APPENDIX B Organization of HealthCare Example

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10-1. emergency visits appropriate triage, treatment and follow-up Emergency Pt.: a. Triaged by Dr. with differential Diagnosis b. Radiograph taken by assistant c. Dr. confirms Diagnosis & does Treatment d. Appropriate FU scheduled if needed or pt scheduled for an initial visit.(appt. in 10 days and recall if missed) Quantitative (April and Oct) 10-2. Comprehensive Examination as scheduled appointment a. Full mouth x-ray (FMX) bite wings or panograph is taken by assistant. FMX consists of 14-22 periapical x-rays including bite wings. representati ve representati ve b. Prophylaxis or polishing of teeth & 80 Search Criteria: Emergency visit code: Search Criteria: Emergency visit April review (Sept 1, 2007 to Feb 28, 2008) Oct. review (March 1- Aug 31, 2008) code: D0140 & or D9110, 10 charts per dentist 10 charts per dentist Peer review 80 Code # D0150 and D1110 (new code combination for 2007) Comprehensive Exam and cleaning in last year

supra-gingival scaling is preformed by hygienist. c. Initial exam is preformed by doctor Quantitative (June) Initial exam requirements 1-5 Document #10-2 attached. Peer Review 10 charts per provider 10-3. Initial Periodontal Therapy Initial Periodontal Therapy is scheduled with the hygienist and consist of: a. periodontal charting b. periodontal scaling / root planning c. re-evaluation d. follow-up based on severity of periodontal issues e. Appropriate referral if no resolution of pocket depth Quantitative (August) Initial Periodontal Therapy protocol attached (#10-3) expanded information for a-e Rep. 80 Peer Review 10 charts per hygienist code: D4342 & D1110 10 charts per hygienist

10-6. Initial and Emergency visits chart reviews Qualitative (September) Protocol of exam attached (#10-6) Rep. 80 Peer review 10 charts per provider (Charts to encompass charts with dental codes D0120, or D0140, or D0150 ) 10-7. Competence and evaluations are done yearly for dental staff members. Results are reported to HJA Board of Directors in May of each year. (7-9 HR) (May) Rep & HR Manager Report number completed 10- TX Completed within 1 year of Comprehensive visit. Oral Health Performance Measure: Percentage of dental patients seen for a comprehensive visit who completed their treatment plan within one year of the 70 charts randomly selected per calendar year reviewed. Universe: Pt with code D0150 Exclusions: pt. who transferred from CHC during the yr. after their comprehensive visit.

comprehensive visit. 9-9. Appropriate follow-up for selected high risk procedures such as: Extractions_-July Quantitative. Extraction (refer to Pt. National Safety Goals-(wrong site) ADA, recommendation ) Time Out Taken (T.O.T.) documented in medical record for all dental surgical procedures to insure the removal of the correct tooth/teeth. Extraction: 1. Consent obtained (Including risks, benefits, & alternatives.) 2. Results of procedure 3. Follow-up if indicated with pt. 4. Complications noted and appropriate follow- Dir. 100% TOT Peer review of all dentists

(July) up as needed. 5. Evidence of having marked x- ray or dental chart as to tooth to be extracted. 5. Time out documented