruments to be handy during the procedures.
iv. Separate designated areas for different sterilization activities.
v. Cabinet for patients' record or the clinic may have a computer for the patient record keeping and
searching reference material etc., subject to affordability and patient load.
Practice can be started at a place, having minimum space as described above. However, availability of
further space for possible expansion must be kept in mind with an increase in the number of patients.
White ceilings and light colors should be used on walls and furniture to provide an overall bright
ambience and clean environment.
Adequacy of the Facilities

Generally, the patients and attendants have to wait for some time at the dental clinic/s, during which they
need to be made comfortable by providing basic essential amenities. The amenities and facilities may vary
depending on the scale of the practice and charges at various dental clinics/practices. However, every
dental clinic is required to provide certain basic requirements like proper reception and sitting
arrangements in waiting areas, arrangements of electricity with at least emergency lights for all patient
areas and a UPS or electric generator for the procedure room, waste container/receptacle/s , proper
ventilation, mosquito and y proo ng (wire gauze), clean drinking water and toilets with adequate washing
and air conditioning where ever required.
Privacy of Patient
The script from the Hippocratic Oath signi es the entire concept of the privacy of the patient as follows:
“………I will respect the privacy of my patients, for their problems are not disclosed to me that the world may
know……….”.
Respecting privacy and con dentiality of the patients during examination is an integral part of the PMC /
PMDC Code of Ethics reproduced below:
Section 17. Examination, consultation or procedures on a female patient
(1) A female patient shall be given consultation either by a female dental practitioner or shall be examined in
the presence of a female attendant by a male doctor.
Section 20. Permission of patient before examination

A doctor shall normally take permission from a patient before making physical examination. In case of
minors, the child's guardian shall be present or give permission for the examination. For any intimate
examination irrespective of age, the patient is entitled to ask for an attendant to be present. Such requests
shall be acceded to whenever possible.
Section 27. Con dentiality

The physician has a right to and shall withhold disclosure of information received in a con dential context,
whether this is from a patient or as a result of being involved in the management of the patient, or review of a
paper, except in the following speci c circumstances where he may carefully and selectively disclose
information where health, safety and life of other individual may be involved, namely:
11- As per the Hospital Waste Management Rules 2014 prescribed under the Environment Protection Act 2012 and as amended from time to time.
24 CG-09RM-Ed2-141021
i. The medical or dental practitioner cannot seek to gain from information received in a con dential
context (such as a paper sent for review) until that information is publicly available;
ii. Dental practitioner may consult his/her legal adviser;
iii. The professional medical record of a patient shall not be handed over to any person without the
consent of the patient or his/her legal representative. No one has a right to demand information
from the doctor about his patient, save when the noti cation is required under a statutory or legal
obligation and when in doubt, the medical or dental practitioner or a dentist may consult a legal
advisor;
iv. Con dence concerning individual or domestic life entrusted by patients to a medical or dental
practitioner and defects in the disposition or character of patients observed during medical
attendance shall never be revealed unless their revelation is required by law;
v. A medical or dental practitioner who gains access to medical records or other information without
consent shall be guilty of invasion of privacy; and
vi. The medical or dental practitioner who grants access of an information of a patient to a third person
except, law enforcing agencies, without consent shall be guilty of breach of con dentiality, but
where a medical or dental practitioner is of the opinion to determine it his duty to society requiring
him to employ knowledge about a patient obtained through con dence as a medical or dental
practitioner, to protect a healthy person against a communicable disease to which he is about to be
exposed, the medical or dental practitioner shall give out information to concerned quarters.
Section 36. Taking of photograph or videos for teaching purpose

Taking of patients' photographs and videos shall be done in such a manner that a third party cannot identify
the patient concerned. If the patient is identi able, he or she shall be informed about the security, storage
and eventual destruction of the record.

Standard 3. ROM-3: The clinic premises support the scope of work/services

Score Score
The size/premises of the dental clinic is as per minimum
Ind 9. 10 80%
requirement
The dental clinic has adequate facilities for the comfort
Ind 10. 10 80%
of the patients
The dental clinic has adequate arrangements for the

Ind 11. 10 100%
privacy of patients during consultation/ examination/
procedures
Total 30
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________
26 CG-09RM-Ed2-141021
Standard 4. ROM-4: The responsibilities of the management are de ned
Indicators (12-13):
The dental clinic management intimates any change in scope or portrayal
Ind 12.
of services, the location of the HCE or the service provider/s etc. to the PHC
Survey Process:
Review the records and check whether any change in the ownership, managerial staff, portrayal/scope of
services and any change in the location of the clinic within a building or relocation at another site if carried out
has been intimated to PHC or not.
i. Electronic/documented evidence of intimation to the PHC of any above mentioned changes as
applicable
Scoring:
If there is evidence of intimation to the PHC of the above mentioned changes, if carried out, then score as
fully met.
If there is no evidence of intimation to the PHC of any above mentioned changes , if carried out, then
score as not met.
The dental clinic management addresses social and community

Ind 13.
responsibilities
Survey Process:
Look for evidence which demonstrates that the dental clinic management is aware and has shown sensitivity
towards its community's healthcare needs and is promoting community dentistry. Look for any voluntary ‘out-
reach’ or ‘on-site’ activities catering for community's health needs such as awareness campaigns regarding
dental hygiene, dental camps and/or providing aid to people hit by calamities, etc., if applicable. The evidence
can be in the form of pamphlets/banners/posters/record of patients seen or educated during such awareness
campaigns.
i. Evidence of any one or more activities such as awareness campaigns regarding dental hygiene, dental
camps and/or providing aid to people hit by calamities, etc.
Scoring:
If there is evidence that the dental clinic is sensitive and catering to social responsibilities as
mentioned above, then score as fully met.
If there is no evidence that the dental clinic is sensitive to social responsibilities as mentioned above,
then score as not met.

Guidelines
Intimation of Changes to PHC

Dental clinics are issued licenses for providing healthcare services by dental practitioner/s currently
registered with PMC at the premises as described and provided in the application submitted to PHC under
Section13, 15-17, after ensuring implementation of MSDS as prescribed under Section 20 and Section 22 of
PHC Act 2010. Therefore, any pertinent change in the status or scope of practice as provided in the original
application, needs to be updated and intimated to the PHC. The evidence of communicating any such
change to PHC needs to be produced to the assessment teams during inspections.
Social and Community Responsibilities

The dental clinic should be sensitive to the needs of the community it serves and should demonstrate
awareness about prevalent health related problems in its catchment area. The demonstration may be in the
form of some record that con rms voluntary'out-reach'or'on-site'activities catering for community's health
needs such as providing health care by camping, awareness campaigns and providing aid to people hit by
calamities, etc.
Private sector dental clinics are also expected to provide lifesaving/emergency care, particularly to those
who fall prey to accidents/emergencies in the proximity of the private dental clinic, or arranging referral of a
serious patient to a public sector HCE for want of free treatment, etc. The expected social responsibility of a
dental clinic would be limited to providing basic life support (BLS) or a dentistry speci c aid, documenting
the lifesaving/emergency measures taken and referring the patient to the appropriate health facility. This
will also require arrangements for providing rst aid to deal with common emergencies as further explained
under the relevant indicator.
Dental clinics are expected to use the potential of CSOs/NGOs, as they are always willing to contribute in
such activities.
28 CG-09RM-Ed2-141021
Standard 4. ROM-4: The responsibilities of the management are de ned

Score Score
The dental clinic management intimates any change in
Ind 12. scope or portrayal of services, the location of the HCE 10 100%
or the service provider/s etc. to the PHC
The dental clinic management addresses social and

Ind 13. 10 100%
community responsibilities
Total 20
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________

2.2 Facility Management and Safety (FMS)
A dental clinic serves the dental care needs of the community and therefore, it needs to undertake regular
maintenance of the infrastructure to ensure functional and safe optimal services. It is imperative that all dental
equipment and support services at the dental clinic remain in prime working condition so that
procedures/surgeries are performed with highest level of precision. It is, therefore, desirable that quali ed
professionals handle and maintain these facilities in accordance with the relevant standards for ensuring
reliability, professionalism and sustaining the reputation of the practice/clinic.
In order to ensure, so that the services and maintenance needs are responded to quickly and efficiently, the
clinic should maintain and implement a preventive maintenance schedule in order to provide un-interrupted
services in a clean, healthy and safe environment. The standards under the functional area of FMS envisage that
the clinic staff is capable of identifying and managing re related accidents and has a provision of safe escape of
the visitors in case there is re emergency.
30 CG-09RM-Ed2-141021
Standard 5. FMS-1: The dental clinic staff is aware of, and complies with, the
relevant laws, rules, regulations, bylaws and facility
inspection requirements under the applicable codes
Indicators (14-19):
Ind 14. The clinic management is conversant with the relevant laws and regulations
Survey Process:
The clinic staff should be knowledgeable about the extent of applicability of the laws/regulations and codes
e.g. pertaining to building safety, re safety requirements, codes related to maintenance of lifts/elevators,
boilers, compressors and generator/s etc to ensure uninterrupted provision of services including power supply
and ventilation. The management/clinic staff also needs to know the laws governing the procurement of safe
pharmaceuticals, etc., supply of clean water12 and have effective contingency plans in the event of primary
system failures for ensuring smooth functioning of the clinic.
i. Staff is conversant with the relevant laws/regulations/codes and inspection requirements
ii. Effective contingency plans in the event of primary system failures
Scoring:
If there is clear evidence that the managerial and operational staff is aware of the relevant laws and their
applicability/requirements, then score as fully met.
If either there is evidence that the managerial staff is not aware of the relevant laws and their
applicability or operational staff is not aware of the relevant requirements, then score as not met.
The clinic management regularly updates any amendments in the

Ind 15.
prevailing laws of the land
Survey Process:
Directly observe and note the availability of updated/current laws that are applicable to the clinic .
i. Availability of copies of updated/current laws which are applicable to the clinic.
Scoring:
If a full range of updated/current laws that are applicable to the clinic is available, then score as fully met.
If even one of the applicable laws is either not updated/current or not available, then score as not met.
12- Punjab Drinking Water Policy 2014.

Ind 16. The management ensures implementation of relevant laws
Survey Process:
Check to see if documentation supports implementation of relevant regulations and that this is con rmed with
observable examples.
i. Evidence for implementation of all relevant laws/regulations including the following
a. Availability of updated/current registration, certi cate/s, license/s by the respective authorities
under the relevant laws/regulations/rules (as applicable)
b. Availability of compliance documents e.g. various SOPs/plans/committees/minutes of
meetings/reports (as applicable)
c. Demonstration of compliance to above in routine work (as applicable)
Scoring:
If there is evidence of compliance with all prevailing applicable laws and regulations, then score as fully met.
If there is evidence of non-compliance with any of the applicable laws and regulations, then score as not met.
There is a mechanism to regularly update licenses/registrations/

Ind 17.
certi cations
Survey Process:
Directly note the validity and currency of the compliance documents and also review the mechanism to
regularly update licenses/registrations/certi cations, etc.
i. Valid registration certi cates/licenses including certi cation of dental X-ray unit available (as applicable)
ii. Documented evidence of mechanism to regularly update the certi cations/ licenses etc.
Scoring:
If there is a full range of current compliance documents, and there is mechanism to regularly update the
above then score as fully met.
If even one of the current compliance documents is not available, then score as not met.
The staff has the knowledge about early detection and containment of
Ind 18.
re and non- re emergencies
Survey Process:
The surveyors shall ask the staff (dental surgeon as well as the support staff ) of the clinic regarding knowledge
about the system/process for early detection and containment of re and non- re emergencies.
i. Evidence of awareness about detection and containment by interviewing the staff
ii. Evidence of re ghting drills by the staff e.g. attendance sheet available in record
13- Early detection at a small scale means to quickly check in person the extra ordinary smoke/burning smells, etc. non- re emergencies: earthquake/building collapse, oods, etc.
32 CG-09RM-Ed2-141021
Scoring:
If the staff has knowledge about the system/process of early detection and containment of re and
non- re emergencies, then score as fully met.
If the staff has no knowledge, then score as not met.
Ind 19. Arrangements to combat re and non- re emergencies are in place

Survey Process:
Observe that arrangements to deal with re and non- re emergencies are available in the clinic. Interview the
staff to assess whether they know how to operate/use the re ghting equipment/other arrangements ⁴.
i. Documented re and non- re safety plan
ii. Fire ghting equipment/other arrangements available
iii. Staff aware about the re ghting system/non- re emergency combat system/process
Scoring:
If the arrangements to combat re and non- re emergencies are available and the staff is aware of
and knows how to use those, then score as fully met.
If the arrangements to combat re and non- re emergencies are available but the staff is not aware
of and does not know how to use those, then score as partially met.
If the arrangements to combat re and non- re emergencies are not available, then score as not met.
Guidelines
Applicability of Laws and Regulations to Dental Clinic/Surgery
A list of the relevant laws applicable to the health sector/healthcare service delivery, with the links to
download, is provided at Annexure-A.
The basic design of a dental clinic/surgery is required to support its functions, including the following:
i. Waiting/reception area
ii. Care of patients including consultation, procedures / treatment and emergency services etc.
iii Diagnostic facilities e.g. x-rays
iv. Research and training
v. Pharmacy services if portrayed (usually in case of polyclinics)
vi. Administrative/Facility management services
vii. Support and supply services
viii. Parking areas, etc.
The legal aspect is the most signi cant consideration in planning and designing the clinic and the
architects, engineers, and allied professionals must have working knowledge of the applicable laws, rules
and regulations and relevant codes of practice.
In the public sector, the Communication and Works Department (C&W) is the responsible agency for
planning and designing hospital and clinic buildings with an architect section headed by the Chief
Architect.
14- Equipment/arrangement suitable for the dental clinic/surgery like, bucket of water/sand, spade and/or re extinguisher, etc., as applicable.

In the private sector, clinic and hospital buildings are designed by architectural rms in accordance with the
codes prescribed by the development authorities/local councils/TMAs, etc. Private clinics on smaller setups
are usually housed in the existing commercial buildings and in houses with self-designed modi cations
generally in disregard and consideration to the above stated statutory requirements. The following aspects
of regulations and codes as generally applicable for designing and planning hospital buildings may be
considered as far as possible and applicable while planning and designing the dental clinic:
1. Zoning Regulations
i. Access and accessibility
ii. Volumetric dimensional limits of the building in terms of site coverage
iii. Building height
iv. Easements and rights of way, if any
These considerations establish the criteria that help to evolve a clinic design which is safe and consistent
with the overall plan for the community, without disturbing the local ethos and environment.
2. Building Code
The following provision of Building Code are considered to achieve maximum safety to ensure structural
stability, so that construction can withstand powerful earthquakes and other calamities:
i. Types of construction
ii. Light and ventilation
iii. Labour safety and welfare during construction
iv. Sanitation
v. Electrical and mechanical regulations
vi. Protection from ionizing radiation from X-ray equipment
vii. Permits and inspection requirements
viii. Any other applicable code
3. Fire Code
The Fire Code is provided by the Rescue Department, which requires complying with the following
provisions in order to minimize injury, death and loss to the staff, patients and families and also to curtail
damages to the hospital infrastructure:
i. General precautions against re
ii. Principles of re safety in buildings/structures
iii. Fire protection appliances
iv. Maintenance of re exits.
v. Suppression control in hazardous areas
vi. Specifying smoking areas as per provisions of relevant law/rules
vii. Management and use of combustible materials
4. Other codes
Other relevant bylaws, regulations and codes include sanitation codes, environmental protection
laws and water codes. These vary in form and content according to the requirements and need of the
clinic and ensure that.
34 CG-09RM-Ed2-141021
i. Design is consistent with the national/international standards for public health and safety.
ii. The permits and licenses necessary for establishing the clinics, related to the above
mentioned codes, are obtained.
iii. Occupational safety and protection against health hazards is ensured.
5. Inspection of Dental Clinic/Hospital Design

During inspection, application of relevant building codes, where necessary, must be checked in
addition to the following parameters:
i. Design or structure of the dental clinic/hospital.

ii. Sanitation codes, environmental protection laws and water codes.
iii. Minimum standards for the width/size of the doors, aisles, passageways, stairways, or other
means of exit.
iv. Structural strength or the stability of the building to withstand any damages by re,
earthquake, wind, ood, or by any other cause.
Compliance with Legislation and Regulations

Dental clinics are required to abide by the relevant laws like hospital waste management, infection control
and building codes etc. to ensure safety and comfort of patients and the care providers. The management
need to be familiar with these laws/rules/regulations, any amendment thereto and ensure implementation
of the same by the relevant staff.
Risk Management
Every organization, depending on its size, is required to designate individual/s to provide oversight for
effective, consistent and continuous implementation of all aspects of the risk management program,
including inter-alia the following:
i. Planning and implementing the program
ii. Educating the staff
iii. Testing and monitoring the program
iv. Periodical review and revision
v. Annual reports to the governing body/board on the effectiveness of the program
vi. Providing consistent and continuous management support
Renewal of Licenses and Certi cations

This indicator applies to the renewals of licenses/certi cations for radiology equipment, lifts, diesel
generating sets, boilers, compressors, etc. The organization should maintain a log book/tracker sheet for
this purpose.
A designated staff member should be responsible to enlist the licenses/registrations/certi cations
applicable to the dental clinic/surgery under the laws and regulations and to implement the respective laws
and regulations by timely renewal of the pertinent licenses/certi cates.
Necessary Items and Equipment

i. Fire-proof blanket
ii. Safety shower
iii. Buckets with sand

iv. Portable re extinguishers which are essentially of two types; CO2 and bromochloride
uoromethane (BCF) (halon, halogenated hydrocarbons) and can be used without causing
damage to electrical equipment. Water has the disadvantage that it conducts electricity,
whereas powder extinguishers (containing salts) cause damage to instruments.
Emergency Exit System
i. The oors of beams of egress shall be illuminated at all points including angles and intersections of
corridors and passageways, landings of stairs and exit doors with bulbs of not less than one
thousandth (0.001) lumens per square centimeter.
ii. Lighting source is of reasonably assessed reliability, such as public utility electric service.
iii. Emergency lighting facilities maintain the speci ed degree of illumination in the event of failure of
the normal lighting for a period of at least one hour.
iv. Illuminated 'EXIT' signs – distinctive in color, reliable source – ve thousandth lumens (0.005) per
square centimeters.
v. Size of signs – plainly legible letters not less than fteen centimeters high with the principal strokes
of letters not less than nineteen millimeters wide.
vi. Provide luminous directional exit signs located one foot or below oor level.
vii. There should be separate ingress and egress routes.
viii. Corridors, hallways and aisles must be 2.4 meters in width.
ix. Use of ramps as access to second and higher oors.
x. Stairways with safe and adequately secured railings.
xi. Stairway must be at least 112 cm. wide and made of concrete.
xii. Any opening in wall/s shall be protected by re doors or xed wire glass windows and must have
protection for vertical openings also.
xiii. Any door in a stairway, ramp, elevator shaft, stairway enclosure or light and ventilation shaft or
chute, shall be self-closing, and shall normally be kept closed.
36 CG-09RM-Ed2-141021
Standard 5. FMS-1: The dental clinic staff is aware of, and complies with, the relevant
laws, rules, regulations, bylaws and facility inspection requirements
under the applicable codes

Score Score
The clinic management is conversant with the relevant
Ind 14. laws and regulations 10 100%
The clinic management regularly updates any

Ind 15. 10 100%
amendments in the prevailing laws of the land
The management ensures implementation of relevant

Ind 16. laws 10 100%
There is a mechanism to regularly update licenses/

Ind 17. 10 100%
registrations/certi cations
The staff has the knowledge about early detection and

Ind 18. 10 100%
containment of re and non- re emergencies
Arrangements to combat re and non- re emergencies

Ind 19. are in place 10 80%
Total 60
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________

Standard 6. FMS-2: The clinic has a programme for management of dental
and support services equipment
Indicators (20-22):
Ind 20. The clinic plans has an equipment in accordance with its scope of services
Survey Process:
Review at the least; i. the inventory of all dental equipment in the clinic and review the documentation to
seethat the minimum required equipment to support basic dental care services and specialized equipment, as
applicable, is listed on the clinic's inventory. ii. Evidence of testing prior to use.
i. An inventory of all dental equipment in the clinic (minimum required equipment to support the basic
dental care services and specialized equipment, as applicable)
ii. A written plan /SOPs for:
a. Testing prior to use
Scoring:
If there is a plan covering the above aspects and evidence that it is being implemented, then score as
fully met.
If the plan exists but it does not include testing prior to use, or there are inadequate skills and resources
for implementation, then score as partially met.
If there is no equipment plan or if it does not include the Sops for testing prior to use or if there is no
inventory of dental equipment, then score as not met.
Ind 21. Quali ed and trained personnel operate and maintain15 the equipment
Survey Process:
To determine if appropriate personnel operate and maintain the equipment correctly (up to user maintenance
level de ned by the equipment manufacturer), look for documented training for use and maintenance as a user
and any data that identi es ‘user error’.16 Also, review the job descriptions of personnel deputed to operate
and/or for maintenance of dental equipment and their personal record to verify that they have the required
quali cations17, knowledge and experience.
i. Equipment maintenance protocols are followed
ii. Appropriate personnel operate and maintain the equipment correctly (up to user maintenance level
de ned by the equipment manufacturer)
iv. Evidence of training for use and maintenance as a user and any data that identi es'user error'
v. Job descriptions of personnel deputed to operate and/or for maintenance of dental equipment
vi. Personal record for verifying that the staff have the required quali cations, knowledge and experience
15- Servicing and planned preventive maintenance can be outsourced to appropriately quali ed technicians if required, or a combination of in-house and outsourced maintenance and servicing would be ne.
16- Equipment failures due to incorrect use.
17- As prescribed by the PMF or any other certifying authority.
38 CG-09RM-Ed2-141021
Scoring:
If the staff are adequately quali ed and experienced and trained to operate and maintain all equipment
within the scope of their ability as described above, beyond which equipment is serviced by contracted
experts, then score as fully met.
If the staff are less quali ed and experienced but trained to operate and maintain all equipment within
the scope of their ability as described above, beyond which equipment is serviced by contracted
experts, then score as partially met.
If staff are less quali ed and less experienced and their competence to operate and maintain the
equipment within the scope of their ability is also questionable and contracted service experts are also
not available, then score as not met.
Equipment is periodically inspected, serviced and calibrated to ensure its

Ind 22.
proper functioning
Survey Process:
There should be a written schedule of inspection, calibration and documented operational preventive
maintenance plan) based at least on manufacturer's recommendations. The inspection, calibration (if needed),
and maintenance must be documented18. The surveyors should review this documentation.
Compliance Requirement:
i. Written schedule of inspection, calibration and periodic preventive maintenance based at least on
manufacturer's recommendations
ii. Documentary evidence of inspection, calibration (if needed), and maintenance carried out
iii. Certi cate by the end user that the; i. the equipment is in working order, and ii. it is being periodically
serviced/calibrated
Scoring:
If ALL the above requirements are implemented and documented, then score as fully met.
Since this is a signi cant patient safety issue, if any of the requirements are not documented, then score
as not met.
Guidelines
Procurement Planning
While selection and procurement of the type and number of various equipment for the dental clinic/
surgery, and nalizing speci cations, the following must be taken into consideration:
i. Scope of services to be provided
ii. Future expansion/up graduation requirements
The SOPs regarding equipment selection and procurement should be periodically reviewed and revised.
18- The log book and history sheet etc. for each equipment should clarify that the inspection, calibration and maintenance is done in accordance with the preventive maintenance schedule detailed in the
Guidelines. The end user/specialist to certify that; i. the equipment is in working order, and ii. it is being periodically serviced.

Collaborative Procurement
Collaborative process in the selection of equipment implies that the end-users and the facility
management, particularly in a poly clinic setting, are involved in decision making.
Quali ed and Trained Operators

Every dental clinic shall ensure that all the equipment installed in the facility are operated by appropriately
quali ed, trained and skilled staff. The dental clinic should ensure that arrangements for proper calibration
and maintenance of equipment are in place. Ideally, the larger set ups of dental clinics shall establish a
Biomedical Engineering section under the supervision of a quali ed biomedical engineer/technician. To
provide calibration, repair and backup support to the end users. For specialized repair/services, the clinic
may make contract arrangements with some rm.
Preventive Maintenance Plan

The dental clinic shall ensure that the staff operating the equipment is trained in handling the equipment as
per the manufacturer’s instruction manual. There shall be a documented preventive maintenance plan for
all equipment and machinery using a log book/tracker sheet.
The clinic shall develop a schedule of weekly/monthly/annual inspection and calibration of equipment in
accordance with Original Equipment Manufacturer (OEM) guidelines. These services can be provided
through an in-house arrangement or alternatively through outsourcing. It shall be ensured that calibration
and conformance testing of the equipment is done prior to commissioning.
The dental clinic shall ensure that the record regarding purchase and maintenance of equipment and
machinery is properly maintained. The facilities shall ensure that no equipment is non-functional/out of use
merely for want of minor repairs, preventive maintenance, lack of essential spares, electrical faults, etc.
Important factors resulting into gross equipment wastage may also include the following:
i. Mishandling of equipment
ii. Use by untrained and unskilled staff
iii. Purchase of highly sophisticated equipment without competent personnel to handle it
iv. Purchase of excess equipment without a justi able demand
This calls for an efficient system for equipment management by introducing an Equipment Audit,
particularly in larger setups, for periodic evaluation of the quality of performance of the equipment which
has the following advantages:
i. It helps in standardization of the equipment

ii. Concurrently evaluates performance and utility
iii. Provides a mechanism to assist phasing out/condemnation and replacement
iv. The equipment audit reports provide an objective method for future procurement.
v. It identi es inadequacies and recommends remedial measures
vi. Cost per reportable result and cost effectiveness can be evaluated
40 CG-09RM-Ed2-141021
Equipment Audit
Equipment audit is the periodic evaluation of the quality of performance of the HCE equipment.
OR
It may cover a retrospective evaluation of quality of performance of equipment by an Equipment Audit
Committee comprising of the head of clinic and end use based on documented records of the equipment
at the time of purchase and its subsequent maintenance.
The Equipment Audit Committee shall meet once in three months and assign tasks to the members
Maintenance of the history sheet and its subsequent write-up is sine-qua-non for performance of the
equipment audit by the committee. A format of the History Sheet and Log Book is given as Annexure-B and C:
The following parameters may be considered in the equipment audit procedure in the larger setups
Procurement
i. Was the equipment required?
ii. Were the technical speci cations worked out and provided by the user department and
speci ed in the purchase order ?
iii. Was the receipt of equipment as per the speci cations of the supply order?
iv. Was availability of spares, after sale services and training of staff incorporated/speci ed in
the contract to ensure uninterrupted functioning?
Performance
Periodic scienti c evaluation of the quality of performance of the equipment is carried out by using the
history sheet and log book. The process of equipment audit is an indispensable tool in formulating
speci cations and establishing benchmarks for medical equipment .
Planned preventive maintenance is a regular, periodic activity carried out to keep equipment in good
working order and to optimize its efficiency and accuracy. This involves regular, routine cleaning,
lubricating, testing, calibrating and adjusting, checking for wear and tear and replacing worn out
components to avoid breakdown. Productive preventive maintenance refers to proper selection of
equipment to be included in planned preventive maintenance and taking decisions on what to include and
to reduce costs making the procurement and maintenance cost-effective.
An important aspect of planned preventive maintenance is the participation of the user who is responsible
for bulk of the work. The task must be performed daily involving the end user and a technician/engineer at
the end of the week. Highly technical repairs, are the responsibility of the engineering section/engineer and
may be scheduled every six months or on a need basis.
Setting up a Planned Preventive Maintenance System

Establishing an effective, efficient planned preventive maintenance system needs a Registry Filing System.
The Manufacturer's Manual for Preventive Maintenance can be supplemented by computer packages in
setting up the system or a manual le can be used to set up the planned preventive maintenance system
entailing the following:
1. Equipment Inventory
All relevant information about the equipment must be entered, including its location, records of
repair and maintenance, and the manufacturer's speci cations/ details.

