Accreditation and Certification of Dental Clinics: Mandatory or premium standard!!!!

With the rapid proliferation of dental clinics/hospitals, including paediatric specialty practices, our patients now increasingly base their choice of provider on a few key factors such as the clinician's expertise, the quality of infrastructure, and accreditations. Hospital accreditation should no longer be viewed as a luxury but currently recognized as an essential benchmark for ensuring safe, standardized, and high-quality care. What was once considered an aspirational standard like JCI or NABH accreditation has now become a regulatory necessity, especially under various government health schemes.

Backed by over a decade of hands-on experience in implementing accreditation standards across both dental colleges and private clinical setups in India, this blog of mine aims to share with you all the practical insights into the accreditation process. This includes a balanced perspective on its merits and limitations, drawn from real-world challenges and outcomes observed during the course of my institutional and clinical evaluations.

Accreditation for Dental Clinics/Hospital

Accreditation is a voluntary process by which a dental clinic/Hospital is evaluated against defined quality standards. It ensures that our clinic/hospital consistently provides safe, effective, evidence based consistent patient-centred care.

Why your clinic/hospital needs to be accredited!!!!!!

• Enhances credibility and trust among patients.
• Promotes a culture of continuous quality improvement.
• Ensures adherence to standardized clinical protocols.
• Improves risk management and infection control.
• Better preparedness for medical/dental emergencies.
• Insurance policies and Government reimbursement programs.

For my fellow Professionals

• Encourages professional development and ethical practice.
• Improves clinical documentation and data management.
• Facilitates legal protection through standardized records.

For our Tiny Tots & their parents

• Safer, Sterile and hygienic environment.
• Assurance of evidence-based treatment.
• Transparency in billing and procedures.
• Timely care and established patient rights management.

Procedure Involved in Accreditation Process

1. Application Submission – Online form to JCI or NABH or ISO body
2. Self-Assessment – Clinic compares current practices with accreditation standards (Set of criteria/framework).
3. Gap Analysis & Corrective Actions – Implement required changes (e.g., documentation, safety protocols).
4. Training of our Staff – On infection control, documentation, emergency protocols, etc.
5. Pre-Assessment Visit (optional) – Preliminary review by assessors.
6. Final Assessment – On-site inspection and interview by official assessors.
7. Accreditation Decision – Accreditation granted if clinic meets required standards.
8. Periodic Reassessment – Every 2-3 years, or as specified.
9. Validity – Entry-level accreditation is valid for 2 years and can be upgraded to full accreditation.

Types of Accreditations in India for Dental Clinics

Brief on NABH Accreditation for Dental Clinics

NABH (National Accreditation Board for Hospitals & Healthcare Providers) offers an accreditation program for dental clinics with standards covering

• Patient rights and informed consent
• Sterilization, biomedical waste, and infection control
• Clinical audit and quality indicators
• Emergency care and referral protocols
• Infrastructure and facility safety

Required Documentation

• Infection control SOPs
• Dental records and treatment documentation
• Consent forms and patient communication
• HR policies and staff roles

Advantages of Accreditation in Health Schemes (Govt & Insurance)

Accreditation of our dental clinics/hospitals significantly enhances a healthcare facility’s eligibility and benefits under various public and private health schemes. Here is how:

Empanelment in Government Health Schemes

Accreditation is often a prerequisite or a strong advantage for empanelment in national and state-run health programs like

• Ayushman Bharat (PM-JAY)
• CGHS (Central Government Health Scheme)
• ECHS (Ex-Servicemen Contributory Health Scheme)
• State Government Health Schemes
• Railway and PSU Employee Schemes

Advantages of Accredited dental clinics in Empanelment

• Faster empanelment and renewal process.
• Higher trust and preference from authorities.
• Eligible to treat larger volumes of insured patients.
• Priority listing in government directories and portals.

Recognition by Insurance Companies

Many private TPAs (Third Party Administrators) and health insurance providers prefer or mandate NABH/ISO accredited facilities for cashless services. Some insurers offer better rates or faster claims for patients treated at accredited clinics.

Advantages

• Easier tie-ups with private health insurers.
• Cashless treatment approvals are faster.
• Less documentation hassle during claims.

Increased Reimbursement Rates

Some schemes offer better reimbursement rates or financial incentives to accredited clinics.

Example: Ayushman Bharat and State Health Agencies sometimes provide additional incentives to NABH-accredited clinics/hospitals. In accredited dental clinics/hospitals the Insurance claim approval rates are higher, and payment cycles are more reliable.Our clinic/Hospital are often listed on official health portals. Patients seeking insurance-covered or government-subsidized care tend to trust accredited clinics more.

