Meeting the Challenge: WSDA's Efforts to Close the Workforce Gap

Quick Bites Closing the dental workforce gap is one of WSDA’s top priorities. Bills passed in Olympia this session will make it easier for licensed hygienists from other states to begin practicing in Washington. WSDA is supporting efforts to create new dental hygiene training programs in the state. WSDA is also leading a multi-state effort to change CODA accreditation standards to allow expansion of existing training programs.

Clarkston dentist Robin Henderson and her husband, Scott, who runs the business side of the practice, are all too familiar with a problem facing many WSDA members. They need to hire another hygienist and there are none to be found. With three to four openings available for every hygienist seeking employment, the gap is large nearly everywhere in the state.

What makes the Hendersons’ predicament even more frustrating is that their office is located within walking distance of a dental hygiene education program. But there’s a catch: the program, operated by Lewis-Clark State College, is located across the state border, in Lewiston, Idaho. Idaho’s hygiene scope of practice is not as extensive as Washington’s – it doesn’t include restorative procedures, for instance – so the program’s graduates are not eligible to go to work for the Hendersons or any other Washington dental office.

^{Robin Henderson, DDS (L) stands with her practice’s hygienist Catherine Tetrick, RDH outside the Lewis-Clark dental hygiene program facility. Tetrick is a graduate of the program, and recent WSDA-supported changes in state law will soon allow Washington dentists like Henderson to again hire program graduates.}

In contrast to the proximity to the Lewis-Clark program, the closest Washington-based hygiene schools are located in Spokane and the Tri-Cities, both more than 100 miles away. It’s hard to pull graduates of those schools to a smaller community like Clarkston unless the individual has some existing connection to the community, such as family in the area.

“It’s incredibly frustrating to have a program so close and not be able to hire its graduates,” said Scott Henderson. “Robin has even endowed a scholarship in hygiene at Lewis-Clark, but we can’t hire any of the recipients.”

Another irony is that this restriction wasn’t always the case. The Hendersons’ current hygienist, who has been with them for seven years, was educated at Lewis-Clark when it was previously credentialed through Lane Community College in Oregon and trained its graduates to Oregon standards, which more closely parallel those of Washington. Now that the program is connected to North Idaho College, however, the lack of alignment in scope between the states has been an absolute barrier.

“Lewiston and Clarkston are almost like one city,” Dr. Robin Henderson said. “But dental offices in the two towns are operating under two sets of rules. It isn’t good when patients have to wait for months to get the preventative care they need. I know that there are patients who still consider themselves patients of our practice, but they haven’t returned yet.”

That is just one of many workforce issues facing WSDA members that the association has been working to resolve. It’s a battle being waged on many fronts. Some of these efforts are already bearing fruit, while others will take longer to show results.

Important Gains in Olympia

The 2023 legislative session saw passage of several bills that will contribute to increasing the supply of hygienists available to work for Washington dentists.

“With an already serious shortage of hygienists and assistants being exacerbated by the COVID-19 pandemic, we need a multifaceted approach to increasing the dental workforce,” said WSDA Director of Government Affairs Emily Lovell. “We presented legislators with a package of proposals and they enacted several that will make a difference starting right away.”

The first of these bills, House Bill 1466, extends the initial limited license period for hygienists moving into the state to complete Washington’s additional educational requirements. That period, currently 18 months, will be extended to five years under the new law. This allows hygienists to begin providing much-needed preventive care to patients while they obtain the additional education in restorative procedures, along with administration of nitrous oxide and local anesthesia that Washington requires of fully licensed hygienists.

Before this extension, some hygienists moving to Washington have been overwhelmed by the limited window to obtain the required additional education while also working. The new law’s longer timeframe provides a practical strategy to help bring more hygienists into the dental workforce.

A related bill, House Bill 1287, removes the requirement that a hygienist in another state or Canadian province be actively practicing in order to qualify for an initial limited license when coming to Washington. The law previously required a hygienist to have worked for a minimum of 560 hours over the previous 24 months in order to be eligible.

Taken together, these laws would allow a graduate of the Lewis-Clark program, for instance, to go to work in Dr. Robin Henderson’s Clarkston office under an initial limited license, and then have a full five years to complete the additional education to gain permanent licensure in Washington.

