Original Notice.

Preproposal statement of inquiry was filed as WSR 00-19-081.

Title of Rule: WAC 246-817-440 Continuing education requirements for dentists.

Purpose: The purpose of this rule is to implement 1999 legislation (chapter 384, Laws of 1999), which mandates the Dental Quality Assurance Commission to implement continuing education requirements for dentists as a condition of renewal.

Other Identifying Information: WAC 246-817-440.

Statutory Authority for Adoption: RCW 18.32.0365.

Statute Being Implemented: RCW 18.32.002, 18.32.180, 18.32.0365.

Summary: The proposed rule will establish continuing education requirements for dentists as a condition of continued licensure.

Reasons Supporting Proposal: The proposed rule will mandate that all dentists licensed in Washington state obtain ongoing education related to the dental profession and will ensure to the public that a mechanism is in place to encourage dentists to become informed of new dental related products, techniques and technologies.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Lisa Anderson, Program Manager, 1112 S.E. Quince Street, (360) 236-4863.

Name of Proponent: Department of Health, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: This rule is being proposed to establish continuing education requirements for dentists as a condition of ongoing licensure. This rule will provide guidelines as to acceptable continuing education coursework, establish the number of hours to be reported, and establish the reporting cycle. The rule will also ensure to the public that a mechanism is in place to encourage dentists to become informed about new products, techniques and technologies related to the practice of dentistry.

Proposal does not change existing rules.

A small business economic impact statement has been prepared under chapter 19.85 RCW.

STANDARD INDUSTRIAL CODE	ECONOMIC ACTIVITY	MINOR COST THRESHOLD
802	Office or Clinic of Dentist	70.00

     Costs Required To Comply: The draft rule will require dentists to obtain twenty-one hours of continuing education on an annual basis. Dentists will be required to pay for their own continuing education courses. Costs will vary depending on the type of CE hours obtained and can range from no cost to very expensive. In any case, compliance with the proposed continuing education rule should not be cost prohibitive for any practitioner and there is enough flexibility in the rule to allow dentists to obtain continuing education hours from many different sources. As part of the membership requirement with the Washington State Dental Association, dentists have for years been required to obtain forty-two hours of continuing education (at own their expense) every two years. It is anticipated that 85% of the dentists in Washington belong to the association. Of the remaining 15% who do not, there is no way of knowing whether or not they obtain continuing education as their own personal commitment to maintaining ongoing knowledge in their profession.

     Does the Cost of the Proposed Rule Exceed the Threshold Where an SBEIS Is Required? 1. The cost to implement the proposed standards is in excess of the minor cost threshold so an SBEIS is required.

     Does the Proposed Rule Affect Both Large and Small Businesses? The Regulatory Fairness Act defines a business as any "entity, including a sole proprietorship, corporation, partnership, or other legal entity, that is owned and operated independently from all other businesses, that has the purpose of making a profit." The act defines a small business as one that employs less than fifty individuals.

     The Department of Health estimates that five thousand dental practitioners will be subject to the requirements of the proposed rules. Each practitioner must obtain a separate, individual credential. Since the proposed rule will only affect individuals, from the perspective of the Regulatory Fairness Act, all affected businesses are small.

     Does the Proposed Rule Impose Disproportionate Cost on Small Businesses? No. Since all practitioners affected by the proposed rules meet the definition of small business, the rule cannot impose disproportionate costs. Therefore, the department is not obligated to provide regulatory relief.

     How Did the Department Involve the Public in the Development of the Proposed Rule? Stakeholder involvement was solicited through open public meetings and open public forums and also by contacting interested persons via the mailing list. Progressive versions of the draft rule were discussed and shared with stakeholders throughout the rule-drafting process. We had very little input from the licensing dental practitioners as a whole but active involvement from the association and educators and a few interested persons. We also solicited continuing education information for every other dental licensing board as a basis for determining rule language, reporting requirements, number of hours required, etc. This provided a well founded basis to ensure that Washington's rules would be somewhat similar to those across the United States.

