“We Have Policies” Usually Means One of Three Things

Almost every dental practice says the same thing when we ask about policies:

“Oh yes, we have those.”

And sometimes they do.

But often, once we start looking a little closer, “we have policies” actually means one of three things:

• They printed the RCDSO guidance and put it in a binder.
• They have a manual from 2019 that no one has reviewed in years.
• They have a few saved documents somewhere, but no one is completely sure what is current.

None of this is unusual. Dental offices are busy. Teams are focused on patient care, sterilization, schedules, emergencies, staffing, and keeping the day moving.

But here is where it gets tricky:

• Guidance is not a policy.
• A template is not a program.
• And a binder that no one uses is not protecting your practice.

Your policies should do more than prove you tried. They should explain how your clinic actually meets the standard.

---

Learning Objectives

After reading this article, dental teams should be able to:

• Understand the difference between regulatory guidance and a clinic-specific policy.
• Recognize why printed RCDSO or Public Health Ontario documents do not replace a customized policy manual.
• Identify signs that a policy manual is outdated, incomplete, or disconnected from daily practice.
• Explain why policies should reflect the clinic’s actual equipment, workflow, documentation process, and staff responsibilities.
• Understand how current IPAC and Health & Safety policies support inspections, onboarding, training, and consistent practice.
• Use practical questions to assess whether their current policies are actually usable.

---

The Difference Between Guidance and a Policy

The RCDSO and Public Health Ontario provide important guidance.
Every dental practice should understand the standards and expectations that apply to infection prevention and control.

But those documents are not your clinic’s policy manual.

Guidance tells you what is expected.

Your policy should explain how your clinic meets that expectation.

For example:

• Guidance may say instruments must be reprocessed according to manufacturer’s instructions.
• Your policy should explain where your MIFUs are stored, how staff access them, who keeps them updated, and how your team confirms equipment-specific requirements are being followed.
• Guidance may say sterilization monitoring must be completed and documented.
• Your policy should explain what indicators are used in your clinic, how results are recorded, who reviews them, and what your team does if something fails.
• Guidance may say the reprocessing area must support one-way workflow.
• Your policy should explain how instruments move through your specific space, from dirty to clean to sterile.

That is the piece many practices are missing.

They have the standard, but they do not have the clinic-specific process.

---

Why Old Policies Can Create New Problems

A policy manual from 2019 might have been great in 2019.

But is it still accurate?

Since then, your practice may have changed staff, sterilizers, disinfectants, dental unit waterline products, logs, documentation systems, operatory flow, training processes, or reprocessing layout.

If the manual has not changed with the clinic, it may no longer describe what your team actually does.

That creates confusion.

Staff may be trained one way, the policy may say something else, and the actual practice may be somewhere in between. During an inspection, audit, complaint, or onboarding process, those gaps become very visible.

A policy manual should not describe the clinic you used to be.

It should describe the clinic you are running today.

---

What a Good Dental Policy Manual Should Answer

A useful policy manual should answer the questions your team actually runs into.

Where are sterilization records kept?
Who reviews failed indicators or failed spore tests?
What PPE is required in the reprocessing area?
Where are MIFUs stored?
How are SDS documents accessed?
Who maintains the dental unit waterline logs?
How are new staff trained?
How is annual education tracked?
What happens after a sharps injury or exposure?
Who is responsible for reviewing cleaning and maintenance records?

If the answer to most of these questions is “ask the office manager” or “I think someone knows,” that is a sign the policy system may not be strong enough.

Good policies reduce guesswork.

They give the team a shared reference point.

---

The Problem with “Template Policies”

Templates can be helpful. They give you a starting point.

But a template is not finished until it reflects your clinic.

Your policy manual should be customized to your actual:

• Equipment
• Sterilizers
• Reprocessing workflow
• Products and disinfectants
• Documentation system
• Staff roles
• Training process
• MIFU and SDS access process
• Health & Safety structure
• Inspection readiness needs

A policy that could apply to any dental office may not be specific enough for your dental office.

That matters because compliance is not just about whether a policy exists. It is about whether the policy matches what is happening in practice.

---

Where IPAC and Health & Safety Connect

Dental practices often think about IPAC and Health & Safety as separate binders.

In reality, they overlap constantly.

Sharps safety affects both patient care and worker safety.
PPE protects both staff and patients.
Chemical handling connects to disinfection, WHMIS, and safe work practices.
Reprocessing involves infection prevention, equipment safety, documentation, and exposure prevention.
Incident reporting supports compliance, training, and risk management.

That is why dental offices often need both an IPAC Policy Manual and a Health & Safety Policy Manual.

The IPAC manual supports safe clinical care, sterilization, cleaning, reprocessing, documentation, and infection prevention practices.

The Health & Safety manual supports workplace responsibilities, hazard reporting, emergency procedures, violence and harassment prevention, WHMIS, inspections, and staff safety.

Together, they help create a more complete compliance structure.

---

What You Should Be Asking Yourself

Before assuming your policies are covered, ask:

• When were our policies last reviewed?
• Do they reflect our current equipment and products?
• Do they match how our team actually works?
• Can new staff use them to understand our expectations?
• Do they explain who is responsible for key tasks?
• Are IPAC and Health & Safety both addressed?
• Would our team know where to find them?
• Would we be comfortable showing them during an inspection?

If any of those questions make you pause, it may be time to review your manuals.

---