Notice of Request for Information on the Department of Veterans Affairs Dental Hygienist Standard of Practice

SUPPLEMENTARY INFORMATION:

Authority

Chapters 73 and 74 of 38 U.S.C. and 38 U.S.C. 303 authorize the Secretary to regulate VA health care professions to make certain that VA's health care system provides safe and effective health care by qualified health care professionals to ensure the well-being of those Veterans who have borne the battle.

On November 12, 2020, VA published an interim final rule confirming that VA health care professionals may practice their health care profession consistent with the scope and requirements of their VA employment, notwithstanding any State license, registration, certification, or other requirements that unduly interfere with their practice. 38 CFR 17.419; 85 FR 71838. Specifically, this rulemaking confirmed VA's current practice of permitting VA health care professionals to deliver health care services in a State other than the health care professional's State of licensure, registration, certification, or other requirement, and thereby, enhancing beneficiaries' access to critical VA health care services. The rulemaking also confirmed VA's authority to establish national standards of practice for its health care professionals, which would standardize a health care professional's practice in all VA medical facilities, regardless of conflicting State laws, rules, regulations, or other requirements.

The rulemaking explained that a national standard of practice describes the tasks and duties that a VA health care professional practicing in the health care profession may perform and may be permitted to undertake. Having a national standard of practice means that individuals from the same VA health care profession may perform the same type of tasks and duties regardless of the State where they are located or the State license, registration, certification, or other requirement they hold. We emphasized in the rulemaking and reiterate here that VA will determine, on an individual basis, that a health care professional has the proper education, training, and skills to perform the tasks and duties detailed in the national standard of practice, and that they will only be able to perform such tasks and duties after they have been incorporated into the individual's privileges, scope of practice, or functional statement. The rulemaking explicitly did not create any such national standards and directed that all national standards of practice would be subsequently created through policy.

Preemption of State Requirements

The national standard of practice will preempt any State laws, rules, regulations, or other requirements that are both listed and unlisted in the national standard as conflicting, but that do conflict with the tasks and duties as authorized in VA's national standard of practice. The term State, as applied here, means each of the several States, territories, and possessions of the United States and is consistent with the definition in 38 U.S.C. 101(20). If a State changes their requirements and places new limitations on the tasks and duties it permits in a manner that would be inconsistent with what is authorized under the national standard of practice, the national standard of practice will preempt such limitations and authorize the VA health care professional to continue to practice consistent with the tasks and duties outlined in the national standard of practice.

In cases where a VA health care professional's license, registration, certification, or other requirement permits a practice that is not included in a national standard of practice, the individual may continue that practice so long as it is permissible under Federal law and VA policy; is not explicitly restricted by the national standard of practice; and is approved by the VA medical facility.

Need for National Standards of Practice

It is critical that VA, the Nation's largest integrated health care system, develop national standards of practice to ensure, first, that beneficiaries receive the same high-quality care regardless of where they enter the system and, second, that VA health care professionals can efficiently meet the needs of beneficiaries when practicing within the scope of their VA employment. National standards are designed to increase beneficiaries' access to safe and effective health care; thereby, improving health outcomes. The importance of this initiative has been underscored by the Coronavirus Disease 2019 (COVID-19) pandemic. The increased need for mobility in VA's workforce, including through VA's Disaster Emergency Medical Personnel System, highlighted the importance of creating uniform national standards of practice to better support VA health care professionals who practice across State lines. Creating national standards of practice also promotes interoperability of medical data between VA and the Department of Defense (DoD), providing a complete picture of a Veteran's health information and improving VA's delivery of health care to the Nation's Veterans. DoD has historically standardized practice for certain health care professionals, and VA has closely partnered with DoD to learn from their experience.

Process To Develop National Standards of Practice

As authorized by 38 CFR 17.419, VA is developing national standards of practice through policy. The overarching directive to describe Veterans Health Administration (VHA) policy on national standards of practice is VHA Directive 1900(3), VA National Standards of Practice, August 30, 2023. The directive is accessible on VHA's publications website at https://www.va.gov/vhapublications. As each individual national standard of practice is finalized, it is published as an appendix to the directive and is accessible at the same website.

To develop these national standards, VA is using a robust, interactive process that adheres to the requirements of Executive Order (E.O.) 13132, Federalism, to preempt conflicting State laws, rules, regulations, or other requirements. For each health care occupation, a workgroup comprised of VA health care professionals in the identified occupation conducts research to identify internal best practices that may not be authorized under every State license, certification, or registration, but would enhance the practice and efficiency of the profession throughout VA. If a best practice is identified that is not currently authorized by every State, the workgroup determines what education, training, and skills are required to perform such tasks and duties. The workgroup then drafts a proposed VA national standard of practice using the data gathered and any internal stakeholder feedback received. The workgroup may consult with internal or external stakeholders at any point throughout the process.

The process to develop VA national standards of practice includes listening sessions for members of the public, professional associations, and VA employees to provide comments on the variance between State practice acts for specific occupations and what should be included in the national standard of practice for that occupation. The listening session for dental hygienists was held on September 7, 2023. No comments were provided on the dental hygienists standard of practice.

After the proposed standard is developed, it is first internally reviewed. This includes a review from an interdisciplinary VA workgroup consisting of representatives from the following offices: Quality Management, VA medical facility Chief of Staff, Academic Affiliates, Veterans Integrated Services Network (VISN) Chief Nursing Officer, Ethics, Workforce Management and Consulting, Surgery, Credentialing and Privileging, VISN Chief Medical Officer, and Electronic Health Record Modernization.

