by Cathy Hester Seckman, RDH
Admit it, you've all been here and done this.
It's mid-February, and you need three more CE credits by March 31. You rummage through a stack of old mail and find a course being offered next week, only 20 miles from home: "Infection Control," by Dr. Long Since Retired, $68. So you sigh, send in the money, and traipse dutifully to class on your day off.
Dr. Retired, it turns out, is a mumbler, and doesn't have so much as a single slide of strep mutans to keep you interested. So you prop your eyes open and try to pay attention, all the while thinking about the closets you could have cleaned, the shopping you could have done, or the bread you could have baked today.
Yeah, you've been there.
Paperwork, Canadian style
Did you know that most Canadian hygienists don't have to go there anymore? Since 1999, more than 7,000 Ontario hygienists have been self-regulated through the College of Dental Hygienists of Ontario (92 percent of Canadian hygienists live in Ontario). An obvious benefit of self-regulation is the ability to set your own standards for professional development.
According to Eleanor McIntyre, RDH, MEd, director of quality assurance for the CDHO, the idea of self-regulation for health professionals began with the Schwartz Commission in the 1980s. She said the "consensus-building project" faced a mandate "to protect the public."
"As a result of the Schwartz Commission, there are now 21 colleges representing 23 disciplines, of which the College of Dental Hygiene is one," McIntyre said.
"Under the Regulated Health Professions Act," McIntyre continues, "our quality assurance (QA) program allows a variety of models. What started as a peer assessment program has expanded to include continuing quality improvement and total quality improvement. The colleges have been encouraged to be innovative.
"The underlying principle is that all quality assurance programs be positive and non-punitive in nature, and offer an alternative to the complaint/discipline process within a health regulatory college."
She said the quality assurance program requires Ontario dental hygienists to participate in continuing quality improvement activities. The activities must be consistent with the CDHO's standards.
Instead of just showing up at whatever continuing education course happens to be offered in their area, hygienists can choose from a variety of much more interesting options.
The primary instrument of the quality assurance program, McIntyre explains, is the "professional portfolio" maintained by every hygienist. Each portfolio consists of nine forms. The first three are personal, educational, and employment resumes.
The fourth form is a chart of a typical day at the hygienist's office. The first column breaks down client groups into categories such as adult recall, periodontal maintenance, new child patient, etc. Other columns outline typical services provided, health and safety and infection control protocols, and documentation and record keeping.
The fourth form sometimes reveals sensitive information. Catherine Grater Nakamura of Pickering, Ontario, outlines the problems a hygienist might have with listing the protocols (or lack of them) in a workplace.
"Although CDHO has made it clear that our first responsibility is to our client, and our second responsibility is to our employer, they are very cognizant of the fact that most of us are, in fact, employees, and do not always have full control of all the equipment, procedures, etc., in the environment in which we work."
Nakamura notes that the criteria for CDHO's standards for infection control state that hygienists "seek and promote a practice environment" where resources enable them to implement "current scientifically accepted infection control protocols."
She sought a clarification from the CDHO since dental hygienists do not "control our practice environment 100 percent."
"We must make every effort to ensure that the infection control protocols meet accepted universal standards," Nakamura said she learned. "I believe that if we were to find ourselves in a practice situation where infection control was not up to standard, we would be expected to try to educate the dentist and/or assistant and document our efforts."
Kim Lawrence of Thorold, Ontario, believes the CDHO teaches hygienists to be responsible for themselves. "I remember from the first portfolio meetings that it was said there are certain things you can't control in your office. But we have practice standards that have to be followed. In the end, you should know what is right. If the dentist does something you don't approve of, it is your responsibility to write it down on the form and try to remedy it, but you can't be punished if it is beyond your control."
The fifth form in the professional portfolio documents professional reading of journals, newsletters, and magazines. Questions asked on the form include include a query on whether the hygienist skim some articles or reads the entire magazine.
The sixth form is a learning plan. McIntyre explains, "We want the hygienists to reflect on their practice as it relates to the CDHO Dental Hygiene Standards of Practice. In doing that, they ask themselves, 'What am I doing well, where could I use enhancement, where is there new information and technology?'
"It's not quantitative. We don't need a certain number of goals in any given year. The assessor looks at the hygienist's goals and tries to establish a relationship with that hygienist's typical day."
A hygienist's goal, Nakamura said, "can be as simple as ensuring that each client wears safety glasses for each appointment. However, I don't think the CDHO would be satisfied to see that single goal. They'd be looking for more."
Some hygienists see the goal requirement as too ambiguous. "It's hard," said Lawrence. "Do I need two goals, or five? What if I have one big goal? Is that enough? Do I need to go to two seminars or four?"
The goals don't have to have a direct link with dentistry, either. Signing up for a computer class that would help a hygienist cope with a paperless office can qualify. So can taking a class in behavioral sciences. Other acceptable goals can include learning French for a bilingual office, or learning therapeutic touch or hypnosis.
It's easy to see how sensibly this can work. If you're the hygienist in a pediatric office, for instance, you might decide to take a class in child psychology, nutrition, or even sign language for babies.
McIntyre continues, "We also ask on Form 6, did the activity you planned address its goal? As hygienists, you're used to the dental health process of evaluating client care. Now take that same process and apply it to your practice. Assess the need, plan a goal, then go back and say, OK, did this action address the goal? Do I need to do more, or go in another direction?"
The seventh form is an activity summary. Hygienists list all the activities related to each goal.
The eighth form is completed for each goal. This form requires general information about activities, and a description of what the hygienist has learned, how it was implemented into the dental practice, and what was the outcome.
The ninth form asks about participation in professional associations.
