18 Practice management

Practice management training and courses are widely available and certainly worth investing in. They can help in developing systems leading to increased efficiency and job satisfaction and decreased stress for the whole dental team. A happy practice environment is not only more pleasant to work in, but the bonhomie will also be transmitted to patients. One of the challenges of trying to manage a dental practice while also being a clinician within it, is that of having enough dedicated time in which to do full justice to your management responsibilities. Due to the number of administrative and legislative requirements that need to be dealt with when running a dental practice, a practice manager has become an essential member of the dental team.

Good communication skills are essential not only between the practice team and patients but equally between team members to ensure smooth running of the practice. Joking about the receptionist’s latest boyfriend (strange though he may be) is not communication. It should be remembered that good communication involves the ability to listen as well as talk. An effective complaints/feedback procedure should allow patients to be able to raise concerns openly (however minor) thereby enabling the practice to learn from the issues raised and improve their service. By addressing problems early, this could prevent a more significant complaint arising at a later stage.

Practice procedures should be in place to ensure messages (whether received by email, telephone, post, or in person) are documented and delivered to the correct team member promptly so they can be acted upon.

For teamwork to be successful the opportunity for team members to discuss problems and ideas for improvements needs to be created. Regular structured staff meetings should be planned with an agenda prepared in advance to which all team members should be encouraged to contribute. Patient feedback, complaints, changes in guidance/policies should be discussed. Minutes of the meeting should be kept, recording date of meeting, members present, matters discussed, and actions taken. The minutes should be accessible to all team members for future reference.

Delegate tasks that do not require your training and expertise. In addition to reducing stress and freeing time to concentrate on tasks that do require your skills, this also increases job satisfaction for ancillary staff, provided they are given the training and time to cope with new responsibilities, e.g. getting team members involved in collecting/auditing feedback.

The importance of building a mutually supportive team can readily be appreciated by trying to work in an environment where everyone has been forced to protect their corner. Successful leadership involves encouraging staff to develop their potential both as individuals and as valued members of the team, encouraging discussion as to what the goals are to be and how to achieve them.

Motivation to work as a team can be fostered by financial incentives linked to the performance of the practice, but it is wise to identify what motivates individual members of the practice as money may not be the most important factor for all employees.

All new staff members should undergo induction training in practice procedures and policies. A record of training provided should be kept. Review of all staff training should be carried out annually and development of further skills encouraged allowing delegation of additional tasks where appropriate. To comply with GDC requirements, all dentists and DCPs must carry out relevant CPD ( Continuing professional development (CPD), p. 738). Practice owners should ensure reasonable opportunity is given to staff members to undertake CPD and ensure their skills and knowledge are updated.

A manual of practice procedures, routines and policies should be kept which is freely available to all staff. All members of staff should be involved in reviewing and updating this information. In-house training days with speakers either from within the practice, or invited, are useful especially in areas such as dealing with medical emergencies and cross infection.

Dentists and DCPs involved in the taking and development of radiographs should have received appropriate training and have this training updated ( X-rays—the statutory regulations, p. 746). Documented evidence of appropriate training should be kept.

Motivation can often be enhanced by financial incentives. Therefore by structuring payment to comprise: (i) a fixed hourly rate; (ii) an individual bonus, which is related to attendance, sickness record, and productivity paid as a percentage of the hourly rate; and (iii) a group bonus which is a fixed proportion of the profits of the practice; all staff have an inducement to reduce overheads and improve efficiency in the practice. Care must, however, be taken to ensure financial incentives are not seen to compromise patient care, e.g. by encouraging patients to opt for a particular treatment or product.

Always put all matters regarding employment in writing. The BDA advice sheet on recruitment and setting up in practice is a useful reference.

The BDA produce advice sheets on dismissal and redundancy. The Advisory, Conciliation and Arbitration Service (ACAS) will also give guidance and have also produced a Code of Practice to assist organizations.¹,² Practically and emotionally, dismissal of staff is not easy and if taken to tribunal, can be expensive. The Trade Union and Labour Relations Acts allows for dismissal due to capability, conduct, contravention of the law, retirement, and redundancy.

Employees commencing work after 6 April 2012 may bring an unfair dismissal claim after 2yrs’ employment (1yr prior to this date and in Northern Ireland). To defend a claim of unfair dismissal the practice should have followed a set disciplinary procedure:

A note of the oral warning should be recorded. The reasons should be given in writing to the employee. Give the employee a timetable for improvement and advise that this is the first stage of the disciplinary procedure.

(first/second/final written warning) that if there is no improvement, dismissal will follow.

if the employee fails to meet the requirements stated in the written warnings. The amount of notice should concord with that agreed in the employment contract. The minimum statutory notice required depends upon length of service: <1 month = no notice; 1 month to 2yrs = 1 week; 2–12yrs = 1 week for each complete year worked; >12yrs = 12 weeks.