A reference number is allocated, printed on a paper label and attached to each item and also
recorded in the ledger of equipment with full identifying details.
All equipment in the clinic that is in the care of the service workshop should be recorded on registers
or cards, as shown in the provided format.
2. Establishing a 'Maintenance Schedule'

After determining what is to be done, the frequency of the task must be decided. A heavily used item
must be cleaned and checked more frequently than one which is used less often. However,
minimum frequency must be decided based on the guidelines in the manufacturer's manual, but
the actual usage should determine the maintenance procedure required.
The schedules presented in the guidelines can be modi ed to conform to the manufacturers'
speci cations. A record card will be included with each schedule for recording measurements and
the engineer/technician should also note on the record card any item that needs to be replaced, if
work is to be carried out later, and whether or not the same engineer is to carry out the work.
42 CG-09RM-Ed2-141021
Standard 6. FMS-2: The clinic has a program for management of dental and support
service equipment

Score Score
The clinic has the equipment in accordance with its
Ind 20. 10 80%
scope of services
Quali ed and trained personnel operate and maintain
Ind 21. 10 80%
the equipment
Equipment is periodically inspected, serviced and

Ind 22. 10 100%
calibrated to ensure its proper functioning
Total 30
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________

2.3 Human Resource Management (HRM)
One pervasive issue impacting the management of the human resource (HR) function in a dental practice is that
despite years of medical education, dentists often are not educated in management and planning aspects.
The objective of the standards under the human resource management (HRM) is to ensure that the
quali cations and competency for the staff positions is determined to match the patient care needs and the
stated goals and mission of the organization. The dental clinic must employ the right number of quali ed staff to
meet the portrayed patient care requirements. The dental clinic also needs to have a system for assessing,
maintaining and improving staff capability and promoting continuous professional development and learning.
44 CG-09RM-Ed2-141021
Standard 7. HRM-1: There is documented personnel record of dental

surgeon/s ⁹ and staff
Indicator (23-23):
Ind 23. The Personnel record and credentials of all staff of the clinic are maintained
Survey Process:
20
Review the personal record of the dental surgeon/s, dental technician/s , dental nurse, dental assistant/s,
dental hygienist/s and other staff (as applicable) to verify the credentials including professional quali cations,
registration with the concerned councils/authorities, validity of registration, experience certi cates, trainings,
current medical tness status, character certi cate/references,21 etc. and job descriptions (JDs) duly signed by
the employer and the employee as applicable.
i. Availability of personal les of staff including certi ed copies of the following:
a. Credentials (quali cation, experience and training)
b. Valid registration certi cate from concerned authorities
c. CNIC
d. Medical tness
e. Character certi cates / reference veri cation(if applicable)
f. Jds
g. Performance appraisal if applicable
Scoring:
If all reviewed records have documented information regarding professional quali cations/credentials
as above, then score as fully met.
If all the above record of the staff is not available , then score as not met.
Guidelines
Personal Files
The personal les provide an updated record of employees and should be maintained because:
i. It makes good business sense to have accurate information in an organized manner to be
use it for an official purpose.
ii. Immediate supervisors will eventually encounter the need to produce documentation about
employee performance and work history.
iii. Some employee records are required by the federal or provincial government/other agencies and
must be kept in the personal les.
iv. Organizing the record of employees in a proper manner facilitates the access for all legitimate
The personal le of each employee is very con dential and access to it is restricted and only allowed after
the approval from a competent authority. Access to information about employees should be strictly limited
to those people in the dental clinic who need to use it for official purposes.
19- Dental surgeon having valid Registration with PMC.

20- Dental technician/dental hygienist/dental assistant means a quali ed person certi ed and registered by the PMF/regulatory authority and a dental nurse registered with the PNC.
21- Details given in the Guidelines.

Since unauthorized access to personal les has severe implications, any breach in this connection should
make the responsible person liable to punitive action. It should be ensured that personal les (hard and soft
copies) are in secure custody and are not left unattended even during working hours. In case an outside
organization asks for 'veri cation' of certain information about the employee/s of the dental clinic, it should
be ensured that only the information which has been authorized by the employee/s is released.
Employment veri cations are usually required to support mortgage and/or credit applications, etc.
Employee authorization should be in writing and specify the information which they permit to be revealed.
Contents of Personal Files

The HR departments in good organizations/larger set ups customarily maintain the following documents in
the personal le of each employee in a standard format:
i. Curriculum vitae
ii. Offer letter
iii. Copy of contract and JD
iv. Joining report
v. Photograph (two, blue background, passport size)
vi. Copy of CNIC
vii. Copies of documents pertaining to all academic and professional quali cations
viii. Copies of trainings/certi cations
ix. Salary slip/certi cate (previous employer)
x. Experience certi cate
xi. Official email account issuance form
xii. Reference form/background check
xiii. Medical/personal information form
xiv. Information for employee/business card
xv. Leave forms (if any)
xvi. Notice (if any)
xvii. Performance evaluation form
xviii. In-service trainings
xix. Salary increment/promotion
xx. Resignation/Termination letter (whichever is received in the HRD)
xxi. Exit interview form (whenever the employee leaves the office)
Review the personal les and check the following:

i. Quali cations of the staff member
ii. Record of in-service education/training
iii. Job description as applicable
iv. Work history/disciplinary background
v. Results of evaluations
vi. Record of health status of employee
46 CG-09RM-Ed2-141021
Standard 7. HRM-1: There is documented record of dental surgeon/s and staff

Score Score
The record/credentials of all staff of the clinic are
Ind 23. 10 100%
maintained
10
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________

Standard 8. HRM-2: The employees joining the dental clinic/practice are
oriented to the environment, respective sections and
their individual jobs
Indicators (24-27):
Each regular/part time employee trainee and voluntary worker is

Ind 24. appropriately oriented to the overall environment of the dental
clinic/relevant section service and programme policies and procedures
Survey Process:
Orientation of the employees should be in three parts: i. orientation to the dental clinic (overall scope of
services,ii. re and general safety, infection prevention & control and CQI/QA), iii. orientation to the assigned
section, and iv. orientation to the speci c job within that section. The content of each level of orientation should
be written to ensure that whoever provides the orientation always covers the same topics.
i. Documented evidence of orientation
ii. Evidence that orientation covers the following:
a. Overall scope of services, orientation to re and general safety, infection prevention & control,
CQI/QA, etc.
b. Orientation to the speci c job assigned in the section
Scoring:
If there are written orientation ‘guides’ covering all three areas and documented participation, then
score as fully met.
If the orientation covers the three areas, but there are no written details of what is to be covered, or if it is
partially conducted (two out of three areas), then score as partially met.
If there is no orientation program, or orientation is not conducted, then score as not met.
Ind 25. Each regular/part time employee is made aware of the job description
Survey Process:
The essence of the indicator is to emphasize the importance of developing job descriptions (JDs) of all the
employees and making them aware about the JD/s for effectively performing assigned duties. Each individual
employee is provided a detailed JD and is made fully aware of requirements given therein. The record bears the
signatures of the concerned employees certifying that it has been read and fully understood.
i. Documented JDs in respect of each employee duly signed by the employee/s and the employer
ii. Evidence that the employee is made aware of JD
Scoring:
If the JDs are available and signed by all employees23, then score as fully met.
If the JDs are available but not signed by any one employee, then score as not met.
22- Employees include all full time/regular or part time/visiting consultants/employees and staff members.
23- The Job Descriptions and Performance Evaluation Criteria for Medical, Nursing and Paramedical Staff 2008-09 developed by the PDSSP and noti ed by the Government of Punjab can be used as a guideline
/adapted for developing JDs for all appointments as required.
48 CG-09RM-Ed2-141021
Ind 26. Performance evaluations are based on the JDs
Survey Process:
Review the system for performance evaluation of the staff (quarterly/yearly, as prescribed) and see if the
performance evaluations are based on the respective JDs.
i. Record/Documented periodic performance appraisal system of the staff
ii. Evidence that performance appraisals are carried out as per the appraisal system and these are based on
the respective JDs
Scoring:
If the performance evaluation system prescribed and record of periodic performance evaluations of the
staff is maintained as above, then score as fully met.
If the performance evaluation system is prescribed and record of periodic performance evaluations of
the staff is maintained but is de cient by 20% only, then score as partially met.
If either there is no performance evaluation system or the record of periodic performance evaluations of
the staff is not maintained as above, then score as not met.
Each regular/part time employee is made aware of his/her rights and

Ind 27.
responsibilities and patient rights and responsibilities
Survey Process:
This indicator would require that written job descriptions (JDs)24 of each staff member points to his/her
responsibilities towards patients and others as well as his/her rights. Staff members rights are detailed in the
human resource/employee manual or other such documentation maintained by the clinic. . The Charter for
Patients, Carers and Others and Charter for HCEs providing detailed rights and responsibilities are available on
the PHC website as downloadable documents for information and compliance. The evidence should exist that
the employee has been made aware of these.
i. Written JDs of each staff member entails his/her responsibilities towards patients and others as well as
his/her rights
ii. The Charter for Patients and Charter for HCEs providing detailed rights and responsibilities are
available/ displayed
iii. All staff members are made aware of the Charters
Scoring:
If there is evidence of orientation of each staff member as above , then score as fully met.
If evidence of orientation of any of the staff member as above is lacking, then score as not met.
24- Mention job description as in Ind 26 & 27 to include responsibilities, particularly towards patients.

Guidelines
General Orientation
Guidelines for orientation is given on Annexure E
Once the selection process is completed, the new employee must be oriented in order to improve his/her
ability to perform the job and also to satisfy the personal desire and feeling that he/she is contributing for
the organization. Supervisors, in coordination with the human resource (HR) department, complete the
orientation by introducing the new employee to the co-workers. Every dental clinic should recognize that
its success and the quality of care provided depends upon the capacities of its staff and shall design a
comprehensive induction orientation programme as an integral component of their capacity building. The
induction and orientation processes will provide the information, guidance and support required for staff to
undertake their assigned responsibilities. This will be achieved by familiarizing the new staff with the
policies, systems, procedures, governance structure and the work location, and encouraging commitment
to the vision, mission and values of the HCE.
Performance management systems of the organization must be explained to the employees at the
induction, in order to align their daily activities with the overall organizational goals (the mission). The new
employee should be briefed about past achievements, in terms of services provided, future objectives,
plans and targets so as to create a positive image about the organization. General responsibilities towards
the institution and as to what the staff will be required to do, should be explained in the detailed guideline
regarding orientation as per format.
Template of job description provided at Annexure-F.
50 CG-09RM-Ed2-141021
Standard 8. HRM-2: The employees joining the dental clinic/practice are oriented to the
environment, respective sections and their individual jobs

Score Score
Each regular/part time employee, trainee and voluntary
Ind 24. worker is appropriately oriented to the overall 10 80%
environment of the dental clinic/relevant
section/service/program, policies and procedures
Each regular/part time employee is made aware of the
Ind 25 10 100%
job description
Ind 26. Performance evaluations are based on the JDs 10 80%
Each regular/part time employee is made aware of

Ind 27. his/her rights and responsibilities and patient rights and 10 100%
responsibilities
Total 40
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________

2.4 Information Management System (IMS)
The exchange of relevant patient data, such as patient's medical/dental history, laboratory reports, and
prescribed medications, between dental and medical clinics has the potential to break down the barriers
between medical and dental practitioners communication. It also allows for better cooperation between
medical and dental clinics, to provide dependable and reliable data regarding patient's overall health. Quick
and timely access to a patient's updated dental history and any pre-existing medical condition allows more
thorough assessments in less time.
The standards pertaining to information management system (IMS) highlight the fact that patient care is highly
dependent upon accurate and correct information. The standards also signify that the work of dental surgeons
and staff in the clinic must be facilitated by timely information to provide coordinated and integrated care. In
addition, it is important to protect the con dentiality of the data/patient information collected during the
course of treatment by limiting unauthorized access.
Medical/dental records serve many functions, primarily to support quality patient care and better outcome.
Although, currently there is a great trend to computerize medical/dental records. The desired bene t of
providing better patient care however only be achieved once the quality of manual records is improved. The
onus for improving medical records lies with individual health professionals as well as the management of the
HCE/practice. Structuring the record can bring direct bene ts by improving patient care, treatment outcomes
and health system performance and ensure safety of services.
52 CG-09RM-Ed2-141021
Standard 9. IMS-1: Patient clinical record is maintained at the dental clinic
Indicators (28-31):
Every patient's medical records has a unique identi er and particulars for
Ind 28.
identi cation
Survey Process:
Check that a system of maintaining medical record that should contain information including serial number,
date, name, parentage/husband name, age, gender, address, etc. computerized / manual is in place. This
symptoms/provisional diagnosis, treatment/procedures provided/performed and referrals (if any) as per the
25
prescribed format . CNIC and contact number of the patient may be noted as a routine if convenient and will be
mandatory when a patient is referred/transferred or is a medico legal case. Patient record should be maintained
in the clinic at least for one year for general records and 12 years for medico legal cases26 (if applicable).
i. The medical record(computerized or manual) covering the following parameters is maintained:
a. Serial number
b. Date
c. Name
d. Parentage/Husband name
e. Age
f. Gender
g. CNIC/Contact number (mandatory when a patient is referred/transferred or is a medico legal case)
h. Address
ii. Evidence that Patient record is maintained in the clinic at least for one year for general records and 12
years or longer as required for medico legal cases
Scoring:
If the patient record is maintained as above, then score as fully met.
If the patient record is maintained but the information is de cient by about 20% only, then score as
partially met.
If no record is maintained or the de ciency is more than 20%, then score as not met.
Ind 29. Only authorized person/s make entries in the record
Survey Process:
If a person other than the dental surgeon is delegated to make entries in the record of the patients, he/she
should be duly authorized in writing to do so and the entries in the record are traceable/identi able when
required. Name and designation of the dental surgeon writing the prescriptions and the person making entries
in other records must be mentioned , in pen or by stamp and signed.27
25- Detailed format given in the Guidelines as well as in the DHIS of the Health Department.
26- As explained in the guidelines, retention of the record for a longer period may become applicable if some other statutes so require.
27- As per details given in the guidelines, the dental surgeon himself in case of single man clinic is responsible for making entries in the record, as such under his/her signatures. The person responsible to
prescribe and perform the required procedure etc. should write full name or use stamp under signatures.

Compliance Requirements
i. Evidence of delegating a person other than the dental surgeon, to make entries in the record of the
patients (if applicable)
ii. Evidence that only the authorized person/s make entry in the record
iii. The dental surgeon writing the prescriptions and other person making entries in the record (if
applicable) is identi able by name.
Scoring:
If the person writing prescriptions/making entries in the patient records can be identi ed by name and
designation from the records checked, then score as fully met.
If the person writing prescriptions/making entries in the patient records can be identi ed as above in
80% of the checked records, then score as partially met.
If the person writing prescriptions/making entries in the patient records can be identi ed as above but
in less than 80% of the checked records, then score as not met.
Ind 30. Every record entry is dated, timed and signed
Survey Process:
Correct recording of time of arrival of a patient at a clinic and the time at which he/she is attended and leaves, is
very important as the same may be required to be produced as an evidence. Focus attention on timing of
patient's arrival, clinical notes including patient's complaints, oral examination, investigations, type of
anesthesia (if applicable), treatment provided/procedure performed, materials used and medication
prescribed/dispensed, etc. Any emergent situation attended or referral is also documented. This can be
evaluated during the review of the previously selected records.
i. Record of clinical notes as stated above
Scoring:
If all entries are dated, timed and signed as above, then score as fully met.
If all entries are dated and signed, but some entries are not timed, then score as partially met.
If any entry is not dated or signed, then score as not met.
The record provides an up-to-date and chronological account of patient

Ind 31.
care
Survey Process:
Review the record to determine if the record adequately documents the care and treatment plan for all patients.
Check the system of record keeping to ensure they are in good order and stored for a period in compliance with
the statutes.28
i. The medical record including care and treatment plan for all patients is kept in a chronological order.
ii. Storage period is compliant to the statutory requirements
Scoring:
This should default to a score of fully met unless the survey team identi es signi cant de ciencies in the
dental records.
28- Health Department letter No SO (H&D) 15-118/63 dated 19-07-1966 and SO (H&D) 1-1/08 dated 21-01-2008 on the subject refers (copy added to guidelines).
54 CG-09RM-Ed2-141021
Guidelines
Unique Patient Identi ers
All patients record must be consistently labelled with at least one unique identi er so that it can be veri ed
that it correspond to particular patients. Computer generated unique ID number is the easiest and correct
identi cation method. The patient's medical record always becomes a focal point whenever there is a
question regarding the care and treatment rendered. It is important that entries in the medical record are
documented timely and accurately. The medical record serves three primary purposes: i. to provide
evidence of the patient's course of illness and treatment; and ii.to facilitate review of the record/ treatment
provided iii. To ensure quality of patient care.
It is often perceived that the medical record is a means of protection or a defense action against medical
malpractice. However, the purpose of the medical record is not only to protect or to provide a defense, it also
preserve the truth. A complete and accurate medical record will protect the legal interests of the patient, the
hospital and the practitioner provide a justi able defense.
Accurate identi cation of the patient is pivotal for an effective and efficient medical record system. Correct
identi cation is needed to positively identify the patient and ensure that each patient has one medical
record number and one medical record and no duplicates. In order to identify patients, we need a UNIQUE
PATIENT CHARACTERISTIC. The type and number of unique patient characteristics will change from one
setting to another and are de ned as below.
Something about a patient that does not change.

Some useful unique patient characteristics are:
I. Client/Patient full name
ii. Gender
iii. Date of birth (DoB)
iv. Computerized national identi cation number (CNIC number)
v. Mother's rst name
vi. Father's rst name
vii. Health insurance number
The following are NOT considered unique characteristics:

i. The place of residence is NOT a unique patient characteristic because it can change.
ii. A person's age is NOT a unique patient characteristic because it does change.
iii. Although it should not change, it is important that a patient's birthplace is NOT used, as it is often
identi ed by most people as being the place where they ‘come from’ as opposed to the place where
they were actually born. Similarly many people are born at the same place/city/hospital/town etc.
SOPs for Identi cation of Medical Record Entries

i. The organization maintains a list of authorized persons along with the details of documents which
they can sign. The list also contains their specimen signatures, initials and the stamps they use. Any
professional who, in the execution of his or her professional duties, signs official documents relating
to patient care, such as prescriptions, certi cates (excluding death certi cates), patient records,
hospital or other reports, shall do so by signing and clearly writing his/her name, appointment/

designation and the date in block letters, stamping the same. A sample of authorized personal list is
given at Annexure-J:
SOPs for Medical Record Documentation

Recording date and time starts from the point a patient enters the clinic for seeking care. Documentation of
medical record starts from the register at the reception, To the time the patient is attended/examined by
the doctor who performs the dental procedure and prescribes medicine/s or refers the patient, if required,
putting the date and time along with his/her signatures on the prescription.
Accurate date and time recording is important whenever it is needed to be produced the as a proof of
certain timely action. It is also a valuable source of data for coding, health research and source of evidence
and rationale for resource management.
Up-to-date Chronological Record

Information documented during or immediately after providing care or about an event which has occurred, is
more reliable and accurate than the information recorded later, based on memory. Chronological entries present a
clear picture of the sequence of care provided/of events over time and facilitates better communication amongst
care providers. Late entries if made should be appropriately recorded as soon as possible, but these should be
endorsed by the in-charge.
Minimum Requirements for Patients' Medical Records. ⁹ Upon completion, medical records for
outpatients shall contain, at a minimum, the documents as speci ed below. Records for patients at the
hospital for other specialized services, such as emergency services or surgical services, shall contain such
additional documentation as required for those services.
a. A unique identifying number and a patient identi cation form.

b. Name, address, DoB, gender and person to be noti ed in an emergency.
c. Diagnosis of the patient's condition.
d. The name of the dental surgeon ordering treatment or procedures.
e. Patient allergies.
f. Dental surgeon's orders or orders from another practitioner authorized by law to give dental
or treatment orders as applicable.
g. Documentation that the patient has been offered the opportunity to consent to procedures
for which consent is required by law/regulations.
h. Reports from any diagnostic testing.
I. Sufficient information to justify any treatment or procedure provided, report of outcome of
the treatment or procedure, progress notes and the disposition of the patient after
treatment.
Records for patients at the hospital for other specialized care, such as emergency services or surgical
services, shall contain such additional documentation as required for those services.
29- Authority O.C.G.A. Sec. 31-7-2.1. History. Original Rule entitled “Medical Records” adopted. F. Nov. 22, 2002; eff. Dec. 12, 2002.
56 CG-09RM-Ed2-141021
Standard 9. IMS-1: Patient clinical record is maintained at the dental clinic

Score Score
Every patient's medical record has a unique identi er
Ind 28. 10 80%
and particulars for identi cation
Ind 29. Only authorized person/s make entries in the record 10 80%
Ind 30. Every record entry is dated, timed and signed 10 80%
The record provides an up-to-date and chronological

Ind 31. 10 100%
account of patient care
Total 40
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________

2.5 Quality Assurance (QA)/Quality Improvement (QI)
Quality assurance is a systemic approach for assessing the quality of care, implementing and evaluating
changes in the patient care to maintain continually improve the quality of care. Each service area in the of
minimum service delivery standards is an integral to the quality assurance system. Quality assurance is a
sequence of actions that lead to performance enhancement. Although QA & QI is relatively a newer concept,
protocols produce encouraging results towards furthering quality in dental practice. Quality assurance is in fact
an on-going evaluation system that focuses on overall patterns of behavior rather than on isolated instances of
behavior.
Continuous Quality Improvement entails the entire systems and process that assure safety for patients and staff
and allowing provision of consistent highest quality care at the lowest justi able cost.
QA/QI requires the participation and input of entire staff working in the clinic and is best implemented through
coordinated activities. Dental team consist of dentist , manager, staff nurse, or any designated person
responsible for maintaining and improving quality. Compliance of these indicators must be ensured by an
internal monitoring conducted on monthly or quarterly basis. While some processes need to be monitored on a
regular basis (e.g., daily, weekly), all functions of the clinic should be reviewed at least annually to ensure that
they are performed according to QA/QI plans, and other organizational objectives.
The standards under the continuous quality improvement/ quality assurance primarily focus on a systematic
approach of using data to measure/ assess the current performance against the set benchmark of quality,
identify gaps and take measures to improve the quality and care in the dental clinic. It is a continuous process
that focuses on outcomes of care, patient safety and satisfaction in terms of health care delivery and must
include reducing actual and potential risks to patient safety. To achieve this goal, the standards emphasize on
the processes, systems and individual behaviors that reduce the likelihood of unanticipated adverse events as
well as near misses.
58 CG-09RM-Ed2-141021
Standard 10. QA-1: The dental clinic has Quality Assurance / Improvement
System in place
Indicators (32-33):
Ind 32. Service provision is as per portrayal
Survey Process:
The indicator focusses on ascertaining that services provided by the clinic staff to the patients are as per the
facilities portrayed and scope de ned in the application for registering/licensing with PHC. There should be no
super uous displays/ portrayals.
i. There is evidence that services are provided as per portrayal essential equipment is available
ii. There are no super uous displays
Scoring:
If the dental services provided are in accordance with those listed in the application form for registration
/licensing with PHC and there is no super uous display, then score as fully met.
If either the dental services provided are not in accordance with those listed in the application for
registration/licensing with PHC or there is/are super uous display/s, then score as not met.
Ind 33. A quality improvement system is practiced
Survey Process:
This indicator is to demonstrate actions taken by the dental surgeon/administrator/manager to make
improvements in the quality of care based on the observations as recorded during his/her monitoring/
evaluations.
The clinic in-charge should periodically check how the patients are being received and seated while waiting
and that the facilities for the comfort of patients like sitting arrangements, drinking water, ventilation, etc. are
available/intact. The clinic in-charge shall use a quality assurance checklist 3 0 for checking on
daily/weekly/monthly/yearly basis that the services provided at the clinic conform to the minimum standards.
The duties assigned to the staff should be included in the JDs and evaluated on the basis of the checklist which
shall be dated and signed and kept in record.
i. Checklist developed and monitored by the clinic In-charge regularly.
ii. Evidence regarding any improvement made by dental surgeon/ in charge /administrator based on
the observations documented during periodic evaluations/inspections
Scoring:
If there is a written record of actions taken as above, then score as fully met.
If monitoring based on the checklist and quality improvement/Quality Assurance is demonstrated but
there is no written record of actions taken a above then score as partially met.
If neither a quality improvement system is demonstrated nor there is record of actions taken then score
as not met.
30- Format of the Checklist provided in the Guidelines can be adapted as per requirement of the clinic.

