Clinical governance for the dental team

Iqra Rashid Chawdhary provides a refresher guide on this important topic as restrictions on dental services start to ease.

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As lockdown restrictions begin to lift and dental practices start to reopen their doors to patients, it is important that the dental team are up-to-date on and aware of the current guidelines and standards that they need to follow in order to ensure that the environment is safe to work in and treat patients. In light of the ongoing COVID-19 pandemic, this article will provide a refresher on one of the most important aspects of dentistry: clinical governance.

What is clinical governance?

Clinical governance is a quality assurance framework that allows practices to monitor their services, seek improvements and minimise risks to patient health and safety. They require effective procedures, policies and systems to be put in place and depend on the performance of the entire dental team in order to secure patient safety and deliver consistent standards of care on which patients can rely. There are seven main 'pillars' or domains which form the basis of clinical governance:¹

1. Patient and public involvement

2. Information and IT

3. Risk management

4. Audit and peer review

5. Training and education

6. Effectiveness (clinical)

7. Staff management.

1. Patient and Public Involvement (PPI)

PPI is about involving and listening to our patients and the public in order to effectively respond to their needs and improve their experiences. This is especially important as practices need to know if the extra measures and precautions they are taking due to COVID-19 are helping to reassure patients that the environment is safe to attend and receive treatment in.

Methods through which this is achieved include:

• Patient feedback questionnaires eg the friends and family test or suggestion boxes

• Having a well publicised complaints procedure in the practice.

Through reviewing patient feedback, comments and complaints appropriately - for example, through audits and staff meetings - the dental team can update policies and procedures to help improve quality assurance systems, patient experiences and also help find ways of encouraging patients to come back to the dental practice.

2. Information and IT

This is about ensuring data protection and patient privacy/confidentiality in order to effectively store, manage and use patient data eg for audits. It is likely that many more dental practices will start to use computerised systems to store patient data and records instead of paper notes in order to help reduce methods of transmitting the Coronavirus to others.

Methods through which this is achieved include:

• Having regular staff meetings and training to ensure everyone in the dental team understands their responsibility in regards to patient confidentiality and complies with the law

• Ensuring the dental team understand and follow the GDPR guidelines on data access, the Data Protection Act 2018, the FGDP guidelines on good record keeping² and the GDC standards on record keeping and confidentiality³

• Performing audits to check compliance with these guidelines eg for GDPR, audits could be done on the data held, where it comes from, why you share it and how long you keep it

• Adhering to the 1997 Caldicott Principles⁴ which state that if we use patient data then we need to justify the purpose, only use it when necessary, use the minimum required and keep access to data on a strict need-to-know basis.

3. Risk management

Practices need to carry out risk management in order to identify and eliminate or mitigate all significant risks to patient and staff safety. It helps to promote a blame-free culture and helps the dental team learn from any mistakes and accidents that have occurred, in order to improve the quality of care patients receive. This is especially important as we are in unprecedented times and it is essential that the dental team work together to find solutions if things do not go to plan. In addition, patients must feel that the dental environment is safe and that the necessary precautions have been taken to minimise the risk of transmission of harmful microorganisms such as the Coronavirus.

Regular team meetings should be organised so staff understand "best practice" standards and are up-to-date with the new practices/protocols.

Methods through which this is achieved include:

• Adhering to the 2013 Department of Health HTM 01-05 guidelines⁵ as well as implementing robust COVID-19 infection prevention and control procedures and following radiography, decontamination, waste management and PPE protocols in line with government advice, for example NHS England⁶ states:

  • For non-AGP care: standard infection control precautions PPE: eye protection, disposable fluid-resistant (Type llR) surgical masks, disposable apron and gloves should be worn
  • For all AGPs: to prevent aerosol transmission: disposable fluid-repellent gown or approved equivalent, gloves, eye/face protection and an FFP3/N95/FFP2 respirator should be worn by those undertaking or assisting in the procedure. A full-face shield/visor must also be worn if wearing an FFP3 mask that is not fluid-resistant

• Any incidents that do occur should be appropriately reported on and learnt from

• Risk reduction processes should be audited to ensure they meet current standards and policies/systems should be reviewed and updated accordingly. In addition, staff should have received the appropriate training needed to comply with these protocols

• Regular team meetings should be organised so staff understand 'best practice' standards and are up-to-date with the new practice policies/protocols and can reflect on them

• The dental team should also liaise with the Local Infection Control Specialist Advisers if needed, in order to support the updating of the infection control policy in regards to COVID-19

• A dental practice risk assessment should be performed and made available to the entire dental team to review and discuss. Risk assessments should also be carried out on all members of staff. A team member should be appointed as the practice COVID-19 lead and all members of the dental team should know who this is.

4. Audit and peer review

Auditing helps evaluate existing practice against the gold standards of practice and current policies/procedures. They highlight any shortfalls and help develop methods to improve our outcomes and performance. It is a CQC requirement to have routine audits on accessibility (in line with the Equality Act 2010), infection control (in line with HTM 01-05)⁵ and X-rays (in line with FGDP standards)⁷.