Instant dismissal is acceptable where an action is deemed to amount to gross misconduct. Examples of gross misconduct may include theft, breach of confidentiality, breach of health and safety regulations, and alcohol/drug-related incapacity.

is dismissal for reasons other than the personal behaviour of the employee. Statutory redundancy payments are required for staff who have been employed continuously for >2yrs (full or part-time). The amount paid depends upon pay, length of service, and age. Employers should provide employees with notice of redundancy in accordance with statutory requirement. Employees are also entitled to paid time off to look for a new job or undergo training.

NB Claims for unfair dismissal on grounds of discrimination have no qualification period.

The HSW Act aims to protect employers, employees, self-employed contractors, and the public within the work environment.³,⁴ Failure to comply could lead to investigation and prosecution by the Health and Safety Executive (HSE), a statutory body responsible for enforcing the HSW Act. The HSE has the power to enter premises (with or without notice) and carry out an inspection. If required they can issue an improvement notice (advising when compliance must be achieved) or a prohibition notice (closing the premises until compliance is achieved) ± prosecution. Employees are expected to take reasonable care for their own and other people’s safety; refusal to comply may be grounds for dismissal.

Compliance with the HSW Act requires:

The Control of Substances Hazardous to Health Regulations 2002 requires employers to identify all substances (e.g. vapours, microorganisms) in the workplace which are potentially hazardous, and take steps to prevent or decrease any risks to health. The following procedure is recommended:

NB Product safety data sheets are not a risk assessment in themselves but provide information which should form part of the risk assessment process.

Encapsulated amalgam should be used in preference to non-encapsulated. Use should be confined to impervious surfaces, ideally a lipped tray lined with foil. Staff should wear gloves when handling Hg-containing substances.

Staff should be trained with dealing with Hg spillage and a policy should be in place. Kits for dealing with spillages should contain a bulb aspirator for collecting large drops of Hg, leakproof container with Hg suppressant (usually CaOH/flowers of sulphur/water), mask, and disposable gloves. Proprietary kits are available.

Amalgam is classed as hazardous waste under the Hazardous Waste Regulations 2005. Waste should be stored in a sealed, labelled container containing solution to suppress Hg. Disposal of amalgam/Hg and capsules should be by a licensed person. Documentation/contract relating to waste disposal needs to be kept.

Amalgam separators are a legal requirement for all dental practices to ensure amalgam is filtered out of the main water drainage.

In January 2013 a UN treaty on the future use of dental amalgam proposed steps to decrease environmental pollution from Hg. No time scale has been imposed for phasing down use of amalgam in dentistry.

There is now sufficient evidence that healthcare workers are at ↑ risk of latex allergy.⁵ More widespread use of latex products has also resulted in an ↑ number of the population being sensitive to latex. In order to ↓ the risk:

Reports of anaphylactic reaction to chlorhexidine have been reported prompting the Medicines and Healthcare products Regulators Agency (MHRA) to issue an alert. Clinicians are advised to be aware of the risk of anaphylaxis, check for known sensitivity and report any adverse reactions.⁷

The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (1995) places a legal duty upon employers, the self-employed and people in control of premises to report:

Reporting of such incidents to HSE should be carried out immediately to allow the HSE and local authorities to investigate. For injuries leading to >7 days off work a report must be made within 15 days. Reports can be made online at  http://www.hse.gov.uk/riddor/online.htm, by post on standard form, or by phone. A written record should be kept of all accidents in the practice documenting date and time of accident, name of person affected and their occupation, nature of injury, and how accident occurred.

NB Deaths and injuries arising from medical/dental treatment carried out by, or under the direct or indirect supervision of, a doctor or registered dentist are exempt from reporting under RIDDOR.

Adverse incidents involving medical devices should be reported to the MHRA. Reports should be made in writing and can be completed online:  http://www.mhra.gov.uk/Safetyinformation/Reportingsafetyproblems/Devices.

In addition, in England, the CQC should be notified of deaths that were, or may have resulted, from the carrying on of a regulated activity. Incidents resulting in serious injury to people using the service also need to be notified. Notification forms can be downloaded from the CQC website.

In Northern Ireland, incidents relating to medical devices, non-medical equipment, plant/building items should be reported to Northern Ireland Adverse Incident Centre (NIAIC).

In Scotland, adverse incidents may need to be reported to Health Facilities Scotland.

When notifying any body of an incident, care must be taken not to disclose confidential information that would be seen to contravene the Data Protection Act 1998.

(See Prevention of cross-infection, p. 744.)

Dentists are responsible for ensuring that any of their staff who carry out procedures that could bring them into contact with blood (e.g. assistants, hygienists, dental nurses) should be immunized against hepatitis B. Any healthcare worker who becomes e-antigen +ve is obliged to cease practising. Advice should be sought from occupational health team.