Guidelines
Quality Improvement System
Provision of quality services requires that these are;
i. Safe: avoiding harm to patients from the care that is intended to help them.
ii. Effective: providing services that would not be bene cial or based on scienti c knowledge that
could bene t and to all who could bene t and refraining from providing services that would not be
bene cial or to those not likely to bene t.
iii. Patient-centered: providing care that is respectful and responsive to individual patients preferences,
needs, and values, and ensuring that patient values guide all clinical decisions.
iv. Timely: reducing waits and sometimes harmful delays for both those who receive and those who
provide care.
v. Efficient: avoiding waste of equipment, supplies, ideas, time and energy.
vi. Equitable: providing care that does not vary in quality because of personal characteristics such as
gender, ethnicity, geographic location, and socioeconomic status.
vii. Patient/clinic satisfaction form is given in Annexure-K
The Quality improvement Methodolgy

QI refers to an approach which entails examining work processes to bring improvement so that these are
effective, efficient, and responsive using following methodology:
Ÿ Recommend data collections programmes designed for the dental industry
Ÿ Highlight key performance indicators in the dental practices
Ÿ Make informed recommendations in a detailed Action Plan
Ÿ Monitor Action Plan progress with regular follow-up monitoring and CQI audits
Ÿ HCE performane measuring checklist for incharge actions taken for improvement of services at
Annexure-L
60 CG-09RM-Ed2-141021
Standard 10. QA-1: The dental clinic has a quality assurance/improvement system in
place

Score Score
Ind 32. Service provision is as per portrayal 10 100%
Ind 33. A quality improvement system is practiced 10 80%
Total 20
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________

Standard 11. QA-2: The clinic identi es key indicators to monitor the inputs,
processes and outcomes which are used as tools for continual
improvement
Indicators (34-38):
Ind 34. Monitoring includes appropriate patient assessment
Survey Process:
When surveying the clinic, review the document that covers i, complete history with initial examination ii,
planned course of treatment, iii, modi cation of treatment on patient medical condition/ demands/ needs,
treatment outcomes. iv, all information is recorded in the clinical records. A carbonized prescription cum
procedure record is also acceptable.
i. Impact of CQI is re ected by the record that includes:
a. Complete history with Initial examination.
b. Planned course of the treatment.
c. Modi cation of treatment on the basis of the patient medical condition andthe needs / demands
and /treatment outcomes.
ii. All information recorded and maintained in the clinical records.
Note: A carbonized prescription cum procedure of maintaining record will be acceptable. eg in the
record of the patients.
Scoring:
If there is documented evidence that patient assessment has been monitored and examples can be
seen as a result of the QI program, then score as fully met.
If not, then score as not met.
Monitoring includes safety and quality control programmes of the

Ind 35.
diagnostic services
Survey Process:
Review the documentation and check that the diagnostic services are monitored by observing the following: i.
documented SOPs for diagnostic services ii. documented occupational health and safety (OH&S) protocols, iii.
documented training of staff on SOPs and OH&S protocols, iv. reference testing/calibration of the diagnostic
equipment to ensure validity and v. external audit of the procedures and protocols of diagnostic facilities.
i. Documented SOPs for use of diagnostic equipment
ii. Documented OH&S protocols
iii. Documented training of staff on SOPs and OH&S protocols
iv. Reference testing/calibration as per OEM guidelines to ensure accuracy
62 CG-09RM-Ed2-141021
Scoring:
If there is documented evidence of the above, then score as fully met.
If there is no evidence of the above, then score as not met.
Ind 36. Monitoring includes ALL invasive procedures and equipment
Survey Process:
Review the documentation along with the equipment and check that during invasive procedures, any adverse
31
occurrences has been reported such as return to dental surgery within 24 hours and re-doing the procedure
within 24 hours, and that such reporting is included in the CQI programme. All the dental equipment is required
to be checked for maintenance, validation and accuracy at least once a month.
i. Documentary evidence of reporting all adverse occurrences.
ii. Documented occupational health and safety (OH&S) protocols for the dental equipment e.g,
maintenance, validation, and accuracy of autoclave, dental compressor, dental unit, dental handpieces,
endomotors, high speed scalers etc.
iii. Reference testing/caliberation of equipment to ensure accuracy
Scoring:
If there is documented evidence that all invasive procedures has been monitored as above, then score as
fully met.
If there is no evidence as above, then score as not met.
Ind 37. Monitoring includes use of anesthetics
Survey Process:
Review the documentation and observe for reporting of adverse occurrence from use of anesthetics and
adequate follow up.
i. Documentary evidence of reporting adverse occurrences during or soon after administration of
anesthetics
ii. Evidence of adequate management/follow up of the adverse occurrence.
Scoring:
If there is documented evidence that adverse occurrences from use of anesthetics have been monitored
and adequately followed up, then score as fully met.
If there is no evidence of the above, then score as not met.
31- An unplanned event with a negative consequence for the patient.

Ind 38. Monitoring includes availability and content of the clinic records
Survey Process:
Review the documentation to check that monitoring the quality of the clinic records has been monitored. Also
check for compliance monitoring and performance monitoring:
Ÿ Compliance monitoring: a regular exercise to check conformity with the Act and standards
Ÿ Performance monitoring: monitoring of employe's performance monitors from top to bottom for increasing
patient satisfaction and achieving treatment goals. This also covers regular and integrated monitoring of
32
record keeping system and the processes
i. Measuring and monitoring the record keeping performance for planning and improvement purposes
ii. Roles and responsibilities for monitoring are outlined
iii. Requirements and timelines for monitoring activities
iv. Evidence of review of the clinic records by the dental surgeon.
Scoring:
If there is evidence of the review of the clinic records as above, then score as fully met.
If there is no evidence of the review as above, then score as not met.
Guidelines
Monitoring of Patient Assessment

Patient assessment in general dental practices involves risk assessment and provide to the development of
care protocols, which act as framework for decision making to provide an optimum level of care. In practice,
a signi cant proportion of patients attend in a symptomatic condition, on continuous and regular basis,
often for a long periods of time. This provides general dental practitioners with a wealth of knowledge
about their patients and enable to inform clinical decision making on an individual basis.
Monitoring of diagnostic services
The hospital / clinic shall develop appropriate key performance indicators suitable for all available
diagnostic services including the monitoring of expiry of lms and timely changing the solution in
accordance with environment protection protocol.
Monitoring of invasive procedure and equipment
Calibration of dental equipment
Ÿ Develop and document validation program and re-validation plans.

Ÿ Review and approve validation test results.
32- Integrated notes involve all care providers writing in the notes in a chronological order and in the same section of the notes. Details added in the Guidelines.
64 CG-09RM-Ed2-141021
Ÿ Ensure that only fully validated load con gurations and cycle parameters are documented in the
relevant operational SOPs.
Ÿ Prepare, approve and execute protocols in Quality Assurance
Ÿ Ensure compliance with this SOPs with speci c regard to installation, operational and performance
and re-validation activities.
Ÿ Ensure compliance with current corporate policy and regulatory requirements.
Ÿ Quality Control
Ÿ Review and approve validation protocols and test documentation.
Ÿ To ensure SOPs contain only current and accurate load patterns and associated autoclave cycles
Ÿ To generate change controls for autoclave cycle/load additions/changes
Ÿ Perform Biological Indicator (BI) analysis.
Ÿ Ensure compliance with this SOP with speci c regards to maintenance, calibration and change
controls.
Ÿ Ensure that autoclave equipment utilities and sensors are compliant with operating limits
Ÿ Ensure autoclave cycle programs, PLCs and chart recorders are up to date, correct and operational
Ÿ Review and approve validation protocols and test documentation
Ÿ Provide access to equipment and resources for carrying out validation work .
Invasive procedures
It is important to understand the difference between invasive and non-invasive procedures as invasive dental
procedures are not recommended when blood cell counts are below certain levels.
Invasive Dental Procedures

Invasive dental procedures include those that involve manipulation of the gums (gingival tissue) or
perforation of the oral mucosa such as tooth extractions, gum surgery (gingivectomy/periodontal Surgery) or
dental implants.
Non-Invasive Dental Procedures

Non-invasive dental procedures include llings (dental restorations), root canal therapy (endodontic
therapy), crowns, bridges and removable prosthodontic devices such as dentures.
Monitoring
Compliance monitoring is the quality assurance testing carried out over the day to day activities of the
business. In the corporate setting, the compliance monitoring team usually sits as an independent function in
the second line of defence and provides assurance to the board that the rm is operating within a compliant
framework.
Performance monitoring may be de ned as the process of appraising an environment of continuous learning
and development. It will be done by maintaining the employee's performance, enhancing individual
competencies to make them more productive for the organization.

Standard 11. QA-2: The clinic identi es key indicators to monitor the inputs, processes
and outcomes which are used as tools for continual improvement

Score Score
Ind 34. Monitoring includes appropriate patient assessment 10 100%
Monitoring includes safety and quality control

Ind 35. 10 100%
programmes of the diagnostic services
Monitoring includes ALL invasive procedures and
Ind 36. 10 100%
equipment
Ind 37. Monitoring includes use of anesthetics 10 100%
Monitoring includes availability and content of the
Ind 38. 10 100%
clinic records
Total 50
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________
66 CG-09RM-Ed2-141021
Standard 12. QA-3: Sentinel events are assessed and managed
Indicators (39-39):
Ind 39. The clinic has enlisted the Sentinel Events to be analyzed and managed
Survey Process:
Surveyor asks for list of possible 'Sentinel Events', record of any sentinel event analyzed and managed in the last
33
12 months and results used for Quality Assurance/Improvement.
I. List of possible 'Sentinel Events.
ii. Documentary evidence if any sentinel event analyzed and managed in the last 12 months.
Evidence of using results of analysis for Quality Assurance/Improvement.
Scoring:
If there is a list of possible sentinel events and evidence of occurrence of a sentinel event that was
analyzed and managed as above, then score as fully met.
OR if there is no evidence of having a sentinel event but the system is in place to manage if one occurs,
then also score as fully met.
If there is no system in place to manage the sentinel events, or the one that occurred was not analyzed
and managed then score as not met.
Guidelines
Sentinel Events
A sentinel event is de ned as “An unexpected occurrence involving death or serious Physical or
Psychological Injury, or the Risk thereof". Serious Injury speci cally includes Jaw fracture during tooth
extraction. Loss of function of nerve/nerve injury due to complicated extraction or wrong technique of
anaesthesia or tuberosity fracture in upper third molar extraction are also considered as serious injuries.
The phrase, 'or risk thereof' includes any process variation for which a recurrence carries a signi cant chance
of a serious adverse outcome.”
Such events are called "SENTINEL" because they necessitate immediate investigation and response.
Most of these medical mistakes are preventable and they are most often caused by systems that break down
and don't support the highly quali ed and dedicated hospital/clinic or care providers the way they should
perform.
While signi cant and attracting attention, medication errors aren't the only types of medical errors that
need attention of the hospitals/clinic.
Sentinel events also include the following, even if the outcome is not death or major permanent loss of
function:
i. Wrong tooth extraction/treatment
ii. Surgery on the wrong individual or wrong side of patient.
33- Unforeseen event like severe drug aggravation, wrong prescription, wrong patient, wrong tooth extraction, jaw fracture during tooth extraction, needle breakage while injecting anesthesia, reamers/ les
breakage during RCT, any foreign object swallowed (arti cial crown/endodontic instrument/dental implant or its abutment etc), patient violence against clinic staff, violence against patients, etc. as detailed in the
guidelines.

iii. Reamer or le broken in the root canal.
iv. Crown accidentally swallowed.
v. File/reamer/ bur displaced and accidently swallowed
vi. Needle breakage during local anesthesia injection.
vii. Any life threatening drug allergic reaction etc.
68 CG-09RM-Ed2-141021
Standard 12. QA-3: Sentinel events are assessed and managed

Score Score
The clinic has enlisted the sentinel events to be
Ind 39. 10 100%
analyzed and managed
Total 10
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________

2.6 Assessment and Continuity of Care (ACC)
Continuity of care can be de ned as the extent to which a person experiences an ongoing relationship with a
clinical team or member of a clinical team and the coordinated clinical care that progresses smoothly as the
patient moves between different parts of the health service/ healthcare service provider.
As patients health care needs can only rarely be met by a single professional, multidimensional models of
continuity have had to be developed to accommodate the possibility of achieving both ideals access and
continuity of care simultaneously. Continuity of care may, therefore, be viewed from the perspective of either
patient or provider. Continuity in the experience of care relates conceptually to patients' satisfaction with both
the interpersonal aspects of care and the coordination of that care. Experienced continuity may be valued in its
own right. In contrast, continuity in the delivery of care cannot be evaluated solely through patients'
experiences, and is related to important aspects of services such as 'case-management' and 'multidisciplinary
team work.
A dental clinic should consider the care it provides as part of an integrated system of services, healthcare
practitioners/ professionals and levels of care which make up a continuum of care. The goal is to correctly match
the patient's healthcare needs with the services available, to coordinate the services provided to the patient in
the organization/ clinic, and then to plan for reception, registration, management, disposal and follow-up. The
result is improved patient care outcomes and more efficient use of available resources.
70 CG-09RM-Ed2-141021
Standard 13. ACC-1: Portrayed service/s conform to the legal provisions

Indicators (40-46):
Ind 40. The services being provided at the clinic are displayed as per Code of Ethics
Survey Process:
There should be a board clearly displaying the scope of services provided at the clinic that are in consonance
with the ethical provisions. This means that only those services are to be offered for which the particular
registered dental practitioner is quali ed and competent to provide. ⁴
i. A board, clearly displaying the scope of services provided at the clinic, in consonance with the legal/
ethical provisions
ii. Services provided at the clinic are in consonance with the legal/ethical provisions
Scoring:
If the displayed services are in compliance with the code of ethics, then score as fully met.
If there is super uous/misleading information or no information displayed, then score as not met.
Ind 41. Specialized services being provided conform to the standards ⁵
Survey Process:
The indicator implies that the specialized services and specialized equipment based evaluation are consistent
with quali cation, training and experience of the care provider, in the portrayed eld as prescribed by the
respective councils/authority.
i. The specialized consultations/ services are provided by the professionals who are accordingly quali ed
and registered with the council/authority
ii. The evaluations and procedures using specialized equipment are consistent with the quali cation/
training/experience of the Health care service provider (HCSP)
Scoring:
If the specialized services are in compliance with the above parameters, then score as fully met.
If the specialized services do not meet the above compliance requirements, then score as not met.
The use and maintenance of specialized equipment conforms to the

Ind 42.
standards ⁶
Survey Process:
The use and maintenance of specialized equipment is ensured in accordance with the manufacturers
guidelines on safety, infection control and accuracy of results. Surveyors are required to check the JDs of
relevant staff (duly signed by the employee and the employer ⁷), guidelines provided to them and the log book
of the equipment to check the maintenance history.
34- PMC Code of Ethics of Practice for Medical and Dental Practitioners in general and provision 11.3 in particular refers.
35- Applicable only when portrayed.
36- Applicable only when portrayed and in accordance with recommendations of equipment manufacturer.
37- Not applicable in a single man clinic.

i. The use and maintenance of specialized equipment is in accordance with the manufacturers guidelines
ii. Evidence of delegating a person (other than the dental surgeon) for maintaining the log book depicting
the use and maintaining of specialized equipment
Scoring:
If the use and maintenance of specialized equipment is based on the manufacturer's guidelines
covering safety, infection control and accuracy of results evidenced as above, then score as fully met.
If the use and maintenance of specialized equipment is not based on guidelines as required above, then
score as not met.
Dental laboratory services, provided, conform to the respective

Ind 43.
requirements
Survey Process:
If the dental clinic provides on-site dental laboratory services, those should conform to the respective
requirements in terms of equipment, staff and SOPs.
i. Dental laboratory services, if provided on-site, conform to the respective requirements in terms of
equipment, staff and SOPs
ii. Dental surgeons obtain off-site services for preparing dentures, etc. from quali ed dental technicians only
Scoring:
If the laboratory services are in compliance with the above parameters, then score as fully met.
If the laboratory services do not meet the above parameters, then score as not met.
Dental radiological diagnostic services, being provided, conform to the

Ind 44.
respective standards
Survey Process:
This means that the x-ray machine/s are used in the clinic for facilitating diagnosis and treatment plan, should
conform to the respective PNRA/DRAP standards, as amended from time to time, in terms of equipment, staff
and SOPs.
i. Applicable guidelines issued by PNRA/DRAP are available and followed
ii. Valid certi cation, as required for the particular radiological equipment in use, is available
Scoring:
If the radiological diagnostic services are in compliance with the above parameters, then score as
fully met.
If the radiological diagnostic services do not meet the above parameters, then score as not met.
Ind 45. Dental health education is provided as per guidelines
Survey Process:
The surveyor is required to look for the display of relevant dental health educational messages for prevention of
dental disease and promotion of oral health. IEC material and/or written instructions delivered to the patients
by the dental care provider should be relevant and as per approved guidelines.
72 CG-09RM-Ed2-141021
i. IEC material including dental health educational messages for prevention of dental disease and
promotion of oral health are displayed
ii. Evidence that the written instructions delivered to the patients by the dental care provider are as per
approved guidelines and are relevant
Scoring:
If there is a display of relevant dental health educational messages/IEC material and consistent
evidence that patients are guided on it accordingly, then score as fully met.
If there is a display of relevant dental health educational messages/IEC material, but inconsistent
evidence of patients being guided on it, then score as partially met.
If there is neither a display of relevant dental health educational messages/IEC material, nor any
evidence that patients are accordingly guided on it, then score as not met.
Ind 46. Preventive services are provided as per guidelines ⁸
Survey Process:
The surveyor is required to look for the display of a list of preventive services being provided, like prevention of
caries, etc. Specialized preventive services, if being provided, should conform to the relevant prescribed
guidelines.
i. Preventive services are provided to patients as per guidelines
ii. Guidelines on preventive services are available/displayed
Scoring:
If the list of services being provided is displayed and the services being provided conform to the
prescribed guidelines, then score as fully met.
If the list of services being provided is not displayed or is not complete, but the services being provided
conform to the prescribed guidelines, then score as partially met.
If there is no list of services being provided or any one of the services provided does not conform to the
prescribed guidelines, then score as not met.
Guidelines
Portrayal of Services39
It is of immense importance for patients to be aware of the services available at a particular dental clinic. It
means that a BDS dental surgeon having valid registration with PMC should display only those services
which are related to general dentistry and for which he/she is trained and certi ed to provide.
Any specialized services provided, must be as per speci ed standards and the health care provider must
have requisite post graduate quali cation duly registered with the Council/ authority.
38- Applicable only when portrayed.

39- Refer to provision Nos. 7, 8, 18, 24, 25, 31 and 39 of Code of Ethics of Practice for Medical and Dental Practitioners published by PMC.

Guidelines
Compliance with Statutes
As per section 19 (1a) of Pakistan Nuclear Regulatory Authority Ordinance 2001, any premises, in which a
radiation facility is provided, shall require registration/licensing by the Authority. PNRA registration/license
is mandatory for possession, installation or operation of any radiation apparatus including Dental X-Ray
machines. Use of radiation apparatus without PNRA valid license interalia, is clear breach of Section 19 of the
PNRA Ordinance. This regulatory enforcement is important to safe guard both the patients/clients and the
dental healthcare providers.
Following dosimetry information is vibrant in this regard;
“Radiation doses that exceed a minimum (threshold) level can cause undesirable effects such as depression
of the blood cell-forming process (threshold dose = 500 mSv, 50 rem) or cataracts (threshold dose = 5,000
mSv, 500 rem)*. The scope and severity of these effects increases as the dose increases above the
corresponding threshold. Radiation also can cause an increase in the incidence, but not the severity, of
malignant disease (e.g., cancer). With this type of effect, the probability of occurrence increases with dose
rather than the severity. For radiation protection purposes it is assumed that any dose above zero can
increase the risk of radiation-induced cancer (i.e., there is no threshold). Epidemiologic studies have found
that the estimated lifetime risk of dying from cancer is greater by about 0.004% per mSv (0.04% per rem) of
radiation dose to the whole body (NRC, 1990).”
Reference: https://www.mun.ca/biology/scarr/Radiation_de nitions.html
Dental radiology and diagnostic imaging services, may be provided within the dental clinic or by agreement
with another organization, or both. The contracted outside source selected by the dental clinic must have
PHC registration/license. The in house, as well as contracted radiology services, must comply with laws and
regulations and must provide safe services of acceptable quality standards in accordance with the de ned
time frame.
All the statutory requirements included in the Pakistan Nuclear Regulatory Authority (PNRA) regulations
e.g. use of dosimeters, lead sheets, lead aprons, thyroid guard, signage, and display etc. and applicable
provision of the Drug Regulatory Authority of Pakistan (DRAP), as amended from time to time, are to be
complied.
Scope of Laboratory Services

i. The dental prosthetic lab, if available, shall be well-organized, adequately supervised and have
adequate space, facilities and optimum temperature for equipment to perform properly.
ii. Basic clinical laboratory services necessary for routine examinations, if available on-site, should
conform to the applicable standards.
74 CG-09RM-Ed2-141021
Standard 13. ACC-1: Portrayed service/s conform to the legal provisions

Score Score
The services being provided at the clinic are displayed
Ind 40. 10 100%
as per Code of Ethics
Specialized services being provided conform to the

Ind 41. 10 100%
standards
The use and maintenance of specialized equipment

Ind 42. 10 100%
conforms to the standards
Dental laboratory services, provided, conform to the

Ind 43. 10 100%
respective standards
Dental radiological diagnostic services, if being

Ind 44. 10 100%
provided, conform to the respective standards
Ind 45. Dental health education is provided as per guidelines 10 80%
Ind 46. Preventive services are provided as per guidelines 10 80%
Total 70
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________

2.7 Care of Patients (COP)
Improving patient care has become a priority for all health care providers with the overall objective of achieving
a high degree of patient satisfaction. Greater awareness among the public, increasing demand for better care,
increasing number of health care regulation, the rise in litigation against medical malpractice, and concern
about poor outcomes are factors that contribute to this change. The quality of patient care is essentially
determined by the quality of infrastructure, quality of training, competence of personnel and efficiency of
operational systems. The fundamental requirement is adoption of a 'patient orientated system of care
provision'.
The standards under the functional area 'Care of Patients' address essential principles and processes for the
clinical care of patients who come to a dental clinic for treatment, with excellent care being the overarching
goal. The standards further entail that comprehensive treatment shall be provided in the respective clinical
specialty, with strict compliance to the prescribed standard. Improvement of patient care is a dynamic process
and should be kept in minds by the medical care personnel. Development and sustenance of a patient-
sensitive system is most critical in achieving this objective. It is important to pay attention to quality in every
aspect of patient care, both medical and non-medical.
76 CG-09RM-Ed2-141021
Standard 14. COP-1: The clinic has a well-established patient management

system
Indicators (47-49):
Ind 47. The clinic has an established registration and guidance process⁴⁰
Survey Process:
Observe as well as check from the record that a reception, registration and guidance⁴ system is practiced to
facilitate the patients. Patients can comfortably reach the reception and communicate with the reception staff,
get registered and obtain token number/time for an appointment. The reception staff is polite and guides the
patients to wait for their turn/time for consultation/examination by the dental surgeon and/or explains such
other requirement/s.
i. The reception, registration and guidance system to facilitate the patient is in place
ii. Patients should be able to comfortably access the reception/reception staff, get registered and obtain
token number/ time for appointment
iii. The reception staff is polite and guides the patients to wait for their turn/time for consultation/
examination by the dental surgeon and/or explains such other requirement/s
Scoring:
If the reception, registration and guidance provided to patients is evident as described above, then
score as fully met.
If there are non-conformances to the above, then score as not met.
Ind 48. Standard/Ethical practice is evident from the patient record
Survey Process:
Observe and check that patients are assessed by the dental surgeon by taking history and vitals(as indicated)
oral examination and documenting the patient's complaints signs and symptoms, diagnosis/differential
diagnosis and relevant evaluations for every affected tooth, as applicable, with the objective of providing
42 43
quality dental care/treatment and follow up , in line with the prescribed Code of Ethics or for referral to the
44
higher level facility. Check documentary evidence of assessment, treatment or referral (as applicable), by
reviewing the representative sample of record of patients which can be a register/copies of prescription and/or
an elaborate record, depending on the scale /scope of practice.
40- Applicable for larger clinics and clinics providing a wider range of dental healthcare services where prior appointments may be necessary/desirable.
41- Direction/Guidance to patients regarding further actions in connection with their dental treatment needs and its management i.e. consultation/specialized testing on equipment/dispensing/referral etc. The
dental surgeon himself or the quali ed and authorized technician/assistant must explain the processes involved in safety/infection control/post op /post procedure complications etc. This requirement has to be
included in the JDs of relevant staff as further explained in the Guidelines.
42- Standard Clinical Methodology respecting patient's privacy is to be adopted while examining the patients.
43- PMDC Code of Ethics of Practice for Medical and Dental Practitioners published on http://www.pmdc.org.pk/Ethics/tabid/101/D efault.aspx#20, PHC Charters published on www.phc.org.pk links
(http://www.phc.org.pk/downloads/-Charter.pdf and as adapted by PMC
44- A dental surgeon is required to refer all those patients to an appropriate dental clinic/surgery, that cannot be/should not be managed at his/her clinic due to the limited scope of services, nature of their ailment or
due to an emergency or medico legal nature. This needs critical judgment and ethical decision by the dentist. Check the referral record to ascertain whether the required details such as serial number, name, son/
daughter of/wife of /address, contact no., symptoms/provisional diagnosis, prognosis, reasons for referral, date and time of referral, place of referral, etc. referred in past 12 months are available at the clinic.

i. Documentary evidence of patient's assessment oral examination and documenting the signs related to
patient's complaints/symptoms, diagnosis/differential diagnosis and relevant evaluations
ii. Register/copies of prescription and/or an elaborate record, depending on the scale/scope of practice
Scoring:
If all checked records of the patients show documentation of patient's assessments and management as
above, then score as fully met.
If less than 20% of the record is de cient on the above, then score as partially met.
If the record shows more than 20% de ciency on the above, then score as not met.
Ind 49. The clinic has referral SOPs

Survey Process:
Check the availability and practice of written SOPs for referral in case of i. emergency, ii. patient demands for a
second opinion, iii. the required treatment is out of scope of dentist's expertise/practice. SOPs for safe and
speedy transfer of patient victims in emergency when applicable that describe how a patient is to be cared for
during transportation and to avoid confusion and delay in taking over the patient at the receiving facility,
should be implemented. The referring dentist should convey appropriate information to the specialist or
consulting dentist, depending on patient's individual needs.
i. Written SOPs for safe and speedy transfer of patients/victims in emergency and for referral to a
specialist/consultant are present.
ii. Evidence that the referral SOPs are complied
Scoring:
If a clinic maintains and practices the referral SOPs as described above, then score as fully met.
If a clinic does not maintain or does not practice the referral SOPs as described above, then score as
not met.
Guidelines
Registration and Disposal
A well-functioning registration and disposal process is an important indicator of an established patient
management system. If the patients are received, registered and appropriately guided for further actions, it
con rms the satisfaction of the patients and other care providers. The following SOPs45 can be adopted and
used as guidelines by appropriate modi cation to suit a particular dental clinic/surgery.
i. Reception / Registration
a. Receptionist (s)/Computer Operator (s) to perform duty according to type of facility/workload
b. Information is provided to the patients both verbally and on telephone in a pleasant manner
c. Patient is sent/guided/ taken to the relevant section/department
d. Particulars of patients are entered in the register/computer and a form or slip is provided
after data entry
e. Minimum time is consumed up to this stage
45- Standard Operating Procedures (SOPs) for Primary and Secondary Healthcare Facilities by the PDSSP 2008-2009 noti ed by the Health Department Government of Punjab may also be consulted for more details.
78 CG-09RM-Ed2-141021
Guidelines
i. Reception / Registration
a. Receptionist (s)/Computer Operator (s) to perform duty according to type of facility/workload
b. Information is provided to the patients both verbally and on telephone in a pleasant manner
c. Patient is sent/guided/ taken to the relevant section/department
d. Particulars of patients are entered in the register/computer and a form or slip is provided
after data entry
e. Minimum time is consumed up to this stage
ii. Guidance of Patients/Visitors
a. Sign boards showing services available in a particular setup (menu of services) are clearly
displayed at the key point/s (gates), key turning points, reception, sections/areas so that
users are facilitated to know and access the services available in a particular facility
b. Sign boards with directional arrows, indicating the location of service areas/speci c
departments, are placed and maintained as required except in the settings which do not
require such directional boards
c. Services available at a particular service area should also be displayed within that area
d. Lea ets providing information about the services in simple language are prepared,
distributed/kept at key point/s to create awareness amongst the patients/visitors about the
available services in the facility
e. Services which are not available are not displayed
f. Use of close circuit TV and public address system may be considered for information and
education of clientele on health matters
Patient Assessment and Management Methodology

The standard way of patient assessment and management is to follow the clinical methods; i. observation,
ii. history of present and past illnesses (pertaining to dental care in particular and any other considered
relevant e.g. hypertension/taking of blood thinning agents) for picking up any relevant points which can be
of signi cance in treatment and/or avoiding post-operative/post procedural complications, iii. social habits,
iv. recording/noting the symptoms, v. oral examination vi. decision about the required laboratory tests and
vii. the line of management to be advised (disposal).
At this stage, the patient shall either have a prescription if only medication is required, along with advised
tests,etc., or have had explained and obtained the consent about the dental procedure/surgery to be
undertaken, followed by post procedure/surgery advice in writing to be followed or referral to another
facility as applicable. The dental surgeon must follow the standardized dental protocols⁴⁶ when managing
any particular disease, at the same time using their own clinical acumen in treating and saving the patient's
oro-dental health.
46- Standardized Medical Protocols (SMPs) for Primary and Secondary Healthcare Facilities developed by the PDSSP for Primary and Secondary Healthcare Facilities of the Government of Punjab, a disease speci c
document may be consulted for guidance.

