Newsletter: December 2018

From the Chief Executive

Message from the Chair

The end of each year is traditionally a time of reflection—a tradition that is especially apt for me as late 2018 coincides with my term as Council Chair drawing to an end. 

Throughout my term as Chair we have continued work that supports Council’s vision of safe oral health care for New Zealanders. In 2015, Council agreed its strategic priorities for 2015–2020 and began a shift towards a risk-based regulatory model. While we are confident that oral health practitioners seek to provide high levels of care, we are also aware that the professions and the Council are responsible for setting standards, systems and processes that clearly articulate our expectations. These systems and processes also need to assure the public that our practitioners are fit and competent to practise at an appropriate standard.

We have focussed on positioning Council as a right-touch, risk-based regulator to minimise non-compliance and public risk, while supporting practitioners to upgrade their knowledge and skills at the same time. I am extremely proud of Council’s three major achievements towards this end since 2015—introducing the Standards Framework, putting in place a new IT system and commencing the review of our recertification framework.

The Standards Framework introduced in 2015 clearly set out the threshold above which all oral health professionals are expected to operate. Assessing ethical conduct, clinical and cultural competence against the principles and standards in the Framework is the Council’s starting point for assuring the public and helping practitioners remain safe to practise. It is pleasing to see more and more practitioners placing these standards at the centre of their professional practice and Council will continue its efforts to help practitioners retain this focus.

Implementing the new IT system has been another important project to support Council’s risk-based approach and future proof the Dental Council’s ability to operate its core functions. The system will give us an IT system capable of greater data collection and analysis to help Council better identify risk and respond in a proportionate, consistent and targeted way.

The IT project has been large and complex piece of work that has taken up considerable Council resources over the last few years. To date, most of this work has occurred behind the scenes. We reached a milestone when Council staff began using the new system in September 2018 and look forward to opening the practitioner portal so practitioners can begin using online services next year.

In reviewing our recertification system, our focus has been on finding the right balance between risk and assurance. Assuring the public that practitioners remain competent and fit to practise throughout their career is a vital part of our regulatory role. 

It is important that evolving the professional development and assurance comprised in a recertification system keeps oral health practitioners engaged in a realistic system.  It is also important that oral health practitioners listen to the expectations of the society they serve, in terms of accountability for their ongoing development, and evolve with the evidence about opportunities for professional learning while they practise.

I am confident that the outcome from the recertification review will be an improved, more flexible system that enables practitioners to undertake professional development relevant to their practice, while providing the right level of intervention to help those with failing competence before they fall below the minimum standards. Supporting and extending our practitioners in this way will provide greater assurance to the public that the ongoing professional development of oral health professionals matches with contemporary practice by other health professionals. 

The recertification review has been one of the major projects we have undertaken over the last three years and I’d like to thank Council members and Council staff for all the work they have put into this project. I’d also like to thank all the practitioners and other stakeholders who have readily shared their views and actively participated in the consultation process.

I would be remiss not to mention two other major milestone achievements over the last three years—creating patient focussed orthodontic resources and introducing the oral health therapy scope of practice.

With a focus on providing public assurance about the quality of orthodontic treatment and ensuring good quality information for the public, the orthodontic working group developed a series of recommendations.  Action on these recommendations is well underway and includes educational material targeted specifically for the younger orthodontic patients. I was particularly pleased with the collaborative approach taken and the inclusion of a lay member and an advocate for children in the working group.  These diverse insights greatly contributed to the recommendation and the outcomes. I believe this project can shape the way that Council develops policy, standards and recommendations in the future and look forward to more opportunities for us to work with the public and practitioners in this way.

Introducing the new oral health therapy scope of practice in late 2017 was in itself a major achievement. However, having over 500 oral health therapists registered with the Council in a modern scope of practice is just a beginning.   Council is considering how this group of practitioners can make even greater contributions to the oral health of New Zealanders. In 2019 we will again consider the oral health therapy scope of practice and will work with tertiary education providers to ensure the necessary training is available. I will remain keenly interested as this work progresses.