Management requires written protocols, see Blood spillages, p. 745.

The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 require practices to carry out risk assessment to prevent sharps injuries. The risk assessment should ensure practices have effective arrangements for safe use and disposal of sharps (including using ‘safer sharps’ where reasonably practicable). New devices may come onto the market to decrease risks but care must be taken to ensure alternative devices are suitable for dental use and do not compromise patient care.

See Computers and visual display units (VDUs), p. 732.

Dentists are responsible for segregating waste, storing it safely, packaging it appropriately for transport, and arranging for its safe and responsible disposal. Practices should have a policy relating to classification and disposal of waste.

Dental practices produce a wide range of both hazardous and non-hazardous waste. The responsibility for determining if waste is hazardous rests with the practice; however, hazardous waste would typically include amalgam, sharps, radiography developing/fixing fluids, clinical waste, and chemical disinfectants.

Policies should confirm procedure for disposal of sharps, medicines, chemicals, amalgam, extracted teeth (containing amalgam and without), study models, clinical, non-hazardous (offensive) and general waste.

In accordance with the Hazardous Waste Regulations 2005, all hazardous waste must be clearly labelled with the nature of the waste and the details of the dental practice. Provided that a practice does not produce >500kg of hazardous waste in any 12-month period, registration with the Environment Agency is not required.

Clinical waste for incineration should be placed in orange bags. Whilst waiting for collection and disposal by a registered collector, if clinical waste is stored outside the practice this must be in a secure container which cannot be tampered with.

Due to the gypsum content of dental study models, these cannot be disposed of in normal/clinical waste due to the production of hydrogen sulphide gas when land-filled. Advice should be sought from waste disposal service providers or local authority waste disposal team.

Care should be taken that any waste containing patient information is disposed of confidentially.

HTM07-01 guidance on Safe Management of Healthcare Waste considers that extracted teeth would be viewed as waste unless a patient has asked to retain it. In this situation the tooth is then not considered waste as it has not been discarded. However, the guidance states the organization has a duty to ensure items returned to a patient are disinfected/cleaned and instructions given to the patient regarding subsequent disposal (ideally providing suitable packaging for the patient to return it to the practice rather than disposal in domestic waste).

A certificate of insurance must be displayed on the premises.

The Health and Safety (First-Aid) Regulations 1981 require all workplaces to have first-aid provisions. The practice should be assessed to ensure compliance based on number of people employed and the risks associated with the work.

Practices with <5 employees should have an appointed person in attendance during practice hours. Practices with >5 employees are advised to have a qualified ‘first-aider’. Larger practices may consider >1 trained person (either in emergency first aid or first aid at work).

Training needs to be undertaken through a HSE-approved course and renewed as appropriate. First-aid boxes should be appropriate for the number of employees and level of risk.

A dental prosthesis or orthodontic appliance is a custom-made device requiring a written prescription from the dentist. Manufacturers of custom made dental appliances need to register with MHRA in UK (or equivalent in other EU countries) and comply with legal requirements of MDD.

The manufacturer of an appliance is legally required to produce a ‘Statement of Manufacture’ which should contain:

The person providing the appliance to the patient must make the patient aware of the availability of the statement and offer a copy. Records should document whether the patient takes the statement or not. If declined, the statement should be retained within the patient’s record for the lifetime of the appliance.

Whilst contracting the manufacture of dental appliances outside of the UK is permissible, the GDC clarifies that a clinician, who elects to do so, will be held professionally accountable for the safety and quality of the appliance. The clinician would need to ensure appliances manufactured outside the UK satisfy the standards and obligations laid out in the MDD. Prescribing clinicians have a duty to ensure appliances made in the UK are manufactured by a registered technician who is then accountable to the GDC in their own right.⁸

Practices should display a ‘no-smoking’ sign at the entrance to the premises. The sign should advise that ‘it is against the law to smoke in these premises’.

See X-rays—the statutory regulations, p. 746.

Dental practices may be subject to inspection (which may be at very short notice) by commissioners of healthcare and statutory bodies. Policies and procedures are high on the agenda of many inspections. The topics just discussed are some, but not all of areas that may be looked at.

A good accountant and a friendly bank manager are invaluable and may be best recruited on recommendation from another practitioner.

It is advisable to develop a structured system for dealing with fees and estimates, tailored to the individual practice, which is understood and adhered to by all staff.

many aspects of calculating and collecting fees (to appropriately trained and motivated staff) should make the practice more cost-effective. However, failure to monitor the situation adequately can, at best, result in a false sense of security.

is time-consuming but necessary. Many book-keeping tasks can be performed by computer, either with an integrated practice management system or stand-alone software. Suggested minimum:

NB The Inland Revenue have powers allowing them to inspect documents relating to accounting/tax. Financial transactions should be recorded separately to patient records to avoid risk of confidentiality being breached.