The referring dentist should convey appropriate information to the specialist or consulting dentist, which
may vary on an individual patient basis, and could include the following:
i. Name and address of the patient
ii. Scheduled appointment date and time with the specialist or consulting dentist
iii. Reason for the referral
iv. General background information about the patient which may affect the referral
v. Authorization or release of records
vi. Medical and dental information, which may include, medical consultations and speci c
problems, contributory dental history, diagnostic casts, radiographic or digital images
vii Future treatment needs beyond referral
viii. Urgency of the situation, if an emergency
Both practitioners should discuss the referral treatment period and the return of the patient to the referring
dentist. This arrangement may be enhanced by an exchange of business cards, referral forms and patient
instructional materials. Availability for emergency treatment during the referral period should be discussed.
The dental clinic should display on a chart all the contact numbers of the local police station, re brigade,
rescue services, electricity complaint cell, ambulance service, etc. so that it is easy to contact these services
in an emergency situation.
80 CG-09RM-Ed2-141021
Standard 14. COP-1: The clinic has a well-established patient management system

Score Score
The clinic has an established registration and guidance
Ind 47. 10 100%
process
Standard/Ethical practice is evident from the patient

Ind 48. 10 80%
record
Ind 49. The clinic has referral SOPs 10 100%
Total 30
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________

Standard 15. COP-2: The clinic has essential arrangements for providing
care to emergency cases
Indicators (50-50):
Ind 50. The clinic has essential arrangements to cater for emergency care
Survey Process:
Check for the portrayal of the list of emergencies that canbe managed and the required arrangements /
47
emergency / rst aid kits to manage the emergencies.
i. List of emergencies portrayed that can be managed
ii. Availability of the emergency/ rst aid kits with up to date contents
iii. List of contact numbers of the following for use in emergency is displayed
a. Rescue 1122.
b. Other ambulance services
c. Nearest referral hospitals/clinics
d. Police station
e. Fire brigade
f. NGOs/ CBOs operating in the area
Scoring:
If the clinic has arrangements to manage the portrayed/listed emergencies, then score as fully met.
If there is any de ciency in the arrangements as described above exists, then score as not met.
Guidelines
EMERGENCY SERVICE
Dentists shall make reasonable arrangements for the emergency care of their patients shall also be obliged,
when consulted in an emergency, to make reasonable arrangements for emergency care. If treatment is
provided, the dentist, upon completion of such treatment, is obliged to return the patient to his/her regular
dentist, unless the patient expressly reveals a different preference.
Policies and Procedures

Each dental clinic/surgery should have well thought out and documented policies and procedures for
emergency care, in line with statutory requirements. These policies and procedures, developed in the light
of applicable laws, shall guide and encourage patient safety as the overall principle for providing healthcare
services. These documents include SOPs/protocols to provide care either for common emergencies as it
may occur at any place/time, e.g. syncope, cardiac arrest, choking, acute bronchospasm, bleeding, fracture,
etc. or for management of speci c conditions, e.g. acute pulpitis, acute alveolar abscess, tooth fractures and
oral and maxillofacial trauma, etc. and shall address both adult and pediatric patients. The procedure shall
incorporate at least identi cation, assessment and provision of appropriate care followed by referral if
required. The policy/SOPs/SMPs of the dental clinic/surgery should spell out and ensure availability of all the
necessary equipment in working order during the operational time of the clinic.
47- List of standard rst aid kits/boxes/trays/trollies with guidelines/SOPs and listing of the types of emergencies portrayed to be managed are included in the guidelines. Arrangements to manage; i. syncope, ii.
respiratory distress, iii. anaphylactic shock, iv. control of bleeding and v. fracture of mandible and other long bones for at least one patient at a time should be available at the clinic. Additional portrayal will be
checked accordingly as an optional binding of the service provider. This is to be linked with sentinel events (Ind 39).
82 CG-09RM-Ed2-141021
SMPs For Medical Emergencies in the Dental Clinics⁴⁸

One cannot be certain that medical emergencies will not occur in a dental clinic and should therefore, be
prepared to manage such an occurrence. HCSPs must have basic knowledge of the signs and symptoms of
these emergency situations to act quickly, efficiently and effectively. In case of uncertainty, the practitioner
should call (shout if so required) for help from a senior clinician or colleague. Most of the emergencies can be
dealt satisfactorily if more than one HCP is competent to attend to the situation.
Preparatory SOPs
FIVE steps to prepare and manage a medical emergency:
i. Medical history including history of allergy and drug history
ii. Assessment of patient's condition
iii. Resuscitation knowledge, training and practice
iv. Pro ciency in the use of emergency medications and devices
v. Calling for medical assistance
Essential Emergency Drugs
Drug Indication Initial Adult Dose
1. Oxygen Almost any medical emergency 100% inhalation
Anaphylaxis. Asthma 0.1mg IV or 0.3-0.5mg IM
2. Epinephrine Unresponsive to albuterol/ 0.1mg IV or 0.3-0.5mg IM
Salbutamol, Cadiac arrest. 0.1mg IV
3. Nitroglycerin Angina pain 0.3-0.4mg sublingual
4. Antihistamine (dephenhydramine
Allergic relations 25-50mg IV, IM. 10-20mg IV, IM
or chorpheniramine)
5. Albuterol/salbutamol Asthmatic broncho spasm 2 Sprays: Inhalation
6. Aspirin Myocardial infection 160-325mg
Additional Emergency Drugs

Drug Indication Initial Adult Dose
1. Glucagon Hypoglycemia in unconscious patient 1mg IV or IM
2. Atropine Clinically signi cant bardycardia 0.5mg IV or IM
3. Ephedrine Clinically signi cant hypotension 5mg IV or 10-25mg IM
Adrenal insufficiency recurrent 100mg IV or IM. 100mg IV or IM
4. Hydrocortisone anaphylaxis
5. Morphine and Angina-like pain unresponsive Tritate 2mg IV, 5mg IM ~35%,
nitrous oxide to nitroglycerin inhalation
6. Lorazepam or Miodazolam Status epileptic us 4mg IM or IV. 5mg IM or IV
7. Flumazenil benzodiazepine overdose 0.1mg IV
48- Readiness in terms of these SOPs/SMPs is considered essential for ensuring safety of patients.

Standard 15. COP-2: The clinic has essential arrangements for providing care to
emergency cases

Score Score
The clinic has essential arrangements to cater for
Ind 50. 10 100%
emergency care
Total 10
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________
84 CG-09RM-Ed2-141021
2.8 Management of Medication (MOM)
Medication errors are one of the most common healthcare issues, with a number of preventable drug-related
mortalities/morbidities. Medication errors are also among the most frequently reported types of adverse events.
Medication management standards help support patient safety and improve the quality of care by creating a
system for selecting, procuring, storing, ordering, transcribing, preparing, labeling, dispensing, administering
and monitoring medications. The standards are designed to reduce practice variations, errors and misuse;
encourage monitoring of the efficiency, quality and safety of medication management processes; promote the
use of evidence-based good practices; and standardize processes in the dental clinic.
Managing medications effectively is a critical component of the dental clinic safety plan. Every attempt must be
made to maintain accurate records regarding a patient's medication use. . Antibiotics are widely used during
different dental treatments both for therapeutic and prophylactic reasons. In recent years the irrational use of
antibiotics has been rapid emergence of antimicrobial resistance. Antibiotics are often prescribed and used
unnecessarily and excessively, thus contributing to the development of resistant microbes.
There is a need of creating awareness amongst the providers as well as the recipients of can in order to increase
understanding of antibiotic resistance through education, communication and training.

Standard 16. MOM-1: Prescribing practices conform to the standards
Indicators (51-53):
Ind 51. Standards for prescription writing are followed
Survey Process:
49
Check that the prescription is written according to the prescribed format and that it contains clear information
such as serial number, name of patient, s/o, d/o, w/o, age, gender, date of visit(s), symptom/s, ndings of
oral/relevant physical examination, provisional diagnosis and instructions/post procedural instructions
regarding dosage/duration of use/revisit or additional procedure later etc.
i. Prescribed format for prescriptions, having space for the above mentioned information is practiced
ii. The prescription contains clear information about and for the patients.
Scoring:
If prescriptions are written as per the above instructions, then score as fully met.
If prescriptions are not written as per the above instructions, then score as not met.
Ind 52. Prescriptions are clear, legible, dated, timed, named/stamped and signed
Survey Process:
Surveyors are required to check that prescriptions are legible, dated, timed, named and signed by the dental
surgeon. Names of the medicines (trade or generic) are clearly written and there is no coding.
i. Prescriptions are legible, dated, timed, named and signed by the dental surgeon
ii. Names of the medicines (trade or generic) are clearly written and there is no coding
Scoring:
If the representative sample of prescriptions are as described above, then score as fully met.
If only up to 20% prescriptions are not timed as above, then score as partially met.
If more than 20% prescriptions are not as above, then score as not met.
Ind 53. Prescriptions are provided to the patients

Survey Process:
Provision of prescription having information about the dental procedure performed can be checked by
observing the practices, as well as interviewing the patient/s who come for revisit, and can also be
substantiated by checking the record maintained at the clinic (carbon copy, register, computer or a
combination).
i. Record of prescriptions is maintained at the clinic
ii. Evidence that the patients are provided prescriptions.
Scoring:
If the clinic provides the prescription slip to the patient and the record is maintained as above, then score
as fully met.
If the clinic does not provide the prescription to the patient or the record is not maintained, then score as
not met.
49- A format of prescription slip/form and SOPs is provided in the Guidelines.
86 CG-09RM-Ed2-141021
Guidelines
SOPs on Prescription of Medications
In dental clinics/hospitals, only medical doctors and dental surgeons are authorized for prescription writing
in their own elds.
Clarity of Medication Orders

All medication orders should be prescribed in writing and should be dated, timed and signed by the
prescribing doctor. There must be a written physician's order for prescription and non-prescription
medications. The prescriber must also note if the patient has any known allergies, contraindications and
body weight, particularly for pediatric patients. Writing diagnosis is an integral part of the medication
prescription, due to 'drug to drug', 'drug to disease' interaction. A complete prescription order must include
the following eight requirements:
i. The client's/ name, parentage, etc.
ii. Weight
iii. Allergies/Contraindications
iv. The date of the order
v. Name of the medication/s
vi. Dosage and administration information
vii. Route of administration
viii. Doctor's signature and name or/and stamp (containing the name of the doctor)
Drugs must be written legibly and clearly, preferably according to the generic name, while brand name can
be used in brackets.
Directions must be clearly stated and should be quali ed e.g. 'Take one or two tablets for pain or headache'
cautioning'Not to be taken empty stomach'and/or'Take one Capsule every 6 hours for ve days'in case of an
antibiotic course for infection, etc. 'As directed' or 'when needed' must be avoided.
Every patient coming to the dental clinic and getting dental treatment must get a clearly written
prescription depicting the complaints, diagnoses, treatment/procedure performed, medication prescribed
and detail of post-op instructions. No verbal instructions regarding taking medications are acceptable.
Post-procedure written instructions in the form of pamphlet/lea et for the awareness of patients having
any surgical procedure, in addition to written speci c instructions, should be used, rather than to
communicate only verbally.

Standard 16. MOM-1: Prescribing practices conform to the standards

Score Score
Ind 51. Standards for prescription writing are followed 10 100%
Prescriptions are clear, legible, dated, timed, named/

Ind 52. 10 80%
stamped and signed
Ind 53. Prescriptions are provided to the patients 10 100%
Total 30
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________
88 CG-09RM-Ed2-141021
Standard 17. MOM-2: Storage and dispensing/usage conforms to the

guidelines⁵⁰
Indicators (54-56):
Ind 54. Medicines/disposables/dental materials are stored as per guidelines
Survey Process:
The guidelines for safe storage include inter-alia⁵ ; i. proper stacking in groups to differentiate common drugs,
injections, anesthetics, look alike and sound alike medicines/cements/materials within the rack/cupboard; ii.
labeling; iii. ventilation; iv. temperature control/refrigerator for sensitive drugs/materials, etc.; v. protection of
high risk and narcotic drugs as the case may be, and vi. record of expiry dates.
i. Proper stacking in groups to differentiate common drugs/materials, injections, look alike and sound
alike medicines/cements/materials within the rack/cupboard
ii. Labeling of drugs/materials etc.
iii. Ventilation
iv. Temperature control/refrigerator for sensitive drugs/materials, etc.
v. Protection/safe custody of high risk and narcotic drugs if applicable
vi. Record of expiry dates
Scoring:
If the medicines/materials are stored as per the above referred guidelines, then score as fully met.
If implementation of parameters at serial numbers i, ii and iii only is inconsistent, then score as partially met.
If implementation of any one of the parameters at serial numbers. iv, v and vi is inconsistent then score
as not met.
Ind 55. Expiry dates are checked prior to administering, as applicable
Survey Process:
Randomly selected medicines/dental materials/anesthetics are checked to make sure that these are within the
expiry limit.
i. Items are within the expiry date printed on the label as per Drug Act/Rules
ii. Evidence that expiry dates are monitored / followed.
Scoring:
If all 5 randomly selected medicines/materials administered/used or to be administered/used are within
the expiry date, then score as fully met.
If any of the randomly selected medicines/materials administered/used or to be administered/used are
not within the expiry date, then score as not met.
50- Details in the Guidelines.

51- Full details available in the manufactures instructions/as per the DRAP Act 2012.

Ind 56. Dispensing/utilization is by an authorized person
Survey Process:
The surveyors should see that the person made responsible to dispense the medicines or use the dental
materials, is a quali ed professional registered with the Punjab Medical Faculty⁵ and is able to correctly read
and identify the medicines/dental materials prescribed/required by the dental surgeon from those in the
store/cabinet. He/she is also able to correctly distinguish look alike and sound alike (LASA) medicines/dental
materials and to dispense/use correctly under the supervision of the dentist as required.
i. The person responsible to dispense the medicines is quali ed and registered with the Punjab Medical
Faculty OR
ii. The person responsible to dispense the medicines is:
a. Matriculate, preferably with science
b. Able to correctly read and identify the medicines/dental materials prescribed/required by the
dental surgeon from those in the store/cabinet
c. Able to correctly distinguish look alike and sound alike medicines/dental materials and to
dispense/use correctly under the supervision of the dentist as required
Scoring:
If the dispensing/use of the medicines/dental materials is by an authorized person as described above,
If the person dispensing/using the medicines/dental materials is neither quali ed/registered nor able to
perform as described above, then score as not met.
Guidelines
Storage and Dispensing Policy
Storage of medicinal materials is an important aspect of the overall drug control system. Environmental
control (i.e., proper temperature, light, humidity, sanitation, ventilation, segregation, etc.) must be
maintained wherever drugs and supplied are stored. Storage areas must be secure; xtures and equipment
used to store drugs should be such that drugs are accessible only to designated and authorized personnel.
Safety is an important factor and proper consideration should be given to the safe storage of poisons and
ammable compounds. Medications meant for external use should be stored separately from those for
internal use. Temperature sensitive medications must be stored in a refrigerator containing only medicines,
and items other than drugs should be kept in a separate refrigerator, e.g; dental materials which need to be
stored in the refrigerator should have a separate storage arrangement.
Drugs/Dental materials storage Inspections

At least quarterly inspections shall be carriedout, of all storage areas within the hospital/clinic under the
supervision of the dentist. A written record shall verify that Safe Storage Practices, including the following,
are implemented:
i. The storage is properly maintained using stacks, bin cards and inventory control documents.
ii. Medications are stored securely and are available to the authorized personnel only.
iii. Narcotic and controlled drugs are stored under lock and key by the authorized person.
iv. Standards of cleanliness are consistent with good medication handling practices.
52- This requirement is relaxed for the initial one year from the noti cation of this MSDS to facilitate availability/employment of such registered professional/s by the dental surgeon. In such cases, certi cation by the
dental practitioner to effect that he is the satis ed with the skill, knowledge and performance of the person trained by him/her will suffice.
90 CG-09RM-Ed2-141021
Guidelines
v. Reconstituted medications are properly labeled with expiry and preparation date.
vi. Illegible labels are replaced.
vii. Liquid bottles are clean and free of spills.
viii. Disinfectants and drugs for external use are stored separately from internal and injectable
medications.
ix. Medications requiring special environmental conditions for stability are properly stored.
x. Non-pharmaceuticals are stored separately.
xi. Expired medications are not stocked.
xii. Medications are not overstocked.
xiii. Medications required on emergency basis are readily available (emergency box, crash carts, etc.).
xiv. Medication room door/cart is locked when unsupervised.
Monitoring of Expiry Dates
All medication/dental materials should be examined to ensure their being in date at the time of use. The
pharmacy in-charge shall ensure implementation of the following SOPs for the monitoring of expiry dates;
i. Check the expiry dates on daily/monthly/quarterly/yearly basis.
ii. Once a drug is re-packaged in a separate container, there is a reduction in the shelf life of the product,
therefore, original expiry dates should not be used. It is the responsibility of the re- packaging
technician to inspect these products for date of manufacturing and then proposed expiry.
iii. Expired stock or products which expire within a month are pulled from the shelves and the
purchasing section noti ed of the need for additional stock.
iv. The pharmacists/pharmacy technicians in the dispensing areas are responsible for inspection of all
drugs in the working stock. Visual inspection to check deterioration and expiry date shall be a
normal practice.
v. Expired medicines/ material shall be pulled from the shelves and held in a segregated area clearly
marked for disposal.
Authorization to Administer the Drugs/Medications/Dental Materials
Administering medication to treat a patient requires speci c knowledge and experience. Each dental
clinic/surgery/hospital is responsible for identifying individuals with the requisite knowledge and
experience who are also permitted by,certi cation or regulations to administer medications (PMC Act2020,
Allopathic System (Prevention of Misuse) Ordinance No. Lxv of, 1962, relevant provision of PMDC
Amendment Act 2012 as retained under the PMC Act, PNC Ordinance, Pharmacy Council Act, Punjab
Medical Faculty Regulations, etc.). Dental assistant is to be trained by the dentist himself if he/she is not
quali ed/registerd by the concerned authority. Minimum requirement is that he/she is litrate and have a
command on written english and is able to understand doctor's handwriting.
A specimen for listing of professionals authorized to administer the drugs/medications is provided

Annexure-N .

Standard 17. MOM-2: Storage and dispensing/usage conforms to the guidelines

Score Score
Medicines/disposables/dental materials are stored as
Ind 54. 10 80%
per guidelines
Expiry dates are checked prior to administering, as

Ind 55. 10 100%
applicable
Ind 56. Dispensing/utilization is by an authorized person 10 100%
Total 30
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________
92 CG-09RM-Ed2-141021
2.9 Patient Rights and Education (PRE)
The dental clinic/surgery shall de ne patient and family rights and responsibilities as per the guidelines
provided by the PHC. The staff is aware of these and is trained to protect patients' rights. Patients are informed of
their rights and educated about their responsibilities at the clinic. They are informed about the disease, the
possible outcomes and are involved in decision making. The treatment costs are explained in a clear manner to
the patient and/or family. Patients are educated about the mechanisms available for addressing
grievances/complaints.
The PHC charter for patients and others is relevant and should be displayed in the clinic.

Standard 18. PRE-1: There is a system for awareness/education of patients
and others regarding the Charter of Rights and
Responsibilities for compliance
Indicators (57-57):
The Charter of Rights and Responsibilities are displayed and patients/

Ind 57.
families and staff are guided on it
Survey Process:
The surveyor is required to see that PHC Charter of Rights and Responsibilities for Patients, Carers and Others, is
displayed at a prominent place in the clinic, like the waiting area or main entrance, for awareness. Also, check
that clinic staff is well aware of the charters for compliance at their end and provide guidance to the patients on
above aspects as and when required.
Patient and others are expected to observe the social norms by waiting for their turn, avoid con ict situations,
following the instructions of the dental surgeon regarding re-visit date and time, etc.
i. PHC Charters of Rights and Responsibilities for Patients and HCEs are displayed at a prominent place in
the clinic, like the waiting area or main entrance for awareness
ii. Clinic staff is well aware of the charters, compliance at their end and provide guidance to the patients on
the above aspects as and when required
Scoring:
If the Charters are displayed as required above and evidence that the patients/families are also guided
on the same, then score as fully met.
If the Charters are available but not displayed as required above but there is and evidence that the
patients/families are guided on the same, then score as partially met.
If the Charters are not available as required above and there is no evidence to the effect that the
patients/families are guided on the same, then score as not met.
Guidelines
The PHC Charter for Patients, Carers and Others and the Charter for HCEs have been provided before as
Annexure-H.
94 CG-09RM-Ed2-141021
Standard 18. PRE-1: There is a system for awareness/education of patients and

others regarding the Charter of Rights and Responsibilities
for compliance

Score Score
The Charter of Rights and Responsibilities are displayed
Ind 57. 10 80%
and patients/ families and staff are guided on it
Total 10
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________

Standard 19. PRE-2: There is a system for obtaining consent for treatment
Indicators (58-59):
Ind 58. The dental surgeon obtains consent from a patient before examination⁵
Survey Process:
Dental surgeons are required to politely seek permission from the patient/parents/attendants before dental
54
examination. This should include the need/role of a chaperon if so required . The 'verbal consent' so'obtained'
is required to be documented on the prescription at the minimum as 'VCO'. To validate the 'VCO', the surveyors
are required to review the register/copy of prescriptions.
i. Documentary evidence that the 'verbal consent obtained' is documented on the prescription at the
minimum as 'VCO'
Scoring:
If there is evidence of VCO, then score as fully met.
If there is evidence of VCO in up to 80% of cases, then score as partially met.
If there is no evidence of VCO as above, then score as not met.
The clinic has listed those situations where speci c informed consent55 is
Ind 59. 56
required from a patient or family and the consent is taken accordingly
Survey Process:
Review the listed conditions requiring informed consent. Then review records of patients from whom speci c
informed consent should have been taken. The informed consent includes providing information in a language
57
and detail that patient/attendant can understand on risks, bene ts, and alternatives and as to who will provide
the treatment or perform the procedure/investigation/test. Informed consent is also required for taking
photographs or making movies during the procedures either for record keeping/preservation of identity or
educational/research purposes, so to respect the individual's religious/social/cultural beliefs58.
i. Procedures/conditions requiring informed consent listed
ii. Speci c informed consent taken as per list
iii. The format of speci c informed consent is available in local language
iv. Informed consent is also taken for taking photographs or making movies during the procedures either
for record keeping/preservation of identity or educational/research purposes.
Scoring:
If the situations requiring informed consent en listed, and the relevant records document an informed
consent accordingly, then score as fully met.
If neither the situation requiring informed consent enlisted nor the relevant records do not document
consent as above, then score as not met.
53- This is to maintain the privacy, respect, dignity and honor of the patients while examining intimately and providing care and to comply with the Patients Charters and the Code of Ethics.
54- ‘Intimate examinations and chaperones (2013)’ GMC Good Medical Practices.
55- This is important for informed decision making as well as patient & care provider's safety. See consent form in the Guidelines.
56- Family consent is required if the patient is not capable to give consent or is a minor. Family means; immediate relatives—mother, father, brother & sister, son & daughter, wife & husband.
57- Further explained in the Guidelines.
58- Refer to PHC Patient Charters.
96 CG-09RM-Ed2-141021
Guidelines
Scope of Informed Consent
Although the client's/patient's general consent is obtained for the proposed care or treatment, a written
consent is mandatory for any invasive procedures or operations and a prerequisite to carry out any surgical
intervention. The patient has the right to refuse or to halt the intervention.In different situations of health
care provision or involvement of the client in any research activity, the mode of consent and action will be as
follows:
i. When a patient is unable to express his or her will and a medical intervention is urgently needed, the
consent of the patient may be presumed, unless it is obvious from a previously declared 'Expression
of Will' that consent would be refused in the situation.
ii. When the consent of a legal representative is required and the proposed intervention is urgently
needed, the intervention may be made if it is not possible to obtain the representative's consent in time.
iii. When the consent of a legal representative is required, patients (whether minor or adult) must
nevertheless be involved in the decision-making process to the possible extent.
iv. If a legal representative refuses to give consent and the physician or other provider is of the opinion
that the intervention is in the interest of the patient, then in case of a non-emergency situation, the
decision must be referred to a court or some form of arbitration.
v. In all other situations where the patient is unable to give informed consent and where there is no
legal representative or representative designated by the patient for this purpose, appropriate
measures should be taken to provide for a substitute decision making process, taking into account
what is known and, to the greatest extent possible, what may be presumed about the wishes of the
patient.
vi. The consent of the patient is required for the preservation and use of all substances of the human
body. Consent may be presumed when the substances/body part are to be used in the current
course of diagnosis, treatment and care of the patient.
vii. The informed consent of the patient is needed for participation in clinical teaching.
viii. The informed consent of the patient is a prerequisite for participation in scienti c research. All
protocols must be submitted to a proper ethical review committee. Such research should not be
carried out on those who are unable to express their will, unless the consent of a legal representative
has been obtained and the research would likely be in the interest of the patient.
As an exception to the requirement of involvement being in the interest of the patient, an incapacitated
person may be involved in observational research which is not of direct bene t to his or her health provided
that, the person offers no objection, that the risk and burden is minimal, that the research is of signi cant
value and that no alternative methods and other research subjects are available.
Informed Consent for Surgery

It is mandatory that the need for the surgery/procedure explained to the patient/next of kin in detail, along
with how it will be carried out and the pros and cons of the procedure/operation. It is essential that the
consent is taken (preferably) by the surgeon himself/herself or by one of the doctors from his team, after
properly introducing himself/herself and explaining the requirement of the operation/procedure. The
consent shall be taken on Informed Consent for Surgery Form.
Details regarding informed consent of the patient have been discussed in Section 2.9 covering Patient's
Rights and Education.

