Dental practice accreditation

Accreditation for private dental practices in Australia is aligned with the National Safety and Quality Primary and Community Healthcare Standards (NSQPCHS). These standards are established and overseen by the Australian Commission for Safety and Quality in Healthcare (The Commission) and apply to a variety of healthcare providers, including GP practices.

What are the Standards?

The NSQPCHS are comprised of a series of "Actions" that healthcare practices, including dental clinics, must comply with to meet safety and quality benchmarks. Dental practices are required to demonstrate how they adhere to these actions. At Smartdentist, we provide guidance on how your dental practice can effectively meet these requirements. Read the Commissions guidelines for complying with the standards (new window).

Voluntary Compliance

"Try before you buy."
Your dental practice can choose to comply with the NSQPCHS standards without the need for a formal, paid assessment. However, if you still wish to be formally accredited , two organizations are authorized to assess compliance against the NSQPCHS:

• HDAA (Health and Disability Auditing Australia)
• QIP (Quality Innovation Performance)

 

Myths About Dental Practice Accreditation

1. "Accreditation is just about confirming what you already do!"

   • While some existing practices may align with accreditation standards, achieving accreditation often requires extensive documentation that many dental practices would not typically maintain.

2. "The ADA runs or assesses dental practice accreditation."

   • The Australian Dental Association (ADA) does not manage or conduct assessments for dental practice accreditation.

3. "There is an alternative accreditation specifically for dental practices."

   • The NSQPCHS is the only accreditation standard specific to dental practices. Alternatives, like ISO 9001 Quality Management, are generic business standards and not tailored to dental healthcare. Beware of misleading advertisements.

4. "Accreditation makes your practice 'bulletproof' with the Dental Board of Australia."

   • Accreditation does not guarantee immunity from scrutiny by the Dental Board of Australia or other regulatory bodies.

5. "Accreditation ensures compliance with all legal requirements."

   • Accreditation evaluates adherence to the NSQPCHS, which may not cover all legal requirements for dental practices. Similarly, some aspects required by law may not be assessed during the accreditation process—even with a physical assessment.

Are These Steps Part of Your Current Practice?

Here's a summary of interesting key actions your dental practice will need to take to align with accreditation requirements.

Patient Forms and Records

1. Identify Aboriginal and Torres Strait Islander Patients

   • Ensure your new patient forms include the question:
     "Are you of Aboriginal or Torres Strait Islander origin?"
     This is required under Action 3.22 and must be recorded in the patient's health record.

2. Identify Patients with Disabilities or from Diverse Backgrounds

   • Your practice must have a documented and defined method to identify patients with disabilities or diverse backgrounds (Action 1.09).
   • Options include reviewing records or asking targeted questions during the intake process.
   • Be specific! For example, accrediting agencies have rejected general questions like "Do you wish to tell us about any other illness or condition?" Instead, you may need to ask:
     "Would you like to self-identify as having a disability?"

Patient Partnerships and Cultural Safety

3. Partner with Patients in Safety and Quality

   • Practices are expected to actively involve patients, carers, and consumers in safety and quality initiatives (Action 1.03).
   • This includes sharing timely updates on your practice's safety and quality performance.

4. Understand and Respond to Your Patient Population

   • Define your patient population and show how this understanding informs your healthcare planning and delivery (Action 1.10).

5. Train Staff in Cultural Safety

   • Provide training to ensure staff can deliver culturally safe services for Aboriginal and Torres Strait Islander patients (Action 1.16).
   • If your practice doesn't record whether patients are Aboriginal or Torres Strait Islander, it's difficult to justify opting out of this action.

6. Create a Culturally Safe Environment

   • Foster an environment that respects and acknowledges the cultural beliefs and practices of Aboriginal and Torres Strait Islander patients (Action 1.25).

Plans and Policies

7. Pandemic and Business Continuity Planning

   • Maintain a pandemic plan (Action 3.12) and a business continuity policy (Actions 1.04, 3.12) to ensure preparedness for disruptions.

8. Reprocessing Reusable Instruments

   • From July 2025, practices will need to provide a gap analysis showing progress toward full compliance with AS 5369 standards for reprocessing reusable instruments (Action 3.13).
   • Note: Accreditation will rely on individual assessors' interpretations of AS 5369, a shift from previously following ADA Infection Control guidance.

Can You Provide Documentary Evidence for These Processes?