It is helpful to bank all monies at the end of each day, as the bank statement then indicates the daily takings. To encourage settlement of fees, it is wise to accept payment in any form, i.e. cash, cheque, or credit card. It is good policy to negotiate overdraft facilities in advance to cover those occasions where cash-flow problems arise.

Although credit cards incur a commission, patients with cash-flow problems may be happy to accept this form of payment as a face-saver; their lack of funds then becomes the credit company’s problem. Organizations that store, transmit, or process card holder data should comply with PCI DSS (Payment Card Industry Data Security Standards) to prevent fraud/theft.

An annual forecast and budget should be prepared jointly with the accountant. This simple form of management control helps you to monitor the practice’s income and expenditure and to identify any variations quickly so that you can act upon them if necessary.

These can often be prevented by having a Practice Payment Policy which is clearly advertised to patients and adhered to; e.g. payment in part at the beginning of treatment and the balance on completion; or payment in full, up front.

At the examination appointment patients should be given a written estimate and advised when payment is due. If a patient forgets, at the last visit they should be asked to sign a form confirming that the treatment has been satisfactorily completed and that they agree to pay (£x) within 7 days. If payment is still not forthcoming, reminders should be sent out at 7, 14, and 28 days. If there is still no joy, consider using debt collectors, but beware of a counter claim of negligence. It is preferable to find out why the patient has not paid before making a further decision.

This is really where a good accountant comes in. By providing him with information on income and expenditure on a monthly basis, he will be able to provide advice on what to do before the end of the financial year to minimize the taxman’s percentage.

Essential for property, contents, equipment, indemnity, staff, loss of income, and personal insurance.

(reformed in 2006) requires those extending credit to the public by allowing them to pay for goods/service in instalments, to obtain a licence. A licence is not required if the business only accepts credit cards provided by another company, or allows customers to pay bills in <4 instalments within 1yr. For further details, contact the Office of Fair Trading  http://www.oft.gov.uk &/or obtain legal advice to assess whether a licence is required.

Running late happens occasionally to everyone, usually when you were hoping to finish early and rush off to do something else. Time pressures can create the risk of clinicians trying to ‘cut corners’, a strategy which can misfire and, at best, result in even more time being wasted at a later stage. There is also evidence that practitioners who habitually work under time pressures and run late have a greater risk from complaints and litigation.

If running late becomes a regular problem, stop and re-assess/audit your working practices. Identify why the clinic runs late: ? unplanned emergencies, ? insufficient appointment length, ? incorrect appointment booking, ? patients attending late, ? clinic not starting on time (staff and colleagues may be able to help provide a more objective view of the reasons).

Once identified, ensure steps are taken to deal with causes of delays.

Some additional hints to decrease everyday stress:

A patient who simply demands to be seen immediately or at a stipulated time may not be a true emergency. Patients with a genuine need for urgent care are more likely to be willing to attend at any time available. Ensure staff understand which conditions need to be seen as an emergency and should not be delayed.

Buffer zones built into day-lists should ensure dealing with emergencies is not a problem. Out-of-hours arrangements should be in place so patients can access advice and treatment if appropriate.

As consumers of healthcare, patients have a choice as to where they go for their treatment. Whether NHS, private, or independent, the success or otherwise of a practice is going to depend on its ability to attract and keep patients. Marketing involves identifying and defining needs/desires of potential clients. Advertising is the means by which we communicate with these potential and existing clients.

Advertising does not need to be brash; after all, it is merely a means of letting the public know about the existence of a practice and the services that are available. Previously advertising in the ‘yellow pages’ may have been the limit of practice advertising; however, a wealth of alternative resources may now be more effective:

The best advert is a satisfied patient who will recommend you by word of mouth.

This starts before the patient arrives at the surgery as most patients will make their initial enquiry by phone.

The phone should always be answered promptly, in person. Many patients are frustrated by being left on hold or receiving an answerphone message, particularly if their enquiry is not then dealt with promptly.

When the prospective patient arrives at the surgery the external and internal decor, together with the welcome they receive, will play a role in determining a patient’s impression of the professionalism of the practice. Ensure non-dental areas are well maintained and that the exterior of the premises looks well cared-for. Dentists providing care at the practice should be clearly identified.

The reception should be as relaxing as possible. A small area for children to play or, if possible, a crèche, are good practice-builders. A range of interesting magazines (look at the range available at your optician’s, rather than the doctors’ waiting room) and practice leaflets on different aspects of dental care/health should be available.

The receptionist must be friendly and helpful (even on Monday mornings). It is worth spending some time with the receptionist team, deciding on stock responses to some of the more common problems that arise (e.g. dealing with the angry patient). Care should be taken receptionists are not seen to provide clinical advice however, increasing their knowledge of dental techniques is helpful so patient queries can be answered appropriately.

