Structural Accountability and Practice-Level Governance as Dual Pathways to Accreditation-Seeking Intention in Private Dental Practice: Evidence from a Mixed Public-Private Healthcare System.

Background/Objectives: Private dental markets operating under fee-for-service arrangements lack the structural accountability mechanisms that typically drive quality governance adoption in publicly funded systems. In Romania, where no private dental office currently holds formal accreditation, accreditation-seeking reflects a genuine behavioral choice rather than a regulatory compliance. This study examined whether financing structure and Professional Governance behavior operate as distinct determinants of accreditation-seeking intention among private dental practitioners and which pathway offers a more tractable entry point for quality policy intervention. Methods: A cross-sectional survey was conducted among 98 licensed private dental practitioners in Romania (November 2025-January 2026). Three domain composites were derived from a 31-item de novo instrument anchored in JCI, ANMCS, and EN ISO 9001:2015 standards: Professional Governance, Patient Rights and Ethics, and Patient Safety Behaviors. The financing profile was operationalized as engagement with the national public insurance system (CNAS). Binary logistic regression modeled high accreditation-seeking intention (Q31 ≥ 4) against standardized domain scores and financing engagement, with bootstrap confidence intervals from 2000 replicates. Results: Two predictors independently and significantly predicted high accreditation-seeking intention. CNAS engagement showed the strongest association (OR = 5.05, 95% bootstrap CI [1.87-17.91], and p = 0.003), while the Professional Governance score remained independently associated (OR = 2.68, 95% bootstrap CI [1.63-5.63], and p = 0.003). The Patient Rights and Ethics score was not significant. Practitioners actively exploring CNAS contracting showed the highest accreditation-seeking intention (exceeding that of established contractors), suggesting a possible transitional accountability dynamic during financing transition, though this interpretation requires prospective longitudinal validation. Model performance was good (AUC = 0.788; Nagelkerke R2 = 0.339). Conclusions: Both financing engagement and governance behavior predicted accreditation-seeking intention after mutual adjustment, representing distinct pathways to voluntary quality adoption in private dental practice. Policy interventions aligned with entry into public contracting and with practice-level governance development are more likely to support accreditation uptake than normative appeals to professional ethics alone.