After the internal review, VA provides the proposed national standard of practice to our DoD partners as an opportunity to flag inconsistencies with DoD standards. VA also engages with labor partners informally as part of a pre-decisional collaboration. Consistent with E.O. 13132, VA sends a letter to each State board and certifying organization or registration organization, as appropriate, which includes the proposed national standard and offers the recipient an opportunity to discuss the national standard with VA. After the State boards, certifying organizations, or registration organizations have received notification, the proposed national standard of practice is posted in the Federal Register for 60 days to obtain feedback from the public, professional associations, and any other interested parties. At the same time, the proposed national standard is posted to an internal VA site to obtain feedback from VA employees. Responses received through all vehicles—from State boards, professional associations, unions, VA employees, and any other individual or organization that provides comments through the Federal Register —will be reviewed. VA will make appropriate revisions in light of the comments, including those that present evidence-based practices and alternatives that help VA meet our mission and goals. VA will publish a collective response to all comments at https://www.va.gov/standardsofpractice/.

The national standard of practice is then finalized, approved, and published in VHA policy. Any tasks or duties included in the national standard will be properly incorporated into individual VA health care professionals' privileges, scope of practice, or functional statement once it has been determined by their VA medical facility that the individual has the proper education, training, and skills to perform the task or duty. The implementation of the national standard of practice may be phased in across all VA medical facilities, with limited exemptions for health care professionals as needed.

Format for the Proposed National Standard for Dental Hygienist

The format for the proposed national standards of practice when there are State licenses is as follows. The first paragraph provides general information about the profession and what the VA health care professionals can do. For this national standard, Dental Hygienists perform oral prophylaxis and other therapeutic or preventive procedures for periodontal disease, caries control, or other dental problems. We reiterate that the proposed standard of practice does not contain an exhaustive list of every task and duty that each VA health care professional can perform. Rather, it is designed to highlight generally what tasks and duties the health care professionals perform and how they practice within VA.

The second paragraph references the education and license, or other requirement, needed to practice this profession at VA. Qualification Standards for employment of health care professionals by VA are available at: https://www.va.gov/OHRM/QualificationStandards/. VA follows the requirements outlined in its qualification standards even if the requirements conflict with or differ from a State requirement. The national standards of practice do not affect those requirements. For dental hygienists, VA requires an active, current, full, and unrestricted State license, and that the dental hygienists meet credentialing standards in 42 CFR part 75, Standards for the Accreditation of Educational Programs for the Credentialing of Radiologic Personnel. The dental hygienists VA qualification standards are available at: https://www.va.gov/OHRM/QualificationStandards/HT38/0682-DentalHygienist.pdf.

The second paragraph also notes whether the national standard of practice explicitly excludes individuals who practice under “grandfathering” provisions. Qualification standards may include provisions to permit employees who met all the requirements prior to revisions of the qualification standards to maintain employment at VA even if they no longer meet the new qualification standards. This practice is referred to as grandfathering. VA dental hygienists have grandfathering provisions included within their qualification standards, and VA proposes to have those individuals authorized to follow the dental hygienists national standard of practice. Therefore, there would be no notation regarding grandfathered employees in the national standard of practice as they would be required to adhere to the same standard as would any other VA dental hygienist who meets the current qualification standards.

The third paragraph establishes what the national standard of practice will be for the occupation in VA. It includes whether the professional can practice all duties covered by their license. For dental hygienists, VA proposes that VA dental hygienists can practice all duties covered by their license and the credentialing standards. VA reviewed State laws and practice acts for dental hygienists in March 2024 and did not identify any conflicts that impact practice of this profession in VA.

This national standard of practice does not address training because it will not authorize VA dental hygienists to perform any tasks or duties not already authorized under their State license or certification.

Following public and VA employee comments and revisions, each national standard of practice that is published in policy will also include the date for recertification of the standard of practice and a point of contact for questions or concerns.

Proposed National Standard of Practice for Dental Hygienists

Note:

All references herein to VA and VHA documents incorporate by reference subsequent VA and VHA documents on the same or similar subject matter.

1. Dental hygienists perform oral prophylaxis and other therapeutic or preventive procedures for periodontal disease, caries control, or other dental problems.

2. Dental Hygienists in the Department of Veterans Affairs (VA) possess the education, license, and certification required by VA qualification standards, available at: https://www.va.gov/OHRM/QualificationStandards/HT38/0682-dentalhygienist.pdf.

3. VA Dental Hygienists can practice all duties covered by their license, and practice in accordance with the credentialing standards in 42 CFR part 75, Standards for the Accreditation of Educational Programs for the Credentialing of Radiologic Personnel, available at: https://www.ecfr.gov/. VA reviewed State laws and practice acts for Dental Hygienists in March 2024 and did not identify any conflicts that impact practice of this profession in VA.

Request for Information

1. Is VA's assessment of what your State permits and prohibits accurate?

2. Are there any areas of variance between State licenses, certification, registration, or other requirement that VA should preempt that are not listed?

3. Is there anything else you would like to share with us about this VA national standard of practice?

Signing Authority

Denis McDonough, Secretary of Veterans Affairs, approved and signed this document on October 22, 2024, and authorized the undersigned to sign and submit the document to the Office of the Federal Register for publication electronically as an official document of the Department of Veterans Affairs.

[FR Doc. 2024-25894 Filed 11-6-24; 8:45 am]

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