In a state with a growing population fueled in part by significant numbers of new people moving into the state, especially in areas with large military populations, these new laws will begin paying real dividends for dentists and their patients almost immediately.

Innovative Approach to Licensure Portability

Better licensure portability is another factor that will make it easier for dental professionals moving to Washington to begin practicing in the state. The Dentist and Dental Hygienist Licensing Compact envisioned under House Bill 1576 will provide that portability.

Licensed dentists and licensed dental hygienists in good standing will be allowed to practice in all states participating in the Compact, rather than having to secure individual licenses in each state. The Compact is in formation, and a minimum of seven states are required for it to become operational. Washington, Iowa and Tennessee are the first states to enact legislation committing the state to participation in the Compact, and similar bills have been introduced or are being considered in a number of other states. Given the fact almost every state is facing a dental workforce shortage, the hope is that the seven-state threshold will be reached quickly and the benefits of the Compact will begin to be seen.

Growing Our Own

As Seahawks General Manager John Schneider will tell you, success comes from a combination of drafting good players who are just starting their careers and adding experienced talent through free agency, but neither is sufficient on its own to fill out the roster.

Similarly, Washington’s severe dental workforce shortage won’t be solved completely by importing new talent, no matter how much more efficient that becomes. The state also must increase its capacity to train new hygienists and assistants.

Part of that increase will come from the expansion of existing programs. That approach was a major factor in WSDA partnering with Delta Dental of Washington and the University of Washington School of Dentistry to maintain the well-regarded Shoreline hygiene program and place it under the auspices of the dental school. The longer-term goal is to prepare the hygiene program to grow.

In recent years, Columbia Basin College in Richland and Bellingham Technical College have both increased the size of their dental hygiene programs. Vancouver’s Clark College is planning an expansion that will increase their cohort size by five additional hygienists beginning in 2027. Additionally, Lake Washington Institute of Technology has not only increased the size of its dental hygiene program, but also restarted its dental assistant program with an evening schedule offered on campus and in conjunction with a local high school skills center.

Expansion of existing programs, however, will only move the needle so far. Washington also needs additional programs to be created and start preparing dental hygienists and assistants.

That process is already well underway at Peninsula College in Port Angeles. According to Paula Watson, the College’s Dental Hygiene Program Director, Peninsula is working its way through the accreditation application process and developing the curriculum and physical spaces it will need to prepare future dental professionals for the local community.

“Program funding and accreditation application development are the most significant challenges in starting a new program. Dental hygiene programs are historically very expensive to develop and operate, due to space and equipment costs. The accreditation application and review process can also be challenging, partly due to restrictive dates that the Commission on Dental Accreditation, or CODA, has for their review schedule,” said Watson.

“We are also making connections with community stakeholders, including looking for innovative opportunities to partner with local public health entities to bring dental hygiene services to those who may have challenges with access to preventive dental care,” she said.

The strength of those local connections are especially important, given the unique situation faced by Peninsula College and its surrounding area.

“It’s no secret that currently there is a nationwide shortage of healthcare professionals in general,” Watson added. “But in our case, the closest dental hygiene program is more than 100 miles from Port Angeles, which heightens the shortage locally. Prospective employers have reported challenges filling open positions and long patient wait times, which impacts continuity of preventive care for their patients.”

Peninsula has had some strong supporters getting to this point.

“WSDA and Delta Dental have shown interest in the development of Peninsula’s program from the beginning to address concerns with workforce challenges. Local dentists have shown interest in our program too, and we have a large advisory committee. As things develop further, it will be important to engage even more dentists and employers in how we can meet their needs and secure funding to establish the program and clinic,” she said.

Peninsula’s experience will provide a roadmap for leaders at Olympic College who have expressed interest in starting a dental hygiene program and are in the very early stages of planning.