Sorting through the portfolios
A random 10 percent of Ontario hygienists have their portfolios examined each year by a peer review team of assessors. McIntyre said. "We have 25 quality assurance assessors. They've stayed with us through the learning process, and they now have five years of experience."
The assessors were selected randomly from different parts of the province and different hygiene disciplines, including clinical practice, education, and community health. Some speak French, and some speak English.
"We're still on a learning curve," she said. "By June 2003, we had reviewed 617 professional portfolios, and 85 percent met the criteria."
The other 15 percent, McIntyre explains, can submit letters of consideration to the assessors, and can be granted extensions, exemptions, or referrals for remediation. "As the QA program is designed to be positive and non-punitive," McIntyre said, "we work with hygienists to achieve successful outcomes of the review while maintaining quality dental hygiene care to the public of Ontario."
One hygienist who went through the audit successfully is Gina Vasiliadis of Toronto, Ontario. "We have to maintain our professional portfolios on a continuing basis. So, when you are asked to submit yours, it should be ready to go. I was one of the lucky ones this year. Yes, I was nervous, but I did feel confident that I would pass. I attend a lot of workshops, and I volunteer on the board of directors for our professional association.
"When I received the letter from CDHO that stated I needed to hand in my portfolio, I had four weeks to submit it. Mine was approximately 25 pages, and I just printed off a copy from my computer. I got a response that I had met all assessment guidelines. By the looks of the review report, they did dissect each section of the portfolio. I'm now off the list for three years, but I will maintain my portfolio anyway.
"Quality assurance sounds a bit scary, but I really do believe it is better than a points program. In this province, we are proving ourselves to be professional, and our quality assurance program is a huge part of that. There are many hygienists out there who wish it were like before, because we did nothing for continuing education. I guess change scares a lot of people, but, of course, we changed for the better. We are much, much more than teeth cleaners!"
As a result of self-regulation, Canadian dental hygienists have proven to be innovators in professional development. Whether a hygienist practices in downtown Toronto or in the sparsely populated areas of British Columbia, she or he is free to use their knowledge and professionalism to develop a personalized method of staying current in the field and complying with continuing education requirements.
Cathy Hester Seckman, RDH, is a frequent contributor who is based in Calcutta, Ohio.A tangible professionalism
Many Ontario hygienists appreciate the new system.
"After all," Catherine Grater Nakamura said, "we all know that points don't really work, do they? Who's to say that a dental hygienists can't simply register for a course, show up, and then go shopping? How does accumulating points assure that the dental hygienist has learned anything and has applied the new knowledge to their practice?
"[With quality assurance (QA)] we are expected to assess if there are any areas in our professional practice that may need addressing or upgrading; we plan what goals we'd like to set, and plan how we are going to go about achieving them; we implement our plan and take the steps necessary to fulfill the goals; then we evaluate the outcomes. What was successful? What was not, and why?"
Kim Lawrence complies with QA in several ways. "I attend professional development seminars, I'm president of my local society, I belong to the Ontario Dental Hygienists' Association and attend their twice-yearly meetings, I read several journals, belong to two Web sites, read dental material online, and I'm in a study group."
Penny Spacie of Aurora, Ontario, likes the professionalism of the new system. "There's a lot of paperwork involved, but you do have a choice in how you set and achieve your own educational requirements. It is a true demonstration that you are a professional when you can self-assess your deficiencies and set goals to correct them. However, it would be easier if all you had to do was show up and sleep through a few meetings in order to collect a bunch of points."
More information on Canada's dental hygiene regulations and policies is available from the Canadian Dental Hygiene Association at www.cdha.ca, or from the College of Dental Hygienists of Ontario at www. cdho.org. The CDHO site includes example of the professional portfolios.CE in the other provinces
Besides Ontario, hygienists are self-regulated in four other provinces: Alberta, British Columbia, Quebec, and Saskatchewan. Those provinces also require professional portfolios from hygienists, according to the Canadian Dental Hygiene Association. But not every province allows non-dental related learning.
Jessica Donnelly of Vernon, British Columbia, is a former Ontario resident, and she's been a little frustrated with the more restrictive British Columbia requirements.
"In Ontario, we were only required to maintain a portfolio of our professional development, but here, we must collect 75 hours of continuing education credits in a three-year cycle. I have to provide proof of every single credit I am claiming, either in the form of a receipt for a course, a certificate to prove attendance, or a written report on a video or self-study.
"I live in a small town and work six days a week. Often, lectures are held in Vancouver on the weekends, but I don't like to take time off work and have the expense of traveling there.
"We used to have a local dental hygiene group that would meet once a month. Someone would come in for a lecture, and we would get two credit hours. Unfortunately, the group fell apart."
Donnelly has also been frustrated by the narrow course content in her area. "The amount of new information is a fraction of the repeated information I find. My main focus in my career is keeping up-to-date on the latest techniques and treatment of periodontal disease, and it's difficult here."
Twenty of Donnelly's credit hours can be from correspondence courses, and she depends on this option. She also attends local CPR and first aid courses for a few credits every other year. At least 50 of the 75 credits must be dental-related, but the remaining 25 can be non-dental, if she can prove professional enhancement. She was able to take several French courses locally, because her practice includes French-speaking clients.
Despite a few frustrations, Donnelly is happy with the system. "I like being made to keep up-to-date and educated in our field. I can see how a person could get lazy," she said.
More traditional continuing education requirements for hygienists are in place in New Brunswick, Newfoundland and Labrador, Nova Scotia, and Prince Edward Island. Requirements vary from 30 to 75 hours, points, or credits in a one- to three-year period.