It is also helpful to find out how patients heard about the practice, so as to better target future marketing strategies. The presentation and attitude of all the staff is of vital importance. An attractive and functional uniform in the practice colour or bearing the practice logo helps to invoke an image of professionalism.

Although it is tempting to exclude non-registered patients from receiving out-of-hours emergency treatment, it is a good practice-builder to see anybody in pain, as some of them will become regular patients.

It is vital to know your patient base. Is there a significant group which may need special attention (e.g. elderly or young families)? What extra services would your patients like to see (e.g. implants; a crèche)? What do they feel about your opening times—is there another group of patients who might attend if the opening times were amended?

Remember, the most important marketing aid is without doubt the personal touch.

Dentists providing NHS services in England/Wales contractually must ensure a practice information leaflet is available and reviewed every 12 months. The contract requires specific information to be included, which is a useful starting point for all practices irrespective of jurisdiction or whether private or NHS:

Further optional information can be included:

Broadly speaking there are two approaches: either get professional help (e.g. designer, photographer, printer) or DIY, using a desk-top printing package on the practice computer. The two are not mutually exclusive and all practices should consider taking advice from a designer. Before seeking help it is important to have some idea of what you want.

It is wise to shop around and examine the work of several professionals before choosing.

As well as providing information, aim to create the impression of a caring practice. The key to success is simplicity. Use of a practice logo ± house style (or colours) helps reinforce practice image. This idea of a corporate image is not new, but has worked well in the business world. A designer will be able to suggest styles and layouts best suited to your projected market, as well as help with the text wording. Photos and illustrations will increase the cost, but also the impact, as will using more than one colour.

Also see Websites, p. 733.

The majority of practices now use computers in some form, whether solely to assist with practice administration or as a fully integrated reception/surgery system. It is important that a backup of all information is carried out daily and the backup data stored off-site securely. An audit trail must be present within the software to allow any alterations made to clinical records to be identified.

The Health and Safety (Display Screen Equipment) Regulations 1992 require employers to minimize risks arising from working with VDUs/monitors/display screen equipment. Employers should assess the work area, furniture and equipment, the nature of the work being carried out and any special needs of individual staff. The following should be addressed:

The Data Protection Act 1998 covers use of manual as well as computerized records. A dentist storing personal data on a computer system must register with the Data Protection Commissioner. The practice should have a data protection policy.

Under the terms of the Act, data must be:

The Act provides that patients have the right to access their health records. A request should be made in writing to the data controller.

Upon receipt of a request, the data controller should provide copies of the requested records within 40 calendar days, subject to the patient having been advised and agreed to pay any appropriate fee. Under the provisions of the Act, a maximum fee of £10 may be charged for provision of a copy of entirely computerized records (includes administration fee and copying costs) or £50 for manual records. The data controller must confirm the identity of the individual making the request and, if it is not the patient, that the patient’s signed authority to release records has been obtained.

GDC guidance stresses the importance of confidentiality and that it is only in exceptional circumstances that it may be justified to make confidential patient information known without consent.¹¹ In situations where a request is made for disclosure without a patient’s authority, advice should be sought from an indemnity provider.

To prevent unauthorized access or accidental disclosure, all staff should receive training and terms of employment should include a confidentiality clause. Computers should be password protected and consideration given to encrypting any personal data stored electronically or transferred via email.

Most patients now expect to be able to find information out about a practice through a website. Websites, however, may also come under scrutiny from commissioning bodies, regulatory bodies, and other colleagues. Registrants must ensure information about themselves and the practice is factually correct and not misleading (see Points to watch, p. 731). Websites must comply with GDC guidance on ethical advertising¹¹ and confirm:

‘Independent’ is the term preferred by many for private practice, perhaps as it sounds less avaricious. An increasing proportion of dentists are turning to other methods of remuneration than the NHS; indeed the pace of change is so fast that it is difficult to provide information that will necessarily be relevant in the future. These pages are limited to discussing general principles.

To develop the potential of a practice it is necessary first to fully evaluate its present position. An appreciation of the existing patient base can be gained simply by going through the manual or computer records and looking at the geographical spread and socio-economic groups. If most patients are part of a family group, then future developments need to provide advantages for parents and children; e.g. if changing to independent practice, then a family-based capitation scheme might be more applicable.

Also, the potential for attracting new patients to the practice, and the competition from other practices in the area for those and existing patients, should be assessed.

It is also important to research and take into consideration staff views about any changes to be made to the practice. Ensure staff are informed about the reasons and advantages these changes will bring.

To be successful a business needs to understand its strengths and weaknesses as well as having a sense of direction and purpose. This can be done through a SWOT analysis (identifies Strengths, Weaknesses, Opportunities, and Threats).

