NEW YORK STATE DEPARTMENT OF HEALTH BUREAU OF DENTAL HEALTH SCHOOL-BASED HEALTH CENTER DENTAL PROGRAM PERFORMANCE EFFECTIVENESS REVIEW TOOL (PERT) March 1, 2007
TABLE OF CONTENTS SECTION I: INTRODUCTION PAGE Purpse f the PERT 1 PERT Prcess 1 Directins fr Cmpleting the PERT 2 Glssary 5 Perfrmance Effectiveness Review Tl Cver Page 6 SECTION II: ADMINISTRATIVE REVIEW Targeting and Ppulatin Prfile 8 Outreach and Prmtin 9 Services Available 10 Access t Services 12 Enrllment and Parental Cnsent 13 Relatinships/Cmmunity Partnerships 14 Maintenance f Dental Recrds 15 Staffing 16 Data Management and Evaluatins 17 Fiscal Operatins and Third Party Billings 18 Quality Assurance 19 Plicies and Prcedures 21 SECTION III: PHYSICAL AND ENVIRONMENTAL REQUIREMENTS Clinic Space 23 Infectin Cntrl 24 Handwashing 25 Persnal Prtective Equipment 26 Husekeeping & Laundry 27 Engineering and Wrk Practice 28 Cleaning, Disinfectin and Sterilizatin 30 Equipment 33 Expsure Cntrl Plan 34 SECTION IV: CLINICAL RECORD REVIEW Dental Recrd Review 36 SECTION V: COMPREHENSIVE SITE REVIEW SUMMARY Cmprehensive Site Review Summary 40
SECTION I: INTRODUCTION PURPOSE The Perfrmance Effectiveness Review Tl (PERT) is a dcument that brings tgether utcme-based evaluatins with prgram prcess standards t define the quality and effectiveness f a Schl-Based Health Center Dental Prgram (SBHC-D) and cmpliance with New Yrk State Department f Health (NYSDOH) regulatins, prgram requirements, administrative plicies, and, where applicable, State and federal laws and requirements. The tl engages in a prcess f self-evaluatin and subsequent validatin by a NYSDOH review team. Under this framewrk, the SBHC-D is an active participant in all aspects f the mnitring and evaluatin prcess. The self-assessment and validatin sectins f the PERT prvide assurance that the Requirements fr a Schl-Based Health Center Dental Prgram in New Yrk State (Requirements) are being adequately met. PERT PROCESS PROGRAM STANDARDS On the far left side f the dcument, prgram standards are listed with a citatin as t their rigin. Each item within the standard is cded by symbls indicating the law, regulatin, r requirements frm which the standards are derived: Requirements fr a Schl-Based Health Center Dental Prgram in New Yrk State Ø ß Í Article 28: Diagnstic and Treatment Center New Yrk State Cnfidentiality Law Health Insurance Prtability and Accuntability Act (HIPAA) Family Educatinal Rights and Privacy Act (FERPA) Maintenance f Medical Recrds Infectin cntrl requirements Chapter 198 f the Laws f New Yrk State Title 8 f the Educatin Law Radigraphic Equipment ˆ Envirnmental Cnservatin Law, 6 NYCRR Subpart 374-4 Please refer t pages 19-20 in the Requirements fr a Schl-Based Health Center Dental Prgram in New Yrk State fr web-based resurces n state and federal laws, rules, and regulatins related t the establishment f a SBHC-D Prgram. SELF-ASSESSMENT cmpleted by SBHC-D staff The SBHC-D is given the pprtunity t assess the quality and effectiveness f its prgram by determining if it is meeting the varius dental health cmpnents f the Requirements, regulatins, r law, as identified by specific items (Prgram Standards) thrughut the PERT. The middle prtin f each page is designed as a self-assessment t be cmpleted by SBHC- D staff. In the Self-Cde clumn, SBHC-D staff cdes the dcument as t whether: M U P TA the standard is met, the standard is unmet, there has been prgress tward meeting the standard, and additinal technical assistance required interpreting r meeting the standard. 1
SBHC-D staff has the pprtunity t describe in the Self-Assessment clumn hw the standard is met and hw each item listed is used t carry ut SBHC-D activities, r the reasns why a standard has nt met and the effrts and prgress being made t address the standard. Sme sectins f the Self-Assessment clumn cntain a list f items/ requirements; the SBHC-D staff shuld check (P) the bx next t each item, if met. VALIDATION cmpleted by NYSDOH staff The tw clumns n the right f each page are used by the reviewer r review team t validate the status f each standard. The validatin prcess takes place in the cntext f site visits t the SBHC-D and utilizes the self-assessment data and infrmatin gathered nsite. EXIT CONFERENCE Onsite reviews end in an exit interview r cnference during which the findings