A major challenge Council faced over my term as Chair has been the disruption caused by the Kaikoura earthquake.  Two years after the earthquake, Council staff have settled into what started as temporary offices in Willis Street.  We continue working with the building owners at 80 The Terrace to satisfy ourselves that it is safe for our staff to return.   

While reflecting back on the last three years I must also mention the tremendous amount of core business the staff of the Secretariat work through every day.  Inquiries from the public and practitioners, applications for registration and scope of practice changes, designing and implementing competence programmes, ensuring help is provided with health conditions and of course making sure practitioners receive an annual practising certificate are core functions of the Council.  I am grateful to each and every one of our staff members who continue to provide a high level of service to Council, practitioners and the public, and in particular to Marie Warner for her ongoing commitment to the work of the Dental Council, and for leading a talented group of staff.

Finally I’d like to thank my fellow Council members for their confidence and their support of my leadership over the last three years.  Council’s strength is in the diversity of views, the collective of professional and lay knowledge and opinion, and in the Council members' commitment to ensuring that the public does receive safe oral health care. I thank all of the Council members for the time and commitment that they continue to give to the Dental Council.

And so it remains for me to offer my greetings for the season. I wish you all the joy of Christmas with your family and loved ones, and a holiday period that is restful and safe.  

Robin Whyman

Chair

From the Chief Executive

Greetings from the Chief Executive

My best wishes to everyone as we work through the last weeks of 2018 and prepare for the festive season and a holiday break.

It’s been a busy year for us at the Dental Council, largely due to the increased pressure of providing regular services to Council and practitioners while implementing a new IT system at the time.

I am thrilled that we were able to start using the new system internally in September and have seen the increased efficiencies and capabilities it offers. The next major step will be opening the practitioner portal so that practitioners can start using the online services next year.  Moving to online services will make the APC process and other interactions with the Council easier. We are looking forward to sharing it with our existing and new practitioners early in 2019.

We expect the dentists and dental specialists who are randomly selected to complete practice standards audit questionnaires, and practitioners renewing their APCs for the 1 April - 31 March APC round will be the first to use the new online services.

In the meantime, please ensure we have a unique email address that will become the user name you’ll need to access the online services. If you are unsure about what address we have on our records please contact us.

Thank you to everyone who has contributed to our work throughout 2018—we thank you all for your commitment and support.

I would like to wish you all a Merry Christmas and a happy and safe holiday season.

Marie Warner
Chief Executive

Recertification review update

Thank you to everyone who attended a forum or webinar, completed a survey, or sent in a written submission during the recertification consultation. 

Our phase two consultation (including forums, webinars, survey submissions and free-form written submissions) on Council’s proposals to improve recertification closed on 26 October 2018. 

You may be interested to know approximately 650 people participated in the phase two forums and webinars compared with approximately 500 people for phase one (resulting in a 30% increase in participation).

We received 417 valid submissions on the phase two discussion document. This represents an overall response rate from less than 10% of our total number of practitioners. However, it is a 62% increase in submissions received in phase one.

The 417 valid submissions were made up of:

• 370 online survey submissions
• 37 free-form written submissions
• 1 ‘in confidence’ submission
• 9 anonymous submissions.

If you have viewed our recertification submissions web page you will see only 385 survey and free-form written submissions have been uploaded to the website. We excluded:

• 9 (7 survey and 2 free-form written) anonymous submissions because the respondents did not provide enough information to accurately attribute the submission to a specific individual, group or organisation
• 23 duplicate submissions.

Please note that the online survey was completed by 543 participants. However, 173 survey respondents only answered the demographic questions (1 to 3) but did not provide responses to any of the questions about the proposals (questions 4 to 21) and accordingly were not deemed valid by Council.

The Council considered the submissions and has agreed in principle to go ahead with the four proposals. However, there is still a great deal of work to be done to develop the operational framework (policy, standards, templates, guidelines etc.) before we put in place any changes. Council has requested the secretariat to start the operational development work for Council to consider in early 2019.   

Accreditation outcomes

We recently completed accreditation reviews for University of Otago, AUT and orthodontic auxiliary training programmes.