If the financial basis of a practice is to be changed a business plan will need to be drawn up and discussed with the practice’s accountants and bankers.

A marketing plan should involve:

This difficult exercise should be carried out in conjunction with the advice of the practice accountant. The following will need to be calculated:

From this the target hourly rate can be calculated. Local market conditions need to be considered, which may necessitate a little rounding down of the profits desired, or a decrease in overheads if that is possible. Once a realistic hourly rate has been calculated, either fees can then be determined for each procedure by the average amount of time taken, to give a set price list, or patients charged according to the time taken. Laboratory charges and hygienist fees, as indicated, should be additional.

There are basically four different approaches:

Types of approaches that may be considered:

When a private patient requires medicines as part of a course of private dental treatment, a private prescription should be provided. Dentists can also supply or sell medicines to any patient, but need to take into account dispensing rules. Alternatively, common drugs can be given as required and their cost included in the overall fee.

Patients may contact the Dental Complaints Service (see Dental Complaints Service (DCS), p. 671) for assistance with a complaint about private treatment.

is designed to give a supervised and mentored introduction into general dental practice and is an obligatory requirement for new graduates working within NHS general practice. Obtaining a FD position requires application through the national recruitment process; in England/Wales/NI via  http://www.copdend.org and in Scotland via the NES portal at  http://www.nes.scot.nhs.uk. Application is open to graduates from UK, EU and eligible candidates from outside EU.

work as salaried practitioners thereby reducing pressure to achieve a high-volume turnover. In England/Wales, a notional allocation of 1865 Units of Dental Activity is attached to a FDT contract. Each scheme organizes a ‘day-release’ programme which should cover the clinical and administrative aspects of NHS practice, as well as patient and financial management. Each trainee will also receive on-the-job training and supervision from their trainer, as well as tutorials on a weekly basis.

Trainees are members of the NHS superannuation scheme and their contribution is deducted at source. On completion of FDT a training number and certificate is awarded which enables a dentist to apply to provide NHS dental services in their own right.

To be accepted, a practice needs to satisfy the criteria set by the Foundation Training committee. The trainer should be present in the practice not less than 3 days a week. Trainers receive training for their teaching and assessment roles. A grant is paid and the trainees’ salary is reimbursed in full.

GDPs with >4yrs’ experience are eligible to become trainers. They are selected after a visit to the practice to check suitability as a training environment and compliance with Clinical Governance and wider legislation. They are also required to attend an interview.

A standard contract, which both parties are required to sign, is available from the BDA and scheme organizers. The contract runs for 12 months, at the end of which each party is free to make their own arrangements. It normally includes a binding-out clause which prevents the trainee subsequently accepting as a patient someone he has treated at the practice, should they move to another practice.

is additional further structured training which provides further professional development. Two-year training schemes are being implemented across a number of deaneries. A second year period of post-graduate training would typically involve working in community/hospital/dental school. A smaller number of more senior training posts are also envisaged (DCT2/3) allowing dentists to obtain additional skills which may form part of a pathway to speciality training.

These are the buzzwords in terms of demonstrating quality assurance and good clinical practice.

Originally part of an NHS drive to ↑ the quality of healthcare and make providers accountable for delivering a consistent standard of care. Practices with an NHS contract must comply with clinical governance arrangements and set out to ensure:

Practices providing NHS services will be subject to inspections undertaken on behalf of the relevant commissioning body. Compliance with clinical governance forms part of the inspection process.

For practices providing private ± NHS care, the quality of care provided comes under scrutiny from the relevant statutory body (England, CQC; Wales, HIS; Northern Ireland, RQIA see Complaints, p. 670).

CPD is mandatory for continuing registration with the GDC.

Recommendations for CPD in ‘core subjects’ applies to each 5yr cycle. Minimum hours verifiable CPD in the following areas is recommended:

Verifiable or non-verifiable CPD is also recommended in:

As radiography is not covered in the curriculum for dental technicians, it is recommended that 5h CPD in materials and equipment is undertaken instead.

All registrants must maintain their own records, keep certificates/proof of attendance, and submit a declaration to the GDC. The GDC may request to inspect records to confirm CPD declared. Records of CPD should be retained for 5yrs after the end of the cycle.

Failure to comply can result in erasure from the Register.

Audit has been defined as ‘a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change’.¹³ The aim is to encourage clinicians to self-assess different aspects of their practice, implement changes, and monitor them with a view to improving service and patient care. Whilst a rolling cycle of audits may be in place, specific audits may be prompted by an adverse incident or complaint.

Improvement of the quality of care provided. This is achieved by identifying less-than-adequate care and raising it to the standard of the agreed best.

Audits can be retrospective or prospective.¹⁴ Retrospective audit may be particularly useful to review practice following, e.g. a patient complaint/adverse incident. Prospective audit looks at future care. The basis of all audit should be frank and open discussion without fear of criticism.

