POLICIES AND PROCEDURES FOR A PLASTIC SURGERY AND DERMATOLOGY

CLINIC
By
Student's Name

Department, Institutional Affiliation

Course Code: Course Title
Professor's Name
Date
 Communication of Procedures and Policies
When the new clinic opens, all personnel will be given an orientation. The clinic's security and
compliance procedures will be covered during orientation. Orientation topics to cover include:
• Business Continuity Plan

• Health Insurance Probability and Accountability Act (HIPAA)

• Disaster Recovery Plan

• Acceptable Use Policy

Involvement of Human Resources & Executive Management

Employees will be given an introduction to these policies throughout the onboarding process, which
will be led by HR and Executive Management. The new staff will be briefed about our clinic's
business practices and expectations.

Incorporating Security Awareness and Training for the New Clinic

Upon their arrival, all new staff will undergo a week of training. Security Awareness, best practices,
and procedures will also be taught to them. If suitable security protocols are not in place during
training, scenarios will be presented to show what could happen. Simultaneous scenarios will be based
on real-world events.

Issuance of a Monthly Organization Wide Newsletter

The newsletter will be emailed to users and notify them of corporate updates and changes. The
newsletter will provide readers with useful information, such as how-to articles and notices of future
events. Employees will also be able to pose questions to top management and receive a response in
this portion of the site.

Implementation of Security Reminders on System Login Screens

Workers' login screens will display security messages reminding them not to reveal their password to
anybody or write it down.

Incorporation of On-Going Security Policy

Periodic audits will be performed to verify that security policies are being adhered to. In order to
ensure that vital assets are protected, the policy will be tested by teams and any vulnerabilities
discovered will be reported. All suggestions and comments will be taken into account and put to good
use in order to strengthen or improve the vulnerabilities that have been identified.

Obtaining of Employee Questions for Feedback for Policy Board

All employees will be invited to complete a digital survey once a month to gather feedback from their
coworkers. When Human Resources has finished reviewing the surveys, they will bring any concerns
to the attention of Executive management. Quarterly meetings will be held to review the results of the
survey.

OPERATION POLICIES

Procedure Of Patients Registration, Attendance and Referrals

All new patients must be entered into the patient database. As soon as a patient arrives, he or she
should fill out the follow-up continuation form. All patients who are referred will be entered in the
referral and death register with all of their accessible information.

Provision Medical Record

When it comes to medical records, the information contained in them must be kept private at all times.
There should be no information shared with anyone outside of the clinic. The confidentiality of all
patient information is of the utmost importance. A unique medical file will be created for each patient.
A patient's name, registration and identification card number will be included in the data as will the
patient's height, weight, and last menstrual period for females in the fertile age range. Other pertinent
data will include blood pressure, temperature, and laboratory/x-ray results, as well as a treatment plan
and a return appointment if one is required.

Medical records are maintained in accordance with Saudi Arabia's legal record-keeping requirements.
Keep records for 7 years following the last year of active usage in normal instances if possible Once
the clinic gets legal proof of the patient's death, the record can be moved to a deceased file.

Periodic quality control reviews of clinic records are the responsibility of the person in charge. To
ensure that the medical records of patients are preserved, the holder of the certificate or person in
charge must follow DG directions when he or she intends to suspend operations. The patient's medical
records may be accessed or seen by any healthcare practitioner who has provided any health treatment
to the patient in order to defend himself in any civil action made against him.

Patients Grievance Mechanism Plan

It is important that all patients are aware of their right to make complaints. If the complainant is not
satisfied with the response, he or she may take the matter up with the Ministry of Health. All patient
complaints must be investigated within 14 days of receipt.