A copy of the statement may be obtained by writing to Lisa R. Anderson, Program Manager, Dental Quality Assurance Commission, 1112 S.E. Quince Street, P.O. Box 47867, Olympia, WA 98504-7867, phone (360) 236-4863, or fax (360) 664-9077.

RCW 34.05.328 applies to this rule adoption. The rule will establish conditions for licensure, and therefore qualifies as legislatively significant under RCW 34.05.328.

     The APA mandates that state agencies make specific determinations in a significant analysis. These are:

     A. Clearly state in detail the general goals and specific objectives of the statute that the rule implements (RCW 34.05.328 (1)(a)): The main intent of this 1999 legislation was to amend chapter 18.32 RCW to establish regulations to make continuing dental education mandatory for Washington state licensed dentists as a condition of licensure renewal.

     The Washington State Dental Association (WSDA) currently has a requirement for all of its members (about 85% of Washington licensed dentists) to meet a membership requirement of forty-two hours of continuing education, reported every two years, however it is an "honors" system and there is limited enforcement mechanisms for noncompliance. Also, there is no way to ensure that nonmembers are obtaining ongoing education.

     Another goal of this legislation is to provide some assurance to the public that there is a formal mechanism in place to encourage all dentists to keep informed of new products, technologies and techniques related to dental practice, after initial licensure. The proposed rules will also provide mechanisms to monitor compliance with this mandate.

     B. Determine that the rule is needed to achieve the general goals and specific objectives of the authorizing statute (RCW 34.05.328 (1)(b)): This rule is needed to provide guidance to dental practitioners in terms of continuing education hours necessary, frequency of reporting cycle, and offers suggestions for types of continuing educational coursework that will be considered acceptable in meeting the intent of the statute. They reference the criteria of RCW 34.05.328.

     C. Determine that the probable benefits of the rule are greater than its probable costs (RCW 34.05.328 (1)(c)). Arguments in favor of mandatory continuing education:

     The following are chief arguments of those in favor of mandatory continuing education. (Brockett and LeGrand, 1992; Little, 1993; Kerka, 1994; LeGrand, 1992; Little, 1993; Nelson, 1988; Queeney and English, 1994; Queeney, Smutz, and Shuman, 1990; Stille, 1993)

•	It ensures participation by the professional in continuing education activities.
•	Studies have demonstrated a positive correlation between recent participation in continuing education activities and proficiency in both general and specific content knowledge.
•	While not abundant, research-based information is emerging that suggests participation in continuing education activities has a positive influence on a professional's learning, capacity to perform, increased self confidence, satisfaction with the job, and competence.
•	Expecting voluntary participation is unrealistic. Those who need it most may be least likely to participate.
•	Mandatory continuing education can provide equal access to a range of opportunities. Studies have shown that there are fewer learning activities available if continuing education is not mandatory.
•	Although imperfect, it is better than such alternatives as examination or practice reviews.
•	By choosing a profession, professionals submit to its norms. A license to practice implies consent to be governed by the rules of the profession.

     Arguments against mandatory continuing education: The mandatory nature of continuing education has been questioned. Health care practitioners need to take a reflective, but critical approach to one's professional education needs. (Hulskamp, 1996) Listed below are arguments for maintaining a voluntary approach to continuing education cited throughout the literature. (Brockett and LeGrand, 1992; Kerka, 1994; Morrison, A., 1992; Morrison, R., 1993; Nelson, 1988; Queeney and English, 1994; Sanders, 1997; Young and Willie, 1984)