Information about Risks, Bene ts and Alternatives
It is the responsibility of the healthcare service provider to take time to explain/discuss with the patient and
his/her attendant about the:
i. Health status/clinical facts
ii. Diagnosis of the problem
iii. Proposed management plan
iv. Expected outcome
v. Costs (expected)
vi. Risks
vii. Preferences/Choices of patients
viii. Follow-up to the clients/patients
ix. Right to read own medical record/ le
After giving information about diagnosis, management and follow-up, the healthcare service provider
should check to ensure that the client/patient has understood the advice. Obtaining this feedback is
important in assessing to what extent the instructions have been understood.
Treating clients/patients with respect, actively listening to them, asking questions about their
choices/preferences, praising, explaining diagnosis and management, describing the follow-up plan, and
taking feedback about their understanding of the given advice/choice are very important components of
health care delivery.
The person performing the procedure shall be responsible for the entire process of taking the consent
including providing explanation and taking the signature. A team member can take consent on behalf of
the person performing the procedure, but their name and designation must be clearly mentioned in the
chart.
When the patient does not speak or understand the predominant language of the community, efforts
should be made to ensure that proper interpretation is done.
For the informed consent process to the conformity to the norms include the following
i. Taking consent before the procedure.
ii. At least one independent witness signing the form.
iii. Taking a fresh consent (for the new procedure) in case the procedure has to be changed during
course of treatment/procedure.
iv. Appropriate information is provided to clients/patients and their families, in a way that they can
understand, on the proposed treatment, the costs, the risks and bene ts of the proposed treatment
or investigation, and the alternatives available.
v. Clients/Patients and their families are fully informed about the client's/patient's health status,
including the clinical facts about their condition, unless there is an explicit request not to disclose a
particular information to the patient Template of consent form is provided at Annexure-O.
98 CG-09RM-Ed2-141021
Standard 19. PRE-2: There is a system for obtaining consent for treatment

Score Score
The dental surgeon obtains consent from a patient
Ind 58. 10 80%
before examination
The clinic has listed those situations where speci c

Ind 59. informed consent is required from a patient or family 10 100%
and the consent is taken accordingly
Total 20
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________

Standard 20. PRE-3: Patients and families have a right to information about
expected costs
Indicators (60-60):
Ind 60. The patient/family is informed about the cost of treatment
Survey Process:
Customarily, the consultation fee is displayed or patients are informed about the fee, the charges for procedure,
etc. by the dentist personally, or by the staff at the reception desk (as applicable), and the cost list is shown if
requested.
i. The consultation fee is displayed
ii. Patients are informed about the fee and the charges for medicines/procedures at the reception desk (as
applicable)
iii. Cost list is shown if requested
Scoring:
If there is evidence that the patients/families are informed about the treatment cost as above, then score
as fully met.
If the patients/relatives are not informed about the expected cost of treatment as above, then score as
not met.
Guidelines
Tariff List
Although customarily, the consultation fee is displayed or patients are informed about the fee and the
charges for medicines, etc., at the reception desk (as applicable), a detailed cost list is shown if requested.
There should be a general tariff/billing system which de nes the charges to be levied for the services
provided by the clinic which may include the following:
i. Consultation fee
ii. Cost of dental procedure/surgery
iii. Cost of investigations if required and carried out onsite
iv. Cost of medicines to be dispensed or to be purchased if prescribed (as applicable)
v. Costs of dentures, bridges, caps and implants, braces, etc., to be provided by the clinic as indicated
The above-mentioned service charges should be a part of the tariff/billing system and must be available in a
le maintained at the clinic. Sometimes, the consultation fee for the rst visit and for subsequent visits (for
new and old patients) may be different. It will be the duty of the receptionist, technician or doctor to inform
the patient of such tariff differences prior to the treatment. Patients/Families/Attendants should be given an
estimate of the expenses, particularly in case of prolonged treatment. It is preferable to provide this
information in writing. However, at minimum, tariff related to consultation fee (which is usually xed) must
be displayed at a prominent place, either at the reception or inside the consultation room.
100 CG-09RM-Ed2-141021
Standard 20. PRE-3: Patients and families have a right to information about expected
costs

Score Score
The patient/family is informed about the cost of
Ind 60. 10 100%
treatment
Total 10
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________

Standard 21. PRE-4: Patients and families have a right to refuse treatment
and lodge a complaint
Indicators (61-62):
Ind 61. Patients and families have a right to refuse the treatment
Survey Process:
Patient and families are expected to respect the instructions/medication orders prescribed by the dental
surgeon, but they have a right to refuse the treatment59 and seek advice from any other dentist of their choice60
as provided in the prescribed Code of Ethics and the PHC Charters61. This necessitates speci cally displaying the
right of refusal. In cases where patients refuse advice, procedures or treatment, it has to be recorded in the
patient's record.
i. The right of refusal for treatment by the patient is displayed in PHC Charter for Patients
ii. The record of patient's refusal (if applicable) is available
Scoring:
Unless the surveyors have a reason to believe that the above provision of the Charters are not being
complied, the score should default to fully met.
Patients and families have a right to complaint and there is a mechanism

Ind 62.
to address the grievances
Survey Process:
Patients and families have a right to complain and put forward their grievances/concerns. There is a mechanism
to handle the complaints effectively. The complaints can be lodged on the spot on occurrence, with some delay,
verbally, in writing or by any other means. A complaint box or a complaint register, display of PHC helpline/web
address and/or availability of a complaint form and le record are evidence of the system being in place.
i. Functional Complaint Management System, evidenced by the following:
a. A complaint register
b. Display of PHC helpline/web address
c. Availability of complaint form
d. File record
ii. Evidence that the complaints are managed.
Scoring:
If there is a display which facilitates/guides the patients about their right of complaint and the system is
being followed as above (including zero report recording in the register), then score as fully met.
If there is no display to facilitate/guide the patients about their right of complaint and/or the system
described above is not being followed, then score as not met.
59- Provisions 12. ©, PMC Code of Ethics of Practice for Medical and Dental Practitioners allows refusal to treat a patient.
60- Provisions 12. (b) and 13., PMC Code of Ethics of Practice for Medical and Dental Practitioners allows independent additional opinions.
61- Annexure-H, also provided on PHC website: https://www.phc.org.pk
102 CG-09RM-Ed2-141021
Guidelines
Right to Express Concern or Complain
An institutionalized, accessible and transparent grievance redress mechanism must be in place. The
information as how to lodge a complaint must be clearly displayed in the local language at prominent
places.
A complaint is an expression of client dissatisfaction and a way to provide feedback on the quality of care
which needs a response. Every healthcare facility should inform the clients/patients about their right to
complain and the complaint handling procedures. A complaint may be written or verbal and be lodged by
the patient, his/her attendants or a legally authorized person. Various ways should be adopted, for example:
i. Display the message clearly in the local language at prominent places in the facility, such as
registration desk, waiting area, OPDs, main entrance, private rooms, etc. (Complaints form
Annexure-P).
ii. Pertinent information may be made available in the form of lea ets/brochures at
appropriate places.
iii. Client feedback/satisfaction must be sought on a prescribed but simple format at the
time of discharge (format attached previously as Annexure-J).
When the treatment plan has been made and discussed with the patient, then it is the
patient's right to agree with the whole treatment plan or disagree with any procedure. In that
case, the patient must be explained about the need or requirement of that speci c
procedure but in any case he/she should not be forced to undergo that procedure. If the
patient still refuses to get treatment, it must be documented in the patient's record.

Standard 21. PRE-4: Patients and families have a right to refuse treatment and lodge a
complaint

Score Score
Patients and families have a right to refuse the
Ind 61. 10 100%
treatment
Patients and families have a right to complain and

Ind 62. 10 100%
there is a mechanism to address the grievances
Total 20
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________
104 CG-09RM-Ed2-141021
2.10 Infection Prevention & Control (IPC)
Prevention of healthcare associated infections (HAIs) represents one of the major safety initiatives a dental clinic
is required to undertake. The standards related to the infection prevention and control provide the framework
for dental surgeries to develop and implement plans to prevent and control infections by using an integrated
approach across all programme, services and settings. The standards call on healthcare establishments to
educate and collaborate with all members of the clinic, including support staff, to participate in the design and
implementation of an effective infection prevention and control programme.
Although the principles of infection prevention and control remain unchanged, new technologies, materials,
equipment and updated data require continuous evaluation of current infection control practices and
continuous education for the oral health team. It is the responsibility of dentists in charge of the practice/ clinic
to establish a protocol that prevents or limits the spread of infection in dental practice for the patients, the staff
and the practitioner himself.
Members of the oral health team are obliged to keep their knowledge and skills up to date with regard to the
diagnosis and management of infectious diseases that may be transmitted in the clinical setting, adhere to
standard precautions and where necessary transmission‐based precautions as set forth by the relevant
authorities and to take appropriate measures to protect their patients and themselves against infections.

Standard 22. IPC-1: The clinic has a well-designed, comprehensive and
coordinated infection prevention and control system
aimed at reducing/ eliminating risks to patients, visitors
Indicators (63-66): and care providers
The infection prevention and control plan is documented which aims at
Ind 63.
preventing and reducing risk of nosocomial/cross-infection
Survey Process:
Check the written IPC Plan to verify that it covers the following aspects:
ü SOPs for Infection Prevention & Control
ü Arrangement for the Infection Prevention & Control Practices as under
i. HCSP Speci c including (but not limited to) the following:
Hand Hygiene
Respiratory Hygiene
PPE
Needle stick/Sharps Safety
Safe Injection Practice
Blood borne Pathogens/ OPIM Standard
Hazards Communication
Immunizations/Post exposure prophylaxis
Emergency Action Plan
Environmental Health & Safety
ii. Patient Speci c including (but not limited to) the following:
Universal Precautions
Sterilization
Surface Disinfection
Waste Disposal62
Dental Unit water decontamination
Suction care
iii. Surveillance activities – post procedure infections

iv. De ned responsibilities of an Infection Prevention & Control Team
i. Availability of documented infection prevention and control plan covering the following;
a. SOPs for Infection control.
b. Arrangements for Infection control practices.
c. Surveillance activities
d. De ned responsibilities and authorities of an Infection Prevention & Control Tea
ii. Evidence that the IPC plan is implemented.
62- In line with the Punjab Hospital Waste Management Rules 2014 issued by Environment Protection Department and as amended from time to time and applicable locally. Details provided in the Guidelines.
106 CG-09RM-Ed2-141021
Scoring:
If there is a documented infection prevention and control plan that includes SOPs for infection control
and arrangements of infection control practices, surveillance activities, and de ned responsibilities and
authorities of an Infection Prevention & Control Team and evidence that the IPC plan is implemented,
If there is either no written plan, or it does not include any one of the above 4 requirements, then score as
not met.
The clinic has designated staff and de ned responsibilities for infection
Ind 64.
control and waste management activities
Survey Process:
Review the documentation regarding designation/appointment and assigned responsibilities (JDs) in that the
staff is assigned the role/s in writing to implement the Infection Prevention & Control Plan (IPC Plan) and clinical
waste management as stipulated in the relevant statutes updated from time to time.
i. Staff designated and responsibilities in respect of infection control activities including medical waste
management as per HWM Rules 2014 (as amended from time to time) are de ned.
ii. JDs of Nurse/Technician/Dental Surgeon on Infection Prevention & Control available and match the
requirements of IPC Plan and PHWMR 2014.
Scoring:
If the quali cation/ credentials of the IPC nurse/(s) match the requirements in the job description, and
their number is adequate to manage the workload, then score as fully met.
If the credentials of the IPC nurse/(s) do not match the requirements in the job description, and or their
number is not adequate to manage the workload, then scored as not met.
The clinic has appropriate consumables, collection and handling systems,

Ind 65.
equipment and facilities for control of infection
Survey Process:
Observe and check that
i. Appropriate collection and handling of consumables is being carried out
ii. Equipment and facilities for control of infection are available, including
- Cleaning
- Disinfection
- Sterilization
63
ii. A full System of Clinical Waste Management is implemented including, the following components in
practice, from the point of generation to the point of destruction
- Segregation
- Collection
- Disposal
63- As per Punjab Hospital Waste Management Rules 2014 as amended from time to time.

i. Facilities for following available;
a. Cleaning
b. Disinfection
c. Sterilization
ii. Clinical Waste Management Plan ensuring availability of:
a. Single use syringes as required and syringe cutters/ auto disposable (AD) syringes
b. Separate containers for hospital waste (for infectious, non-infectious and sharps)
iii. Evidence of Waste Management system including the following components in practice;
a. Segregation
b. Collection
c. Disposal
Scoring:
If there is full system of clinical infection prevention and control including all above mentioned
elements from i- iii, to serve all care and treatment areas, , then score as fully met.
If any one of the elements in the clinical infection control from i-iii above is not complied with, then score
asnot met.
ALL staff involved in the creation, handling and disposal of dental/clinical

Ind 66. waste shall receive regular training and ongoing education in the infection
control and safe handling of waste
Survey Process:
Identify the staff that conduct training in Infection Prevention & Control including the Clinical Waste
64
Management and review the training material. Speak with staff involved in infection prevention and control
and the generation, handling and management of medical waste to determine their level of training and
applied knowledge. The training system employed by the clinic should encompass all the infection prevention
and control activities including Clinical Waste Management System covering full process on site as per clinic's
local policy based on PHWMR 2014 (as amended from time to time) and what happens once the waste leaves
the site. Adequate training on the systems, facilities and safety equipment/consumables should be observable.
i. Evidence of training of staff on Infection Prevention & Control including the Clinical Waste Management
ii. The training material / training should cover all the infection control activities including WM System, full
process on site and what happens once the waste leaves the site.
iii. Applied knowledge of staff on infection prevention and control including generation, handling and
management of medical waste
Scoring:
If there is evidence of training of the staff on infection prevention and control including Clinical WM
System at induction and when the new System are introduced, or when new component, consumables
or equipment related to IPC and clinical waste management are employed, then score as fully met.
If there is no training at all or training material does not cover all the IPC activities OR if any one of the
above conditions are not ful lled, score as not met.
64- Staff means permanent, temporary or short term employees of the HCE/any third party.
108 CG-09RM-Ed2-141021
Guidelines
Documented Infection Prevention & Control (IPC) Programme

The Dental Clinic/Surgery must have a documented IPC Programme which aims at preventing and reducing
the risk of cross infection and nosocomial infections. National65 and International Guidelines, scienti c
knowledge, professional bodies and statutory requirements shall be considered for developing an IPC
programme. CDC and WHO guidelines should be used as reference documents.
1. Hospital-acquired or nosocomial infections are infections that patients acquire during their stay or
treatment at a health centre. Such infections are easily transmitted during daily clinical practice if;
a. The instruments used during surgery are not free of micro organisms
b. The staff do not wash their hands properly before and after treating patients
c. The material used during the treatment is not free of micro organisms
d. Contaminated waste is not disposed of properly
2. Cross-infections are infections transmitted from one patient to another through contaminated
equipment, instruments and materials. Cross-infection is one of the major causes of nosocomial
diseases and has a huge impact on the patient.
Following different processes involved in minimizing cross infection and assure quality treatment go side
by side in a dental operatory.
1. Cleaning
The process of removing dirt and soils, that does not involve killing micro organisms and spores.
2. Disinfection
The process of destroying all pathogenic microorganisms, but not bacterial spores.
3. Sterilization
The process of destroying all forms of microbial life including bacterial spores on inanimate surfaces.
Cleaning Disinfection Sterilization
Dirt and soils Microorganism Spores
Each Dental Clinic must comply with the following requirements.

1) Develop an IPC Programme (or using the national guidelines) to ensure wellbeing of both patients
and staff.
2) Provide sufficient resources to support the IPC programme.
3) Ensure that risk prevention for patients and staff is a concern of everyone in the facility, and must be
supported by the senior administration.
4) The Infection Prevention & Control Program must cover the following salient components.
65- Pakistan National Infection Prevention & Control Guidelines, 2006 as updated from time to time.

i. Healthcare personnel speci c:
Hand Hygiene
Respiratory Hygiene
PPE
Needle stick/Sharps Safety
Safe Injection Practice
Blood borne Pathogens/ OPIM Standard
Hazards Communication
Immunizations/Post exposure prophylaxis
Emergency Action Plan
Environmental Health & Safety
ii. Patient Speci c:

Universal Precautions
Sterilization
Surface Disinfection
Waste Disposal
Dental Unit water decontamination
Suction care
For sustained effectiveness, the IPC programme will have to be comprehensive, include surveillance and
prevention activities and staff training. It must also be able to draw upon effective support at national and
regional levels.
Organization of an Infection Prevention & Control (IPC) Programme

The primary responsibility lies with the dental surgeon who should:
i. Designate an Infection Prevention & Control team or an officer, with dedicated time and
who can enforce rules and attend to daily needs of the programme in real time.
ii. Provide adequate resources for effective functioning of the IPC programme.
Responsibilities of IPC Team

i. Must meet regularly on daily basis.
ii. Enforce compliance with basic IPC standards.
iii. Develop a yearly programme for surveillance and prevention activity
iv. Ensure appropriate staff training in IPC and safety management, provision of safety materials such
as PPE and products.
v. Oversee training of dental assistants in IPC.
Infection Prevention & Control Practices

Infection control practices can be grouped into two categories;
i. Standard Precautions, that must be applied to all patients at all times, regardless of diagnosis or
infectious status
ii. Additional Precautions, that are speci c to modes of transmission or transmission-based i.e.
airborne, droplet and contact.
110 CG-09RM-Ed2-141021
Standard Precautions
Treating all patients in the healthcare facility with the same basic level of “standard” precautions involves
work practices that are essential to provide high level of protection to patients, healthcare workers and
visitors. These include the following:
HAND HYGIENE
Hand washing and hand antisepsis with following speci c antiseptics
I. 2%-4% chlorhexidine
ii. 5%-7.5% povidone iodine
iii. 1% triclosan
iv. 70% alcoholic hand rubs. waterless, alcohol-based hand rubs: with antiseptic and emollient gel and
alcohol swabs, that can be applied to clean hands.
Facilities for Drying Hands

i. Disposable towels, reusable single use towels or roller towels, which are suitably maintained.
ii. If there is no clean dry towel, it is best to air-dry hands.
iii. Equipment and products are not equally accessible to all Dental Clinics. Flexibility in products and
procedures, and sensitivity to local needs will improve compliance.In all cases, the best possible
procedure should be instituted.
PERSONAL PROTECTIVE EQUIPMENT (PPE)

i. Adequate and appropriate PPE, soaps, and disinfectants should be available and used correctly.
These should be available at the point of use and the organization shall ensure that it maintains an
adequate inventory and stock of items.
ii. Using PPE provides a physical barrier between micro-organisms and the wearer and offers
protection by helping to prevent micro-organisms from
a. Contaminating hands, eyes, clothing, hair and shoes.
b. Being transmitted to other patients and staff.
iii. PPE including the following on mandatory requirements.
a. Gloves
b. Protective eye wear (goggles)
c. Masks
d. Aprons
e. Gowns
f. Boots/shoe covers
g. Caps/hair covers
PPE should be invariably used by:

a. Healthcare workers who provide direct care to patients and who work in situations where they may
have contact with blood, body uids, excretions or secretions.
b. Support staff including medical aides, cleaners, and laundry staff in situations where they may have
contact with blood, body uids, secretions and excretions.
c. Laboratory staff, who handle patient specimens.
d. Family members who provide care to patients and are in a situation where they may have
contact with blood, body uids, secretions and excretions.

SAFE INJECTION PRACTICES
In dentistry, short and long needles are used during treatments to administer anesthesia. Irrigation syringes
are also used during multiple procedures. All the disposable syringes should be discarded in sharps
container after cutting the needles. In case of local anesthetic syringes, needles should be discarded in the
sharps container along with anesthesia cartridges and syringes itself should be sterilized / disinfected for
reuse.
PREVENTION OF NEEDLE STICK/SHARPS INJURIES

Take care to prevent injuries when using needles, scalpels and other sharp instruments or equipment. Place
used disposable syringes and needles, scalpel blades and other sharp items in a puncture-resistant
container with a lid that closes and is located close to the area in which the item is used. Take extra care when
cleaning sharp reusable instruments or equipment. Never recap or bend needles. Sharps must be
appropriately disinfected and/or destroyed as per the guidelines provided in the PHWM Rules 2014.
BLOOD BORNE PATHOGEN/ OPIM

All occupational exposure to blood or other potentially infectious materials (OPIM) place workers at risk for
infection with blood borne pathogens. Blood refers to human blood, human blood components, and
products made from human blood. Other potentially infectious materials (OPIM) means, any body uid that
is visibly contaminated with blood, and all body uids in situations where it is difficult or impossible to
differentiate between body uids like saliva.
Cleaning of the dental surgery environment

Routine cleaning is important to ensure a clean and dust-free environment. There are usually many micro-
organisms present in “visible dirt”, and routine cleaning helps to eliminate these. Administrative and office
areas with no patient contact require normal domestic cleaning. Patient care areas should be cleaned by
wet mopping as dry sweeping is not recommended. The use of a neutral detergent solution improves the
quality of cleaning.
Hot water (80°C) is a useful and effective environmental cleaner. Bacteriological testing of the environment
is not recommended unless seeking a potential source of an outbreak. Any areas visibly contaminated with
blood or body uids should be cleaned immediately with detergent and water.
Additional Precautions (transmission- based)

Additional (transmission-based) precautions are taken while ensuring that Standard Precautions are
maintained and the following include:
i. Airborne precautions
ii. Droplet precautions
iii. Contact precautions
Mechanical ventilation - reduces the risks of airborne spread by removing bacteria from the patient's
room and by excluding bacteria present in the outside air from the room.
The transfer of infection by the airborne route can be controlled either by con ning the affected patient in a
separate room or by rapidly removing the internal air by forced mechanical ventilation).
112 CG-09RM-Ed2-141021
Prevention of infection spread by Direct Contact

Infection is transmitted by direct contact when the infected blood or saliva of one person comes in contact
with another person's exposed skin or mucous membrane. Direct contact is important because the skin of
the dentist's hand may not be intact due to the presence of small cuts and abrasions.
Prevention of infection spread by Indirect Contact

Indirect contact involves microbial spread through contaminated instruments, operatory equipment, or
environmental surfaces that are touched by many individuals and the HCPs during the delivery of care e.g.
patient charts, radiographs, handles, switches, doorknobs etc.
Prevention of infection spread by Contact with Airborne Microorganisms

Coughing, sneezing, or talking may also cause droplet formation. Saliva or blood may also splash or spatter
out of the oral cavity during procedures. Microorganisms suspended in air may be inhaled into the lungs or
they may also come in contact with the oral or nasal mucosa, or the eye conjunctiva.
Standard Precautions, Universal Precautions

Precautions taken to prevent cross infection are called Standard Precautions or Universal Precautions and
must be taken for all patients. It is difficult to identify high-risk patients, and many patients hide information
about infectious diseases. Standard precautions apply to all patients in health care settings, regardless of
their diagnosis or presumed infection status. The standard precautions are devised to reduce the risk of
transmission of microorganisms from both recognized and unrecognized sources of infection.
Standard Precautions are used when coming in contact with blood, body uids, secretions (except sweat),
non-intact skin and mucous membranes. In all dental work contact with saliva is expected. The saliva
frequently contains the patient's blood. Standard precautions need to be used for all patient contact.
Surface disinfection/ Environmental Infection Prevention & Control

Environmental surfaces are the surfaces or equipment that does not contact patients directly. These
surfaces may be contaminated with microorganisms if touched by the dentist or assistant during a
procedure. When these surfaces are contacted again with instruments or hands, the microorganisms
spread.
The management of clinical contact surfaces in the dental setting is accomplished either by the use of
surface barriers or the process of cleaning and disinfecting the surfaces that are not barrier-protected. While
disinfection and application of surface barriers are both effective, some surfaces are easier to cover, while
disinfection may be the best method with other surfaces. The use of barrier protection or chemical
disinfection is largely a matter of practicality and personal choice. Effectively managing clinical contact
surfaces in the dental settings uses a combination of both approaches to reduce contamination.
Environmental Barriers
The purpose of surface barriers is to prevent contamination of the surface or equipment and reduce the
need to clean and disinfect that surface or equipment before reuse. Barrier protection is the most efficient
way to protect difficult-to-clean, electronic, and smaller surfaces. Surface barriers should be used on as
many surfaces as possible, particularly on surfaces that are difficult to disinfect or access, and that are
touched frequently by gloved hands during patient care and likely to become contaminated. A variety of
barrier materials are available, such as clear plastic wrap, bags, sheets, tubing, and plastic-backed paper. Any
barrier material chosen for use on clinical contact surfaces must be impervious to both moisture and uid.