The quality of care provided should be objectively assessed against an agreed standard of care. Standards should not be fixed and immutable, so as to allow evolutionary change. It is imperative that the results of such discussion should lead to changes in practice when indicated. Confidentiality is an absolute prerequisite.

Audit can involve all the dental team. Examples of areas that can be subject to audit include compliance with radiography requirements (e.g. justification/reporting), record keeping, cross infection, and time keeping. With all audit crucial requirements are genuine motivation and interest amongst the participating staff, objectivity, honesty, and adequate data.

An ‘audit cycle’ is illustrated in Fig. 18.1.

The aim of peer review is to improve the quality of care provided in dental practice by encouraging communication between dentists and to identify areas in which change can be made.

involves making clinical decisions based on the best available evidence, which should include sound research, epidemiology, basic science, and clinical experience.¹⁵ This involves using those clinical interventions which have been shown to be effective both by research and audit.

The ‘gold standard’ for clinical studies is a well-planned RCCT as these minimize the risk of bias. But in many areas of clinical practice evidence from such trials is yet not available. In the meantime clinicians should continue to evaluate carefully the techniques they use and the results of studies reported in the literature, although the sheer volume of scientific literature makes keeping up to date a difficult task.

A method of collating and assessing the results of research on a particular topic. This implies that a thorough search for suitable articles and indeed unpublished work has been made, and explicit criteria used to decide whether an article should be included or rejected.

A systematic review which uses special statistical methods to combine the results of several studies. Only RCCTs should be included. By considering a number of studies the effects (and side effects) of a treatment are magnified as the sum total of subjects is effectively increased. Whether the findings are consistent for different population groups or treatment variations can also be evaluated. For example, if this technique had been used to evaluate the results of research into the use of streptokinase in the treatment of myocardial infarction a positive benefit would have been demonstrated almost 20yrs before it became apparent from the individual studies.

aims to collate the results of systematic reviews in all areas of healthcare and ensure that the findings are kept up to date. The results can be accessed electronically via the Cochrane library, on CD-ROM, and the Internet ( Useful websites, p. 774).

are defined as ‘systematically developed statements which assist clinicians and patients in making decisions about appropriate treatment for specific conditions’.¹⁶ They may be developed nationally or locally, but should always be seen as guidance and are not a substitute for clinical judgement. To be effective, clinical guidelines should be brief, practical, and based on the results of sound research. They should be reviewed regularly in the light of new research and their effectiveness audited.

Clinical guidelines can be drawn up by any group of clinicians; in dentistry this approach is mainly being coordinated nationally by the Royal Colleges &/or specialist societies.

NICE refers to The National Institute for Clinical Excellence, a government based body which on 1st April 2013 changed its name (but not the acronym by which it continues to be referred to) to the National Institute for Health and Care Excellence. One of the roles is to investigate the effectiveness of different treatment modalities. Of relevance to dentistry are the guidelines relating to the removal of wisdom teeth, dental recall interval, and antibiotic prophylaxis.

Under the provisions of the Health and Social Care Act 2008, the Code of Practice on the Prevention and Control of Infections applies to all dental settings in England. Practices in England will be assessed on compliance with the code which covers ensuring systems are in place to monitor, prevent, and control infection.¹⁷

Cross-infection is the transmission of infectious agents between patients and staff within the clinical environment. Potential risks include not only hepatitis and HIV, but also other viruses (e.g. herpes) and bacteria (e.g. Streptococcus pyogenes, MRSA). Transmission can occur by inoculation or inhalation by direct or indirect contact.

Many patients may be unaware they are carriers of infections and therefore universal precautions are mandatory to ensure a standard cross-infection control policy for all patients. It is unethical to refuse dental care on the grounds that it could expose the dentist to personal risk. Clinicians can be challenged on the grounds of discrimination for declining to treat a patient, or treating a patient differently, on this basis.

All staff should have documented training in cross-infection control and every practice must have a written infection control policy displayed in every surgery to ensure uniformity of procedures. Compliance with cross-infection policies should be audited.

All clinical staff must be immunized against hepatitis B with a single booster 5yrs after the primary course. Protection is indicated by HbsAb >100mIU/mL. Antibody levels <10mIU/mL indicate a non-responder. Poor responders have antibody levels of 10–100mIU; it is not clear what protection is afforded by this level of response so consultation with occupational health services is required to determine need for additional blood tests/boosters. Documentary evidence of immunization and response for all staff should be retained. Staff should also be immunized against common illnesses.

Tact and discretion are required if truthful answers are to be obtained to sensitive questions. Clinicians should not rely on a patient’s written questionnaire alone and should confirm the medical history verbally to ensure no information has been missed.

