This decision support tool has been developed as general guidance for dental practices and services undertaking self-assessment. It lists common actions
within and across the Standards and describes satisfactory and unsatisfactory performance.
Issue Satisfactory performance Unsatisfactory performance
Policies, procedures and/or
protocols are in use Documents detail the date they become effective and the date they are due for revision
Source documents are referenced, particularly where they are
represented as best practice
Documents may reference the consultation processes undertaken
or collaborative group involved in their development
Documents are adapted to the specific context and setting in which
they are used by the dental practice
Team members know the documents exist, can access them, and
know and use the contents
Documentation is:
Outdated
Incomplete
Either overly complex and detailed or lacking in
specificity
Not related to the practice, for example policy
developed by another organisation or body and not
adapted for use by the dental practice
Not accessible or unknown to users
Monitor and report Data sampling or collection occurs across the dental practice
Quality of data is known
Processes exist to test and improve the quality of the data
Feedback is provided to targeted areas and is available across the
dental practice
Data presented in reports is meaningful and relevant
Data collection and reporting informs a problem area or an area of
specific risk
Timeliness of the collection and review of the data is consistent with
the issue being examined
Data is not sufficiently proximal to the issue being
examined to provide meaningful information
No feedback is provided or the feedback provided is
not sufficiently specific to be of use
Feedback is not available to individuals, the team,
units, governance committees or areas that can make
improvements
Data is not sufficiently recent to be relevant to the
current provisioning of service
Issue Satisfactory performance Unsatisfactory performance
Action is taken to improve The action being taken:
o is applicable broadly across the dental practice
o is readily transferable across the organisation
o focuses on key risks or priority areas identified by the dental
practice
Action outcomes will inform future improvement plans across the
dental clinic or target specific risks
Action outcomes are, or will be, communicated to the team, patients
and carers, and governance committees
Action is timely and responsive to issues as they arise
Action is coordinated
Action claims to be organisation-wide, but relates to a
localised issue, process or situation and there is no
clear outcome with the transfer of lessons learned
across the dental clinic
Action is limited to an area of interest rather than an
organisational priority or risk
Significant delays exist between the identification of an
issue and action being taken
Action is disparate and not coordinated, duplicated
across the organisation
Training Training provided or accessed is matched to team training needs
A system, such as a register, is in place to track team participation
in training and qualifications
Training programs are evaluated
Training does not address safety and quality of care
needs, or team training needs
The team is not aware of training
The team is not able to access training
The team is not given the opportunity to provide
feedback on training
Risk assessment Clear and agreed processes exist to identify risks for the
organisation and risks for individual clinical areas
A scale to rate risk is consistently applied
The risks are reviewed on a regular basis
Risks are assessed at all levels of a dental clinic
There is no formal process for identifying and rating of
risk, or where risk exists, the formal process is not
applied
Risks are identified and rated at an organisational
level, not at an individual service level
Issue Satisfactory performance Unsatisfactory performance
Regular review Review occurs across the relevant organisation or a for a
representative sample that is appropriate for the issue under review
Risk assessment is used as the basis to determine the location and
size of the sample
Frequency and timing of the review is appropriate for the
organisation, and consistent with the level of risk of the issue
Frequency of review is insufficient in providing
information that can be used to introduce change
Size of the review is too small or limited to provide
meaningful information
Data collected is not current
Reviewed data is not representative of all areas where
the issue occurs
The review inappropriately excludes consumers
Evidence-base or best practice Reference is current and source is accepted as reputable and
authoritative, and may include professional body, published articles,
published research or approved guidelines
May be peer reviewed
Where possible or appropriate, are consistent with national
specifications, standards and approved guidelines
Material or resources are not referenced, or source is
not clear
Reference material is out of date
Inconsistencies are apparent in the material or
resources
Processes and/or systems are
in place Processes and/or systems: o are responsive in their ability to address issues
o clearly delineate roles and responsibilities
o interface with risk management, governance, operational
processes and procedures for each Standard
The team is not aware of the processes and/or
systems
Processes and/or systems are cumbersome and/or
not adhered to
Issue Satisfactory performance Unsatisfactory performance
Communication Format of communication (for example email, posters or website
updates) is appropriate to the purpose
Language is clear and concise
The team is aware of the communication
Processes are in place for routinely distributing relevant
communication materials are in place
The effectiveness of the communication strategy is evaluated
The needs of culturally and linguistically diverse populations are
taken into consideration
Communication strategies are evaluated and modified accordingly
Format is inappropriate for purpose
Communication is not adapted for the target audience
Key pieces of communication do not reach the target
audience
Communication strategies are rarely or not evaluated
Equipment The team is trained in use of equipment
Records are kept of equipment maintenance
The team does not know how to use the available
equipment appropriately
Equipment is not available
Equipment is not maintained
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