Compliance Proofing Dental Practice

Compliance Update Autumn 2020

Whats in This Issue

    1. Radiation Webinars: HIQA’s take home message
    2. Amalgam Inspections: What should you do now?
    3. Ventilation: Recommended Air Changes/Hour
    4. Health & Safety Authority: COVID-19 Inspections
    5. Upcoming Radiation Training Masterclass
    6. Governance – how does it fit into your dental practice?
    7. Online Practice Compliance Advisory Programme now available

Hello again!

In this newsletter, Dental Compliance looks at Autumn 2020’s regulatory “hot topics”. It is worth noting that in 2020 at least 4 Regulators are active in carrying out assessments in practices:

  • HIQA
  • HSA
  • EPA
  • Local Authorites

Just “more stress” is the comment Dental Compliance is hearing from practitioners who areincreasingly exhausted practising within COVID-19 restrictions. A real risk is “Compliance Fatigue” creeping into your practice. At Dental Compliance we support you in maintaining focus on a safe workplace now and into thefuture

Radiation Webinars: HIQA’s take-home message

Dental Compliance notes here the keys messages of HIQA’s recent webinars (Sept 2020) onself-assessment and inspection processes in the dental sector:

  • HIQA is rolling out its programme of a risk-based, graded approach to regulating thedental sector starting with CBCT installations in 4th Quarter 2020
  • Over the coming months, HIQA will begin to issue undertakings with self-assessmentquestionnaires (SAQ) to assess their regulatory compliance
  • HIQA is setting up a portal system to facilitate communications via a reliable electronic-based process
  • It is a regulatory requirement to provide information to HIQA who have the enforcement powers of

    • Compliance notices
    • Prohibition orders
  • HIQA acknowledged that dental exposures are generally seen as low risk but newtechnology e.g. CBCT may pose an increased risk for patients
  • As the inspection programme rolls out most inspections will be “announced” with a 10-day notification being emailed to the designated manager and copied to the Undertaking
  • Following the inspection visit, a draft report will be sent to the Undertaking for feedbackand factual accuracy checking
  • The final report will be published on

Each Undertaking and designated manager should be familiar with HIQA’S 50 page “Guide to the inspection of dental services providing medical exposure to ionising radiation

Waste Amalgam Inspections: what should you do?

Recently a small number of dental practices received self-assessment declarationquestionnaires for their Local Authority. The responsibility to monitor compliance with the safe disposal of dental amalgam waste isassigned to individual Local Authorities. During the current COVID-19 restrictions the Department of Communications, ClimateAction & Environment have advised Local Authorities to undertaking assessment of dentalpractice compliance through a self-declaration questionnaire.

Dental Compliance recommends that you prepare by:

  1. Reviewing your current hazardous waste management policy
  2. Discussing the matter with your licensed hazardous waste disposal operator.
  3. Ensure that your waste amalgam separator complies with the EU standard or equivalent(95% particle retention level)
  4. Confirm that you are using only UN Certified Waste Amalgam Containers for capsules, particles, residue, sludge, tooth box, etc
  5. Finally, check that all documentation is collated in your practice waste folder/file and thatyou are up to date on your collection and maintenance processes.

Practices which do not require a dental amalgam separator should undertake a riskassessment documenting why this is the case. Failure to complete and return the questionnaire may result in an inspection visit.
Need advice? click here

Ventilation and Recommended Air Changes/Hour

The HPSC advises that increased ventilation in a dental surgery may be achieved by an openwindow or use a simple mechanical ventilation system e.g. Xpelair fan. Dental Compliance recommends:

  • If you are considering the purchase of a simple extraction fan ensure it is quiet (some are very noisy) and that you can carry out the “routine cleaning” of the unit’s vents andblades.

  • Heating Ventilation and Air Conditioning systems (HVAC) will filter, heat and cool. Such systems are worth considering when simple systems are not an opinion. Look for anHVAC system with a HEPA filtration unit. Note you will require an annual service contract when you purchase these systems.
  • Experts recommended that you do not use an air-conditioning system with arecirculation function ONLY as this is considered high-risk in the current COVID-19 environment

Clinical areas e.g. surgeries, x-ray room, decontamination room, are recommended to have 6– 10 Air Changes per Hour (ACH); current thinking is the closer to 10 the better.
Use this formula to calculate:
ACH = (CFM* X 60) / (Room Area x Ceiling Height)
*This value should be available on the extraction fan/system (CFM = cubic feet per minute)
If in doubt seek the professional assistance of an engineer or architect

HSA & COVID-19 Inspections

The Government’s “Return to Work Safely Protocol” (May 2020) requires dental practices to maintain preventive measures and suppress COVID-19 in the workplace. Health and Safety Authority (HSA) inspectors have visited dental practices in recent monthsto confirm compliance with this protocol. A key component of these measures is that your practice must have a written Response Plan which includes:

  1. A COVID-19 risk assessment, and associated updating of your existing Safety Statement
  2. Procedures to manage employees who are deemed as high risk under the currentrestrictions
  3. Procedures to deal with a suspect COVID case, whether it’s an employee or patient
  4. Contingency measures to address any changes in the workplace during environmentalchanges e.g. within the changing levels of local restrictions
  5. Proof that the response plan has been communicated and understood by staff

It is advised that your practice’s Response Plan is regularly reviewed in a spirit ofconsultation, collaboration and communication between employer and employees.

Upcoming Radiation Training

Email to Register

Governance – how does it fit into your dental practice?

Increasingly you are seeing the term “governance” being mentioned in the regulator’sguidance e.g. HIQA, and codes of practice e.g. Dental Council.

What should you do to get started?

  • You must have evidence of how your practice is directed, controlled, and managed
  • This should be updated and regularly reviewed
  • Governance documents should be as clear and concise as possible with the leastcomplicated or complex structure


  1. Your practice governance document should identify each member of staff both by nameand job title
  2. The responsible person must be identified – usually the principal dentist
  3. There should be a brief outline of each staff member’s responsibility within their role
  4. The communications pathway should be outlined, demonstrating how information is clearlydisseminated within your practice
  5. Be user friendly, a simple 1-page flow-chart can illustrate your practice governancestructure. This should be supported with a clear, concise written document that you have available for inspection

Book an Advisory Session with our Governance Specialist click HERE

NEW: Practice Compliance Advisory Programme

Are you seeking advice and clarity on tackling your regulatory concerns?
Programme fee: €500 + VAT
Designed to give you peace of mind

2 x 50-minute online sessions discussing solutions specific to your practice withtopics agreed in advance, for example:

  • Inspection Preparation
  • Policies, Protocols and Staff Training
  • Surgery Design and Layout
  • Health and Safety
  • Dental Practice Governance

This programme is designed for Principal Dentists, Dentists, or PracticeManagers

Click HERE to get a call from Dental Compliance to discuss this programme

Be proactive today, protect your practice for tomorrow and the foreseeablefuture