University of Otago

The University of Otago offers 12 postgraduate programmes that are accredited for registration as a dental specialist or a clinical dental technician with the Dental Council in New Zealand. These include the Doctor of Clinical Dentistry programmes in 10 disciplines, a Master of Community Dentistry and a Postgraduate Diploma in Clinical Dental Technology.

A joint postgraduate accreditation review was conducted, with the site visit from 16 to 19 July 2018 at the University of Otago Faculty of Dentistry in Dunedin. The site evaluation team (SET) interviewed stakeholders that included:

• faculty and postgraduate programme staff
• programme leads
• postgraduate students
• recent graduates
• relevant professional bodies. 

This is the first New Zealand accreditation where the new Dental Council (NZ)/Dental Board of Australia dental specialist competencies were used as a benchmark for the dental specialist curriculums and assessments.

The SET consisted of a core team that reviewed all the generic accreditation standards, with discipline specific groups comprising of an international academic primarily from Australia, and a New Zealand practising dental specialist from each discipline who focussed on the individual curriculum and assessment aspects of the programmes under review. This significantly strengthened the review process with the relevant discipline expertise available to inform the process. 

Accreditation outcomes

The SET concluded that the following eight postgraduate programmes met all the accreditation standards, and were granted accreditation until 31 December 2023:

• Doctor of Clinical Dentistry (endodontics)
• Doctor of Clinical Dentistry (oral pathology)
• Doctor of Clinical Dentistry (oral surgery)
• Doctor of Clinical Dentistry (orthodontics)
• Doctor of Clinical Dentistry (periodontology)
• Doctor of Clinical Dentistry (prosthodontics)
• Master of Community Dentistry
• Postgraduate Diploma in Clinical Dental Technology.

The Doctor of Clinical Dentistry (paediatric dentistry) programme was also granted a five year accreditation period until 31 December 2023 conditional on increased clinically immersive hospital sessions and/or placements being put in place by May 2019. The reason for the condition is to increase the exposure of paediatric postgraduate students to the management of acute paediatric dental emergencies and complex paediatric cases, and experience in hospital management of paediatric patients.

Two of the DClinDent programmes did not meet the programme of study accreditation standard, and substantially met the assessment standard. These were the oral medicine and special needs dentistry programmes.

Due to the nature and extent of the shortcomings identified, the assessors considered these programmes have significant shortcomings that support a shorter accreditation period. However, the assessors considered that the programmes can put appropriate measures in place to address these shortfalls within a reasonable timeframe to ensure graduates are competent at completion of their programme.

DClinDent Oral medicine programme

The programme was granted accreditation with conditions until 31 December 2019.

Key concerns of the oral medicine programme were:

• The structure of the programme, with the medical degree not being an entry requirement. Due to the lack of fundamental medical knowledge and experience of patient management of students without a medical degree, achieving the appropriate level of knowledge and necessary clinical experience to attain all the oral medicine specialist competencies was considered challenging.
• The breadth and depth of core oral medicine clinical exposure, as well as those additional general medicine exposures of importance to oral medicine specialty training were deficient; current rotations were mostly observational rather than clinically immersive.

Conditions were put in place for the programme with strict timeframes within which evidence that these have been implemented should be provided to the Council, the last of which should be reported back by 15 November 2019.

The conditions relate to:

• strengthening and extending of clinical attachments
• medicine to become an entry criteria for the programme or completion of the medical degree early in the DClinDent programme structure (similar structure to the earlier conjoint MDS/MBChB (OM) programme)
• ensuring external examiner participation in the final assessments by a registered oral medicine specialist
• reporting on the assessment process to the Council. 

DClinDent special needs programme

The programme was granted accreditation with conditions until 31 March 2020.

Key concerns related to the special needs dentistry (SND) programme were:

• exposure to an adequate number and range of SND patients, and that the treatment complexity available to students appears to be on the lower end
• insufficient supervision of students by SND dental specialists, in particularly during outplacements. Where dentists supervises SND students, the dentists must have extensive SND experience.
• limited opportunities for joint treatment planning with other restorative dental specialist disciplines, such as endodontics, periodontics and prosthodontics.
• concerns related to the final examination processes. 