Peninsula's Lessons Learned Peninsula College is well into its program planning, development, and accreditation application processes. Along the way, program administrators have learned a few things that should be helpful for their peers at Olympic College or any other school looking to create dental hygiene or dental assistant education programs. Conduct a thorough assessment of the key factors that will determine whether the program will be successful, such as: Local dental hygiene job demand Community oral health needs Employer needs Student interest Proximity of other programs Ensure that the program will have the support from college administrators who will be making decisions about space and budget for the program. Build support from the local community, including local dentists and other community leaders. Engage other supporters, such as WSDA and Delta Dental of Washington, that are committed to solving the dental workforce shortages. Consider whether innovative or unique service delivery models are appropriate, such as partnering with local health care agencies for clinical opportunities, or providing hybrid instructional models that allow students to do some of their classroom work from home. Identify and confirm that adequate funding will be available to create and sustain the program. Allow plenty of time for all elements of the accreditation application process.

Expanding Capacity – Questions for CODA

While the CODA accreditation process is a critical milestone that must be completed for a new hygiene program, many find parts of the agency’s accreditation standards to be a barrier to expanding dental hygiene and assisting programs. CODA is the only health care profession accrediting body that utilizes explicit faculty-to-student ratios in some of its accreditation standards. CODA does not use a faculty-student ratio in its accreditation standards for dental school but does have a ratio for dental allied health professions – dental hygiene, dental assisting, and dental therapy.

Dental hygiene has the most stringent faculty-to-student ratio at 1 to 5, whereas dental therapy and dental assisting require a 1 to 6 ratio. Moving dental hygiene’s ratio to 1 to 6, consistent with that for dental assisting and dental therapy, would increase capacity of existing hygiene education programs by up to 20 percent. That potential is a major reason why WSDA has spearheaded a group of 19 state dental associations asking CODA to reconsider its approach to faculty-to-student ratios in dental allied health education.

Vicki Wilbers, of the Missouri Dental Association, and Mark Paget, of the Wisconsin Dental Association, are two of the state dental association executive directors who worked with WSDA’s Bracken Killpack in pulling together the request of CODA. Their rationale for doing so was simple.

“Just like everywhere else, we have a major shortage of hygienists and assistants here in Wisconsin. It’s a major pain point for our members,” Paget said.

“Here in Missouri, we have reports of people waiting more than three years to get a spot in hygiene school,” said Wilbers. “There was one person working at a school with a hygiene program, and they still couldn’t get in.”

“We talked to administrators at every hygiene and assisting education program in the state, and every single one of them said that finding qualified faculty is their biggest challenge – even more so than other challenges like the cost of space and equipment. If we can increase the faculty-to-student ratio, programs could add 5-10 slots apiece, creating more opportunities for students and helping our members,” she added.

Unfortunately, CODA’s initial response to the state associations’ overtures was dismissive. Both the Council’s Hygiene Committee and its Assistant Committee responded that “teaching ratios have a long-standing history within the CODA Accreditation Standards for allied dental education programs. The ratios are in place to ensure appropriate instruction and supervision of students.”

However, the state dental associations did not take CODA’s initial response as the conclusion of the discussion. The state associations raised concerns that CODA has no consistent methodology or oversight for establishing faculty-to-student ratios and that CODA cannot articulate what facets of dental hygiene education necessitate a lower faculty-to-student ratio than dental therapy or dental assisting

CODA reconsidered the issue at its first meeting in early 2023 and agreed to form an Ad Hoc Committee to review its faculty-to-student ratios. In addition, the agency requested excessive data from the state associations that have participated in this effort for reason that remains elusive to the states. It’s clear that this issue is unlikely to be settled quickly.

“We’re extremely disappointed in CODA’s response. They’re trying to stall by asking us to provide proof and examples to support our position, rather than providing evidence to support their position,” Paget said. “If they were doing their job, they would be out talking to the technical schools that are already CODA accredited and listening to what is really going on.”

Wilbers agrees. “It’s extremely frustrating. They should be listening to us. We are the boots on the ground,” she said.

The two executive directors also agree on another issue, too: “Kudos to Bracken for taking the bull by the horns on this issue,” Paget said. “He’s been leading the charge.”

Recognizing the size of the challenge, Executive Director Bracken Killpack said WSDA will be charging forward with multiple workforce initiatives in the months and years ahead.

“We’ve made some real progress over the last year, especially on the legislative front,” Killpack said. “Other strategies, like starting a new hygiene school or convincing CODA to change its accreditation standards, will take time. But one thing is certain: addressing the dental workforce shortage will remain one of our association’s top priorities for the foreseeable future.”

---

This article originally appeared in Issue 2, 2023 of the WSDA News magazine.