WSR 22-23-076

PROPOSED RULES

DEPARTMENT OF HEALTH

(Dental Quality Assurance Commission)

[Filed November 10, 2022, 3:38 p.m.]

Original Notice.

Preproposal statement of inquiry was filed as WSR 17-17-089.

Title of Rule and Other Identifying Information: WAC 246-817-701 through 246-817-790 for administration of anesthetic agents for dental procedures. The dental quality assurance commission (commission) is proposing rule amendments to establish new and updated requirements for the administration of anesthetic agents for dental procedures.

Hearing Location(s): On January 20, 2023, at 8:30 a.m., in person at Olympia Parks, Arts and Recreation, Multipurpose Room B, 222 Columbia Street N.W., Olympia, WA 98501; or virtual https://us02web.zoom.us/webinar/register/WN_E8QNdtFsTIqF_Kb4ZdAN4A. The public hearing will be hybrid. Participants can attend at either the physical location or virtually by registering via Zoom.

Date of Intended Adoption: January 20, 2023.

Submit Written Comments to: Amber Freeberg, P.O. Box 47852, Olympia, WA 98504, email dental@doh.wa.gov, fax 360-236-2901, by January 6, 2023.

Assistance for Persons with Disabilities: Contact Amber Freeberg, phone 360-236-4893, fax 360-236-2901, TTY 711, email dental@doh.wa.gov, by January 6, 2023.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The proposed rule includes 24-hour on-call availability, updates basic life support education, adds requirements for emergency protocols and training, clarifies recordkeeping and emergency medications, establishes self-inspections for all dentists when anesthetic is administered, updates on-site inspections for dentists with moderate sedation with parenteral agents or general anesthesia permits, and creates a pediatric sedation endorsement.

Reasons Supporting Proposal: The current rules have had several updates and a complete review was necessary. Creating a pediatric sedation endorsement is necessary to provide safeguards for the unique sedation needs of pediatric patients. Interested parties have expressed concern with lack of 24-hour on-call availability after dental procedures. Although current rule requires 24-hour on-call availability when anesthesia is used, there are complex dental procedures that do not involve anesthesia and on-call availability is necessary. Self-inspections are needed to ensure all dentists are prepared for dental emergencies when any type of anesthetic is administered during a dental procedure. Current rule requires on-site inspections for dentists holding general anesthesia permits; the proposed rule amendment adds moderate sedation with parenteral agents permits and creates standards for the on-site inspections to ensure patient safety.  

Statutory Authority for Adoption: RCW 18.32.002 and 18.32.0365.

Statute Being Implemented: RCW 18.32.640.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: Dental quality assurance commission, governmental.

Name of Agency Personnel Responsible for Drafting: Jennifer Santiago, 111 Israel Road S.E., Tumwater, WA 98501, 360-236-2985; Implementation and Enforcement: Amber Freeberg, 111 Israel Road S.E., Tumwater, WA 98501, 360-236-4893.

A school district fiscal impact statement is not required under RCW 28A.305.135.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Amber Freeberg, P.O. Box 47852, Olympia, WA 98504, phone 360-236-4893, fax 360-236-2901, TTY 711, email dental@doh.wa.gov.

This rule proposal, or portions of the proposal, is exempt from requirements of the Regulatory Fairness Act because the proposal:

Is exempt under RCW 19.85.025(3) as the rules only correct typographical errors, make address or name changes, or clarify language of a rule without changing its effect.

Explanation of exemptions: See explanation above.

Scope of exemption for rule proposal:

Is partially exempt:

Explanation of partial exemptions: WAC 246-817-730 and 246-817-771 are both exempt under RCW 34.05.310 (4)(d) as the proposed rules in both clarify current requirements without material change.

The proposed rule does impose more-than-minor costs on businesses.

Small Business Economic Impact Statement

The commission is proposing rule amendments to establish new and updated requirements for the administration of anesthetic agents for dental procedures. The proposed rule includes 24-hour on-call availability, updates basic life support education, adds requirements for emergency protocols and training, clarifies recordkeeping and emergency medications, establishes self-inspections for all dentists when anesthetic is administered, updates on-site inspections for dentists with moderate sedation with parenteral agents or general anesthesia permits, and creates a pediatric sedation endorsement.