Patients’ Rights

 Estimated service costs should be provided to patients before they get care or treatment.
 Before giving consent, the patient should be informed about the nature of his medical
condition, any suggested treatment, investigation, or operation, and any associated costs.
 Patients must be treated with respect.
 At any moment, patients can request referrals to other healthcare facilities.
 A reasonable fee must be paid by the patient in exchange for receiving the medical report
within a reasonable timeframe.
 Complaints or comments should be sent to the clinic or other relevant bodies.
Incident Reporting

Patients' deaths, fires or robberies, assaults or battery of patients, and malfunction or purposeful or
unintentional misuse of patient care equipment during treatment or diagnosis of patients must be
notified immediately to the person in control of the premises. Reports to the Ministry of Health and/or
police are expected within 10 working days or immediately. Information in the report will include
things like the date and time, along with possible causes or circumstances, as well as a description of
what happened and who was in charge when it happened. Professionals should keep a copy of the
report and all of the supporting documents in a separate file for your records. Requests for the report's
reception will be made.

Infection Control

To ensure that the clinic's infection control measures are up to par with Ministry of Health standards,
the person in charge is responsible for developing and implementing them.

1. Controlling System
The Ministry of Health must notify the appropriate authorities of any and all diseases that are treatable
in the clinic using the Standard Notification form. Infectious or communicable disease carriers must
abstain from working in the clinic unless they are cleared by a licensed physician. In the course of
treating a patient with an infectious disease, no equipment that has been exposed to contamination
should be used.
 2. Practice Among Staff
The Person in Charge or the Assistants are responsible for maintaining a current contract and
monitoring record with the Private Clinical Waste Disposal Company.

Practice Standard Precautions

 The importance of proper hand-washing cannot be overstated.

 Gloves, masks, eye protection, gowns, face shields, and boots should be worn correctly.
 Keep the house clean and clean up any spills.
 Sterilize and disinfect all patient care equipment before reusing it.
 Take care of soiled and contaminated linen.
 Sharps and infectious waste must be disposed of appropriately in order to prevent transmission
of disease.
Emergency And Disaster Preparedness

Patients who arrive at the clinic with potentially life-threatening injuries or diseases will be treated
with medical emergency procedures as a first line of defence. If a disaster occurs, the clinic has an
established strategy for saving patients' lives. All members of the team will be given emergency
response training. Emergent patients will be sent to a designated area of the clinic and given basic life
support.

The clinic's emergency care services include the following: - Basic life support - Any other steps
necessary, depending on the capacity of the person in charge and the clinic. Notify the ambulance
service if it is necessary to transfer the patient to the nearest hospital.

In case of an emergency, the appropriate hospital will be called as soon as the patient is stable enough
to go home on his or her own. The Referral Register must be updated whenever a patient is transferred
to another healthcare facility.

Waste Management

Preparation and containerization of medical waste is required before it can be transported in a sealed,
leak-proof package. Sharps should be disposed of in an adequate sharps container that is puncture
resistant, leak proof, and able to be properly sealed in order to prevent the sharps from spilling.

Electrical And Plumbing Facilities

Any issues with the HVAC, lighting, electrical outlets, or plumbing will be documented by the
assistants. Once they have notified the appropriate party, they should contact the appropriate company
to schedule a repair or service. Any private company's work, as well as their billing to that corporation,
must be documented.

Incident Reporting

Each and every incident that occurs in a private clinic must be reported in writing to the
Director General or another person designated by the Director General to receive a response.
1. It shall be reported the next working day or the day after the incident occurred.

2. The unforeseeable or unanticipated incident shall include: -

2.1 deaths of patients of the private clinic from unexplained cause or under
suspicious circumstances that are required to be reported to the police.

2.2 fires in the private clinic resulting in death or personal injury.

2.3 assault or battery of patients in the private clinic by staff.

2.4 malfunction or intentional or accidental misuse of patient care equipment that

occurs during treatment or diagnosis of patient in the private clinic. This can have
an adverse effect on the patient or staff.

3. A privte clinic shall retain all reports on investigations and findings in any
incident as required by the law.

4. The Director Generalequest any further information if necessary.

5. The holder of COR or PIC shall not discriminate or retaliate against anybody who
in good faith provides any information.

