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17 Harry Cayton Chief Executive Do regulators measure up?

18 Reflective practice The unexamined life is not worth living. Socrates

19 A warning: we are divided by a common language.

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21 Five agents of quality Law Professionals Regulators Service users Regulators - Includes professional, system and product regulators Service users - Includes their carers, families, advocates and representative organisations Service providers - Includes NHS, local authorities, private and voluntary employers and commissioners of services Professionals - Includes peer groups, teams and professional organisations Service providers Law - Includes all legislation, case law and common law

22 ENTRY COMPLIANCE EXIT INTERNATIONAL Recognition of international qualifications and systems of assurance Outcome: Students develop the knowledge and skills to join the register and practise effectively; Registrants commit to high standards of conduct and competence. Output: A network of quality assured education providers; An up to date public list of registrants. Outcome: Registrants demonstrate their compliance with standards and commitment to continuous development. Output: Clear standards and guidance are published; The register reflects the continuing fitness to practise of registrants. Outcome: Timely and proportionate action is taken when a professional fails to meet the standards expected of them. Output: An accessible, transparent and trusted system for handling concerns about professionals; The register includes any sanctions imposed on registrants. NATIONAL Cooperation with sector regulators and other agencies GOVERNANCE Outcome: Professionals, service users, providers and the public have confidence that the regulator s functions are carried out effectively, efficiently and in the public interest. Output: Well governed, independent and publically accountable organisations. Confidence in regulation Public protection

23 Elements of the right-touch approach Identify the problem before the solution Quantify the risks Get as close to the problem as possible Focus on the outcome Use regulation only when necessary Keep it simple Check for unintended consequences Review and respond to change

24 The Professional Standards Authority Oversees the nine health and care professional regulators and reports annually to parliament on their performance Accredits voluntary occupational registers to improve public protection and raise standards Conducts audits and investigations and can appeal cases to the high court if sanctions are unduly lenient Sets standards for the appointment of members to regulator s Councils and advises the Privy Council on appointments Conducts research and advises the four UK governments on improvements in regulation Promotes Right-touch regulation Conducts reviews and provides consultancy for governments and regulators in other countries

25 The Standards of Good Regulation Setting professional standards and guidance Quality assuring education and entry to the profession Holding a register Dealing with conduct, competence and health issues

26 Some 2013 publications by the Authority Fit and Proper? Governance in the public interest Continuing fitness to practise; a right-touch regulation approach Lapses in professional registration: Impact, issues, and ideas for improvement Assuring International Registrations Duty of Candour

27 Regulatory outcomes are what matter

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29 The Canadian Experience With Reciprocal Agreements Based on Accreditation

30 10 Canadian Dental Schools University of Alberta University of Saskatchewan University of Manitoba McGill University Université de Montréal Université Laval University of British Columbia University of Toronto University of Western Ontario Dalhousie University

31 10 Provincial Licensing Authorities

32 NDEB of Canada 1952 Act of Parliament Establishing qualifying conditions for a national standard of competence for general dental practitioners Issuing certificates to dentists who meet the standard.

33 NDEB of Canada 12 Board Members - 1 appointed by each of 10 Provincial Boards - 2 approved by Commission on Dental Accreditation

34 Accreditation Very important to NDEB Defined by Supreme Court Judgement - bonafide, ongoing - allowed to discriminate between groups based on accreditation NDEB and Regulatory Authorities actively involved and financially support

35 Accreditation Confidence and trust in competency of graduates NDEB certification process based on accreditation

36 Reciprocity Agreements Between the Commission on Accreditation of Canada and equivalent authority Based on real (bonafide) knowledge of the systems in both countries or institutions - therefore expensive and ongoing

37 Reciprocal Agreements Currently - US, ADC, DCNZ, IDC Quebec - France agreement not recognized by NDEB

38 NDEB Certification Process 2011 Graduates of Accredited Programs Written and OSCE Certified and Portable

39 NDEB Certification Process 2011 Graduates of Accredited Programs Graduates of Non-accredited Programs NDEB Equivalency Process Written and OSCE Certified and Portable

40 NDEB Certification Process 2011 Graduates of Accredited Programs Graduates of Non-accredited Programs Qualifying Program at Accredited school NDEB Equivalency Process Written and OSCE Certified and Portable

41 NDEB Certification Process 2011 Graduates of Accredited Programs Graduates of Non-accredited Programs Qualifying Program at Accredited school NDEB Equivalency Process Written and OSCE Certified and Portable

42 Number of applicants * 1020 Total 4912 *as of Sept

43 104 Different Countries INDIA 1315 IRAN 422 PHILLIPINES 395 EGYPT 350 IRAQ 218 PAKISTAN 179 CHINA 131 COLOMBIA 106

44 New Dentists in Canada 2012 Canadian DDS/DMD* 445 (54%) US, NZ and Australian* 170 (21%) QP/DC Programs 76 (9%) Equivalency Process 130 (16%) Total 821 *best estimates

45 Questions?

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48 Dedicated to the EVALUATION and IMPROVEMENT of educational programs located in post-secondary institutions and health facilities that prepare oral health providers to serve the Canadian public

49 The promotion of excellence through participation in a national accreditation process that provides external validation about the quality of a program. A peer review process conducted by a nongovernmental agency who appoints accreditation survey team members (surveyors) to evaluate if a program meets published requirements.

50 Develop and maintain national accreditation requirements for oral health education programs and health facility dental services based on CURRENT THEORY and PRACTICE in consultation with stakeholders. Evaluate post-secondary educational programs and health facility dental services that prepare oral health care providers to BE SAFE and COMPETENT PRACTITIONERS.

51 Identify post-secondary educational programs and health facility dental services in compliance with the national accreditation requirements using defined policies and processes. Promote the use of CURRENT EDUCATIONAL THEORY and INNOVATIVE INSTRUCTIONAL STRATEGIES. Promote the inclusion of oral health services as part of the INTERDISCIPLINARY PARTNERSHIPS for providing overall patient care in health facilities.

52 The NATIONAL STANDARD that permits graduates to write the National Dental Examining Board (NDEB) exam and apply for registration/licensure without further assessment. Permits national mobility Permits Canadian graduates to be recognized for licensure/ registration in the USA, Australia, New Zealand and Ireland.

53 CDAC accredits programs National Dental Examining Board (NDEB) certifies graduates Regulatory authorities emit practice licenses

54 CDAC does not select its membership. Members are nominated by their stakeholder groups. CDAC consists of 21 members representing: -- Regulatory authorities (5) -- Educator groups for dentistry, dental specialties, dental hygiene, dental assisting, health facilities and dental internship programs (7) -- Professional organizations: CDA, CDHA and CDAA (3) -- Certification agencies (5) -- Public member (1)

55 12 dental programs including qualifying programs 30 dental specialty 38 dental hygiene 37 dental assisting 42 health facilities and dental Residency programs

56 CDAC representatives include: EDUCATORS to reflect related educational expertise and interests REGULATORY AUTHORITIES to reflect the registration/licensure requirements and the interests of the authorities to whom the profession is accountable CERTIFICATION and NATIONAL EXAMINATION ORGANIZATIONS to reflect the evaluation of the practitioners PROFESSIONAL ASSOCIATIONS to reflect the practice of the profession

57 External surveyors review programs in relation to the accreditation requirements. External surveyors are: -- Dentists and/or other dental health professionals with educational and clinical experience. -- Representatives from the Certification and Regulatory Authorities.

58 Surveyors collection of accreditation survey visit facts, based on program responses to accreditation requirements, faculty members interviews and student feedback. Formally structured to state the program s compliance with the accreditation requirements. Contains Recommandations and Suggestions for program quality improvement.

59 Accreditation granted based solely on a paper review Accreditation granted based on a paper review that is further verified during an accreditation on-site survey visit

60 INSTITUTIONAL STRUCTURE EDUCATIONAL PROGRAM -- Admissions -- Curriculum management -- Curriculum content -- Patient management and treatment, and student evaluation

61 FACULTY and FACULTY DEVELOPMENT -- Program administration -- Faculty and Faculty development EDUCATION SUPPORT and SERVICES -- Physical facilities -- Learning resources -- Didactic and clinical support -- Student issues

62 CLINIC ADMINISTRATION -- Clinic operations -- Health and safety provisions -- Patient care and quality assurance RESEARCH and SCHOLARLY ACTIVITIES PROGRAM RELATIONHIPS

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65 Québec-France Agreement on the Mutual Recognition of Professional Qualifications Presentation to the 1 st International Conference of Dental Regulators By: M e Caroline Daoust Directrice générale et secrétaire October 12, 2013

66 Summary of the presentation 1. The Agreement between Quebec and France 2. The Mutual recognition agreement model also refered to as the MRA 3. The MRA signed between the ODQ and the ONCD (Ordre National des chirurgiens-dentistes de France) 4. Questions

67 Agreement between Quebec and France

68 Québec-France Understanding on the Mutual Recognition of professional Qualifications The Québec-France Understanding on the Mutual Recognition of Professional qualifications is an innovative agreement that marked a first between Europe and America. It was presented as a major building block of Quebec's new economic space and supports efforts aimed at negotiating an economic partnership between the European Union and Canada.

69 Québec-France Understanding on the Mutual Recognition of professional Qualifications Signed on October 17, 2008, by the President of the French Republic, Nicolas Sarkozy, and the Premier of Quebec, Jean Charest, the Understanding is designed to facilitate and accelerate the acquisition by people in France and Quebec of a permit to practice a profession or regulated trade in the other territory, through the adoption of a common procedure for recognizing professional competence. It was expected that by the end of 2010 the procedure would be applied by about a hundred professional orders and trades, enabling the signing of mutual recognition arrangements (MRAs) in globally equivalent areas. As of today, 24 professional orders have signed MRA s. Among them: Architects, lawyers, general accountants, nurses, ingeneers, dentists, medical doctors, pharmacists, midwifes.

70 Nature of the Agreement Facilitate access to the job market but does not give automatic access to it. Is not an international trade treaty. It is also not an understanding modifying immigration rules or rules pertaining to security checks that apply to the entry of foreign nationals.

71 Nature of the Agreement By this agreement, Quebec and France have agreed to adopt a common procedure to facilitate and accelerate the recognition of professional qualifications and pledge to implement the procedure in their respective legislation. The procedure for recognition was common to all professions.

72 Nature of the Agreement All 46 professional orders in Quebec were asked by government to participate actively and to reach an agreement with their counterparts in France. In the case of dentists and most health related professions, the government asked that an MRA be signed before the end of 2009.

73 Guiding principles of the agreement Protect public health and safety Maintain the quality of professional services Reciprocity

74 Who benefits from the provisions of the Quebec- France understanding? The Understanding covers regulated professions and trades in France and Quebec. Applicants must have earned a degree from a recognized institution in France or Quebec and hold a valid permit to practice issued in France or Quebec. They must then furnish regulating authorities of their trade or profession with the required documents for analysis of their application. A list of required documents and information will be drawn up by the competent authorities concerned based on what was agreed upon in the mutual recognition arrangements (MRA s).

75 How will the understanding speed up recognition of qualifications? The Understanding provides for applicants to be able to know the conditions for accessing the regulated profession or trade in question beforehand. In some cases, the recognition of professional qualifications may be automatic. In others, the applicant may be required to take compensatory measures. These will be limited to an internship along with an aptitude test, when necessary. Refresher training may be mandatory if public health and safety so require. In some cases, professional experience may make up for differences in training.

76 Will recognition of qualifications allow the Quebec professional to work anywhere in Europe? Yes, the rules of the European union and its member states will apply.

77 Will French nationals whose qualifications are recognized in Quebec be able to practice their trade or profession anywhere in Canada? AIT applies In the case of dentists, the answer is yes, within the conditions of the mobility agreement signed July 2009 by all ten provinces.

78 The Mutual recognition Agreement model also refered to as the MRA s

79 Common Procedure for the recognition of professional qualifications Step 1- Overall examination of qualifications by competent authorities Quebec - France Step 2- Assessment Step 3- Conditions for Recognition

80 Step 1 Overall examination of qualifications by competent authorities Quebec - France 1. Overall examination of fields of practice. 2. Overall examination of formal qualifications or apprenticeship program.

81 Step 2 and Step 3 Assessment and Conditions for Recognition Scenario 1 Fields of practice and formal qualifications deemed equivalent overall Recognition of professional qualifications The competent authorities issue an authorization to practice that is subject to the same conditions as those required of individuals practicing a regulated profession or trade in the territory of the receiving party

82 Step 2 and Step 3 Assessment and Conditions for Recognition Scenario 2 Substantial differences in the fields of practice and/or formal qualifications Sufficient professional experience may compensate for differences in training, and/or Compensatory measures may be called for: preferably an adaptation period or, if required, an aptitude test. Additional training when necessary for public health and safety reasons The competent authorities issue an authorization to practice that is subject to the same conditions as those required of individuals practicing a regulated profession or trade in the territory of the receiving party

83 Step 2 and Step 3 Assessment and Conditions for Recognition Scenario 3 Fields of practice and formal qualifications deemed incompatible No recognition of professional qualifications The applicant must enroll in a program of study leading to a qualification

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85 Step 1 Overall examination of fields of practice of dentists Fields of practice of a Quebec dentist and of a French dentist are equivalent.

86 Step 1 Overall examination of formal qualifications or apprenticeship program In Canada, we have CDAC. (Commission on dental accreditation of Canada) In France, there is no Commission on accreditation like CDAC. In France, there is a body of dental faculty deans and in Europe there is an Association for dental education. In France, university programs may have some variations. To examine qualifications and programs, ODQ asked experts for help.

87 Step 1 Overall examination of formal qualifications or apprenticeship program What was done Examination of documentations pertaining to dental medecine programs in France. Comparisons were made between the accreditation requirements for DDS or DMD of CDAC and French the Referentiel Monteil (document that specifies objectives of programs, theory and practice necessary to obtain a diploma). Comparisons were also made between the accreditation requirements of CDAC and the Profile and competences for the European dentist published in November 2004 by the Association for dental Education in Europe.

88 Step 1 Overall examination of formal qualifications or apprenticeship program What was done Overall the comparison on documents was conclusive in a positive manner. A visit of six French dental faculties was organized in June of Experts designated found some differences: - The amount of time spend for practice may vary from one university to another; - The manner in which dentistry is practiced (no hygienist or denturologist in France); - Standards and nomenclature regarding prescription of drugs; - Laws and regulations applying to both jurisdictions; - No common exit exam at the end of the program but each university has his own exit exam which is called Certificat de synthèse clinique et thérapeutique.

89 Step 2 Assessment After overall examination of qualifications and with the help of the expert group, Assessment shows there are some differences in formal apprenticeship programs or qualifications. Therefore scenario 2 of the common procedure had to apply.

90 Step 3 Conditions for recognition Compensatory measures may be called for: Preferably an adaptation period or, if required, an aptitude test. Additional training when necessary for public health and safety reasons.

91 The MRA signed between the ODQ and the ONCD (Ordre National des chrirurgiens-dentistes du France)

92 The MRA signed between the ODQ and the ONCD (Ordre National des chrirurgiens-dentistes du France) Conditions for recognition of professional qualifications in Quebec: 1. To hold a diploma that gives entrance to a permit in France (16 universities answer this criteria); 2. To hold a permit to practice with the ONCD; 3. To achieve, at the choice of the candidate one of the following compensatory measure: or i) a training period of six months in Quebec in a dental faculty, a health facility or a dental clinic under the responsibility of a member recognize as a trainor by the ODQ. The objective to this training period is to familiarized the candidate with the organization of work including the learning of rules and regulations; The specific content of the training period will include education sessions and evaluation criterias. ii) NDEB exam (written and OSCE)

93 The MRA signed between the ODQ and the ONCD (Ordre National des chrirurgiens-dentistes du France) In Quebec, informations on good standing are required. A temporary licence will be delivered for those who choose the training period. After the signing of the MRA, ODQ appointed another committee to determine the specific of the training period in order to produce an amendment to MRA. This amendment was incorporated to the MRA. Regulation was adopted by the Board and the government and is into force since April 2012.

94 Questions?

95 The GDC and Complaints Ian Jackson Director for Scotland

96 GDC We are the organisation that regulates dental professionals in the United Kingdom. We set Standards for the Dental Team, conduct Fitness to Practise cases and operate the Dental Complaints Service.

97 Patient satisfaction The vast majority of patients are satisfied with the dental treatment they receive, with: 57% very confident 38% fairly confident 3% not satisfied or confident There was a substantial increase in FTP cases and complaints in Figures from GDC Patient and Public Survey 2012

98 Patient complaints Clinical 47.5% Behaviour or conduct 21% Other 7% Caution/Conviction 6% Advertising 5% Cross infection control 2% Fraud 2% Scope of Practice 2% Fees charged 2% Health issues 1% GDC figures for 2012

99 Complained or considered complaining When asked about whether a patient has complained or has considered complaining: 95% have never considered complaining about a dental professional 93% have never complained about a dental professional Figures from GDC Patient and Public Survey 2012

100 Motivation behind complaint Relatively few patients complain. Of those who do complain, the majority do so: To raise concerns about professional performance To ensure other patients don t have these same problems So dental professional can improve performance Figures from GDC Patient and Public Survey 2012

101 Barriers to complaining Of those patients who wanted to complain, they did not because: Didn t know where to start Didn t know who/where to go for information on how to complain Didn t believe that the matter would be investigated Didn t have the time Figures from GDC Patient and Public Survey 2012

102 Current patient engagement Currently patients find out about us through: Practice leaflets Media Patient groups We find out about patients through: Annual patient survey

103 Future patient engagement In 2014 we will be working to increase our profile with patients through: Launch of online patient forum GDC logo and Standards posters in practices Patient focused media strategy New Standards that focus on communicating effectively with patients

104 Questions?

105 The National Registration and Accreditation Scheme for Health Practitioners A New Model of Regulation in Australia 1st International Conference of Dental Regulators Martin Fletcher Chief Executive Officer martin.fletcher@ahpra.gov.au tanya.vogt@ahpra.gov.au Tanya Vogt Executive Officer, Dental Australian Health Practitioner Regulation Agency

106 Australia 23 million people Federal system of government Joint government funders 70% public 30% private mix 9.3% of GDP on health Good health status overall Major gap for indigenous health Maldistribution of heath practitioners Significant international workforce

107 Over 150 years to establish consistent rail gauges in Australia

108 Long and Proud History Former Tasmanian Medical Council 1837 regulation of medical practitioners in Van Diemens Land (Tasmania) Predates UK by 21 years States have power to register/ regulate - not Commonwealth History of piecemeal changes Major transformation in past 3 years

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110 Patient safety and workforce driving reform

111 Objectives of Legisla tion Protection of the public Workforce mobility within Australia High quality education and training Rigorous and responsive assessment of overseas trained practitioners Facilitate access to services in accordance with the public interest Enable a flexible, responsive and sustainable health workforce and enable innovation

112 A major transformation since 2010 Eight State and Territory based arrangements >95 health profession boards 75 Acts of Parliament 38 regulatory organisations 1.5 million data items from 94 sources One national scheme 14 health profession boards Nationally consistent legislation (largely) One national organisation National on line registers

113 Health Practitioners July chiropractors 2. dental care (including dentists, dental hygienists, dental prosthetists & dental therapists), 3. medical practitioners 4. nurses and midwives 5. optometrists 6. osteopaths 7. pharmacists 8. physiotherapists 9. podiatrists 10.psychologists July Aboriginal and Torres Strait Islander health practitioners 2. Chinese medicine practitioners 3. medical radiation practitioners 4. occupational therapists

114 How many registered practitioners in Australia? 10

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116 Key features 14 National Boards set policy (largely) and exercise regulatory functions: set standards for registration take action where concerns about conduct, performance or health protective jurisdiction Administered by a single national organisation (AHPRA) Self funded and no cross subsidisation between professions Standards of education largely through independent accreditation authorities: Boards approve standards and programs of study Role for Ministerial Council in oversight and specific policy matters

117 What do we do? Professional standards Registration Notifications Compliance Accreditation

118 Registration standards Common Domains 1. Criminal history 2. English language requirements 3. Professional Indemnity Insurance arrangements 4. Continuing Professional Development 5. Recency of Practice

119 What does this look like for dental practitioners in Australia?

120 Dental regulation - a major transformation since 2010 Eight State and Territory Dental Boards and four Dental Prosthetist Boards At least 12 Acts of Parliament 12 registrars and staff across 12 offices Dental Board of Australia One piece of nationally consistent legislation (largely) One organisation supporting the Dental Board and its delegates (AHPRA)