Conditions were placed on the programme relating to: establish appropriate outplacement opportunities for all SND students; revisiting and strengthening its final examination process and assuring SND external examiner participation, with an external examiner report to the Council confirming that the issues identified have been addressed. The last condition must be reported on by 31 January 2020. 

Conditions common to all programmes

Conditions applicable to all the accredited postgraduate programmes were placed relating to: 

• ongoing monitoring during the dental school building project
• embedding of cultural competence into the postgraduate programmes
• review and strengthening of the assessment strategies and standard-setting procedures
• correction and update of outdated or misleading registration information in the course materials.

Oral and maxillofacial surgery programme

The SET considered that based on the evidence provided the accreditation standards related to the programme of study and assessments were not met. Consequently, accreditation for the programme was declined.

The key concerns by the team were:

• A medical degree is not required for entry into the DClinDent OMFS programme. Within the current curriculum design, it is unclear how the programme will meet the requirements of OMFS training without the completion of a medical degree before the higher surgical training in this programme. Insufficient evidence was produced to demonstrate sufficient medical teaching of students in the absence of a medical degree. An educational approach that relied on customisable education according to the needs of the specific student, particularly whether they have completed their medical training before entering the programme or not, was described. However, this was not documented in the handbook or the primary submission document, and no evidence of how this would work was given.
• Insufficient evidence was provided to ensure all the OMFS attributes and competencies required would be attained through the course – both didactically and clinically. 
• The concerns about the very limited involvement of medical teaching and clinical staff extend to assessments.
• There is no evidence of contemporary external input or review of the programme, or benchmarking against international contemporary programmes.

The assessors identified a number of areas that the programme must address to enable the programme to meet the required accreditation standards. This will allow the programme to address the deficiencies. The Faculty can resubmit the programme for accreditation once they consider that the accreditation standards are met. Revisiting the accreditation of the programme can then occur. There was no active DClinDent OMFS student in the programme at the time of the visit.

What do shortened accreditation or accreditation declined mean?

The three programmes with conditions must report on their conditions to the Dental Council by the timeframes stipulated. All reports will be submitted to the ADC/DC(NZ) Accreditation Committee, following which the Dental Council will consider whether the conditions have been met. Accreditation of programmes may be revoked if the Council considers that the conditions have not been met.

The programmes with shortened accreditation periods or where accreditation was declined, will communicate the accreditation outcome to existing students and future applicants to the programmes. Graduates from unaccredited New Zealand programmes are not eligible for registration with the Dental Council.

Accreditation report
The full report  is available on  our website. Section 2.1 relates to the accreditation standards common across all programmes, and the programme-specific commentary follows in section 2.2.

Overall, the Council was concerned about the level of serious deficiencies identified in a number of programmes. With the Faculty being the sole dentist and dental specialist training provider in New Zealand, the Council saw this as a risk for the education of the dental workforce. The Council believes that it is in the best interest of patient care to have access to a range of dental specialty educational programmes to serve the oral health needs of the New Zealand population, but it must ensure that the graduates entering the profession are competent and safe to practise within their respective scope of practice.

To this end the Council is committed to work with the Faculty to ensure that the programmes where serious deficiencies have been identified, are brought back up to standard.

Auckland University of Technology Bachelor of Health Science in Oral Health accreditation 2018

The Bachelor of Health Science (oral health) programme gained full accreditation in 2008, ending on 31 December 2018. The site visit was conducted on 20 and 21 September 2018 at the Faculty in Auckland.

During the site visit, the site evaluation team (SET) held interviews with the Faculty and programme leadership teams, staff from all years, most clinical educators, students from all years, recent graduates, Māori and Pasifika specialist advisors, clinic managers, chair of the advisory committee and professional bodies. 

The new AUT University Akoranga Integrated Health Clinic, Buckland Road clinic and pre-clinical space were visited by the SET.

The SET considered that all the accreditation standards were met, but made a number of quality improvement suggestions to ensure that the programme continued to meet the accreditation standards and improve programme delivery.

The primary areas of focus for the programme are:

• With the increase of student numbers, ensuring appropriate programme resources. These include adequate patient numbers and student operator experiences, sufficient and functional pre-clinical and clinical equipment and adequate material, clinical and administration staff, and adequate clinical supervision.
• Revisit the overall vision of the type of practitioner that the programme wants to deliver in light of the role that oral health therapists can play in the delivery of New Zealand’s oral health care.
• Progress the integration of oral health care delivery within the programme, moving away from the historically separated restorative and periodontal clinics.
• Explore further opportunities for outplacements to broaden the students’ clinical and practice experiences. 
• Increased academic staff members would allow the Department a greater opportunity to contribute towards oral health care research; a workforce review to rationalise the small fractional appointments would enable holistic and consistent contributions to programme delivery and benefit student learning. 
• Explore strategies for oral health students to engage and participate in the School of Clinical Sciences’ interprofessional education.
• Develop and use clearly defined selection criteria and a transparent process for the appointment of clinical educators.
• Standardise the requirement for patients, or their representative, to reconfirm consent for treatment for each appointment and especially when another student continues the treatment at follow-up appointments, and assuring the recording of all informed consent in patient treatment notes.
• Explore ways to generate clinical activity summary sheets, ideally digital, to more effectively monitor students’ progress and to identify any gaps in clinical exposure in a timely fashion.

New Zealand Association of Orthodontists - Orthodontic Auxiliary Training Programme

The New Zealand Association of Orthodontists - Orthodontic Auxiliary Training Programme (NZAO OATP) leads to the Certificate of Orthodontic Assisting and enables successful trainees to register as orthodontic auxiliaries with the Dental Council in New Zealand.

The programme was developed by the NZAO to address the workforce needs for auxiliary staff to assist orthodontists, and was granted its first accreditation in 2010. Training is undertaken in-house in orthodontic practices, and trainees are supervised by approved orthodontists.

The site visit was conducted on 31 August 2018 during the final assessment held at the Faculty of Dentistry Department of Orthodontics in Dunedin. Interviews were held with the programme leadership, administrator, supervisors, clinical evaluator, chief examiner, examiners, and current and recent trainees.

The site evaluation team (SET) considered that all accreditation standards have been met.

A number of focus areas have been identified to ensure the programme continues to meet the accreditation standards, along with some suggested improvements. These include:

• Ensure updated online course material that reflects contemporary practice within the New Zealand context.
• Strengthen the cultural competence module and its assessment.
• Introduce written individualised feedback to trainees after the final assessment.
• Explore opportunities to increase the availability of the final assessments to three per year.
• Encourage voluntary short-term outplacements in other NZAO approved training practices, under supervision of that orthodontist, to increase exposure to different clinical approaches, techniques, equipment and broader patient and case mix. Such placements, if occurring, should be under signed agreements with clearly defined educational objectives and appropriate clinical supervision arrangements.
• Update the transmissible major viral infections (TMVI) evidence requirement during the application phase.
• Ongoing focus on improvement of communication with trainees and supervisors, in particular what to expect during the final assessment process.

The Council granted accreditation until 31 December 2023.

Sharing concerns

As oral health practitioners, we occasionally become concerned about our colleagues and the potential harm to patients from the way they practise. The concerns may be about our colleague’s clinical competence, their behaviour, or their health.

Without your help and support, a practitioner who is unwell or falling below the minimum levels of competence puts the public at potential risk, and also risks damage to their reputation and to the profession. Ignoring or covering up a competence or health issue is not the right thing to do. At the same time, notifying the Council about one of your colleagues is a difficult step to take.

In this article, we outline the relevant professional standards that apply in this situation and ways to act on your concerns.

The Standards Framework

The Standards Framework sets out the minimum standards of ethical conduct, and clinical and cultural competence that patients and the public can expect from oral health practitioners.

Registered oral health practitioners must adhere to the ethical principles at all times. One of the five ethical principles in the framework is to ‘maintain public trust and confidence’.

Under this principle sit two professional standards that outline how you should deal with concerns about risk of harm.

• Professional standard 27: You must protect the interests of patients and colleagues from any risk posed by your personal issues or health, or those of a colleague.
• Professional standard 28: You must protect the interests of patients and colleagues from any risk posed by your competence or conduct or that of a colleague or an employee.

When do I have a legal obligation to notify Council?

Most professional standards include guidance notes to help practitioners meet the professional standards.

The most important things to note from the guidance for professional standards 27 and 28 are your legal obligations as a health practitioner to notify Council in two particular circumstances.

First, if you have good reason to believe a colleague is suffering from a health condition (including substance abuse or addictions) which could affect their ability to deliver patient care or place colleagues at risk, you must notify the Council.

Second, if you employ a practitioner who is dismissed or resigns from their job for reasons relating to competence, you must notify the Council.

In these situations you are legally required under sections 45 and 34 respectively of the Health Practitioners Competence Assurance Act 2003 (the Act) to give the Council written notice of health or competence issues.

Do I have other professional obligations to inform Council?

Yes, as indicated in the guidance notes for both standards 27 and 28.

Your professional obligations are to:

• seek medical advice if your own or a colleague’s personal or health issues may be a risk to your patients or colleagues
• inform the Dental Council if you suspect or know that your mental or physical health may be a risk to patients or colleagues
• inform the Council if you know or suspect that your own competence or conduct, or the competence or conduct of a colleague, may be a risk to patients or colleagues.

Although the intent of these standards is clear—to ensure people are protected from any risk from health, competence or conduct issues—acting on your concerns is not always easy.

What should I do?

The overriding principle is public welfare. Sometimes it helps to apply the “daughter test” to help you decide how to proceed. Ask yourself if you would be happy for the practitioner to treat a relative or close friend. If the answer is “no”, then you should let us know.

If a practitioner is suffering from a physical or mental health issue, they are likely to be going through a stressful period. This is a time when expressing your concerns to the practitioner involved, offering advice and giving collegial support are more important than ever. Your professional association may be able to offer support and guidance through the process.

Doctors Health Advisory Service is a national network that provides collegial support and arranges counselling for dentists and other health professionals with health problems and stress. The DHAS is a personal advisory service for practitioners and students. If requested, appropriate referral for treatment, or other support can be arranged.

You could also seek personal help and advice from your GP, a counsellor or an employee service such as EAP.

What happens when I do notify the Council?

Here are some things to know and remember, about what happens if you do notify the Council of your concerns:

• Notifications need to be in writing (or email).
• Council’s policy is full transparency so anonymous phone calls are not helpful.
• When a serious concern is received in writing about a practitioner the Council will act on that concern.
• Fairness principles mean an informant’s written notification of concerns will be disclosed to the practitioner, allowing them an opportunity to comment.
• You should objectively include the basis for the notification.
• It is inappropriate for you to actively seek further evidence of concerns and it is unacceptable to create situations to entrap practitioners.

Council will follow up with the appropriate inquiries in a timely fashion. This includes considering the possibility that the notification could be frivolous or vexatious. A report is provided to Council as a foundation for a decision on what, if anything, should be done. Council may seek further information before deciding what, if any, action to take. Fairness and privacy issues mean that the notifying practitioner may not receive immediate or full feedback on any actions taken by Council.

Council’s processes are designed to be supportive and educational. A fundamental tenet of the Act is that concerns about competence are addressed through education and remediation of the practitioner, wherever possible. Where issues affect a practitioner’s health the Council will again endeavor to work with a practitioner to balance an ability of a practitioner to work safely, with the public interest of safety.

Options available to Council when considering a notification include seeking assurance that any concerns have been addressed, independent assessment and advice about a practitioner’s health, a competence review, or referral to a professional conduct committee if concerns around conduct are apparent. In the situation where a risk of harm to the public is apparent then it may be necessary, in the interim, to alter a scope of practice or introduce supervision or mentoring.