STANDARD PRECAUTIONS AND ADDITIONAL PRECAUTIONS – GENERAL

i. Hand Hygiene

Proper hand washing technique should be practiced by all healthcare providers

under these circumstances:
 Before and after coming into contact with patient
 Before and after each patient care procedures
 When there is contamination with blood and blood fluid
 After removing gloves
Hand rub with Alcohol not less than 60% emollient can be used when hands are
not visibly dirty. Other disinfectants that can be used are chlorhexidine
preparations e.g., Hibiscrub, obstetric cream, 0.5% aqueous chlorhexidine etc.
 Appropriate handwashing facilities must be available in all healthcare facilities at
appropriate locations such as wards, treatment rooms etc. These include suitable
sinks (deep with no overflow hole), hands free tap, hands free towel and soap
dispensers.

ii. Personal Protective Equipment (PPE)

Gloves
 Sterile gloves are a must for all aseptic procedures.
 Disposable gloves are used when touching blood, body fluids, secretions,
mucous membranes, non-intact skin, excretions and contaminated items.
 Gloves should be discarded or changed after touching these materials,
between procedures and between patient contacts.

Mask/goggles/face shields
 Should be used when performing procedures which generate splashes of
blood, body fluids, secretions and excretions.

Plastic aprons and rubber boots (overshoes)

 Use disposable plastic aprons and change after every patient/procedure
 Rubber boots should be used if gross contamination or spillage is expected

iii. Housekeeping and Management of Spillage

As a general rule, all private healthcare facilities and services must be cleaned
regularly. Sinks and toilets should be cleaned once daily or when necessary.

Whenever there is spillage, area of spillage should be quarantined with proper

signage to avoid further contamination. Recommended dilutions of Sodium
Hypochlorite for spill management are:
  1.0% (10,000 ppm available chlorine) for heavy spillages of blood and body
fluids
 0.1% (1000 ppm available chlorine) for general cleaning when disinfection is
required

Chlorine releasing granules (2-3% hypochlorite) can be used for direct

application to spillage of blood and body fluids.

All equipments used for cleaning should be kept in a janitor area or an area
equivalent. Cleaning solutions must be kept in a safe place.

iv. Disinfection and Sterilization

The principles of cleaning are using detergent and hot water followed by
thoroughly drying. Where sterilization is required, heat methods such as
autoclaving are most appropriate. All reusable instruments and items must be
thoroughly cleaned, disinfected and sterilized after each use.

Cleaning

Cleaning with moist heat, for example boiling or washing with hot water and
detergent, followed by drying is often adequate.

Disinfecting

Chemical disinfectants are often used for disinfecting instruments and items
where sterilization is not required and when heat treatment is possible. However,
they may not work properly when they are:

 used on dirty objects

 not freshly made up (never top up)
 made up with wrong concentration
 mixed with incompatible chemicals
 expired

Never disinfect single-use disposable items. These items should be discarded

the proper way. Examples of chemical disinfectants are Presept, Mythelated
Spirit 70%, Hibitane and Amphyl (different concentration for different items or
equipments). Other method for disinfecting is by thermal heat at:

 70˚C with minimum heating time 15 minutes

 >80˚C with minimum heating time 2 minutes
 90˚C with minimum heating time 1 minutes

Sterilization

Sterilization is required for instruments, equipment and dressings that are to be

used for surgical procedures or that come into contact with open wounds or
sterile body sites (semi-critical and critical items). The following methods are
used:

i. High Temperature (Heat)

 dry heat in the oven at 160˚ C with heating time 2 hours or 180˚C
with heating time 1 hour
 Steam under pressure/moist heat at 134˚C with heating time 3-
3.5 minutes for fabric and 121˚C with heating time 7-12 minutes

ii. Low Temperature

 Gas plasma sterilization at 50-57˚C with heating time 6-10
minutes
 Ethylene Oxide sterilizer
v. Management of Soiled/Contaminated Linen

Appropriate laundry bags, hampers or trolleys which ensures no leakage and

made from impervious materials must be used for transportation of clean and
dirty linens.