Disposable gloves, eye protection, and face protection are necessary for clinical procedures. Hand washing/disinfection should occur at the start and end of each session, before and after removing PPE, after washing instruments, completion of decontamination procedures, and before handling sterilized instruments. In addition, when carrying out decontamination procedures PPE should include heavy-duty gloves and disposable aprons. To prevent skin drying out a water-based cream should be used at the end of each session.

Surgeries should include separate areas which are designated ‘clean’ and ‘dirty’ zones. Layout and equipment must be planned to allow easy cleaning and to minimize the number of surfaces touched; e.g. taps or lights that can be turned on with infrared light switches or foot controls.

A system of zoning increases efficiency as only those areas which are in the contaminated need to be disinfected with a suitable disinfectant.

Disposable instruments and cleaning materials should be used, wherever possible, especially instruments that are difficult to clean. Reusable items must be cleaned and sterilized after use according to the manufacturer’s decontamination instructions. A washer-disinfector is favoured to manual washing of instruments prior to sterilization, not least because it minimizes the need for manual handling of contaminated instruments, thereby reducing the risk of inoculation injuries being suffered by staff members.

Where endodontic files are designated as being re-usable they should be treated as ‘single-patient’ or ‘single-use’. If files are to be retained for use on the same patient, effective measures must be in place to ensure safe storage and exclude any risk of use on another patient in error.

During use, instruments should be placed on a sterilizable tray or impervious disposable covering. Care is required to avoid contamination of areas which are difficult to disinfect. Equipment handles, controls, and tubing should be covered by disposable plastic sheeting. Work surfaces should be disinfected using appropriate products between patients. All surfaces should be cleaned at the end of every session, even surfaces apparently uncontaminated.

Minimize these by high-volume suction. PPE should be worn. Flush aspirators and tubing through daily with a recommended disinfecting agent. Use of rubber dam reduces splatter and aerosols.

Immediately cover with disposable towels; treat with 10 000ppm sodium hypochlorite solution. After 5min dispose of in clinical waste. Use protective clothing and heavy duty gloves.

Care is required to prevent needlestick injuries, and preferably a re-sheathing device should be used. Sharps must be placed in a rigid sharps container and not filled to more than 2⁄3 full. (See Sharps, p. 721 re: sharps regulations.)

(See Needlestick injuries, p. 355.) Allow wound to bleed, and wash under warm water. Get advice from occupational health services. If a risk of infection, serological tests of staff and patient may be indicated.

Rinse and disinfect all impressions and appliances according to the manufacturer’s recommendations prior to dispatch and on return from the lab. Ensure lab sheet is marked to show appropriate disinfection of laboratory items has been carried out.

Risks from Legionella must be assessed and a written scheme in place for preventing and controlling any identified risks.

The person responsible for implementing the regulations and good working practice. Usually the practice owner.

The person appointed by the legal person who is responsible for implementing the local rules. Can be an appropriately trained dentist or DCP.

A person appointed in writing to provide advice on complying with legal obligations, e.g. testing of equipment, staff training, risk assessment, quality assurance programme, etc.

The dentist responsible for justifying an exposure and ensuring the benefits outweigh the risks.

A dentist who refers a patient to an IR(ME)R practitioner for radiological examination.

Any person who carries out all or part of the practical aspects associated with a radiological examination, including taking the X-ray, developing films, identifying the patient, etc.

In complying with the regulations,¹⁹,²⁰ the legal person must:

A number of requirements are necessary in order to ensure radiation doses are kept ‘as low as reasonably practicable’:

Use of CBCT in dentistry has ↑ in recent years, particularly in relation to planning treatment for implants and orthodontics. Radiation doses from CBCT (including potential doses to those operating equipment) can be significantly higher than those for conventional radiography equipment. As the existing regulations for conventional dental radiography were not sufficient to cover use of CBCT, specific guidance has been produced by the Health Protection Agency.²¹ The legal person is required to ensure the following:

See Table 18.1 for film faults.

Do this either in a darkroom or a daylight processing tank. It is important to always keep the developer and fixer baths in the same order.

Method:

If a film is urgently required the films can be viewed ‘wet’ after 2–4min in the fixer, but they should be returned for complete fixing.

There are several dental types available which can process IO and some EO films. It is faster as the first wash is eliminated and rollers squeeze off the solutions.

The quality of the image can be affected by deterioration of equipment and fluid. A quality assurance programme should be in place to ensure deterioration in quality is prevented. A radiograph of a test object/guide can be used as a reference and compared to repeat exposures of the same test object taken following replacement of fluids or regular intervals.

The developer and fixer are contained within a sachet, which also contains the film. Following exposure, tabs are pulled which release first developer and then fixer onto the film. The film is then removed and rinsed. Although this method obviates the need for processing equipment, the results tend to be inferior.

allow an image to be viewed and stored on a computer.