•	Mere participation in an educational activity, no matter how well structured, does not constitute acceptable evidence that competence has been acquired.
•	The ultimate responsibility remains with the individual practitioner. Practitioners should be accountable for effective performance, not participation.
•	No one can be forced to learn. Requiring participation may hinder learning by reducing motivation and individual responsibility.
•	Centralized control does not necessarily enhance individual practice.
•	Evidence that mandatory continuing education results in improved practice is lacking. All that is mandated is attendance, which will not necessarily change attitudes, motivation, determination to practice responsibly, or the ability to learn.
•	Mandatory continuing education could result in practitioners playing the points game rather than learning or becoming more competent.
•	Mandatory continuing education does not ensure effective or competent performance and may mislead both the public and professionals by implying that those who devote a minimum number of hours to their education are competent and those who do not are incompetent.
•	Mandatory continuing education violates adult learning principles, such as voluntary participation, the informal nature of adult education, and adult self-direction.
•	By definition, professionals are supposed to be autonomous, self-managed, and responsible for mastery of knowledge. Mandatory continuing education creates a punitive attitude towards participation in adult learning.
•	Programs are not consistently and uniformly available. Many lack quality and relevance to the health care practitioner's needs.
•	Practice patterns or patient outcomes do not change because the education occurs at the wrong time and the wrong place.

     Costs Associated with Mandatory Continuing Education: Any approach to mandatory continuing education requires a means of enforcement. Costs are passed on to the health care practitioner through licensing fees associated with the regulatory staff work done to ensure compliance.

•	Processing renewal notices with continuing education affidavits,
•	Conducting random audits,
•	Conducting investigations, and
•	Taking legal actions for noncompliance with CE requirements.

     Costs to practitioners obtaining mandatory continuing education cannot be overlooked. To calculate the cost to dentists, the department assumes that approximately 15% of the dentists would not obtain continuing education without a mandate. The department knows that 85% of the dentists licensed in this state belong to the Washington State Dental Association and that they are already required to obtain forty-two hours of CE every two years as a condition of membership. This suggests that seven hundred fifty dentists are directly impacted by these rules. Combining a conservative wage rate of $100 per hour for twenty-one hours of continuing education, this amounts to a cost of $2100.00 per year. This calculation indicates that obtaining continuing education is costly and most of those costs would then be passed on to the consumers. In obtaining continuing education there are various sources available to provide coursework. Some are low or minimal cost, and some are very expensive depending on the complexity and type of course offered.

     Findings: Requiring continuing education for credential renewal is not a major force in protecting the health, safety, and welfare of the public. Resources should be directed toward monitoring the practice of those practitioners who, for whatever reason, are unable to practice safely and competently.

     In light of the literature around the efficacy of continuing education requirements and the concerns voiced by the legislature through regulatory reform and Governor Locke's Executive Order 97-02, continuing education rules should represent the least restrictive provisions consistent with public protection and be established only when the public is not effectively protected by other means. RCW 18.32.180 does not mandate a number of hours of continuing education that must be obtained but it does require the commission to implement the statute, and makes reporting of continuing education hours required after renewal cycles after July 2001.

     D. Determine, after considering alternative versions of the rule, that the proposed rule is the least burdensome alternative for those required to comply with it that achieves the goals and objectives of the authorizing statute (RCW 34.05.328 (1)(d)): Department staff have worked to incorporate stakeholder comments in the successive drafts of this rule. Program workload demands are the reason that the department opts for a continuing education reporting cycle concurrent with the annual renewal cycle. The rule allows many different options for acceptable continuing education coursework and does not "limit" dental practitioners from seeking other appropriate coursework as well.

     E. Determine that the proposed rule does not violate any other federal or state statute (RCW 34.05.328 (1)(e)): No federal law or other state statute will be violated.

     F. Determine that the proposed rule does not impose more stringent performance from private entities than public entities (RCW 34.05.328 (1)(f)): There are no differences in the requirements for public and private entities.

     G. Determine that the rule does not differ from federal regulation or statute which is applicable to same activity or subject matter or justify difference (RCW 34.05.328 (1)(g)): There are no federal regulations or statutes which are applicable to the same activity for dentists.