Methods through which this is achieved include:

• Carrying out an audit. The audit cycle involves identifying a problem/concern, setting a standard to compare to eg a local guideline, collecting the data to compare (retrospective/prospective), comparing the data to the standard and identifying any shortcomings, implementing methods of change and then re-auditing after a period of time to close the 'audit loop' and assess the improvements

• Peer review involves a group of 4-8 dental professionals working together to improve the quality of service they provide through sharing their knowledge and experiences - this is very important in light of COVID-19. If not already part of a group, it would be good idea to contact other practices/dental professionals to form a peer review group. In these challenging times you must remember that you are not alone and work together to help one another.

5. Training and education

Policies and procedures are there to protect patients. However, they depend on the performance of the entire dental team. This is achieved through continuing professional development (CPD) to ensure members of the dental team remain up-to-date with the latest research, knowledge and skills.

The GDC Standards for the dental team 7.1.1 states: 'You must find out about current evidence and best practice which affect your work, premises, equipment and business and follow them at all times'.³ Due to COVID-19 there have been many new guidelines produced on what we can or cannot do and also on how we can safely treat patients. It is important that all members of the team are aware of these.

Methods through which this is achieved include:

• Completing further training and attending courses - due to COVID-19 this hasn't been possible, however various webinars and online CPD programmes have been created to help dental professionals continue to further their knowledge and skills from home

• Work appraisals with colleagues to assess competency, identify areas of further training, help develop the dental team and broaden the skill mix to deliver services in a more efficient and resilient way

• Having important policies on raising concerns and safeguarding and making sure the entire dental team are aware of these and adhere to them

• Giving staff the additional training needed so they are up-to-date with the changes that have been made to practice protocols/policies due to COVID-19

• Fit testing of the N95/FFP2/FFP3 masks should be done on all clinical team members to ensure they are safe to carry out an aerosol generating procedure (AGP) on a patient if necessary

• The donning and doffing of PPE and their designated areas should be demonstrated to the dental team prior to starting work eg via a video tutorial. The dental team should be given the opportunity to practise this too

• The patient flow should be explained to all members of the dental team prior to reopening, to help them understand the intended flow from triage to patient treatment, discharge and follow-up

• The dental team should review these requirements frequently to ensure everyone is up-to-date with the changes that are occurring. Instead of staff meetings in person, discussions can be done through WhatsApp group-chats, phone calls or online 'Zoom' meetings

• It is important to remember that this is a group effort and the dental team should be mindful and help each other in order to effectively work together to meet these standards and requirements. These changes may cause staff concern, stress and anxiety and it is important to ensure all members of the team are adequately supported and can be directed to mental health and wellbeing resources, should they need it.

6. Clinical effectiveness

This is about ensuring we adopt an evidence-based approach to provide the best possible outcomes for patients. It is about improving and changing our practice to meet 'best practice' guidelines in order to provide the best care for our patients.

Methods through which this is achieved include:

• Using evidence-based research to help formulate treatment plans and decision making

• Using standards and guidelines to help inform care eg FGDP radiograph guidelines,⁷ NICE guidelines on wisdom teeth extractions⁸ and DBOH guidelines⁹

• Implementing new standards and guidelines as they develop, undertaking CPD that is evidence-based and changing current practice in accordance with the new evidence that is being produced.

7. Staff management

This ensures each member of staff has the appropriate training and registration for their job. It ensures each member of the dental team knows their role and works together to understand, implement and follow practice policies and procedures.

Methods through which this is achieved include:

• Understanding the GDC Scope of practice¹⁰ and Standards for the dental team³ documents

• Having regular practice meetings, staff training, feedback, appraisals and CPD

• Having an open attitude between employer and staff members in order to provide a good working environment and appropriately manage the team

• With regards to COVID-19, staff need to be aware of the new levels of PPE needed and the new practice protocols. The dental team need to be aware of all the changes being made and should have received the additional training before they return to work. Staff should be given adequate notice for the staff training and should be aware of all the precautions that are being put in place to protect them for when they return to work

• Developing a dental practice Standard Operating Procedures (SOP) document that works on a local level and allowing all members of the dental team to read it before starting work. This will also give staff the opportunity to ask any questions regarding the document before returning to practice. This document needs to be reviewed regularly so that it keeps up-to-date with the most current guidelines.

Further guidance

Various new guidelines have been produced by Public Health England,¹¹ NHS England⁶ and the SDCEP¹² to help dental practices adapt to the 'new normal' of care due to COVID-19 and help the dental team transition as restrictions continue to lift.

I hope this article has provided you with a refresher on why clinical governance is important in dentistry and how the dental team can use these seven pillars to ensure patient and staff safety in order to effectively resume dental services as restrictions ease.

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Author information.

Iqra, from London, has recently qualified with a Bachelor of Dental Surgery degree (BDS) from the University of Plymouth and will be starting Dental Foundation Training in London this September. Iqra has a keen interest in restorative dentistry and dental public health.

CPD questions .

This article has four CPD questions attached to it which will earn you one hour of verifiable CPD. To access the free BDA CPD hub, go to https://cpd.bda.org/login/index.php.