Once properly affixed to the clinical contact surface, barriers are very effective in preventing both direct and
indirect contamination.
Wrapping of aluminum foil around light handles, handpiece tubing, and on switches is easier to use than
many other barriers. After use, if the foil is not damaged or visibly contaminated, it may be cleaned,
disinfected, and autoclaved once more for use before discard. If surfaces are not covered by barriers, these
may be touched during the procedure using a barrier like cotton gauze or sterile paper, or plastic wrap. Once
used the gauze/paper/plastic should be discarded. Plastic/Cellophane over-gloves, worn over the latex
gloves, can also be used to touch non-sterile surfaces during a procedure.
Disinfectants
A surface barrier cannot effectively cover many surfaces in the dental treatment area. Clinical contact
surfaces that do not have a surface barrier, or become contaminated during removal of a barrier, should be
cleaned and disinfected after every patient contact.
An intermediate-level disinfectant is speci cally indicated when the surface is visibly contaminated with
blood, and a low-level disinfectant is not appropriate to be used on surfaces contaminated with blood.
Additionally, while low-level disinfectants may effectively inactivate blood- borne pathogens such as HIV
and HBV, they are not effective against more resistant organisms that would be inactivated with a
tuberculocidal product (an intermediate-level disinfectant). The use of a tuberculocidal agent that is
effective against nonenveloped viruses offers a broader spectrum of antimicrobial activity, a property that
is highly desirable for environmental surface disinfection in the dental practice.
Tuberculocidal Activity
Although tuberculosis is transmitted by airborne infective droplets and not transmitted by contaminated
environmental surfaces, the ability to kill Mycobacterium tuberculosis is used as a benchmark to measure
how effectively a disinfectant will kill microorganisms. Tuberculosis is a very difficult organism to kill; only
bacterial spores are more difficult to inactivate than Mycobacterium tuberculosis. Any chemical germicide
with a tuberculocidal claim (Intermediate-level disinfectant) is considered capable of inactivating a broad
spectrum of microorganisms of most concern in the dental setting, including less-resistant organisms such
as blood-borne pathogens e.g., hepatitis B and C viruses, HIV. More importantly, nonenveloped viruses such
as coxsackievirus and rhinovirus (the cause of many upper respiratory infections), human papillomavirus
(HPV, the cause of cervical and oropharyngeal cancer), and multiple species of fungi are inactivated only by
an intermediate-level disinfectant and but these organisms are not inactivated by low-level disinfectants.
Many hospital disinfectants are now available as presoaked wipes and the use of disinfectant wipes is
becoming more widespread in the health-care environment. These products offer a convenient option for
use of disinfectants and have a number of advantages. First, the wipe signi cantly limits the indiscriminate
application of any chemical agent and the chemical is only applied to the area that the wipe contacts. This
decreases human contact and the amount of chemical introduced into the environment. Wipes are also
easy to use and store. The ease of use of ready-to-use cleaning-disinfection products has the potential to
increase cleaning-disinfection compliance when compared to products that require daily preparation of
solutions.
114 CG-09RM-Ed2-141021
Pump spray bottles, in most instances, are an appropriate method of applying liquid germicides. An
advantage of a pump spray bottle is better penetration of the liquid germicide into crevices in the
equipment where wipes may not effectively contact.
DISINFECTION OF DENTAL UNITWATER LINES:

Ÿ Develop policies for disinfecting and testing dental unit waterlines.
Ÿ Ensure all staff that are responsible for disinfecting the lines and/or testing water quality,have been
trained and can demonstrate competency.
Ÿ Dental unit waterlines should be regularly disinfected to meet drinking water standards. Check the
unit manufacturer's instructions (e.g. owner's manual) for appropriate disinfectant and frequency.
Ÿ Monitor the dental unit waterlines to ensure the water meets drinking water standards (<500
CFU/mL of heterotrophic water bacteria). Check with the unit manufacturer's instructions, the
disinfectant manufacturer's instructions to determine frequency of monitoring. In-office
monitoring kits are available as are kits from commercial water testing laboratories. When using any
water quality testing kit, follow the instructions precisely being sure not to inadvertently
contaminate the testing materials since this will affect culture results.
Ÿ Discharge water and air for a minimum of 20 – 30 seconds after each patient, from any device
connected to the dental water system that enters the patient's mouth e.g., handpieces, ultrasonic
scalers, and air/water syringes. Flushing after every patient is recommended even with
antiretraction valves.
Ÿ For units using separate water reservoirs, purge the dental unit waterlines every night and whenever
units are out of service to prevent stagnant water from settling within the waterlines.
Ÿ Follow the dental unit manufacturer's instructions for replacement or other actions to repair lines
that are visibly contaminated or damaged as well as all for periodic maintenance instructions.
Ÿ It is recommended stay alert to musty odors, clogged lines, cloudy or particulates in the water as
signs of bio lm formation and to take appropriate action based on the unit and/or disinfectant
manufacturer's instructions.
Ÿ For surgical procedures such as biopsy, periodontal surgery, apical surgery, implant surgery, and
surgical extractions of teeth it is recommended to
¡ Use sterile water or sterile saline for irrigation or cooling
¡ Use sterile delivery systems that are disposable e.g. bulb syringes or that can be sterilized after
each patient.
IMMUNUZATION AND POST-EXPOSURE PROPHYLAXIS
Immunization against Viral hepatitis and Tetanus is recommended for all personnel handling waste and
infectious material with Hepatitis B vaccination/immunoglobulin if a clinic employee has not been
vaccinated against Hepatitis B
Hep. B results show insufficient antibodies, Hep. B immunoglobulin must be administered within 72 hours.
If sufficient antibodies are present, a Hep. B vaccination booster will only be required.
Atetanus injection will be required if not received within the last 5-10 years. HIV/Hepatitis C results must be
collected in person within 7 days.

Follow-up blood tests (after 1st initial blood test) will be required for
Hepatitis B 3 months after injury (titer levels)
Hepatitis C 3 months after injury, then 6 months
HIV 3 months after injury, then 6 months
Management of Healthcare Waste

A sound waste management system needs to be developed and closely monitored
Uncollected, long stored waste or waste routing within the premises must be avoided.
Training in Safe Handling of Medical Waste

i. All staff working in areas where infectious waste is handled, is trained on the hazards of waste,
management of waste and IPC. All staff shall be trained and shall use procedures recommended for
different types of waste;
a. Collection
b. Segregation at source
c. Storage
d. Transportation
ii. Hospital/Clinical waste in Punjab is regulated under the punjab Hospital Waste Management Rules,
2014. According to the rules, every clinic shall be responsible for the proper management of the
waste, through developing a 'Clinical Waste Management Plan'. The plan will be facility speci c,
containing a list of activities and quantity of required materials. Development of the plan is the
responsibility of Waste Management Officer (a designated member of the Clinic's Waste
Management Team (WMT). The plan will be reviewed and nalized by the clinic WMT and should aim to:
a. Protect public health and safety.
b. Provide a safer working environment.
c. Minimize waste generation and environmental impacts of waste treatment/disposal.
d. Ensure compliance with legislative requirements.
SEGREGATION OF CLINICAL WASTE
Risk Waste Non Risk Waste
Sharp containers for

White Bags
sharp materials
Yellow Bags
116 CG-09RM-Ed2-141021
Noti cation of Infection Prevention & Control Team

An IPC team will be put together with responsibility for the day-to-day activities of the IPC programme.
Ideally 2 members (Infection Control Officer [ICO] and/or Infection Control Nurse [ICN]) should suffice as IPC
Team Leader 1 and 2 for most facilities although in smaller facilities this could mean a single person (part or
full time) with additional IPC responsibilities. The team is responsible for the day-to-day functions of IPC, as
well as preparing the daily/monthly/quarterly/yearly work plan for review by the in charge. These
teams/individuals should be noti ed by the Dental Clinic/Surgery and should have scienti c and technical
support/responsibilities, e.g. practical supervision, evaluation of material and products, overseeing
sterilization and disinfection, ensuring the sound management of medical waste and the implementation
of training programs. Requirement of various materials will depend on the workload of the healthcare
facility. Calculation of the daily requirement of gloves, gowns, masks, etc., helps in organizing the everyday
logistics, and annual planning.
Disposal of Contaminated Waste material

Contaminated waste should be disposed in yellow biohazard bags that should line the waste bins/baskets
present in the clinic. Once lled the yellow bags should be sealed and sent for incineration.
A separate waste basket for household waste should also be present in the clinic next to the yellow
contaminated waste bin/basket for collection and disposal of Non-contaminated items.
Contaminated waste items

1) Gloves and gauze pieces or cotton rolls contaminated with large amounts of liquid or semi-
liquid blood/saliva that could release such uids if squeezed.
2) Pathological waste (teeth and other body tissues)
3) Sharps (e.g., needles, scalpel blades, sutures and wires)
Handling of Sharp items and needles

There are numerous sharp items in dental surgeries that can cause needle stick injuries if not handled and
disposed properly. These sharps include: syringes, needles, local anesthetic cartridges, scalpel blades,
sutures, orthodontic wires, endodontic les, reamers or broaches. Do not recap used needles using both
hands rather use a one handed scoop technique or use a mechanical device designed for holding the
needle cap when recapping needles. Sharp items should be disposed in a puncture proof sharps box, and
not in the yellow bags
Disposal of Sharp Items

All these sharp items should be disposed in sharp containers that are impervious to puncture. These are
commonly made of thick plastic and should be sent for incineration when 2/3rd full.

Standard 22. IPC-1: The clinic has a well-designed, comprehensive and coordinated
infection control system aimed at reducing/eliminating risks to
patients, visitors and care providers

Score Score
The infection control plan is documented which aims

Ind 63. at preventing and reducing the risk of nosocomial / 10 100%
cross-infections
The clinic has designated staff and de ned

Ind 64. responsibilities for infection control and waste 10 100%
management activities
The clinic has appropriate consumables, collection and

Ind 65. handling systems, equipment and facilities for control of 10 100%
infection
ALL staff involved in the creation, handling and disposal

of dental/clinical waste shall receive regular training and
Ind 66. 10 100%
ongoing education in the infection control and safe
handling of waste
Total 40
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________
118 CG-09RM-Ed2-141021
Standard 23. IPC-2: There are documented procedures for sterilization

activities in the clinic
Indicators (67-69):
Ind 67. There is adequate space available for sterilization activities
Survey Process:
The de nition of 'adequate' includes enough space as speci ed by the manufacturer of the sterilizing
equipment and sterilization activities (separated or at least by physical barriers) to ensure separation of 'clean'
and 'dirty' areas. Cleaning and washing of the contaminated used instruments is not allowed recommended
inside the dental unit area/surgery. Separate rooms or physically separated areas in a larger room for cleaning,
washing, drying & packing and for Autoclaving & storing of autoclaved/sterilized packs should be available.
i. Separate room or physically separated space as speci ed by the manufacturer of sterilizing
equipment/autoclave.
ii. Well-demarcated areas for processing of contaminated and non- contaminated instruments.
Scoring:
If there is adequate space including clear separation of 'clean' and 'dirty' areas with adequate barriers,
If there is no separation or if it is inadequate then score as not met.
Ind 68. Regular validation tests for sterilization are carried out and documented
Survey Process:
This is an important patient safety issue. Review the procedure to validate that complete sterilization has
occurred. This should be uniformly done on each batch that is sterilized. There are several methods such as color
change strips etc. Whatever method is used, it must be effective and documented. Observe that the date of
sterilization and expiry are clearly indicated on the packaging.
i. Complete sterilization process is documented for each batch that is sterilized that can be con rmed by
using color change strips etc.
ii. Date of sterilization and expiry are clearly indicated on the packaging.
Scoring:
If there is a procedure to verify that complete sterilization has occurred, it is used for ALL batches that are
sterilized, it is documented and sterilization and validity dates are indicated, then score as fully met.
If there is no procedure, or if it is rarely (once a day) used, which includes monitoring of autoclaving
through validation tests or if it is not documented, or dates are not indicated, then score as not met.
There is an established procedure for recall in case of breakdown in the

Ind 69.
sterilization system
Survey Process:
Review any written recall procedure employed in case of breakdown of sterilization system. If an actual
breakdown had occurred, review how the recall was implemented. Check to see if staff members are aware and
receive training in the procedure.
i. Documented recall system is employed in case of breakdown of sterilization system.
ii. Staff members are aware and trained on recall procedure.
iii. Recall procedure if employed in case of breakdown of sterilization system is documented.
Scoring:
Score as fully met if a written recall procedure exists and staff is aware of it.
If there is no written recall procedure, then score as not met.
Guidelines
Documented Layout and Processes
The de nition of 'adequate' includes enough space (or at least physical barriers) to ensure separation/well
demarcated areas for handling of contaminated and non-contaminated instruments considering the
workload. The de ned Sterilization department/area should have provision to physically separate the areas
where instruments undergo different steps of sterilization. These include:
i. Sorting of instruments:
This step helps to identify the instruments cleaning technique that can be classi ed as;
a. Critical Instruments
Critical instruments are those used to penetrate soft tissue or bone, or enter into or contact
the bloodstream or other normally sterile tissue. They should be sterilized after each use.
Critical instruments include forceps, scalpels, bone chisels, scalers and surgical burs.
b. Semi-critical Instruments
Semi-critical instruments are those that do not penetrate soft tissues or bone but contact
mucous membranes or nonintact skin, such as mirrors, reusable impression trays and
amalgam condensers. These devices should also be sterilized after each use. In some cases,
however, sterilization is not feasible and, therefore, high-level disinfection is appropriate.
c. Non-Critical Instruments
Objects that are in contact with intact skin. Low-level disinfection is required. These items are
less likely to spread infections, except when contaminated with pathogens by the hands of
health-care personnel. They require rigorous cleaning, washing and disinfection, and hands
must be washed after handling them.
ii. Rinsing and scrubbing:

Remove debris and residue from the instruments by rinsing them under sterile water and using a
toothbrush or other scrubbing tools.
Mix proper amounts of sterile water and enzymatic detergent in a clean container large enough to
hold the instruments. The proper ratio of enzymatic detergent and sterile water will be determined
and followed as per manufacturer's instructions.
Place the instruments in the container with the enzymatic detergent and sterile water formula,
making sure that they are fully covered by the solution.
Soak the tools in the solution for 20 minutes to effectively sterilize the instruments before reuse.
120 CG-09RM-Ed2-141021
iii. Disinfection:
Many disinfectants are present commercially and should be used with the given guidelines:
Disinfectant should be mixed with sterile water in proper ratio to ensure disinfection.
The contaminated instruments should be soaked in the solution for the prescribed time.
iv. Washing:
All disinfected instruments are washed carefully not leaving behind any debris.
v. Drying:
Drying can be either done by spreading instruments in rows on a towel or by drying it separately
with a piece of cloth. Wet instruments should not be packed.
vi. Packaging:
Different sizes of sterilization pouches are available commercially. Over-packing should be avoided
Pouches should be sealed properly.
vii. Storage after sterilization:

The pouches should be inspected to ensure complete closure of the package before and after
sterilization.
Storing sterilized equipment in open environments, such as open shelves, resulted in faster
microbial penetration than storing in closed cabinets with dustcovers. It is recommended to store
sterilized packages in reserved closed cabinets. Storage environment may cause sterilization breach
and contamination of instruments.
Barrier efficiency of packaging material should be evaluated by visual evidence of compromised
packages through:
Ÿ Tears
Ÿ Holes
Ÿ Rupture of Seals and Closures
Ÿ Wetness
Ÿ Crushed Packages
Ÿ Storage conditions(Temperature and humidity control)

Sufficient space as recommended by the Original Equipment Manufacturer (OEM) shall be provided for
autoclave and associated equipment.
Autoclave efficacy is highly dependent on time, temperature, and pressure, and these parameters can be
manipulated and optimized to create speci c sterilization cycles for each application.
Monitoring of Sterilization:
Monitoring is a quality assurance procedure used to ensure that the autoclave reaches adequate
temperature for an adequate holding time to complete sterilization.
Each autoclave should be validated every 40 operating hours. See the “Cumulative Time” on the Autoclave
Operation Log to determine when validation is necessary.
Each time the autoclave is validated, the date of validation, pass/fail and other relevant information should
be noted on the Autoclave Validation Log.
When the cumulative time reaches 38-40 hours, a validation test must be performed.
The sterilization procedure should be monitored routinely by using a combination of mechanical, chemical,
and biological indicators to evaluate the sterilizing conditions and indirectly the microbiologic status of the
processed items.
Mechanical Indicators
The mechanical monitors for steam sterilization include the daily assessment of cycle time and temperature
by examining the temperature record chart (or computer printout) and an assessment of pressure via the
pressure gauge.
Chemical indicators
These indicators undergo a chemical change when exposed to ''Time – Steam – Temperature (TST)''.
Chemical indicators are convenient, inexpensive, and indicate that the item has been exposed to the
sterilization process. Chemical indicators should be used in conjunction with biological indicators, but
based on current studies should not replace them because they indicate sterilization at marginal
sterilization time Therefore, only a biological indicator consisting of resistant spores can measure the
microbial killing power of the sterilization process.
Chemical indicators usually are either heat-or chemical-sensitive inks that change colour when one or more
sterilization parameters are present.
External/Internal indicator - Tape/ Test strips

These indicators are used only to identify packages that have been through a sterilization process.
Autoclave indicator tape consist of yellow indicator stripes and pressure-sensitive adhesive. When the
steam sterilization is completed, colour of the indicator strips will turn from yellow to dark brown or black.
Test strips also indicate the same.
122 CG-09RM-Ed2-141021
The Bowie-Dick test is performed to assess air removal efficiency in steam sterilizers used in pre-vacuum
sterilization cycles. It detects air leaks and inadequate air removal.
S.M.A.R.T. PACK II S.M.A.R.T. PACK II S.M.A.R.T. PACK II
New Test Paper Failed Test Result Passed Test Result

(all Blue) (half blue/half black) (all black)
A commercially available Bowie-Dick test sheet is placed in the center of the package. The test package is
placed horizontally in the front, bottom section of the sterilizer rack, near the door and over the drain, in an
otherwise empty chamber. The test is run at 134°C for 3.5 minutes. The test is performed each day the
vacuum-type steam sterilizer is used, before the rst load is processed. Air that is not removed from the
chamber will interfere with steam contact the sterilization process. They should be representative of the
load and simulate the greatest challenge to the load. Sterilizer vacuum performance is acceptable if the
sheet inside the test package shows a uniform color change. Entrapped air will cause a spot to appear on the
test sheet, because the steam is unable to reach the chemical indicator.
If the sterilizer fails the Bowie-Dick test, do not use it until it has been inspected by the maintenance
personnel and passes the Bowie-Dick test.
Biological indicators
Biological indicators are recognized by most authorities as being closest to the ideal monitors of the
sterilization process because they measure the sterilization process directly by using the most resistant
microorganisms (i.e., Bacillus spores), and not by merely testing the physical and chemical conditions
necessary for sterilization.
The use of biological monitors (spore tests) is the most reliable method to validate that the sterilizer is
functioning and that the sterilization of instruments is effective. These monitors consist of paper strips or
vials impregnated with bacterial spores that are speci cally resistant to the sterilization process. These tests
allow quick remediation and validate proper infection control procedures without a long lag time during
which the sterilization procedure may have become ineffective but is not known.
Record of Validation Tests

Documented processes/procedures should be there to provide guideline for complete sterilization. This
should be uniformly done on each“batch”that is sterilized. There are several methods that can be used (such
as colour change strips). Every method used must be documented and effective. The date of sterilization
and expiry are clearly indicated on the packaging. This should be done by accepted methods, e.g.,
bacteriologic, strips, etc. Engineering validations like Bowie Dick tape test and leak rate test need to be
carried out. WHO recommends each load to have number, content description, temperature, pressure and
time-record chart, physical/chemical tests daily, weekly biological tests and steam processing.

For further reference regarding sterilization and Cross-infection Control in Dentistry, the following report
originated in the National Center for Chronic Disease Prevention and Health Promotion, United States,
provides a detailed and comprehensive report and the guidelines given in this document are very useful for
practicing dentistry.
CAUSES OF STERILIZATION FAILURE

i. Choosing the Wrong Cycle for Autoclave Contents
ii. Inappropriate Cleaning, Packaging
iii. Improper or Overloading
iv. Poor Steam Quality
v. Vacuum Failure
vi. Inadequate Temperatures
Breakdown Recall
Like all other healthcare settings, the Dental Clinic/Surgery should develop and maintain a written recall
procedure and the staff members should be trained on these procedures. The Dental Clinic shall ensure
that the sterilization procedure is regularly monitored and in the eventuality of a breakdown it has a
procedure for withdrawal of such items. A batch processing system with date and machine number for
effective recall should be in place. Whenever a breakdown in the sterilization system is noted, all packs
sterilized by the faulty machine should immediately be called back from the respective areas where the
sterile packs has been supplied and should be sent for re-sterilization using a proper machine/technique.
The IPC Team shall ensure that Clinical IPC policies are consistent with contemporary provincial/national
guidelines and shall conduct IPC audit periodically e.g., at least monthly in areas where materials are
reprocessed to ensure policy compliance. Any breaches in the policy should be documented and corrective
action instituted.
SHELF LIFE OF STERILIZED PACKAGED INSTRUMENTS

Many hospitals consider 30 days to be the standard time period for dating hospital wrapped sterile supplies,
principally on the basis shelf-life studies conducted by the Center for Disease Control.
The shelf life of sterilized packaged instruments can be either date-related or event-related; both are
acceptable. Date-related shelf life refers to a rst-in rst-out policy, meaning that the items that are
sterilized rst are used rst, so long as the packages have maintained their integrity.
Event-related shelf life refers to an approach that recognizes that a package and its contents should remain
sterile until some event such as tearing or moisture penetration causes the package to become
contaminated. All packages should be inspected before use to verify barrier integrity and dryness.
Standards re ect the premise that contamination is "event-related" and not "time-related", and recognize
the hospital's expertise in maintaining and delivering sterile products.
Expiry dates vary with packaging materials, but a general guideline is 1 month from the date of sterilization.
Commercially available plastic dust covers will extend the shelf life to 6-12 months.
124 CG-09RM-Ed2-141021
Standard 23. IPC-2: There are documented procedures for sterilization activities in the
clinic

Score Score
There is adequate space available for sterilization
Ind 67. 10 100%
activities
Regular validation tests for sterilization are carried out

Ind 68. 10 100%
and documented
There is an established procedure for recall in case of

Ind 69. 10 100%
breakdown in the sterilization system
Total 30
Name:__________________________________ Name:__________________________________
Date:___________________________________ Date:___________________________________

SUMMARY SHEET FOR SELF ASSESSMENT
FUNCTIONAL AREAS Max. Grading Weightage

Score Score
2.1 Responsibilities of Management (ROM) 130
2.2 Facility Management and Safety (FMS) 90
2.3 Human Resource Management (HRM) 50
2.4 Information Management System (IMS) 40
2.5 Quality Assurance (QA)/Quality Improvement (QI) 80
2.6 Assessment and Continuity of Care (ACC) 70
2.7 Care of Patients (COP) 40
2.8 Management of Medication (MOM) 60
2.9 Patient Rights and Education (PRE) 60
2.10 Infection Prevention & Control (IPC) 70
TOTAL 690
126 CG-09RM-Ed2-141021
PART 3

ANNEXURE. A: Health Related Legislation
Sr.# Health Related Laws Link to Download
1. The Punjab Healthcare Commission Act 2010 http://punjablaws.gov.pk/laws/2434.html

2. http://www.pmdc.org.pk/LinkClick.aspx? leticket
PMDC Ordinance 1962 =7AY1%2fco4suQ%3d&tabid=292&mid=850
http://www.pmdc.org.pk/LinkClick.aspx? leticket
3. PMDC (Amendment) Act 2012 =a8Uzv7NVyX4%3D&tabid=292&mid=850
4. Punjab Local Government Act 2013 Punjablaws.gov.pk/Laws/2542.html
Lahore Development Authority Amendment www.punjabcode.punjab.gov.pk/.../LAHORE%20
5. Ordinance 2013 DEVELOPMENT%20Authority
6. Civil Defense Act 1952 www.punjabcode.punjab.gov.pk/
7. The Punjab Emergency Services Act 2006 http://punjablaws.gov.pk/laws/

(Act IV of 2006)
Drug Regulatory Authority of Pakistan http://www.na.gov.pk/uploads/documents/
8. (DRAP) Act 2012 1352964021_588.pdf
http://www.dra.gov.pk/user les1/ le/FFMedical
9. Medical Devices Rules 2017 DevicesRules2017Noti edon16-01-2018.pdf
Drug Labeling & Packaging Rules 1986 http://www.healthkp.gov.pk/downloads/

10. Druglabeling.pdf
11. The Punjab Blood Transfusion Safety Act 2016 http://punjablaws.gov.pk/laws/2664.html
(Act Xlvi Of 2016)
12. THE PUNJAB HEPATITIS ACT 2018 (Act XII of 2018) http://punjablaws.gov.pk/laws/2704.html
13. The Punjab Environmental Protection Act 1997 http://punjablaws.gov.pk/laws/2192a.html
amended in 2009
https://epd.punjab.gov.pk/system/ les/Punjab%
14. Punjab Hospital Waste Management Rules 2014 20Hospital%20Waste%20Management%20Rules
%2C%202014.pdf
Injured Persons (Medical Aid) Act 2004 http://www.punjablaws.punjab.gov.pk/public/dr/