Compliance & Legal Protection

While the exact number of cases filed each year varies in our country, the 5.2 million figure is widely cited and highlights the substantial impact of medical negligence. Accreditation ensures our dental clinic/hospital is already aligned with such expectations. Helps avoid legal or administrative issues during audits or empanelment reviews.

So what are those Checklists & Standards???

Patient-Centric Standards

It is ultimately the patients who stand to gain the most from these quality initiatives. The objective of this standard is to evaluate how well our patients' well-being are taken care. It includes the patient and the attender rights & responsibilities the moment they enter the hospital, initiatives taken by our management, periodic evaluation and necessary actions taken if there are any deviations.

• Patient Rights and Responsibilities
• Informed Consent
• Patient Feedback System

Infection Control & Safety

Sterilization and disinfection are the mainstay in any hospitals irrespective of their accreditation status. It is our moral responsibility to provide basic infrastructure facilities and consumables for the proper sterilization. This standard evaluates the dental clinic protocols for used instruments, periodic calibrations.

• Sterilization SOPs
• Biomedical Waste Management
• Hand Hygiene Protocols

Clinical Services

All patients who enter our dental clinic should be made aware of the scope of services provided in our Clinic/hospitals, the charges which they have to pay, the proper operating protocols for each procedure, Number of visits, duration, frequency, necessary treatment specific consent forms, documentation, follow up visits.

• Treatment protocols (e.g., RCT, Space maintainers, extraction)
• Case documentation
• Emergency preparedness

Facility Management

The standard deals with the basic maintenance of the dental hospital setup, parking facilities for our patients, lift facilities, ramp for special children, management for fire and non-fire emergencies, signages, periodic calibrations, maintenance schedule of our dental equipment.

• Dental chair maintenance records
• Water quality logs
• Fire safety equipment

Human Resource Management

It is mandatory that our dental hospital/clinics have basic manpower based on scope of service, consultants who visit our clinics are adequately trained, supporting staff records including their qualifications, training records, vaccination certificates.

• Staff qualification records
• Job responsibilities
• Training and appraisal records

Information Management

In the era of digital healthcare, the importance of privacy and medical record laws has never been more critical. With the widespread adoption of electronic health records (EHRs) and telemedicine, vast amounts of sensitive patient data are being collected, stored, and shared. Laws such as Digital Personal Data Protection Act, 2023 (India) HIPAA (Health Insurance Portability and Accountability Act) in the U.S and similar frameworks globally, are essential to ensure that personal health information is kept confidential, secure, and used ethically.

• Medical Records SOP
• Data privacy policy
• Patient registration logs

Quality Improvement

Quality Improvement (QI) is a structured approach to enhance patient care, safety, and operational efficiency in healthcare settings. Accreditation bodies emphasize continuous quality improvement as a core standard to ensure that institutions meet and maintain high levels of clinical and administrative performance.

• Incident reporting
• Internal audits
• Corrective Action & Preventive Action (CAPA) reports

What all Committees should we formulate?

Infection Control Committee (ICC)

• Develop and review infection control SOPs
• Monitor sterilization protocols
• Conduct hand hygiene audits
• Train staff on PPE and waste management

Safety Committee

• Fire drills and emergency evacuation plans
• Ensure proper signage and emergency exits
• Electrical safety audits
• Equipment maintenance logs

Quality & Patient Safety Committee

• Monitor and review clinical audits
• Investigate patient complaints
• Implement CAPA (Corrective and Preventive Actions)
• Monitor treatment success rates and complications

Patient Grievance Redressal Committee

• Collect and review patient feedback forms
• Address complaints within defined timelines
• Maintain a grievance register
• Ensure corrective actions are taken

Training & Credentialing Committee

• Conduct regular training on SOPs, infection control, emergency response
• Maintain records of staff induction, CME, and evaluations
• Validate licenses and qualifications of dental surgeons and assistants

What is the ultimate takeaway?

Accreditation in our dental hospitals/clinics serves as a benchmark for quality, safety, and patient-centered care. It ensures that we follow standardized protocols, maintains clinical excellence, and upholds ethical practices in every aspect of service delivery. Beyond regulatory compliance, accreditation fosters a culture of continuous improvement, enhances patient trust, and improves operational efficiency. As dental care evolves with advancing technology and patient expectations, accreditation becomes not just a recognition of quality but a strategic investment in long-term credibility and success.