 Red alginated and labeled (Biohazard) laundry bags should be used for
contaminated/infected linens.
 White bags should be used for ordinary linens.
 Grossly contaminated, heavily soaked linen must be placed in a yellow plastic
bag and sent for incineration.

Contaminated linen should be washed under running water, soaked with Sodium
Hypochlorite 1 in 80 for 30 minutes then launder as usual.

vi. Sharps and Wastes Disposal

In general, wastes can be segregated as follows:

 Clinical waste - yellow plastic bags

 Sharps, syringes and needles - Sharp containers
 General domestic waste - Black plastic bags
 Radioactive waste - Advice to be sought from Environmental
Department

Appropriate sharp bins and infectious waste bins should be provided next to the
work place in appropriate areas in any healthcare facilities. Bins must be yellow
coded, labeled and made from impervious materials for easy cleaning.

The principles of sharp disposals are:

  Discard only sharps in sharp bins
 Sharp bins should not be more than 2/3 full
 DO NOT recap or manipulate sharps
 Use forceps if you need to pick up sharps
 ‘You use it, you throw it’

Blood and soiled dressings should be discarded as clinical waste. Excreta and
other body fluids should be discarded into sluice.

Additional Precautions in Specific Health Facilities

i. General Wards

All wards must adhere to general Standard Precautions outlined above. In

addition, Isolation Practices and Specimen Collection and Handling Guidelines
must also be followed.

ii. High Risk areas

High risk areas are as stated below:

 Intensive Care Unit

In addition to Standard Precautions, closed system for blood taking must be

practiced. Additional face shield must be used for procedure which may
generate aerosols.

 Labour Room

In addition to Standard Precautions, long sleeved aprons/gowns must be used.

All placentas are handled as clinical waste and must be placed in yellow
 bags and incinerate if unclaimed. For contaminated placenta, place it in
Biohazard labeled bags.

 A&E, Treatment Room and Dental Clinic

In addition to Standard Precautions, surgical hand scrubbing must be

practiced and use disposable items as much as possible.

 Operation Theatre

In addition to Standard Precautions, surgical hand scrubbing must be

practiced. Infectious cases must be last in list.

 Renal Dialysis Unit

In addition to Standard Precautions:

- All patients must be screened for Hepatitis B, Hepatitis C and HIV
- All staffs must be screen against Hepatitis B, Hepatitis C and HIV and
immunized for Hepatitis B.
- Use disposable or heat labile items
Standard Precautions for Laboratory Services Including Blood Transfusion Services

All laboratory staffs are at risk for all types of infections. Therefore, strict compliance
with Standard Precautions and Additional Precautions guideline are important to prevent
occupational exposure.

In addition to the general Standard Precautions, additional precautions as stated below

should be practiced:

 Personal Protective Equipment

 Policies and Procedures for A Plastic Surgery and Dermatology Clinic14

 Lab coat to be buttoned and worn at all times

 Change lab coats regularly at least once a week, if
contaminated to be changed immediately
 Contaminated coat to be soaked with Sodium Hypochlorite 1
in 80 for 30 minutes before laundering
 Remove coat when leaving laboratory

 Laboratory activities
 Laboratory activities should be carried out in a bio-safety cabinet
 Wash hands with antiseptic cleanser after removing
gloves and before leaving laboratory

 Collection, dispatch, reception and disposal of specimens

 Treat all specimens as potentially infectious
 Specimens must be collected in screw-capped and leak-
proof container in upright position and properly labeled
 All specimens should be discarded as clinical waste
 Left over specimen in reusable container should be
decontaminated by autoclaving before the content is
discarded

Maintenance Of Equipment for Sterilization

1. Yearly certification of fitness from JKKP is needed for all autoclaves.

2. Mechanical tests should be carried out routinely e.g., Dummy Run,
Bowie Dick and B.I. once a week, during installation, after major repair
and for validation.
3. Maintenance and usage should follow manufacturer’s instructions.