15. (XII Of 2004) INJURED%20PERSONS%20(%20MEDICAL%20AID
%20)%20ACT,%202004.doc.pdf
http://punjablaws.punjab.gov.pk/public/dr/DISA
16. The Disabled Persons Ordinance 1981 BLED%20PERSONS,%20(EMPLOYMENT%20AND%
20REHABILITATION)%20ORDINANCE,%201981.doc.pdf
17. The Punjab Food Authority Act 2011 http://punjablaws.gov.pk/laws/2460.html
http://www.punjablaws.punjab.gov.pk/public/dr
18. The Hazardous Occupations Rules 1963 /WEST%20PAKISTAN%20HAZARDOUS%20OCCU
PATIONS%20(LEAD)%20RULES,%201963.doc.pdf
128 CG-09RM-Ed2-141021
Sr.# Health Related Laws Link to Download
19. The Punjab Forensic Science Agency Act 2007 http://punjablaws.gov.pk/laws/492.html
http://www.fmu.gov.pk/docs/laws/Control%20of
20. Control of Narcotics Substance Act 1997 %20Narcotic%20Substances%20Act.pdf
http://www.punjablaws.punjab.gov.pk/public/dr
21. The Medical & Dental Degrees Ordinance 1982 /THE%20MEDICAL%20AND%20DENTAL%20
DEGREES%20ORDINANCE,%201982.doc.pdf
22. Provincial Employees Social Security http://punjablaws.gov.pk/laws/187.html
Ordinance1965
23. The Epidemic Diseases Act 1958 http://punjablaws.gov.pk/laws/90.html
http://punjablaws.punjab.gov.pk/public/dr/THE%
24. Boilers and Pressures Vessels Ordinance 2002 20BOILERS%20AND%20PRESSURE%20VESSELS%
20ORDINANCE,%202002.doc.pdf
25. The Punjab Health Foundation Act 1992 http://punjablaws.gov.pk/laws/386.html
26. The Punjab Consumer Protection Act 2005 http://punjablaws.gov.pk/laws/477.html

http://www.punjablaws.punjab.gov.pk/public/
27. The Pakistan Nursing Council Ac 1973 dr/THE%20PAKISTAN%20NURSING%20COUNCIL
%20ACT,%201973.doc.pdf
Pharmacy Council Act 1967 http://www.pmdc.org.pk/LinkClick.aspx? le

28. ticket=j9LEQikCYbs%3D&tabid=102&mid=588
http://www.punjablaws.punjab.gov.pk/public/dr/
29. The Unani Ayurvedic And Homeopathic UNANI,%20AYURVEDIC%20AND%20HOMOEOPA
(Practitioners) Act 1965 THIC%20PRACTITIONERS%20ACT,%201965.doc.pdf
http://www.dra.gov.pk/gop/index.php?q=aHR
Drugs Act 1976 0cDovLzE5Mi4xNjguNzAuMTM2L2RyYXAvdXNl
30. cmZpbGVzMS9maWxlL2RvY3MvVGhlRHJ1Z3N
BY3QxOTc2LnBkZg%3D%3D
Pakistan Nuclear Regulatory Authority (http://www.pnra.org/upload/legal_basis/

31. Ordinance 2001. Ordinance%202001(Amennded).pdf)
Regulations on Radiation Protection (PAK/904) (http://www.pnra.org/upload/legal_basis/RP%
32. as amended from time to time 20Regulations%20PAK-904.pdf )
http://phkh.nhsrc.pk/sites/default/ les/201911/
32. PMC Act 2019 Pakistan%20Medical%20Commission%20Ord%
202019.pdf

ANNEXURE. B: Equipment History Sheet
HISTORY SHEET
S/no. Description
1. Name of Equipment
2. Date of Purchase
3. Cost of Equipment
4. Name and Address of Supplier
5. Date of Manufacture
6. Date of Installation
7. Department where Installed
8. Environmental Control*
9. Spare Parts Inventory
10. Technical Manual/Circuit Diagrams/Literature
11. After Sale Service Arrangement
12. Warranty Period
13. Life of Equipment
14. Depreciation per year
15. Charges of Tests**
16. Use Coefficient***
17. Down-time/Up Time
18. Cost of Maintenance
19. Date of Condemnation
20. Date of Replacement
21. Other Relevant Remarks
*Proper environment control in terms of temperature, lighting and ventilation should be ensured and
recorded, wherever applicable.
**Wherever applicable, charges of tests must be speci ed.
***Should be applied to assess the utilization of equipment.
130 CG-09RM-Ed2-141021
ANNEXURE. C: Sample Equipment Service History Form
Sample Equipment Service History Form
Name of Facility EQUIPMENT FUNCTION

Location
Deaprtment
Date
Name of Equipment: Approved by:
Installed:
Manufacturer: Manuals:
Power:______ v Freq. of P.M:
Distributor:
_____a no. of wires:
Model Number: Type of Enclosure: Remarks:
Serial Number: Type of Plugs:
W.O LEAKAGE WORK Total Labour Parts

Date C/P Work By Remarks
N.O. GRD O.GRD DONE Hours Cost
C = Curative repair P = Preventive repair Leakage = Leakage current

ANNEXURE. D: Equipment Log Book
Log Book
Description
Validity Period of Date of Details of
S/no. Name of Equipment Warranty Date of Cost
Maintenance Repair Preventive
Period Breakdown Incurred
Contract Maintenance
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
132 CG-09RM-Ed2-141021
ANNEXURE. E: Orientation Guideline

General Orientation
Once the selection process is completed, the new employee must be oriented in order to improve his/her
ability to perform the job and also to satisfy the personal desire and feeling that he/she is a productive
contributor and part of the organization's social fabric. Supervisors, in coordination with the human
resource (HR) department, complete the orientation by introducing the new employee to the co-workers.
Every dental clinic should recognize that its success and the quality of care provided by it depends upon the
capacities of its staff and shall design a comprehensive induction orientation program as an integral
component of their capacity building. The hospital's induction and orientation processes will provide the
information, guidance and support required for staff to undertake their assigned responsibilities and to
succeed in their new role. This will be achieved by familiarizing the new staff with the signi cant policies,
systems, procedures, governance structure and the work location, and encouraging commitment to the
vision, mission and values of the HCE.
The 'Balanced Score Card' (Corporate Finance, Treasury and Risk Management) approach is a good start
towards implementing performance management systems in any organization which must be explained to
the employees at the induction, in order to align their daily activities with the overall organizational goals
(the mission). The new employee should be briefed about past achievements, in terms of services provided,
future objectives, plans and targets so as to create a positive image about the organization. General
responsibilities towards the institution and as to what the staff will be required to do, should be explained to
the employee.
1. Policy
The aim of the policy is to specify a program to introduce new joiners to the organization, work
colleagues, its culture and environment. All new employees will go through an induction orientation
program designed by the HR Department, which should include the following:
i. The vision, mission, values, objectives and policies of the dental clinic/surgery
ii. Overview of the organizational structure, systems and key processes
iii. Brief on key processes of the relevant department
iv. Description of the dental clinic's specialty and target population
2. Procedure
At the time of joining the dental clinic, the employee will submit photocopies of his/her past
credentials to the designated HR representative who will complete the following necessary
documentation and will get signatures of the employee where necessary:
i. Appointment letter
ii. Joining report
iii. Statement of ethics (Annexure-D)
iv. Con dentiality agreement
v. Reference forms for at least two referees will be lled by the employee (referees must not be
blood relations)
vi. Employee will ll a Health Questionnaire Form

After completion of documentation, the designated HR person will brief the employee about the vision,
mission, values, objectives, policies of the dental clinic/surgery and will issue the Employee Handbook to
him/her in order to study all the policies in detail. The employee will also be introduced to all the colleagues
through a physical tour of the HCE.
The Employee Handbook should ideally contain the following:
i. Mission statement, values and goals of the organization.

ii. Standard Code of Conduct to follow (towards a client, for communication, teamwork,
maintaining sense of accountability, appearance, etc.).
iii. Expectations from employees and their responsibilities, such as to keep personal business to
a minimum, reporting procedures and personnel, disciplinary action to be taken in various
situations.
iv. SOPs to follow in the respective departments and in emergency situations.
v. Efficient and safe use of equipment with regards to health and safety standards.
vi. Information regarding employee bene ts schemes and special recognition criteria, etc.
After orientation, the HR representative will issue an orientation checklist to be lled by the employee
giving feedback about the orientation. The checklist will be led into the record of the employee and
feedback will be used for required improvements in the orientation program.
134 CG-09RM-Ed2-141021
ANNEXURE. F: Statement of Ethics
1) We do not make misleading claims for our services or criticize our competitors before clients. We only
believe in servicing our client's needs to the best of our efforts.
2) We perform our work according to the speci ed quality standards
3) We avoid con icts of interest either of a nancial or personal nature; these could compromise the
objectivity and integrity of our work.
4) We exercise our professional judgment impartially while taking any decisions related to work, keeping
all pertinent facts, relevant experience and the advice of our management in mind.
5) We hold the affairs of our clients in the strictest con dence. We do not disclose personal information
during service provision or derive bene t from using information outside the clinic.
6) We act with courtesy and consideration towards all with whom we come into contact in the course of
our professional work.
7) We do not accept any favors, gifts or inducements, including undue hospitality and entertainment, from
the clients. The only expectations would be if the gifts are of promotional nature (diaries, calendars, etc.)
or of a nominal value, the indulgence of which would not damage the doctor's/clinics reputation.
8) We are fully committed to the principle of equality and non-discrimination on the grounds of disability,
gender, age, race, color, ethnicity, origin or marital status. We do not indulge in any intimidation and
harassment of any sort at work.
9) We will communicate with our clients and its representative in an effective and timely manner.
10) We would be perceived by clients and other thought leaders as setting the standards in client focus and
client service among professional service companies.
Declaration
I have read and understood the “Statements of Ethics” and stand committed to it.
Signature:
Name: Date of Joining:

ANNEXURE. G: Template of JD
Components of a Job Description
i. Job Code. It is a speci c number assigned to the document e.g. 001, 004, etc.
ii. Position Name. It is exactly the title which the employee will use and conveys the main function
of the job/position.
iii. Physical location and surroundings. This description provides information about the place where
a particular dental clinic/surgery is located and what are its surroundings and communication links.
iv. Reporting. Name of the authority to whom the employee has to report.
v. A Summary statement. It includes the scope of duties.
vi. Functions of the position. It provides details of what the job actually entails and can be quite
speci c. It should also provide any supervisory functions in addition to being as speci c as possible
while describing tasks the employee will face every day. This is also the best place to indicate
whether the person will deal with customers, the public or only internal employees. This section can
also be used to prioritize the activities.
vii. Attributes needed for the position. If the position involves the use of machinery (or computers),
spell out what type of machines or software the employee will use. Also detail any technical or
educational requirements that may be critical or desired. This will also provide an insight into the
type of work environment to be maintained.
viii. Reporting. Provide details on the reporting and organizational structure to help the employee
better understand how their activities t into the total organization.
ix. Compensation. Including a grade/range instead of a speci c gure will give you more exibility, but
most people will feel they should be at the top of the range. It is usually better to have a speci c
amount, especially when the job description is being given to the employee.
x. Evaluation criteria. This section will de ne what is most important for the organization as well as
the employee in speci c terms. The evaluation criteria of the position will promote the type of
activities to enhance the success of the business and will also provide details on when evaluations
will take place.
xi. Acknowledgment. This includes the signatures of the authorized person of the dental
clinic/surgery, who usually is Manager HR/HOD/MS/CEO, and the employee, to con rm that he/she
has read and is aware of the JD.
136 CG-09RM-Ed2-141021
JDs and Performance Evaluation Criteria - 2008-2009 for the employees in the Public Sector Hospitals of
Health Department Government of Punjab were developed by the PDSSP, taking into account the above
mentioned parameters and service package provided for the Primary and Secondary Healthcare in Punjab.
The JD of a senior dental surgeon at THQ Hospital is given below as a sample. JDs of all other categories of
hospital staff can be seen in the above referred and noti ed document ⁷ These JDs c n be used s guidelines
nd m di ed t suit the l c l requirements f the priv te sect r h spit ls clinics etc
Sample Job Description
Senior Dental Surgeon

Job Code :
Job Title : Senior Dental Surgeon
Quali cation & Experience : BDS and FCPS/MDS (if person possessing FCPS/MDS is not available,
then MCPS or other equivalent quali cation recognized by PMDC)
BPS: 18
Recruitment: Initial/Transfer
Position Type: Full Time
Dress Code :
Jurisdiction : THQH
Reports to : MS
Job Summary
In-charge of the dental unit for deliverance of optimal standard of dental care. Scope of work includes
dental OPD, admission of patients needing indoor dental care, care of admitted patients and planned
procedures on speci c days (only applies to OMFS department).
Duties/Responsibilities
I. Curative/Clinical
a. Overall in charge of the dental OPD and admitted patients.
b. Conducts dental OPD regularly on noti ed days and time.
c. Reviews referrals by MOs/other specialists and from the lower facilities to establish
diagnosis and proper management.
d. Plans and performs procedures e.g. RCT, surgical extraction, IMF, etc. on speci ed days
and time as per hospital policy.
e. Performs emergency dental procedures on patients admitted through A&E.
Department as and when required.
f. Writes post procedural notes and instructions for each case.

g. Takes one planned round of the wards daily along with doctors and staff nurse to
review/follow-up the old cases and examines in detail the newly admitted. Round is
repeated if required (only applies to OMFS department).
h. Ensures that treatment prescribed is being administered to the patients.
i. Ensures availability of medicines/functioning of equipment to handle emergencies at
all times in the unit.
j. Exercises authority for discharge of patients from the ward/emergency.
k. Explains the patients about the use and effects of prescribed drugs.
l. Refers the patients to other specialists within the hospital and/or to higher level
facilities if needed.
ii. Preventive/Promotive
a. Ensures compliance of SOPs particularly on infection control and waste management
in the OPD, dental clinics and surgical wards.
b. Ensures that instruments/equipments being used in examinations and procedures are
properly sterilized.
c. Ensures that all staff participating in the procedures are physically well protected by
wearing of proper dress i.e. gowns, masks, caps, gloves and shoes.
d. Provides educational information about common diseases and ways to promote
physical health.
iii. Rehabilitative
a. Provides psychological, social and nutritional rehabilitative measures to patients if required.
b. Teaching/Supervision.
c. Trains dental, nursing and paramedical staff as per departmental/specialty
requirements/ protocols and work instructions.
iv. General
a. Checks the cleanliness and up keep of the unit.
b. Ensures that responsible staff regularly upkeeps and maintains electro-medical
equipment of the unit to ensure their functionality at all the time.
c. Ensures that responsible staff is regular in supply/replenishments of medicines and
stores.
d. Provides technical assistance to the management for purchase of new equipments/
instruments needed from time-to-time for the unit.
e. Ensures the preparation and implementation of the duty roster for his unit.
f. Checks that the subordinate staff performs their duties as per JDs, SOPs and SMPs.
g. Writes objective Performance Evaluation Reports of subordinate staff.
h. Performs outreach duties to lower facilities as required.
i. Performs any other professional duty assigned by higher authorities.
I have read and accept the job description. Signature of the incumbent:
138 CG-09RM-Ed2-141021
Using JDs helps a dental clinic to better understand the experience and skill base needed to improve service
delivery. They help in hiring, evaluation and termination of employees when required. Quite often, there is a
misunderstanding of what a position entails and in that case, a well-prepared job description can help both
sides share a common understanding.
Frequency of Performance Appraisals

Customarily this is done within rst 3-4 months (probation period) for new employees and at least annually
for ALL other employees in the public sector. The HCE/dental clinic can de ne the frequency of performance
appraisals as it suits.
I. Responsibilities
The HR Department must have well-de ned JDs for each category of staff, which will also be an
important component of the respective personal le duly signed by the employee.
ii. Rights
The rights of the staff member should be detailed in the employee manual maintained by the HR
department which should also be shared with the employee/s.
iii. Patients' Rights
The rights and responsibilities of the patients are available as Patient Charters (Section 2.9
PRE-Annexure-H).
The following points regarding the rights and responsibilities of employees are to be considered:
a. Staff members may have cultural, religious or personal con icts concerning their
involvement with speci c components in the care or treatment of patients. The dental
clinic shall provide a mechanism for employees' to submit their requests for review of work
assignments by their HoD. However, the continuum of patient care services shall be
ensured at all levels.
b. The HoD, manager or supervisor shall make every effort to accommodate the request and
maintain the duties referenced in the employees' JD.
c. The HoD, manager or supervisor shall reassign duties, if reasonable and possible, to
accommodate the request and meet the needs of the patient.
d. Response to all requests for reassignment of duties, whether approved or denied will be
provided in writing to the employee.
e. A record of all requests and actions taken shall be maintained in the employee's
departmental le.
f. If the request of the staff member cannot be granted, the employee may appeal to the next
higher authority to review the request. The decision of the human resources department
shall be nal to the extent of respective request.
Similarly, the staff is to be apprised about the rights and responsibilities of the patients and the dental clinic,
as provided as part of Annexure-H.

ANNEXURE. H: PHC Charters
PHC CHARTER FOR PATIENTS AND OTHERS
Part A: Rights of Patients and Others

A patient/client or his carer, as the case may be, or any other person to whom healthcare services are being
rendered, shall have a right to:
1. Health, well-being and safety;
2. Easy access to registration/help desk to get registered and be guided to the respective services as per
requirement.
3. Special arrangements for elderly people and disabled to have easy access to required health services;
4. Be attended to, treated and cared for with due skill, and in a professional manner for the highest
attainable standard of health in complete consonance with the principles of medical ethics;
5. Be made aware of the full identity and professional status of the Healthcare Service Provider(s) and other
staff providing services;
6. Be given information to make informed choices about his healthcare and treatment options and/or to
give informed consent, in terms and in a language that he understands;
7. Seek second opinion when making decisions about his healthcare, and may be assisted by the
Healthcare Establishment/healthcare service provider in this regard;
8. Accept or refuse any treatment, examination, test or screening procedure that is advised to him,
exceptions being in cases of emergencies and/or mental incapacity in accordance with the relevant law;
9. Personal health information to be kept secure and con dential;
10. Access his own medical records, including but not limited to, comprehensive medical history,
examination(s), investigation(s) and treatment along with the progress notes, and obtain copies t
hereof;
11. Not to be discriminated against because of age, disability, gender1, marriage, pregnancy, maternity,
race, religion, cultural beliefs, color, caste and/or creed;
12. Expect that any care and/or treatment being received is provided by duly quali ed and experienced
staff;
13. Expect that the healthcare service provider or the Healthcare Establishment, as the case may be, has the
capacity and required necessary equipment in order and working condition, for rendering the requisite
services, including but not limited to treatment;
14. Receive emergency healthcare, unconditionally. However, once the emergency has been dealt with, he
may be discharged or referred to another Healthcare Establishment [emergency requiring healthcare, is
a situation threatening immediate danger tolife2 or severe irreversible disability, if healthcare is not
provided urgently];
15. Be treated with respect, empathy and dignity irrespective of age, disability, gender, marriage,
pregnancy, maternity, race, religion, socio-economic status, cultural beliefs, colour, caste and/or creed;
16. Be treated in privacy and with dignity, and have his religious and cultural beliefs respected throughout
the duration of care, including but not limited to, taking history, examination or adopting any other
course of action;
17 Be made aware of procedures for complaints and resolution of disputes and con icts;
18. File a written complaint to the concerned healthcare service provider, official of the Healthcare
Establishment or such other organization/person, as the case may be and be associated throughout the
progress of the complaint and its outcome;
140 CG-09RM-Ed2-141021
19. Seek compensation if he has been harmed by, including but not limited to maladministration,
malpractice, negligent treatment, or failure on the part of a healthcare service provider or any
staff/employee or others rendering services at the Healthcare Establishment;
20. Be informed and to refuse to participate in research, or any project dealing with his disease, care and
treatment;
21. Be accompanied by a family member or carer, as the case may be, particularly in cases of
children, females, elderly and disabled. The healthcare service provider and/or the Healthcare
Establishment, as the case may be, are to ensure that in cases of children and females in the immediate
post anesthesia phase, a female staff shall be present until a family member or carer can join the
patient/client, The healthcare service provider and/or the Healthcare Establishment, as the case may be,
are also to ensure that in cases of children and females an authorized family member or a carer or if not
so possible, at least a female staff is present during physical examination and investigation procedures
where physical contact and or exposure of body part(s) is required.
22. Expect that the Healthcare service provider, the Healthcare Establishment, and/or such other person
rendering similar services, as the case may be, shall not misuse nor abuse their duciary position vis-à-
vis him or his carer(s) or family members, as the case may be, for undue favour(s) including but not
limited to sexual favour(s) or any other undue or uncalled for reward or privileges in terms of
professional fee or gifts etc;
23. Be informed as early as possible regarding cancellation and/or postponement of any appointment,
surgery, procedure, treatment or meeting, as the case may be;
24. Be made aware of the costs, fee and/or expenses, prior to the consultation, treatment or other services,
and/or operation/procedure, as the case may be, and receive payment receipt(s) for the same;
25. Be given written instructions regarding his treatment, including instructions at the time of discharge;
26. Examine and receive an explanation for the bill(s) regardless of the source of payment;
27. End of life care3;
Nothing in this Charter prevents any organization/healthcare service provider/healthcare
establishment from recognizing additional rights of the Patient/Client and/or the carer, as the case may
be. The purpose of this Charter is to inculcate and invigorate in the community the understanding and
recognition of the fact that health, care and/or treatment is a right of an individual even when he is
unborn and the same continues from his cradle to coffin. This document will be reviewed annually or
earlier, as deemed appropriate by the Punjab Healthcare Commission, in view of its experiences,
through a consultative process involving patients, former patients, family members, related
professionals, staff and other stakeholder groups.
Explanatory Notes
1. Gender includes male, female, transgender and intersex individuals.
2. Life, in the context of mental emergency, includes those of others.
3. End of Life Care includes healthcare, not only of patients in the nal hours or days of their lives,
but more broadly, care of all those with terminal illness or terminal condition that has become
advanced, progressive and incurable. Accordingly, it may so happen that no treatment may be
advisable and or given but the care should continue, keeping in view the ethics of the profession.

Part B: Responsibilities of Patients and Others
The patient/client or carer, as the case may be, is responsible to the Healthcare Establishment, its staff or the
Healthcare Service Provider for: -
1. Providing, accurate and complete information, to the best of his knowledge, regarding medical history,
including but not limited to, present medical condition and complaints, medications, allergies and
special needs, past illnesses, prior hospitalizations etc., as is required;
2. Reporting unexpected changes in his condition;
3. Adhering to the treatment plan prescribed to him;
4. Keeping appointments and when he is going to be late or is unable to do so for any reason, notify the
concerned about the same, as soon as possible;
5. Taking responsibility for his actions if he refuses treatment or does not follow the given instructions;
6. Ensuring that the nancial obligations of his care are ful lled as promptly as possible;
7. Following the Healthcare Facilities' Rules and Regulations relating to patient care and conduct of others,
including carers and or visitors;
8. Behaving in a courteous and polite manner which is non-threatening;
9. Refraining from conducting any illegal activity while he is at their premises;
10. Informing of any change of address and other requisite information.
PHC CHARTER FOR HEALTHCARE ESTABLISHMENTS

Part A: Rights of Healthcare Establishments/Healthcare Service Providers
The Healthcare Establishment or the Healthcare Service Provider, as the case may be, shall have the right to: -
1. Collect accurate and complete information from the patient/client or carer, to the best of his knowledge,
regarding medical history including but not limited to, present medical condition and complaints,
medications, allergies and special needs, past illnesses, prior hospitalizations etc., as is required;
2. Require the patient/client to follow treatment instructions, including the written instructions explained
at the time of discharge;
3. Require all patients to abide by its rules and regulations regarding admission, treatment, safety, privacy
and visiting schedules etc.;
4. Limit visiting hours and number of visitors in the best interest of the patient/client and that of the others
in the Healthcare Establishment;
5. Limit number of carers in the best interest of the patient/client, and that of the others, while keeping in
view the special needs of particular patients, for example, minor children, women, elderly and/or
seriously ill patients;
6. Be timely noti ed by the patient/client regarding cancellation of appointment, consultation,
procedure, surgery, etc. or delay in his arrival at the Healthcare Establishment;
7. Require the patient/client and/or carer(s) to cooperate with Healthcare Establishment staff in carrying
out assessments, prescribed investigations and treatment procedures.
8. Require from the patient/client or carers and visitors, as the case may be, to understand the role and
dignity of the Healthcare Establishment, its staff and/or the Healthcare Service Provider, as the case may
be, and treat them with due respect at all times;
9. Report and take legal action against the patient/client and/or his carer(s), visitors, in case of harassment
of its staff, damage to its property and disturbance to other patient(s), as the case may be;
142 CG-09RM-Ed2-141021
10. Demand abstinence from the use of violent and disruptive behaviors or language abuse and take
appropriate legal action in case of breach;
11. Prohibit smoking and/or substance/drug abuse on the premises and take appropriate legal action in
case of breach;
12. Limit its liability for misplacement or theft of valuables and belongings of the patient/client, carer and
visitor;
13. Be paid for all services rendered to the patient/client, either personally or by the carer or through the
third party, e.g. insurance company.
14. Be noti ed of any change of contact, address and other details of the patient/client, as the case may be;
15. Ask for information from the patient/client regarding its services for the purposes of improving the
healthcare services/systems within the Healthcare Establishment;
16. Maintain and utilize the data collected from the patient/client, subject to the principles and law relating
to con dentiality, for the purposes of improving the healthcare services/systems within the Healthcare
Establishment;
17. Ensure that while using the available facilities and equipment, due care and caution is taken by the
patient/client and/or their carers and visitors, as the case may be.
The Punjab Healthcare Commission while recognizing the fact that each Healthcare Establishment is a “House
of Hope” where advice and treatment, including other services, are rendered to the public at large, has
developed this Charter of Rights for all Healthcare Establishments/Healthcare Service Providers in the Province
of Punjab. All these rights are to be exercised with a view to make better services available to the masses.
The Punjab Healthcare Commission further assures that it stands committed to the cause of the Healthcare
Establishments/Healthcare Service Providers in the exercise of these rights and shall always be ready and
willing to support in the implementation and enforcement of the rights envisaged herein. This document will
be reviewed annually or earlier, as deemed appropriate by the Punjab Healthcare Commission, in view of its
experiences, through a consultative process involving patients, former patients, and family members, related
professionals, Healthcare Establishments/Healthcare Service Providers, staff and other stakeholder groups.
Part B: Responsibilities of Healthcare Establishments/Healthcare Service Providers

The Healthcare Establishment or the Healthcare Service Provider, as the case may be, shall be responsible for:-
1. Ensuring the safety of patient/client.
2. Establishing such systems which enable easy access to services as are required by the patient/client.
3. Maintaining the services being provided through fully competent professionals.
4. Establishing systems to ensure that the rights of the patient/client and others are enforced and fully
protected.
5. Adopting open policies regarding its procedures in relation to treatment of the patients/clients
including but not limited to, their care and complaints etc.
6. Invigorating in their staff including but not limited to, Consultants and other professionals rendering
services at the Healthcare Establishment, the importance and thorough practice of professional ethics.
7. Complying with all the governing laws, rules and regulations while operating, maintaining and
rendering services.