     H. Determine that the rule is coordinated, to the maximum extent practicable, with other federal, state and local laws applicable to the same activity or subject matter (RCW 34.05.328 (1)(h)): DOH staff worked to coordinate drafting of the continuing education rule with multiple stakeholders including the Washington State Dental Association, dental practitioners, dental hygienists, dental educators, specialty organizations, private entities, etc. The proposed rules were also written to incorporate compliance with OSHA and WISHA regulations as an acceptable means of obtaining continuing education hours.

Hearing Location: Phoenix Inn, 415 Capitol Way North, Olympia, WA 98501, on June 29, 2001, at 9:00 a.m.

Assistance for Persons with Disabilities: Contact Lisa Anderson by June 25, 2001, TDD 1-800-833-6388, or (360) 236-4863.

Submit Written Comments to: Lisa Anderson, fax (360) 236-4863, by June 25, 2001.

Date of Intended Adoption: June 29, 2001.

May 14, 2001

Gail Zimmerman

Executive Director

OTS-4854.1

NEW SECTION
WAC 246-817-440   Continuing education requirements.   (1) Purpose. The dental quality assurance commission (DQAC) has determined that the public health, safety and welfare of the citizens of the state will be served by requiring all dentists, licensed under chapter 18.32 RCW, to continue their professional development via continuing education after receiving such licenses.

     (2) Effective date. The effective date for the continuing education requirement for dentists is July 1, 2001. The first reporting cycle for verifying completion of continuing education hours will begin with renewals due July 1, 2002, and each renewal date thereafter. Every licensed dentist will be required to sign an affidavit attesting to the completion of the required number of hours as a part of their annual renewal requirement.

     (3) Requirements. Licensed dentists must complete twenty-one clock hours of continuing education, each year, in conjunction with their annual renewal date. DQAC may randomly audit up to twenty-five percent of practitioners for compliance after the credential is renewed as allowed by chapter 246-12 WAC, Part 7.

     (4) Acceptable continuing education - Qualification of courses for continuing education credit. DQAC will not authorize or approve specific continuing education courses. Continuing education course work must contribute to the professional knowledge and development of the practitioner, or enhance services provided to patients.

     For the purposes of this chapter, acceptable continuing education shall be defined as courses offered or authorized by industry recognized state, private, national and international organizations, agencies or institutions of higher learning. Examples of sponsors, or types of continuing education courses may include, but are not limited to:

     (a) The American Dental Association, Academy of General Dentistry, National Dental Association, American Dental Hygienists' Association, National Dental Hygienists' Association, American Dental Association specialty organizations, including the constituent and component/branch societies.

     (b) Basic first aid, CPR, BLS, ACLS, OSHA/WISHA, or emergency related training; such as courses offered or authorized by the American Heart Association or the American Cancer Society; or any other organizations or agencies.

     (c) Educational audio or videotapes, films, slides, Internet, or independent reading, where an assessment tool is required upon completion are acceptable but may not exceed three hours per year.

     (d) Teaching a seminar or clinical course for the first time is acceptable but may not exceed ten hours per year.

     (e) Nonclinical courses relating to dental practice organization and management, patient management, or methods of health delivery may not exceed seven hours per year. Estate planning, financial planning, investments, and personal health courses are not acceptable.

     (f) Dental examination standardization and calibration workshops.

     (g) Provision of clinical dental services in a formal volunteer capacity may be considered for continuing education credits when preceded by an educational/instructional training prior to provision of services. Continuing education credits in this area shall not exceed seven hours per renewal cycle.

     (5) Refer to chapter 246-12 WAC, Part 7, administrative procedures and requirements for credentialed health care providers for further information regarding compliance with the continuing education requirements for health care providers including:

     (a) When is continuing education required?

     (b) How to prove compliance.

     (c) Auditing for compliance.

     (d) What is acceptable audit documentation?

     (e) When is a practitioner exempt from continuing education?

     (f) How credit hours for continuing education courses are determined.

     (g) Carrying over continuing education credits.

     (h) Taking the same course more than once during a reporting cycle.

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