121 Who is on the Dental Board of Australia (DBA)? 12 members Five dentists One oral health therapist One dental hygienist One dental prosthetist Four community members

122 How many registered dental practitioners in Australia? Divis ion ACT NSW NT QLD SA TAS VIC WA No PPP To ta l Dental Hygienist ,270 Dental Hygienist and Dental Therapist Dental Prosthetist Dental Therapist Dentist , , , ,863 1, ,642 1, ,020 * Oral Health Therapist To ta l 19,912

123 Divisions of the DBA register Dentist Scope of practice - Registration Standard Independent practitioner who may practise all parts of dentistry, are clinical team leaders, able to supply and fit dental appliances for the treatment of sleep disorders. Accreditation Standards and Competencies and Attributes DH/DT/OHT Dental Prosthetist Autonomous decision making in areas of formal education/training, structured professional relationship with a dentist, must not practise as independent practitioners Accreditation Standards and Competencies and Attributes Independent practitioners in making, fitting, supplying and repairing removable dentures and flexible, removable mouthguards.

124 Dentist specialist practice Type Conscious Sedation endorsement Description Dentists who practice conscious sedation Annual renewal requirements Additional practice requirements 13 Specialties - Specialist Registration Standard Dento-maxillofacial radiology Endodontics Oral and maxillofacial surgery Oral pathology Oral medicine Oral surgery Public health Forensic odontology Special needs dentistry Prosthodontics Priodontics Pediatric Orthodontics

125 What does the Dental Board of Australia do? Public protection - broader requirement to respond to workforce needs, mobility, flexible workforce Registration Establish standards and oversee registration processes. Develop guidance for dental practitioners and students. Oversee the assessment of overseas trained applicants for registration in Australia Notifications - Health, performance or conduct Oversee and manage Accreditation - Approve programs of study as a qualification for registration or endorsement as a dental practitioner accredited by the DBA s Accreditation Authority

126 Some reflections

127 Reflection on a National Scheme from a dental perspective Achieved consistency not possible under multiple pieces of legislation Consistent approach to dental practitioner divisions and dentist specialties More cost effective than running 12 Boards Less dental specific control Concern that relativities of dental need to be better reflected within the National Scheme

128 Some challenges Responsiveness to specific profession needs within a multi-profession model Managing fitness to practice well Building community trust and understanding Dynamic authorising environment Longer road to maturity

129 Changes in Australia reflect global trends with opportunity to learn from each other Professionally led rather than self regulation with greater public involvement Common frameworks across professions Emphasis on ongoing competence to practise Greater focus on patient and public safety but what is place of workforce objectives? Challenges of global mobility of health workforce Regulatory data as an information asset Costs of regulation and economies of scale

130 www. ahpra.gov.au

131 What should new regulators be mindful of? (and old regulators try not to forget) Harry Cayton Chief Executive

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133 You are here to protect the public

134 Three purposes of regulation Patient safety Upholding standards of the profession Maintaining confidence in regulation

135 Outcomes or processes?

136 Right touch regulation Right touch regulation is based on a proper evaluation of risk, is proportionate and outcome focussed; it creates a framework in which professionalism can flourish and organisations can be excellent. Excellence is the consistent performance of good practice combined with continuous improvement. Harry Cayton CHRE Review 2009

137 The first law of right touch regulation Use only the regulatory force necessary to achieve the desired effect.

138 The features of good governance Responsibility and accountability Personal behaviour, roles and relationships Dealing with disagreement Conflicts of interest Transparent decision making Understanding performance Handling corporate complaints Credibility not representation

139 International trends in regulation Greater co-operation underpinning professional mobility Simplification and cost-effectiveness; sharing operational functions, even mergers Right-touch principles; outcomes, proportionality, alternatives to regulation information sharing and collaboration; active regulation Reforms of governance including smaller boards and increased external accountability Assuring continuing competence and good conduct

140 Future possibilities? Simplification and cost-effectiveness; sharing operational functions, even mergers Right-touch principles; outcomes, proportionality, alternatives to regulation Co-operation and information sharing; active regulation Reforms of fitness to practise, including greater use of mediation and consent Reforms of governance including smaller boards and increased external accountability.

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