ANNEXURE. I: Weeding of Old Record
144 CG-09RM-Ed2-141021
ANNEXURE. J: Sample Authorized Personnel List
Sr.# Particulars & Appointment Authorization Initials Signatures Stamp
1. Prof. Dr. ___ (HOD Surgery)
2. Dr. _____ (Registrar)
3. Dr.________ (PG Trainee)
The organization must provide the individual signatories

ANNEXURE.K: Sample Client Satisfaction Form
Sr.# Questions Response

1. Are you satis ed with the services, behavior of
staff and the environment at clinic ABC
________________? Yes No
2. If YES, how? (You can circle more than one 1. Complete information provided
response and write below) 2. Services available when needed
3. Services are affordable
4. Convenient to reach the facility
5. Staff is courteous
6. Relevant staff is available
7. Privacy is observed
8. Female staff is available
9. My condition improved after treatment
10. Other (specify) _________________________
3. If NO, why? (You can circle more than one) 1. Issues of con dentiality
response and write below) 2. Issues of privacy
3. Lack of attention
4. Inadequate information provided
5. I was asked to come another time without
examination
6. Medicines/Services are costly
7. Waiting time is too long
8. Staff is discourteous/unsatisfactory behavior
9. Staff is not competent
10. Relevant staff NOT available
11. Female staff NOT available (gender issue)
12. I suffered from side effects of the treatment
13. Relevant staff NOT available
14. Other (specify) _________________________
Signature of patient/relative:
Action by the person in-charge with date:
146 CG-09RM-Ed2-141021
ANNEXURE. L: HCE Performance Measuring Checklist for In-charge
1. Name of HCE:
2. Name of in-charge:
3. Date & time of inspection:
Daily/Weekly Monitoring Tasks Observation Recommendation
4. General cleanliness
5. Washroom cleaned/functional
6. Drinking water available
7. Seating arrangement for patients
8. UPS/Generator/Emergency light functionality
9. Staff attendance register/Biometric/Movement register/Leave register
10. Staff wearing identi cation badges
11. Emergency room ready/drug list/essential supply
12. Oxygen cylinder lled/ready (where applicable)
13. Clinic waste segregated and disposed of properly
14. Sterilization/Hand washing facilities
15. Daily expense register maintained
16. Patient registration/guidance system
17. Patients privacy ensured during consultation/examination
18. Medicines are being labeled while dispensing
19. Availability of complaints register
20. Additional points for implementation of MSDS

ANNEXURE. M: Actions Taken for Improvement of Services
Date: x.y.z
No.______ held on.______ ,20______
Sr No # Observation Decision for Improvement Other Remarks

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23
148 CG-09RM-Ed2-141021
ANNEXURE. N: Specimen Authorization of Professionals to Administer

the Drugs/Medications
Sr. No. Particulars of Professionals Authorization PMC/PNC/PMF, etc. Validity Date

1.
2.
3.
4.
5.
Signature of the Administrator of the Dental Clinic_____________________________________
Date________________________________

ANNEXURE. O: Consent Form
Patient's Informed Consent Treatment or Investigation
Treating Consultant lls Patient's Name:

for speci ed conditions CNIC # :
Name of HCE: S/O, D/O, W/O:
Patient's Reg. #: Age: Gender:
Address: Diagnosis:
Declaration of Doctor/Proceduralist (to be completed by the clinician obtaining consent)
Tick the boxes or cross out and initial any changes or information not appropriate to the stated procedure
I have informed the patient of the treatment options available, and the likely outcomes of each
treatment option, including known bene ts and possible complications. (State options)
1.
2.
I have recommended the treatment/procedures/investigations noted below on this form.
I have explained the treatment/procedures/investigations, identi ed below, with bene ts/risks.
I have provided the patient with information speci c to the procedure identi ed. The patient has
been asked to read information provided and ask the doctor/proceduralist questions about
anything that is unclear.
An identi able copy of the information about the procedure to the patient provided with copy in
the medical record (MR).
Treatment/Procedure/Investigation
List the treatment/procedures/investigations to be performed, noting correct side/correct site
This procedure requires: General or Regional Anesthesia Local Anesthesia Sedation

Speci c risks to this patient explained by the anesthetist at least 12 hours before procedure are:
1.
2.
Patient's Informed Consent Treatment or Investigation
Full name _____________________ Full name _____________________

Position/Title___________________ Position/Title___________________
Signature _______________________ Signature _______________________
PMC Reg# ______________Date:___/___/___ PMC Reg# ______________Date:___/___/___
150 CG-09RM-Ed2-141021
Patient's Declaration (Patient required to read carefully, discuss with the doctor if there are
any concerns and tick the understood and agreed points)
i. The doctor/proceduralist has explained my medical condition and prognosis as well as

explained the relevant diagnostic and treatment options that are available to me and associated
risks, including the risks of not having the procedure.
ii. The risks of the procedure have been explained to me, including which are speci c to me and the
likely outcomes. I have had an opportunity to clarify my concerns with the doctor/specialist.
iii. I understand that the result/outcome of the treatment/procedure cannot be guaranteed.
iv. I understand that tissue samples and blood removed as part of the procedure or treatment will be
used for diagnosis and common pathology practices (which may include audit, training, test
development and research), and will be stored or disposed of sensitively by the HCE.
v. I understand that a photograph, if taken during examination/procedure or treatment, will be
used for academic purposes only and that too ensuring con dentiality and privacy.
vi. If a staff member is exposed to my blood, I consent to a sample of blood being collected and
tested for infectious diseases. I understand that I will be given the results of the tests of the taken
sample.
vii. I agree for my medical record to be accessed by staff involved in my clinical care and for it to be
used for approved quality assurance activities, including clinical audit, etc.
viii. I understand that if immediate life-threatening events happen during the procedure, I will be
treated accordingly.
ix. I understand that I have the right to change my mind at any time before the procedure is
undertaken, including even after signing this form. I understand that I must inform my doctor if
this occurs.
x. I consent to undergo the procedure/s or treatment/s as documented on this form.
xi. I understand that conditions requiring blood transfusions are not treated in clinics and require a
proper hospital setup, as required under other laws requiring a separate consent. Yes No
Pre-Procedural Con rmation of Consent

Patient’s Full Name:________________________ I certify that I have recon rmed the validity of the
Patient’s Signature: ________________________ above details to the patient in a language he/she
understands:
Date/Time:___________________
Parent/Guardian Signature: _____________
Signature and Stamp of the Practitioner:
CNIC # : CNIC # :

ANNEXURE. P: Complaints Management
1.0 OBJECTIVE
To ensure that complaints are handled in a standardized manner at all healthcare establishments (dental
clinics/surgeries) in Punjab.
2.0 SCOPE
This document provides general guidelines to Healthcare Service Providers (HCSPs) to develop or
improve their Complaint Management Systems.
3.0 RESPONSIBILITY
The responsibility of complaints handling rests with the HCSP. However, all staff members of the
establishment are responsible for providing the necessary support.
4.0 DISPLAY OF INFORMATION
4.1 Inform the patient of his/her right to express his/her concern or complain either verbally or in
writing.
4.2 This shall be done by clearly displaying the following information, in Urdu, at the entrance, help
desk, every department (and at the back of admission and discharge slips)
5.0 COMPLAINT HANDLING

5.1 Put into place a documented process for collecting, prioritizing, reporting and investigating
complaints, which is fair and timely.
5.2 Registration
5.2.1 A Complaint Management Register shall be maintained by each clinic, which shall be
available at the help desk/reception during working hours.
5.2.2. Register shall have:
5.2.2.1 A 3” X 4” white paper pasted on the cover page with the following:
Opened on: (Mention date as XX-XX-XXXX)
5.2.2.2 The following certi cate on the inner side of the cover page:
“It is certi ed that this register contains _____ pages; each page has been numbered
(at the top center), stamped with the dental clinic/surgery seal (at top right corner) and
initialed by me.”
Date: XX-XX-XXXX (Signature and Name of HCSP)
152 CG-09RM-Ed2-141021
5.2.2.3 Format of the complaint management register:

1 2 3 4 5 6 7 8 9 10 11 12
S r . Complainant's Contact Address Description Signature/ Details Date(s) Outcome Date Quality Signature
No. Name No. of the Thumb Print of the Complainant Complainant improvement
Complaint of Investigation Contacted Informed Policy or
Complainant Procedure
Change
Column 2-6 shall either be lled by the complainant or someone else

(whom the complainant trusts) on his/her behalf.
5.2.3 Every written or verbal complaint directly made to the HCSP shall also be entered in
the
register by the HCSP, within 24 hours and processed immediately.
5.2.4 All complaints should be resolved expeditiously.
5.3.5 Enter important points of the complaint in the register and take notice of allegations
and requests made.
5.3.6 Investigate in an impartial manner.
5.3.7 Keep the time factor in mind because any undue delay will re ect poorly on the
management.
6.0 COMMUNICATION
6.1 Inform the complainant about the progress of the investigation at regular intervals and
inform him/her about the outcome.
6.2 Stay in contact with the complainant and regularly update him/her about the progress made in
the investigation.
6.3 Record the outcome of the investigation and inform the complainant accordingly.
6.4 Don't indulge in argumentation and be polite and empathetic.
7.0 QUALITY IMPROVEMENT

7.1 Use the results of the complaints investigation as part of the quality improvement process.
7.2 The registers should be perused by the Chief Executive of the establishment, at least once a
month.
Make necessary changes in policy and procedures to improve the quality of clinical services.

ANNEXURE. Q-I: First Consultation - 8 Dec, 2015
Sr. #. Name Designation /HCE/Organization

1. Dr. Muhammad Ajmal Khan Chief Operating Officer PHC
2. Dr. Mushtaq Ahmad Director (Clinical Governance & Organizational Standards) PHC
3. Prof. Dr. Riaz Ahmad Tasneem Director (Complaints) PHC
4. Dr. Riaz Ahmad Ch. Director (Licensing & Accreditation) PHC
5. Lt. Col. Retd. Dr. Anees Ahmad Qureshi Additional Director (Clinical Standards Development) PHC
6. Dr. Majed Latif Additional Director (Training) PHC
7. Dr. Shahid Amin Deputy Director (Clinical Standards Development) PHC
8. Dr. Mukhtar Ahmad Awan Deputy Director (Training) PHC
9. Dr. Sha q ur Rehman Deputy Director (Training) PHC
10. Dr. Waheed-ul-Hamid Professor, Principal, De'Montmorency College of
Dentistry, Lahore
11. Dr. Naeema Mansoor Director Dental Health Services o/o DGHS Punjab
12. Dr. Arham Nawaz Chohan Associate Professor LM&DC, Lahore; VP PDA Punjab
13. Dr. Baber Subzwari Principal Dental Surgeon Health Department
14. Dr. Sheikh Iftekhar Uddin Principal Dental Surgeon Govt Khawaja Saeed Hospital,
Lahore
15. Dr. Asim Habib Vohra Dental Surgeon Cosmetic Dentistry, Lahore
16. Dr. Nadeem Tarique APMO/ Associate Professor Dental Section, PMC,
Faisalabad
17. Dr. Muhammad Salman Chishti Assistant Professor Islam Dental College, Sialkot
18. Dr. Malik Azhar Ali Senior Dental Surgeon RHC Phool Nagar, Kasur
19. Dr. Nadeem Usman Siddiqui Dental Surgeon Punjab Medical College, Faisalabad
20. Dr. Muhammad Farooq Riaz CEO Denti-care, Lahore
21. Dr. Muhammad Altaf Dental Surgeon DHQH Fateh pur, District Layyah
22. Dr. Muhammad Qasim Dental Surgeon PESSI Hospital, Sialkot
154 CG-09RM-Ed2-141021
Sr. #. Name Designation /HCE/Organization

23. Dr. Azhar Saleem Dental Surgeon THQ Hospital Bhera, District Sargodha
24. Dr. Sibghat Ullah Dental Surgeon RHC Tibbi Qaisrani, D.G Khan
25. Dr. M. Saif Ullah Sial Dental Surgeon RHC Sajha, District R.Y Khan
26. Muhammad Sumair Farooq Dental Surgeon Sharif Medical and Dental College, Lahore
27. Dr. Hamid Ali Dental Surgeon DHQ Hospital, Okara
28. Dr. Wasif Ali Khan Associate Professor De'Montmorency College of
Dentistry, Lahore
29. Dr. Mushtaq Ahmad Alam MS Punjab Dental Hospital, Lahore
30. Dr. Qasim Saleem Dental Surgeon District Government, Punjab

ANNEXURE. Q-II: Second Consultation - 22 Dec, 2015
Sr. #. Name Designation/HCE/Organization

1. Dr. Muhammad Ajmal Khan Chief Operating Officer PHC
2. Dr. Mushtaq Ahmad Director (Clinical Governance & Organizational Standards) PHC
3. Prof. Dr. Riaz Ahmad Tasneem Director (Complaints) PHC
4. Dr. Riaz Ahmad Ch. Director (Licensing & Accreditation) PHC
5. Lt. Col. Retd. Dr. Anees Ahmad Qureshi Additional Director (Clinical Standards Development) PHC
6. Dr. Majed Latif Additional Director (Training) PHC
7. Dr. Shahid Amin Deputy Director (Clinical Standards Development) PHC
8. Dr. Mukhtar Ahmad Awan Deputy Director (Training) PHC
9. Dr. Sha q ur Rehman Deputy Director (Training) PHC
10. Prof Dr. Nazia Yazdanie Principal FMH College of Dentistry, Lahore
11. Asst. Prof. Dr. Wasif Ali Khan Associate Professor De'Montmorency College of
Dentistry, Lahore
12. Dr. Naeema Mansoor Director Dental Health Services o/o DGHS Punjab
13. Assoc. Prof. M Sumair Farooq Assistant Professor Sharif Medical & Dental College,
Raiwind Road, Lahore
14. Dr. M. Asim Habib Vohra Dental Surgeon Cosmetic Laser Dentistry, Lahore
15. Dr. Muhammad Salman Chishti Assistant Professor Dental Surgeon Islam Medical &
Dental College, Sialkot
16. Dr. Malik Azhar Ali Senior Dental Surgeon RHC Phool Nagar, Kasur
17. Dr. Aamer Raza Dental Surgeon IPH, Lahore
18. Dr. Muhammad Farooq Riaz C.E.O Denti-care, Lahore
19. Dr. Muhammad Altaf Dental Surgeon DHQH, Layyah
20. Dr. Hamid Ali Sr. Dental Surgeon, Principal Dental Surgeon, DHQH
Okara
21. Dr. Muhammad Qasim Dental Surgeon Aslam Dental Clinic, Daska, Sialkot
22. Dr. Azhar Saleem Malik Senior Dental Surgeon THQH Bhera, District Sargodha
23. Dr. M. Saif Ullah Sial Dental Surgeon RHC Sajha, Tehsil Khanpur, District
R.Y Khan
156 CG-09RM-Ed2-141021
Sr. #. Name Designation/HCE/Organization

24. Dr. Qasim Saleem Dental Surgeon RHC Manthaar, District R.Y Khan
25. Dr. Muhammad Amjad Bari Assistant Professor Nishtar Institute of Dentistry, Multan
26. Dr. Naghma Parveen Assistant Professor Nishtar Institute of Dentistry, Multan
27. Dr. Zaheer Iqbal Dental Surgeon THQ Hospital Pindi Bhattian, District
Ha zabad
28. Dr. Asma Atique Dental Surgeon RHC 222/E.B, District Vehari
29. Dr. Saeed Ur Rehman Dental Surgeon RHC Garh Maharaja, District Jhang
30. Dr. Sonia Qaisar Dental Surgeon RHC Abdul Hakim, District Khanewal
31. Dr. Ahmed Jahangir Dental Surgeon RHC Dera Bakhaa, Bahawalpur
32. Dr. Muhammad Rashid Ghauri Dental Surgeon THQ Hospital Ahmad pur East, District
Bahawalnagar
33. Dr. Muhammad Shakeel Nazar Dental Surgeon RHC Mong, District Mandi Bahauddin
34. Dr. Mohammad Irfan Latif Senior Dental Surgeon DHQ Hospital, Mianwali
35. Dr. Ahmad Ayub Shah Dental Surgeon RHC Mandi Sadiq Garh, Bahawalnagar
36. Dr. Hannan Majeed Dental Surgeon BVH, Bahawalpur
37. Dr. Zubair Ahmed Khan Dental Surgeon FMH College of Dentistry, Lahore
38. Dr. Imran Naseer Principal Dental Surgeon Jinnah Hospital, Lahore
39. Dr. Muhammad Shoaib Iftikhar Dental Surgeon RHC Khewra, District Jhelum
40. Dr. Muhammad Amir Shahzad Dental Surgeon RHC Daultala, District Rawalpindi
41. Dr. Hira Azmat Dental Surgeon RHC Bahatar, District Attock
42. Dr. Sharea Ijaz Deputy Director IADSR, Lahore
43. Dr. Muhammad Ilyas Assistant Professor De'Montmorency College of
Dentistry, Lahore
44. Dr. Uyoon Shamail Dental Surgeon RHC Madrissa, District Bahawalnagar
45. Dr. Nadeem Usman Siddiqui Senior Dental Surgeon PMC, Faisalabad
46. Dr. M. Ra q Siddiqui Principal Dental Surgeon Punjab Dental Hospital,
Lahore

ANNEXURE. Q-III: Field TestMSDS/RM - March 30-31, 2018
Sr. #. Name Designation / HCE Name

1. Dr. Asrar Ahmed Assistant Professor De'Montmorency College of
Dentistry, Lahore
2. Dr. Ha z Shaker Mahmood Shaker Dental Medical Clinic, Lahore
3. Dr. Arhum Butt Mian Dental Clinic, Shad Bagh, Lahore
4. Dr. Naseer Ahmad Chaudhry Bites & Braces Dental Surgeon, Johar Town, Lahore
5. Dr. M. Yasir Ishfaq Saleem Dental Clinic, Baghbanpura, Lahore
6. Dr. Zahoor Ahmad Dental Care Clinic, Tufail Road, Lahore
7. Dr. Saima Sohail Muhammadi Dental Clinic, Nishat Colony, Lahore
8. Dr. Ali Raza Dawood Dental Clinic, Darogywala, Lahore
9. Dr. Farhan Ahmed Siddique Dental Surgery, Y Block DHA, Lahore
10. Dr. Hamood Ur Rehman Bright Smile Centre, 99 R Block DHA, Lahore
11. Dr. Muhammad Siddique Chohan Siddique Dental Surgery, 82/3 Ferozepur Road, Lahore
12. Dr. Bilal Yousaf Smile Experts Dental Clinic, Bahria Town, Lahore
13. Dr. Nasrullah Khan The Dental Associates, Muslim Town, Lahore
14. Dr. Aqib Aziz Raza Dental Clinic, Shad Bagh, Lahore
15. Dr. Khulood Siddiq Ahmad A A Khan Dental Surgeon, Saddar Bazar Cantt, Lahore
16. Dr. Muhammad Saeed Saeed's Dental Surgery, Commercial Area, Lahore
17. Prof. Dr. Ayyaz Ali Khan Dental Services, DHA, Lahore
18. Dr. Madiha Chishti Khan Dental Surgery, Green Town, Lahore
19. Dr. Ali Waqar Hasan Dental Smile Clinic, DHA, Lahore
20. Dr. Haider Javed Sohaib Clinic,162-C Rehman Pura, Lahore
21. Dr. Fahim Mustafa Qureshi Dental Zone, Old Anarkali, Lahore
22. Dr. Farman Ul Haq Smiles Dental Clinic, Zarrar Shaheed Road, Lahore
23. Dr. Salman Ashraf Khan Happy Teeth The Dental Surgery, New Garden Town,
Lahore
24. Dr. Sobia Malik Garden Dental Clinic, New Garden Town, Lahore
158 CG-09RM-Ed2-141021
Sr. #. Name Designation/HCE Name

25. Dr. Taimoor Sha q Taimoor Dental Clinic, Commercial Area, Lahore
26. Dr. Farooq Masud Khan Al Falah Dental Clinic, Baghbanpura, Lahore
27. Dr. Wasif Rashid Dental Health Care, DHA Phase I, Lahore
28. Dr. Muhammad Ammad Nasir Nadeem Dental Clinic, Aziz Bhatti Town, Lahore
29. Dr. Moeen Ud Din Ahmed Specialist Dental Centre Johar Town, Lahore
30. Dr. Omair Anjum Elite Dental, Punjab Cooperative Housing Society, Lahore
31. Dr. Shahid Ali Smile Centre, Jail Road, Lahore
32. Dr. Muhammad Asim Habib Vohra Asim Dental Clinic, Model Town, Lahore
33. Dr. Zubair Ahmed Khan Smile Center, Gulberg-5, Lahore
34. Dr. Muhammad Farooq Riaz Denti Care, Garden Town, Lahore

ANNEXURE. R: Development Team
Writers
Sr. # Name Designation
1. Dr. Muhammad Saqib Aziz Chief Executive Officer PHC

2. Dr. Mushtaq Ahmed Salariya Director (Clinical Governance & Organizational Standards) PHC
3. Dr. Shahid Amin Additional Director (Clinical Standards Development) PHC
4. Dr. Asrar Ahmed (Consultant) Assistant Professor, De'Montmorency College of Dentistry, Lahore
Reviewers/Contributors
1. Dr. Majed Latif Additional Director (Internal & External Training) PHC
2. Dr. Basharat Javed Khan Deputy Director (Training) PHC
3. Dr. Sha que ur Rehman Deputy Director (Training) PHC
4. Dr. Imtiaz Ali Deputy Director (Training) PHC
5. Ha z Dr. Fayzan Akhtar Deputy Director (Training) PHC
Reviewers
1. Dr. Sana Hassan Deputy Director (clinical Standards Development) PHC

2. Dr. Nadia Rasheed Manager ( Clinical Standards Development) PHC
Design and Support

1. Miss Rashda Parveen Assistant Manager (Research and Development) PHC
2. Mr. Kashif Siddique Awan Graphic Designer PHC
160 CG-09RM-Ed2-141021
The Punjab Healthcare Commission (PHC) has been established under the Punjab Healthcare Commission Act, 2010. It is an
independent health regulatory body with the mandate to introduce a regime of clinical governance through enforcing
Minimum Service Delivery Standards (MSDS) at the primary, secondary and tertiary healthcare establishments (HCEs), in
both public and private sectors, to improve the quality of healthcare service delivery in Punjab. All HCEs are required to
imp[lement MSDS to acquire a license for thin lawful operation and to deliver healthcare services in Punjab.
www.phc.org.pk
Office No. 1 & 2, 4th Floor, Shaheen Complex, PUNJAB HEALTHCARE COMMISSION
38 Abbott Road, Lahore, Pakistan.
042-99206371-78 042-99206370 TOLL FREE 0800 00 742

info@phc.org.pk
All rights reserved. No part of this publication can be reproduced in any form or by any means without written permission from the PHC.

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CG-09RM-Ed2

Punjab Healthcare Commission

Prof. Dr. Attiya Mubarak Khalid

2 Standards and Indicators 11

Standard 3. ROM-3: Clinic premises support the scope of work/services 22

Standard 4. ROM-4: The responsibilities of the management are de ned 27

2.2 Facility Management and Safety (FMS) 30

2.3 Human Resource Management (HRM) 45

2.4 Information Management System (IMS) 53

2.5 Quality Assurance (QA)/Quality Improvement (QI) 59

Standard 12. QA-3: Sentinel events are assessed and managed 68

2.6 Assessment and Continuity of Care (ACC) 71

2.7 Care of Patients (COP) 78

2.8 Management of Medication (MOM) 87

Standard 16. MOM-1: Prescribing practices conform to the standards 88

Standard 17. MOM-2: Storage and dispensing/usage conforms to the guidelines 91

2.9 Patient Rights and Education (PRE) 95

Punjab Healthcare Commission 3

2.10 Infection Prevention & Control (IPC) 107

List of Acronyms and Abbreviations

Punjab Healthcare Commission 5

Punjab Healthcare Commission 7

1- Refer to Sections 13, 14, and 20 of PHC Act 2010

Punjab Healthcare Commission 9

1.2 MSDS Reference Manual for Dental Clinics

Lowest Shades of Level of Implementation Highest

STANDARDS & INDICATORS

Punjab Healthcare Commission 11

2. Standards and Indicators

Ind 2. The patient/client has easy access to the clinic

Punjab Healthcare Commission 13

Ind 3. The dental clinic is registered/licensed with the PHC

Ind 5. The staﬀ on duty uses identity badge/s ⁴

Ind 6. Consultation hours are displayed

Punjab Healthcare Commission 15

Location and Accessibility

Registration and Licensing

Authority for Issuing Identity Badges

Name:_____________________ Designation: _____________

Date Of Issue: ______________ Employee Sig: ____________

Punjab Healthcare Commission 17

Indicators 1-6 Max. Weightage Grading

Ind 2. The patient/client has easy access to the clinic 10 80%

Ind 3. The dental clinic is registered/licensed with the PHC 10 100%

Door plate/s clearly display name and quali cation/s of

Ind 5. The staﬀ on duty uses identity badge/s 10 100%

Ind 6. Consultation hours are displayed 10 100%

Standard 2. ROM-2: The manager and the healthcare service provider/s at

Ind 8. PMC Registration Certi cate of the dental surgeon is displayed

Punjab Healthcare Commission 19

Assessment Scoring Matrix

Indicators 7-8 Max. Weightage Grading

PMC Registration Certi cate of the dental surgeon is

Punjab Healthcare Commission 21

Ind 9. The size/premises of the dental clinic is as per minimum requirement

Punjab Healthcare Commission 23

Adequacy of the Facilities

Section 20. Permission of patient before examination

Section 27. Con dentiality

Name:_________ Designation: _

Date Of Issue: __ Employee Sig: