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Quality Assurance - Ontario Regulation 607/98

Made under the
Dental Hygiene Act, 1991
Made: August 28, 1998
Approved: November 18, 1998
Filed: November 19, 1998
Amending O. Reg. 218/94
(General)

Note: Ontario Regulation 218/94 has not been amended in 1998. For prior amendments, see the Table of Regulations in the Statutes of Ontario for 1997.

1. Ontario Regulation 218/94 is amended by adding the following Part:

Part VI
Quality Assurance

General
16.

In this Part,
"assessor" means a person, who may be an employee of the college, appointed by the Committee under section 81 of the Health Professions Procedural Code, to conduct an assessment under section 82 of the Code:

"Committee" means the Quality Assurance Committee and includes a panel of the Committee.

17.

(1) The Committee shall administer a quality assurance program that includes the following components:
1. Total quality improvement.
2. Continuing quality improvement measures.
3. Peer assessment, practice review and remediation.
4. Remediation of behaviour and remarks of a sexual nature.

(2) The business of the Committee may be conducted by a panel, selected by the chair from among the members of the Committee.
(3) A panel shall be composed of at least three persons, of whom one shall be a person appointed to the Council by the Lieutenant Governor in Council.
(4) Any two members of a panel constitute a quorum but one of the members must be a person appointed to the Council by the Lieutenant Governor in Council.

Total Quality Improvement
18.

(1) The College shall collect and analyze information about the nature and quality of the practice of dental hygiene, including information from members, and shall make group-based comparisons of the information.
(2) The College may use the information and its analysis to disseminate advice or guidelines to the profession to facilitate total quality improvement for the practice of dental hygiene and to adjust the College's quality assurance program.
(3) Members shall provide statistical information with respect to services provided by members for compilation when requested by the College.

19.
(1) Each member of every class of certificate of registration shall develop and maintain a professional portfolio in accordance with the Committee's specifications that the college has published and distributed to the members.
(2) Each professional portfolio shall include at least,

(a) a statement of the member's planned continuing quality improvement goals for each year and the relationship of each goal to the member's practice and the College's standards of practice and ethics;
(b) a description of a typical day in each of the member's workplaces;
(c) a description of the member's continuing quality improvement measures; and
(d) for each continuing quality improvement measure, an assessment of the implementation and outcome of the acquired knowledge, skills, judgment and attitudes in the member's dental hygiene practice.

20.

(1) Subject to subsection (2), starting on the later of January 1 in the year following the year in which a member obtains a general or a specialty certificate of registration and January 1, 1999, the member shall during every year participate in continuing quality improvement activities sufficient to indicate that the member continues to have and to apply in his or her dental hygiene practice the knowledge, skills, judgment and attitudes required to practice dental hygiene in compliance with the College's standards of practice and ethics.
(2) If, in 1999 or any subsequent year, a member obtains a general or a specialty certificate of registration before July 1 in the year after having ceased to hold that class of certificate for any reason, the member is required to participate in the activities described in subsection (1) from the time that the member obtains the certificate of registration.
(3) The member shall, during every year that the member participates in the activities, accurately and completely document the activities in the member's professional portfolio.

21.

(1) The College shall review annually the forms, policies and procedures for professional portfolio.
(2) If the College makes any changes to the forms, policies and procedures for professional portfolios, it shall publish them for inspection by members one year in advance of the January 1 on which they are to come into effect.

22.

(1) Upon paying the annual fee to renew a general or specialty certificate of registration, each member shall provide satisfactory evidence of having maintained the professional portfolio in accordance with the regulations and the forms, policies and procedures of the College.
(2) If a member does not provide the evidence required under subsection (1), the Registrar shall refer the matter to the Committee.
(3) After reviewing the reasons for the referral, a panel of the Committee may appoint an assessor to assess the member's quality improvement activities.
(4) The assessor shall give the Committee and the member a written report of the assessment together with a notice that the member has the right to make written submissions to the Committee on any deficiency noted by the assessor within 30 days of delivery of the notice.
(5) After reviewing the assessor's report and, if available, the member's professional portfolio and considering the written submissions of the member, if any, the Committee may do one or more of the following:

1. Grant the member an extension for a specified period of time to achieve specified continuing quality improvement goals.
2. Grant the member an exemption from some or all of the requirements for the year in question.
3. Direct the member to complete specified continuing education within a specified period of time.
4. Direct a peer assessment and practice review of the member's practice at his or her practice location under section 23.
1. Direct that no further action is required if it does none of the actions mentioned in paragraph 1, 2, 3 or 4.

Peer Assessment, Practice Review And Remediation
23.

(1) The Committee shall appoint an assessor for the purposes of this section.
(2) The Committee shall select the name of members in each year for an assessment, using a stratified random sample based on demographic criteria.
(3) A member shall undergo an assessment if,

(a) The Committee selects the member's name under subsection (2) for an assessment;
(b) The Committee makes a direction under paragraph 4 of subsection 22 (5); or
(c) The Registrar, the Complaints Committee, the Discipline Committee or the Board refers the member to the Committee and the Committee decides to have the assessor do an assessment.

(4) In an assessment, the assessor shall assess the member's professional portfolio, quality improvement activities and practice to evaluate the member's knowledge, skills, judgment and attitudes.
(5) The assessor shall give the Committee and the member a written report of the assessment together with a notice that the member has the right to make written submissions to the Committee on any deficiency noted by the assessor within 30 days of delivery of the notice.
(6) After considering the report and the written submissions of the member, if any, the Committee may do one or more of the following:

1. Give the member an opportunity to correct any deficiency in continuing quality improvement activities within a specific period of time.
2. Grant the member an exemption from some or all of the requirements for the year in question.
3. Direct the member to complete specified continuing education or remedial programs within a specified period of time.
4. Subject to subsection (7) and (8), direct the Registrar to impose terms, conditions or limitations on the member's certificate of registration for a specified period, not exceeding six months if the Committee finds the member's knowledge, skills, judgment or attitudes to be unsatisfactory and the Committee believes that an order under paragraph 1, 2 or 3 is inadequate to address the concerns.
5. Direct that no further action is required if it does none of the actions mentioned in paragraph 1, 2, 3 or 4.

(7) The Committee shall not make an order under paragraph 4 of subsection (6) unless it has given the member written notice of its intention to make the order and at least 15 days to make written submissions to the Committee.
(8) The Committee shall not make an order under paragraph 4 of subsection (6) more than twice pursuant to any one assessment.
(9) If the Committee makes an order under paragraph 1, 2, 3 or 4 of subsection (6), it may at that time or a later time appoint an assessor to conduct a follow-up assessment to determine whether the member's knowledge, skills, judgment and attitudes are satisfactory, and subsections (1) to (8) apply to the follow-up assessment.

24.

(1) Subject to subsection (2), if a member does not participate in or does not successfully complete a continuing education or remedial program specified by the Committee in an order made under paragraph 3 of subsection 23 (6), the Committee may direct the Registrar to impose terms, conditions or limitations on the member's certificate of registration for a specified period not exceeding six months.
(2) The Committee shall not make an order under subsection (1) unless,

(a) it has given the member written notice of its intention to make the order and at least 15 days to make written submissions to the Committee; and
(b) it has considered the written submissions of the member, if any.

25.

The Committee may direct the Registrar to remove the terms, conditions or limitations that it imposes under paragraph 4 of subsection 23 (6) or subsection 24 (1) before the end of the specified period if it is satisfied that the member's knowledge, skills, judgment and attitudes have become satisfactory.

Remediation Of Behaviour And Remarks Of A Sexual Nature
26.

(1) Subsection (2) applies to matters referred to the Committee by,

(a) a panel of the Complaints Committee under subsection 26 (3) of the Health Professions Procedural Code; or
(b) the Executive Committee, the Complaints Committee or the Board under section 79.1 of the Health Professions Procedural Code.

(2) The Committee may require a member to undergo a psychological assessment or another assessment specified by the Committee if a matter described in subsection (1) respecting a member is referred to it.
(3) Subject to subsection (4), after receiving the report of an assessment under subsection (2), the Committee may require the member to undertake specified measures, such as education, therapy or counseling, if the Committee is of the opinion that the measures will help the member to refrain from sexual abuse.
(4) the Committee shall not issue a requirement under subsection (3) unless,

(a) it has given the member notice of its intention to issue the requirement and at least 15 days to make written submissions to the Committee; and
(b) it has considered the written submissions of the member, if any.

(5) Subject to subsection (6), if the member refuses to undergo an assessment under subsection (2) or does not undertake or complete the measures specified by the Committee under subsection (3), the Committee may direct the Registrar to impose terms, conditions or limitations on the member's certificate of registration for a specified period not exceeding six months.
(6) The Committee shall not give a direction under subsection (5) unless,

(a) it has given the member written notice of its intention to give the direction and at least 15 days to make written submission to the Committee; and
(b) it has considered the written submissions of the member, if any.

(7) The Committee may direct the Registrar to remove the terms, conditions or limitations before the end of the specified period if it is satisfied that they are no longer needed.

Council Of The College Of Dental Hygienists Of Ontario
Evie F. Jesin President
Fran Richardson Registrar
Dated on August 28, 1998.
49/98