The current rules have had several updates and a complete review was necessary. Creating a pediatric sedation endorsement is necessary to provide safeguards for the unique sedation needs of pediatric patients. Interested parties have expressed concern with lack of 24-hour on-call availability after dental procedures. Although current rule requires 24-hour on-call availability when anesthesia is used, there are complex dental procedures that do not involve anesthesia and on-call availability is necessary. Self-inspections are needed to ensure all dentists are prepared for dental emergencies when any type of anesthetic is administered during a dental procedure. Current rule requires on-site inspections for dentists holding general anesthesia permits; the proposed rule amendment adds moderate sedation with parenteral agents permits and creates standards for the on-site inspections to ensure patient safety.

There are costs for licensed dentists to comply with the proposed rules. Costs are associated with 14 sections of the proposed rules. Cost estimates are for the average dental office. There is no anticipation of loss of sales or revenue to comply with the proposed rules. Costs and time associated with complying with the proposed rules were gathered through various sources, including:

WAC 246-817-701 Administration of anesthetic agents for dental procedures: The existing rule excludes procedures using only local anesthesia. The proposed rule amendment modifies 24-hour availability to include local anesthetic and adds options to meet requirements for availability.

The commission anticipates that for a dentist to establish a prearranged agreement with another provider for immediate care to a patient will take 15-30 minutes. The average hourly salary of a dentist is $79.001. Therefore, the anticipated cost of compliance to the proposed rule is $40.00.

WAC 246-817-720 Basic life support requirements: The existing rule requires health care provider basic life support certification requirements for dental staff. The proposed rule amendment adds a hands-on component for initial [initiation] and renewal of health care provider basic life support (BLS) certification and education standards.

The commission anticipates no new cost to obtain health care provider BLS certification with a hands-on component, as dentists are currently required to have health care provider BLS certification. There are a variety of courses and locations available to obtain health care provider BLS certification. The cost of a seven-hour in-person course through American Red Cross is $1202 and there is no difference in cost in a health care provider BLS certification course with and without a hands-on component.

WAC 246-817-722 Defibrillator: The existing rule requires a licensed dentist providing anesthetic agents to ensure a defibrillator or automated external defibrillator is accessible to all staff within 60 seconds and excludes local anesthesia from this requirement. The proposed rule amendment adds this requirement when local anesthetic is administered. There is a new cost for dentists that do not already have a defibrillator or AED in office. It is not always possible to predict how a patient is going to respond to anesthetic agents and practitioners need to be able to rescue that patient. A defibrillator or AED average price range is $1200 to $19003. There are a variety of types, models, and distributors available to obtain a defibrillator or AED. There are a variety of courses and locations to obtain defibrillator or AED training.

WAC 246-817-724 Recordkeeping, equipment, and emergency medications or drugs: The existing rule requires specific patient record documentation, equipment, emergency drugs, and excludes minimal sedation by inhalation. The proposed rule amendments include the following:

There is a cost to develop and maintain written emergency protocols. There is an additional cost for staff training and documenting the annual review. Costs greatly differ depending on whether the dentist and staff establish their own written infection prevention policies and training or if the dentist determines to use an outside organization to develop policies and training.

The commission assumes that an average staff makeup in a dental office includes one dentist, two hygienists, two dental assistants, and one administrator. Salaries based on the Bureau of Labor Statistics are:

The commission assumes [that the] that either a staff person in the dental office or the dentist will develop, maintain, and provide training for emergency protocols. The time spent is estimated at 20 hours for initial development. It is estimated that two hours of initial training will be needed for all staff, and one-hour annual training for all staff.

By using straight-line depreciation (spreading the cost of an asset evenly over the asset's useful life) and assuming a five-year useful life (defined as the estimated time that an asset provides value) costs to comply with this section are provided below8:

WAC 246-817-740 Minimal sedation with nitrous oxide: The existing rule provides minimum requirements for a licensed dentist to administer (inhalation) minimal sedation. The proposed rule amendments include the following:

The commission anticipates there are no new additional costs for a dentist to comply with training requirements, recordkeeping, or BLS certification, as none of the proposed amendments add additional time for a dentist to comply. Clarification for training requirements is consistent with American Dental Association's Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students9.

The commission anticipates there are new additional costs for the continuing education change from every five years to every three years. Seven hours every five years equals 1.4 hours annually. Seven hours every three years equals approximately 2.34 hours annually. The proposed rule amendment increases the continuing education by 0.94 hours annually. Continuing education costs vary dramatically depending on number of hours obtaining, where, and method of obtaining continuing education. The average two-hour continuing education course offered by University of Washington, School of Dentistry is $6910. The cost for one additional hour annually is $34.50. Because there are several acceptable ways proposed in new WAC 246-817-773 to complete continuing education at no cost, the commission assumes minimal or no cost to comply with this change.