Compliance with accreditation standards requires detailed documentation of everyday processes. Below is an outline of areas where you would need to produce documentary evidence, along with tips for streamlining compliance.

Incident Reporting and Risk Management

1. Incident Register

   • Record all incidents in an Incident Register, including what was done in response.
   • Engage staff by asking for their input on incidents and record their feedback in the register.

2. Risk Register

   • For ongoing issues, transfer information from the Incident Register into a Risk Register.
   • This process should involve input from the workforce and reflect collaborative decision-making.

3. Quality Improvement Register

   • Document planned changes made in response to incidents or risks on a Quality Improvement Register.
   • While these processes may feel intuitive, recording them in detail is essential for compliance.

4. What to Record as an Incident

   • Capture every improvement or issue as a recordable event, including:
     • Patient complaints (e.g., about appointments or billing).
     • Staff compliance concerns.
     • Workplace improvements (e.g., repainting walls, replacing computers, upgrading soap dispensers).
   • This approach ensures you consistently generate data for analysis.

Data Correlation and Reporting

5. Data Analysis and Action

   • Regularly correlate data from incidents and risks to identify trends.
   • Develop action plans based on this analysis and report outcomes to staff in a documented format (e.g., emails or meeting minutes).

6. Streamlined Analysis

   • Use a simple system to analyze incident data quickly, enabling you to create actionable reports and send updates to staff as evidence of compliance.

Patient and Staff Involvement

7. Consumer/Patient Involvement

   • Include a consumer or patient representative (e.g., it could be a trusted family member or friend) on your safety and quality management committee to meet accreditation requirements.

8. Training and Competency Assessments

   • Maintain records of training or competency assessments for the 20 topics required by the NSQPCHS.

9. Audits

   • Conduct and document audits for the 8 topics specified by the NSQPCHS.

Practitioner Scope and Compliance

10. Scope of Practice

• Monitor and document that all dental practitioners and staff are working within their scope of practice and following the policies and procedures.
• This can be particularly challenging for sole practice owners but is a critical aspect of compliance.

Communication and Documentation

11. Communication Records

• Ensure all safety and quality communications are documented through emails or meeting minutes to provide clear evidence of discussions and decisions.

Patient record keeping

12. Exam 011

• Is your 011 record keeping up to expectations? You need to be able to show patient records which record the patients goals of care (Action 3.21) with risk assessment and diagnosis recorded. You need to have an agreed treatment plan and show delivery of that agreed plan or documentation of any variation.

How Smartdentist Simplifies Accreditation

The Smartdentist system streamlines the process of managing incidents, risks, and quality improvements by automating data collection—provided forms are used correctly. Executive reports compile this information, making it easy for a safety and quality committee to review.

Within Smartdentist, you can set up a committee with defined aims and members, allowing you to clearly demonstrate its purpose and functions. Additionally, the platform enables seamless communication, with emails aligned to relevant accreditation actions, making the process more manageable for your practice.

How Accreditation Works Best and Enhances Your Practice

At Smartdentist, we aim to guide your practice through the accreditation process to help ensure you achieve success. However, there are challenges to consider:

1. Finding a Dedicated Staff Member

   • Success depends on having someone within your team who is motivated to drive the accreditation process, complete forms, and perform audits consistently.

2. Staff Training and Policy Engagement

   • Staff must complete online training modules and take the time to review and understand your policies.

3. Ongoing Use of Systems

   • Continuous use of incident and quality improvement forms is essential to maintain compliance.

4. Commitment to Long-Term Activities

   • Accreditation is not a one-off event; it requires an ongoing commitment to:
     • Annual audits of every staff member.
     • Regular competency assessments.
     • Recording and addressing incidents and complaints, following them through to risk assessments or quality improvements.
     • Re-accreditation every 2 years (only allowed twice)
     • A virtual assessment or on-site assessment will be needed within 6 years and this may involve assessments with only 24 hours notice to maintain accreditation.

Does Accreditation Improve Your Practice?

The benefits of accreditation depend on your perspective and goals. While accreditation encourages structured processes and consistent improvements, its actual impact varies for each practice.

For many dental practices, the primary concern is: "Am I doing the right thing with infection control?"

• Accreditation provides a framework for quality and safety but does not always deliver definitive answers to specific concerns like infection control. Ultimately, the improvements accreditation brings will depend on how your practice uses the process to enhance operations and patient care (this was written by AI!).

Let Smartdentist be your partner in navigating accreditation, helping you focus on what matters most—providing safe, high-quality dental care.