are summarized and recmmendatins fr imprvement are made. SBHC-D staff has the pprtunity t discuss the varius findings, clarify their assessments, and request any cnsultatin r technical assistance that is needed. REVIEWER SUMMARY The verall evaluatin f the SBHC-D is then summarized in the Reviewer Summary; this sectin f the PERT utlines the SBHC-D s strengths, needs, and pririty actins and the recmmendatins needed t be implemented fr prgram imprvement. Here, reviewers and the SBHC-D jintly priritize areas fr imprvement in the frm f key recmmendatins. FOLLOW-UP After cmpletin f the nsite review, NYSDOH staff will send a letter t the SBHC-D Prgram Directr, alng with cpies f the cmpleted and validated PERT, the Clinical Recrd Review, and the Reviewer Summary. The letter addresses strengths, areas needing imprvement, and the items cntained in the priritized list that require immediate attentin and that shuld be incrprated int the SBHC-D s quality imprvement prcess/actin plan. ACTION PLAN An Actin Plan must be submitted t the NYSDOH Bureau f Dental Health within 6 weeks f receipt f the fllw-up letter. The Actin Plan shuld include: strategies fr apprval, activities t crrect all referenced items, plicies and prcedures t supprt the activities, a timeline fr implementatin, staff respnsible, and evaluatin measures. Technical assistance frm the NYSDOH Bureau f Dental Health is available, as needed, thrughut the prcess. Additinal n-site visits t evaluate changes, peratinal imprvements and the degree f prgress will be scheduled as necessary. DIRECTIONS FOR COMPLETING THE PERT SECTION I: COVER PAGE Under the Self-Assessment prtin f the Cver Page, enter the name f the spnsring agency, the SBHC-D Prgram Directr r cntact, and date the self-assessment cmpnent f the PERT was cmpleted. List each SBHC-D site at which services are t be prvided and the name and telephne number f SBHC-D staff member respnsible fr site peratins. 2
SECTION II: ADMINISTRATIVE REVIEW Self-Assessment: The middle prtin f this sectin is cmpleted by SBHC-D staff. All Self-Cde and Self-Assessment clumns fr each perfrmance standard and crrespnding items listed in the first clumn f the frm are t be addressed. Indicate in the Self-Cde clumn if the standard is met (M) r unmet (U) and whether technical assistance (TA) is required. If the standard is unmet, indicate, as applicable, if prgress (P) has been made tward meeting the standard. In the Self-Assessment clumn, describe hw the standard is met and hw each item listed is used t carry ut SBHC-D activities. If the standard is nt met, give the reasns why and describe what is being dne t achieve the standard. In sme sectins f the Self-Assessment clumn, a list f items/requirements is presented; check (P) the bx next t each item, if met. A next t the Prgram Standard heading means that ALL items in this sectin must be cmpleted fr the pre-pening certificatin. Validatin by NYSDOH Staff: The right side f the PERT frm is cmpleted by NYSDOH staff. In the Reviewer Cde clumn, the reviewer indicates if the standard has been met (M) r unmet (U), if technical assistance (TA) is required, and if the standard is unmet, if prgress (P) has been made tward meeting the standard. The Validatin by Reviewer clumn is used t recrd any cmments and/r explanatins nting whether r nt the perfrmance standard/item/requirement has been fully met. The reviewer als indicates if the findings are based n: I O interviews bservatins P/P Plicy and Prcedure Manual review Min review f meeting minutes R/R recrd review The fllwing Prgram Standards are included in the Administrative Review Sectin: Targeting and ppulatin prfile Outreach and prmtin Services available Access t services Enrllment and parental cnsent Maintenance f dental recrds Relatinships and cmmunity partnerships Staffing Data management and evaluatins Fiscal peratins and third party billings Quality assurance Plicies and prcedures 3