WAC 246-817-745 Minimal sedation: The existing rule identifies the minimum requirements for a licensed dentist to administer a single dose or agent for minimal sedation with or without nitrous oxide. The proposed rule amendments include the following:

The commission anticipated that there is a potential cost savings by reducing the initial education and training hours from 21 to 16 hours. The average two-hour continuing education course offered by University of Washington, School of Dentistry is $6911. There are no new costs for a dentist to comply with training requirements, recordkeeping, or BLS certification as none of the proposed amendments add additional time for a dentist to comply. Reduction and clarification for training requirements are consistent with American Dental Association Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students.

The commission anticipated that there is minimal or no additional cost for a dentist to complete a patient evaluation as patient evaluation is a standard of care currently expected. The proposed rule identifies the American Society of Anesthesiologists patient classification requirements12.

The costs for continuing education change from every five years to every three years is [are] provided in WAC 246-817-740 analysis.

WAC 246-817-755 Moderate sedation with enteral agents: The existing rule identifies the training and administration requirements a licensed dentist must comply with to administer moderate sedation. The proposed rule amendments include the following:

The commission does not anticipate additional costs for the proposed rule increasing training hours and hands-on skill training. The proposed increase in hours and clarification for training requirements are consistent with American Dental Association Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students. The proposed increase of 37 hours of education and training from 28 hours includes the education of 16 hours required for minimal sedation proposed in WAC 246-817-745. The remaining proposed 21 hours of education and training must be in moderate sedation. There is a net increase by four hours between these two rules. These additional hours are routinely provided in sedation-related available courses. Increased initial training costs range from $0 to $13813. The commission has reasonable belief that a dentist can comply with the proposed rule change at no cost for the increased training hours; therefore, the commission does not anticipate an additional cost to comply with the rule.

The commission anticipated that there is minimal or no additional cost for a dentist to complete a patient evaluation, as patient evaluation is a standard of care currently expected. The proposed rule identifies the American Society of Anesthesiologists patient classification requirements.

The costs for continuing education change from every five years to every three years is [are] provided in WAC 246-817-740 analysis.

WAC 246-817-760 Moderate sedation with parenteral agents: The existing rule identifies the training requirements a licensed dentist must complete to administer moderate sedation with parenteral agents. The proposed rule amendments include the following:

The commission anticipates additional costs of the proposed rule to increase supervised patient experience from 15 to 20 patients. Supervised patient experience is obtained during training. Most programs already provide at least 20 patient experiences, as this is a requirement under American Dental Association Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students. DOCS Education provides IV Sedation Training for Dentists at a cost of $23,49514. This is not a new cost and not an increase in cost. Additionally, education and training costs may be higher than the documented range due to the proposed added requirement that the training must include hands-on skills training. Although most training courses already include hands-on skills, there are several courses that have not incorporated this component, as the rule has not previously required it.

The commission does not anticipate additional costs for clarifying language and terms, listing prohibited drugs, adding a patient evaluation requirement, clarifying monitoring requirements, updating examples of emergency drugs, clarifying ACLS certification, or adding authorization for lower-level sedation administration, because the standard of care for dentists include all these standards.

The commission anticipates a negligible cost to increase pulse oximetry and respiratory recording from every 15 minutes to every five minutes. Costs are associated with dentist and staff time. The commission anticipates the average staff assisting in a sedation procedure is one dentist and two dental assistants. Salaries based on the Bureau of Labor Statistics are dentist - $7915 hourly wage and dental assistant - $1916 hourly wage. The proposed rule adds that an additional two recordings are required every 15 minutes. Approximately 30 seconds are needed to view the monitor and to record, that is 60 seconds of increased time spent every 15 minutes for a dentist or dental assistant during a sedation procedure; approximately four minutes per hour. An average sedation procedure is one hour. The commission believes this proposed time increase for monitoring and recording during a sedation procedure is negligible for this reason.

The commission anticipates no new costs to have equipment calibrated, adding requirements for operating theater, table or chair, lighting system requirements, and additional emergency drugs. The existing standard of care currently includes ensuring offices where sedation is administered be appropriate for sedating patients, and equipment is maintained and in good working order. Office and equipment standards are recommended by the American Association of Oral and Maxillofacial Surgeons17.

The commission anticipates an added cost to purchase additional emergency equipment for laryngeal mask airway and electrocardiographic equipment if the office does not already own them. There are many distributors of emergency equipment. Grayline Medical offers a laryngeal mask at $3518. Discount Cardiology offers an electrocardiographic monitor for $109519.

The commission anticipates an additional cost for requiring a written contract when providing sedation in another practitioner's dental office. Costs include time spent developing and managing a written contract. There is a one-time cost developing standard contract language. The commission also anticipates additional costs when executing a contract with individual practitioners. The commission estimates up to one hour of both office administrator and dentist time to develop a standard contract and an additional one hour of time for the dentist to execute an individual contract. Salaries based on the Bureau of Labor Statistics are dentist - $7920 hourly wage and office administrator - $4821 hourly wage. The probable one-time costs to develop standard contract language include dentist and administrator time of $127. The probable cost to execute a contract is estimated at $79.

The commission anticipates a potential cost savings for proposed continuing education reducing hours from 18 to 14 hours every three years (reduction of 4 hours every three years). Continuing education costs vary dramatically depending on number of hours obtaining, where, and method of obtaining continuing education. The average two-hour continuing education course offered by University of Washington, School of dentistry is $6922. The commission anticipates that a potential savings could be between $0 - $138 every three years.

New WAC 246-817-765 Pediatric sedation endorsement: The proposed new section establishes a new pediatric endorsement requirement for a dentist to administer sedation to a pediatric patient when using moderate sedation with enteral and moderate sedation with parenteral permit holders. The proposed rule allows delayed implementation, administration of intranasal midazolam using moderate sedation with enteral agent permit authorization, clarifies administration of intranasal drugs, requires moderate sedation with parenteral agents permit for patients over age 12, includes education and training requirements and BLS and Pediatric Advanced Life Support (PALS) requirement to obtain and maintain BLS and PALS certification, and establishes a continuing education requirement.

The commission anticipates additional costs to comply with this proposed rule for dentists who sedate pediatric patients. Not all dentists administer sedation nor do all dentists sedate pediatric patients. Pediatric dentists who are specialists obtain additional education and training as part of their national specialty certification provided in the proposed rule. The proposed rule is consistent with the American Academy of Pediatric Dentistry guidelines. The commission assumes most, if not all, dentists providing pediatric sedation already meet these standards. It is proposed that dentists without pediatric specialty training must complete an additional 14 hours in pediatric sedation education. Costs for this education range from $1500 to $250523.

The commission anticipates potential costs for adding 14 hours of continuing education every three years for a dentist who obtains the pediatric endorsement. The commission anticipates that the cost for complying to the proposed additional continuing education is $48324 every three years. Several acceptable ways to complete continuing education are proposed in new WAC 246-817-773 and can be achieved at no cost; therefore, the commission believes that there are no additional costs for a dentist to comply with this rule.

WAC 246-817-770 General anesthesia and deep sedation: The existing rule establishes deep sedation and general anesthesia standards that must be met before administering. The proposed rule amendments include the following:

There are no costs for clarifying language and terms, listing prohibited drugs, adding the patient evaluation requirement, clarifying monitoring requirements, updating examples of emergency drugs, clarifying ACLS certification, adding authorization for lower-level sedation administration, updating AED requirements, and moving continuing education requirements to new section.

The costs to have equipment calibrated, adding requirements for operating theater, table or chair, lighting system requirements, and additional emergency drugs is provided in the WAC 246-817-760 analysis.

The commission anticipates no new additional cost to the proposed addition of ACLS or PALS emergency drugs, as the existing standard of care includes ensuring the office is prepared for an emergency.

The cost for requiring a written contract when providing sedation in another practitioner's dental office is provided in the WAC 246-817-760 analysis.

The commission anticipates an additional cost of one additional assistant when administering anesthesia. Based on the Bureau of Labor Statistics, the hourly wage for a dentist is $79 and $19 an hour for a dental assistant. An average sedation procedure is one hour; the anticipated additional cost is $19 per sedation procedure.

The cost to increase respiratory recording from every 15 minutes to every five minutes is provided in the WAC 246-817-760 analysis.

WAC 246-817-772 Requirements for anesthesia monitor: The existing rule provides anesthesia monitor training requirements and identifies when a licensed dentist administering anesthesia must also have an additional appropriately trained individual monitoring the patient. The proposed rule amendments include:

The commission anticipates a cost to obtain additional anesthesia monitoring. Anesthesia monitoring education and training can be obtained through an education course or in-office training by the dentist. An education course provided through American Association of Oral and Maxillofacial Surgeon Dental Anesthesia Assistant National Certification Examination costs $54525. In-office training is estimated to cost $1372 based on the average hourly wage for a dentist at $7926 and dental assistant at $1927 for 14 hours each.

New WAC 246-817-773 Continuing education for dentists administering sedation: The proposed new section consolidates all sedation permit continuing education requirements into one section, provides for content of continuing education, methods to complete continuing education, and allows delayed implementation to comply with new requirements.

The commission anticipates additional costs for the proposed continuing education change from every five years to every three years. Costs to comply with this section are provided in the WAC 246-817-740, 246-817-760, and 246-817-765 analyses. The commission concludes that there is no additional cost to consolidate continuing education requirements into one section.

WAC 246-817-774 Permitting and renewal requirements: The existing rule identifies the requirements to receive and renew a permit to administer moderate oral or parenteral or general anesthesia, including deep sedation. The proposed rule amendments include the following:

The cost to obtain the pediatric endorsement is provided in the WAC 246-817-765 analysis. There is no additional cost to clarification of the rule requirements. The commission does anticipate potential additional cost for a dentist to obtain on-site inspections, conduct emergency drills, and to maintain site visit and drill documentation. The commission anticipates that average staff participating in on-site inspections and drills include one dentist and two dental assistants. Salaries based on the Bureau of Labor Statistics are:

The commission anticipates that the average on-site inspection takes four hours. Nationally certified oral and maxillofacial surgeons are currently required to have an on-site inspection every five years to maintain their professional certification by the American Association of Oral and Maxillofacial Surgeons30. The commission anticipates no additional increased cost for certified oral and maxillofacial surgeons, as under current rule, they already comply with the proposed rule. Other dentists providing anesthesia may conduct peer on-site inspections at no cost or choose to obtain on-site inspections through the authorized organizations at a cost of $0 - $50031. In addition to on-site inspection costs, it is anticipated that potential staff time for on-site inspections is for one dentist and two dental assistants. Onsite inspections are required once every five years; annual recurring costs for inspection and staff time range from $93.60 to $193.60.

A standard emergency drill may take up to 15 minutes per drill. The proposed rule now requires 24 drills annually. At 15 minutes per drill, a total of six hours of dental staff time could be expected annually. Staff time is for one dentist and two dental assistants. The anticipated costs to comply with the proposed rule is $702 annually.

The commission anticipates an additional cost to document and maintain on-site and emergency drill information. The commission estimates two hours per year for an office administrator to document and maintain information. The salary based on the Bureau of Labor Statistics for Office Administrator is $4832 hourly wage. The anticipated cost to comply with the proposed rule is $96 annually.

New WAC 246-817-775 On-site inspections: The proposed new section consolidates self- and on-site inspections into one section with the following:

The commission anticipates additional costs for dentists to self-assess their office for emergency preparedness. The commission anticipates that an annual assessment will take 30-60 minutes annually and the cost range is $29.50 to $79 for a dentist33. The commission does not anticipate any additional costs for a dentist who holds a moderate sedation with parenteral agents or general anesthesia permit, as it is assumed that they also hold a dentist license and must complete the annual self-assessment under the proposed rule. The commission does not anticipate any additional cost to use the commission-approved form.

Onsite inspection costs are provided in the WAC 246-817-774 analysis.

WAC 246-817-776 Discharge criteria: The existing rule requires licensed dentists to follow specific discharge criteria after administering sedation. The proposed rule amendment adds two exceptions when taking vital signs is not required. There is no cost to comply with this rule amendment.

WAC 246-817-780 Mandatory reporting: The existing rule requires a licensed dentist without a general anesthesia permit, to establish a contract outlining responsibilities of other providers administering anesthesia in a dental office. The proposed rule amendments update the section title from nondental to nondentist and creates specific requirements and responsibilities for written contract requirements that include:

The commission does not anticipate any new costs to comply with the proposed rule amendments. A written contract is a current requirement under rule. The proposed rule amendments create and clarify specific written contract content requirements.

WAC 246-817-780 Mandatory reporting: The existing rule identifies mandatory reporting requirements for licensed dental providers. The proposed rule amendment adds hospital discharge records, if available, to be submitted.

The commission anticipates a negligible cost for a dentist to comply with this proposed rule amendment. The commission anticipates that it takes an average of five minutes for a dentist to request and obtain hospital records prior to submitting a report to the commission and, for this reason, the commission anticipates the cost to comply with the proposed rule to be negligible.

WAC 246-817-790 Application of chapter 18.130 RCW: The existing rule applies chapter 18.130 RCW for sedation permits. The proposed rule amendment adds issuance and renewal of the proposed pediatric endorsement to authority under chapter 18.130 RCW.

The commission anticipates there is no additional cost for a dentist to comply with this proposed rule amendment because chapter 18.130 RCW applies to all credentialed health care practitioners.

Summary: The commission anticipates the probable cost estimate for a dentist to comply with the proposed rule changes in WAC 246-817-701 through 246-817-790 is between $0 to $9,277 one-time cost and $0 to $1,408.60 annually.

Analysis of whether the proposed rule may impose more-than-minor costs on businesses in the industry: The commission has determined that $0 to $9,277 one-time cost and $0 to $1,408.60 annual cost for the proposed rules will exceed minor economic impact of $3,415 for dentist offices. Costs associated with sedating patients and responding to emergencies range significantly because not all sedation cases or emergencies are the same. Specific levels of education depend on level of sedation being performed; a variety of monitoring and emergency equipment and drugs are necessary to ensure the dentist is prepared for any emergency.

Rule making supports the overarching goal of chapter 18.32 RCW by assuring dentists, anesthesia providers, and patients that dentists are adequately trained, complying with nationally accepted standards of practice, and prepared to respond to emergencies during administration of anesthetics, confirming that the public policy goals of the dental commission are achieved.

Determination of whether the proposed rule may have a disproportionate impact on small businesses as compared to the 10 percent of businesses that are the largest businesses required to comply with the proposed rule: The proposed rule may have a disproportionate impact on small businesses versus large businesses. Whether a licensed dentist is practicing in an independent practice setting or is part of a larger group or clinic, the administration of anesthetic agent requirements applies to wherever anesthetic agents for dentistry are administered in the state of Washington.

Licensed dentists work in many settings: independent practice, partnerships, group practices, community clinics, general dental clinics, and universities. There are approximately 7,200 licensed dentists as of April 2022. We are unable to determine how many licensed dentists work in each of the different practice settings. Dentists in independent practice or partnerships will incur all the costs to comply with the proposed rules. Dentists that are part of larger group practices will be able to share in the costs to comply with the proposed rules. Dentists that work for community clinics, general dental clinics, or universities will most likely incur minimal, if any, costs to comply with the proposed rules. As business models differ, so does the expectation of who will cover the costs to comply with the proposed rules. Ultimately, the licensed dentist needs to ensure all requirements have been met where anesthetic agents for dentistry are administered in the state of Washington.

If the proposed rule has a disproportionate impact on small businesses, the steps taken to reduce the costs of the rule on small businesses. If the costs can not be reduced, provide a clear explanation of why: Although the proposed rule may have a disproportionate impact on small businesses versus large businesses, the commission determined to delay implementation of pediatric endorsement, continuing education changes, and on-site inspections in proposed rules WAC 246-817-765, 246-817-773, and 246-817-775 to help reduce the first-year cost impact of the proposed rules.

Description of how small businesses were involved in the development of the proposed rule: The commission worked closely with interested parties and other constituents to minimize the burden of this proposed rule. The commission held open public meetings from December 2017 through February 2022, allowing interested parties, including the Washington State Dental Association, Washington State Society of Oral and Maxillofacial Surgeons, and Washington State Society of Mobile Dental Anesthesia, to provide suggested rule changes and comments. During open public rules meetings, alternative versions of the rules were discussed. After careful consideration, some of the suggested changes were accepted while others were rejected. Mutual interests were identified and considered through deliberations.

The commission's public participation process encouraged interested individuals to:

The proposed rule amendments went through several stages of edits, review, and discussion and then further refinement before arriving at the final proposal. The results of this process are proposed changes that will provide increased rule clarity, guidance, and will ultimately be less burdensome than the original rule.

The estimated number of jobs that will be created or lost as the result of compliance with the proposed rule: The commission does not anticipate any jobs created or lost because of compliance with the proposed rule.

A copy of the statement may be obtained by contacting Amber Freeberg, P.O. Box 47852, Olympia, WA 98504-7852, phone 360-236-4893, fax 360-236-2901, TTY 711, email Dental@doh.wa.gov.

November 10, 2022

Lyle McClellan, DDS, Chairperson

Dental Quality Assurance Commission

OTS-3080.4