A Practical Guide to Compliance- Outcome 2

Welcome to the second edition of the 'Practical Guide to Compliance' series.  This series is intended to act as informal guidance to dental teams working toward CQC compliance.  The contents of these articles are based on personal opinion and interpretation of the CQC framework and other relevant legislation.  Whilst the author has full confidence in the suitability and appropriateness of the information contained within these articles, the information shall not be regarded as fact and those requiring definitive information should consult the relevant governing body. 



Outcome 2- Consent to Care & Treatment

What do the regulations say?
“Before people are given any examination, care, treatment or support, they should be asked if they agree to it”.
-          CQC Essential Standards



Compliance to outcome 2 is all about making sure your patients are given the support and information to make an informed decision about their care, it requires you to have procedures in place to determine whether an individual lacks the competence to make a particular decision and for each member of the team to know what to do in this situation.  For those that are considered competent, we need to be providing them with all the information relevant to their care this could include discussion of treatment options, information leaflets, videos or online information.  We must make the patient fully aware of all advantages, disadvantages and alternatives for all treatment and ensure that they are fully informed before asking them to make any decisions.

Consent is not a new term in dentistry it is something we have all worked with for a long time but now is a good time to review your policies and procedures to make sure they are meeting the requirements of outcome 2 and any relevant legislation.

Through using the 4 stages of compliance method you can ensure that your practice and your team are covering all the bases for this outcome.

The first stage will see the creation and implementation of a solid consent policy, one that takes the Mental Capacity Act into consideration to ensure there are clear procedures in place for assessing competence and guidelines in place for dealing with a patient who is not considered competent.

Your consent policy should outline the procedure for gaining consent, how it is obtained and how it is recorded.

You should also have patient information available for all procedures, leaflets are a good option as they can be handed out to patients after a discussion to allow them to have a reference for what has been discussed.  Other forms of information can also be used such as educational videos, handouts and directing the patient to an online source of information.  Regardless of what information you provide and how you provide it, it is advisable to record that you have done so.

Consent forms are also a useful way to present information to patients as they will focus their attention to the important information such as potential risks or side effects that may alter their choice of treatment.  It is important to remember that a signed consent form does not constitute as informed consent, these should be used as a means for providing information but not as the only way of confirming that the patient understands what has been said.

The Mental Capacity Act 2005 has a published code of practice which provides guidance to anyone who is working with and/or caring for adults who may lack capacity click here to download this document. 

Dental Protection has produced a useful document on consent click here to download it.  The GDC document ‘Principles of Patient Consent’ is also useful guidance click here to download it.

So now that you have laid the foundations for compliance to outcome 2 you can now move onto stage 2- train your team.  Your team should undertake some training on Consent and the Mental Capacity Act to ensure they have a thorough understanding of the subject as this will help them apply the principles to their day to day work.

As a team you should agree the implementation of your consent procedures and also agree a consistent method of recording consent, this will allow for much easier monitoring of compliance at a later stage.

It is important that your team understand what is considered valid consent.  All discussions with patients should be recorded with consent in mind, did you explain the procedure, did you invite questions, did you give satisfactory explanations, were all the patients questions answered, did you verbally confirm that the patient understood what had been said and most importantly did the patient agree to the procedure? These are all important questions that need to be applied to every treatment discussion.

So you’ve laid the foundations and you have trained your team, it’s now time to practice, practice, practice!  Implement the procedures and the learning that has occurred and apply this to your daily work. 

You are almost there, now that you have everything in place you must monitor and review to achieve ongoing compliance.  This could involve audits of consent and patient records, team quizzes and spot tests or even patient surveys.  The important thing is that you regularly measure the effectiveness of your procedures and make any necessary changes when things are not working.  As part of this process it is important to stay abreast of any changes in legislation that may affect how you work.

In summary, in order to achieve compliance to outcome 2 we must respect a patient’s right to choose whether or not to have a dental procedure, we must assess a person’s competence to make a decision and their ability to understand information relating to their treatment.  If a patient is considered incompetent to make a particular decision we must act in line with the Mental Capacity Act Code of Practice to ensure we are supporting the patient and/or their carer to understand and make an informed choice. It is our obligation and duty to provide the patient with as much information as is appropriate and relevant and we must invite and answer any questions the patient may have.  Gaining consent is not merely getting a signature on a form it is a process of communicating information to a patient about their needs and your recommendations.  You must ensure that consent is volunteered and the patient is fully informed.  It is vital that good records are kept on all matters concerning consent to care and treatment, consent should form a part of every single clinical record made.  Last but not least monitor consent and regularly review the effectiveness of your procedures.

If you’d like to know more about how Practice Perfection can help you with CQC compliance please get in touch at [email protected]