SECTION III: PHYSICAL AND ENVIRONMENTAL REQUIREMENTS Self-Assessment: Indicate in the Self-Cde clumn if the standard is met (M) r unmet (U) and whether technical assistance (TA) is required. If the standard is unmet, indicate, as applicable, if prgress (P) has been made tward meeting the standard. In the Self-Assessment clumn, describe hw the standard is met and hw each item listed is used t carry ut SBHC-D activities. If the standard is nt met, give the reasns why what is being dne t achieve the standard. In sme sectins f the Self- Assessment clumn, a list f items/requirements is presented; check (P) the bx next t each item, if met. A next t the Prgram Standard heading means that ALL items in this sectin must be cmpleted fr the pre-pening certificatin. Validatin by NYSDOH Staff: The reviewer indicates in the Reviewer Cde clumn if the standard has been met (M) r unmet (U), if technical assistance (TA) is required, and if the standard is unmet, whether prgress (P) has been made tward meeting the standard. The Validatin by Reviewer clumn is used t recrd any cmments and/r explanatins nting whether r nt the perfrmance standard/item/requirement has been fully met. The dcumentatin used t determine if the standard has been met is als indicated. The fllwing Prgram Standards are included in the Physical and Envirnmental Requirements sectin: Clinic space Infectin cntrl Handwashing Persnal prtective equipment Husekeeping and laundry Engineering and wrk practice Cleaning, disinfectin, and sterilizatin Equipment Expsure cntrl plan Once the self-assessment prtin f the PERT is cmpleted, it is t be returned t the NYSDOH Bureau f Dental Health ne week prir t the n-site review. SECTION III: CLINICAL RECORD REVIEW This sectin is cmpleted by the NYSDOH review team. Generally, a minimum f 10 charts per site reflective f SBHC-D enrllment will be randmly selected and reviewed. Depending n the number f students enrlled, the review team will have the discretin f either reviewing mre r fewer recrds. The chart review tl t be used is included in the PERT. SECTION IV: COMPREHENSIVE SITE REVIEW SUMMARY The NYSDOH review team cmpletes the site review summary reprt based n infrmatin btained frm the Self Assessment, Validatin, and Clinical Recrd Review Sectins f the PERT. The strengths and needs f the SBHC-D are summarized and all pririty actins and recmmendatins needed fr prgram imprvement are identified. 4
GLOSSARY COMPREHENSIVE SITE REVIEW An fficial prgram review cnducted by a NYSDOH review team t evaluate all aspects f the peratin f the SBHC-D. This evaluatin will be cnducted at a minimum, nce every three years. FOCUSED SITE REVIEW An fficial prgram review cnducted by a NYSDOH review team t review selected aspects f the peratin f a SBHC-D. This review may be cnducted between cmprehensive site reviews based n prgram perfrmance measured by previus cmprehensive site reviews and the ability f the prgram t implement and achieve wrk plan activities. INTERIM VISITS/CONTACT Site visits r telephne calls made by reginal ffice staff r Bureau f Dental Health staff fr fllw-up n cmprehensive site reviews and/r t prvide needed technical assistance and cnsultatin between review visits. NEW SITE A SBHC-D nt previusly in peratin. This may apply t a spnsring agency that already perates ne r mre ther SBHC-D sites r t ne that has never perated any sites. PERT The Perfrmance Effectiveness Review Tl is a tl used t evaluate the peratin f the SBHC-D. The tl includes a self-assessment f administrative perfrmance standards and physical requirements cmpleted by the SBHC-D prvider and an n-site validatin by the NYSDOH Bureau f Dental Health and/r reginal ffice staff. The tl is used fr prepening certificatin, fcused reviews, and cmprehensive site reviews. PRE-OPENING CERTIFICATION VISIT This is a site visit t a newly established SBHC-D and ne r mre sites by NYSDOH reginal staff t cnduct an evaluatin f the prvider s readiness t prvide services. Selected prtins f the PERT, including the self-assessment and NYSDOH validatin, will be used t determine prgram readiness. PRE-OPENING TECHNICAL ASSISTANCE Technical assistance and cnsultatin prvided t the prvider by NYSDOH reginal and/r central ffice staff in preparatin fr the pening f a new schl-based health center dental prgram. SELF-ASSESSMENT A narrative descriptin f the strategies emplyed by a SBHC-D prvider t meet prgrammatic requirements and/r t accmplish wrk plan activities. This narrative is cmpleted by the SBHC-D prvider using the PERT prir t a pre-pening, fcused, r cmprehensive site review. SITE-REVIEW TEAM NYSDOH staff cmprised f reginal and central ffice staff and ther resurce persns, as needed, t cnduct the Cmprehensive Site Review. 5