text:
January 22, 1993
Members of the Arizona Legislature
The Honorable Fife Symington, Governor
Dr. Ronald J. Peterson, D. D. S., President
Arizona State Board of Dental Examiners
Transmitted herewith is a report of the Auditor General, A Performance
Audit of the Arizona State Board of Dental Examiners. This report is in
response to the provisions of Laws 1990, Chapter 218, Section 22, which
directs the Auditor General to evaluate the performance of the Board in
handling consumer complaints.
In 1979 the State Board of Dental Examiners was one of the f i r s t health
licensing boards audited under the State's Sunset Laws. This report now
represents our fourth audit of the Dental Board. From our f i r s t ' audit we
have reported on the need for the Board to better protect the public
through i t s handling of complaints against licensees. Although the years
have brought changes in Board members, Board s t a f f and some Board
statutes, today we s t i l l find the Board can s i g n i f i c a n t l y improve i t s
complaint handling and disciplinary processes. Only now, the problems
are compounded by a large backlog of complaints which has developed in
the past two years.
My s t a f f and I w i l l be pleased to discuss or c l a r i f y items in the report.
This report w i l l be released to the public on January 25, 1993.
DRN : l mn
Enc .
2910 NORTH 44TH STREET 1 SUITE 410 . PHOENIX, ARIZONA 85018 l( 602) 553- 0333 FAX ( 602) 553- 0051
The Office of the Auditor General has conducted a limited scope
performance audit of the Arizona State Board of Dental Examiners, under
the provisions of Laws 1990, Chapter 218, Section 22, which authorizes
the review and specifically directs the Auditor General to evaluate the
performance of the Board in handling consumer complaints. This is the
fourth performance audit of the Board conducted by the Auditor General.
The Arizona State Board of Dental Examiners is responsible for regulating
the practice of dentistry in the State. The Board, comprised of 11
members, licenses approximately 2,600 dentists, 1,500 hygienists, and 14
c e r t i f i e d denturists. The Board's operations are supported by 90 percent
of the licensing fees i t collects.
The purpose of the Board is to protect the public against unqualified
practitioners. In each of the three previous audit reports, we found
that the Board had not taken appropriate disciplinary actions or
adequately handled consumer complaints in i t s regulation of licensees.
In 1990, the Legislature mandated this special audit to determine the
adequacy of the Board's handling of consumer complaints.
The Board Has An Overwhelming
Backloa of Complaints That Will
Require Additional Measures to Address
( see pages 5 through 14)
Due to excessive delays in hand l ing complaint cases, the Board has
accumulated a backlog of over 300 cases, which seriously affects i t s
a b i l i t y to resolve complaints in a timely manner. For example, a
complaint f i l e d today w i l l not likely be resolved for one and one- half
years. This backlog has been increasing since 1990, when several events
slowed the complaint handling process enough to create an accumulation of
cases. To handle this backlog, the Board should take aggressive
measures, including temporarily hiring additional staff and seeking
additional funding.
The Board Should Improve Its
Com~ laint lnvestiaation Process
( see pages 15 through 20)
The Board's use of committees to investigate complaint cases results in
fragmented and incomplete investigations that are poorly perceived by
both complainants and licensees. Although a 1989 statutory change
eliminated the Board's specific a b i l i t y to use investigative committees
and authorized the use of investigators to investigate complaints, the
Board continues to rely on investigative committees. The Board should
eliminate the investigative interview committee and u t i l i z e a staff
investigator, similar to several other healthcare regulatory boards in
Arizona. U t i l i z i n g staff investigators could improve the quality of the
investigations, improve the perceptions of both complainants and
licensees, ensure e f f i c i e n t use of investigative resources, and increase
the Board's access to further information about cases.
The Board Needs To Take Steps To
Address Problem Dentists and lm~ rove
Its Manner of Deliberatins Complaint Cases
( see pages 21 through 25)
Although the Board has statutory authority to take disciplinary actions
against licensees who repeatedly violate the statutes, i t is reluctant to
take action against repeat offenders. For example, while most licensees
do not receive even a single complaint each year, we identified 14
dentists who had received as many as 20 complaints and seven disciplinary
actions in the last seven years; however, the Board has i n i t i a t e d an
e f f o r t to remove the license of only one of these 14 dentists. The
Board's failure to adequately track violations and take disciplinary
actions may contribute to i t s reluctance to act against repeat
There are also problems with the manner in which the Board reaches
decisions on cases. Two recent court rulings raised serious questions
about the process the Board follows when deliberating complaint cases.
In both cases, the courts concluded that the Board lacked substantial
evidence to amend i t s investigative committees' findings and conclusions
and, therefore, the courts reversed the disciplinary action ordered by
the Board.
Current Reauirements Discouraae
Complaint Filin
( see pages 27 & rough 28)
The Board requires that persons f i l e a " verified" complaint on the
Board's complaint form, which must be notarized and accompanied by an
author izat ion for release of records. These requi rements are burdensome
and may discourage the f i l i n g of complaints. The Legislature should
consider removing the statutory requirement for complaint verification,
and the Board should discontinue the requirement for the authorization
for release of records.
lNTRODUCTlON AND B A C K 0. . . . . . . . . . . . . . . .
F l NO l NG I : ME BOARD HAS AN OVERWHELM I NG
BACKLOG OF COUPLAl NTS MAT W l LL
Backlog of Complaint Cases i s Seriously Impacting Complaint Handling . . . . . . . .
Several Factors Have Contributed
to the Growing Backlog . . . . . . . . . . . . . . . .
Changes Are Needed
toHandleBacklog . . . . . . . . . . . . . . . . . . .
Recommendations . . . . . . . . . . . . . . . . . . . .
Limitations of
Current Process . . . . . . . . . . . . . . . . . . . .
Revising the Process Could Ensure
Comp l ete l nvest i gat ions and lmprove
Public Perceptions . . . . . . . . . . . . . . . . . .
Recommendation . . . . . . . . . . . . . . . . . . . .
FINDING I l l : ME B O W NEEDS TO TAKE STEPS
Board Needs to
Increase Efforts Against
Repeat Violators . . . . . . . . . . . . . . . . . . .
Board Needs to Improve
Deliberation Procedures . . . . . . . . . . . . . . . .
Recommendations . . . . . . . . . . . . . . . . . . . .
F i l i n g Requirements
AreBurdensome . . . . . . . . . . . . . . . . . . . .
Other Medical Boards
Do Not Have Similar Requirements . . . . . . . . . . .
Recommendations . . . . . . . . . . . . . . . . . . . .
Table 1 Board of Dental Examiners
Statement of FTEs and Actual and
Budgeted Expenditures
F( uisncaauld iYteeda) r s .19.90.- 9.1,. 1.99.1-. 92., . an. d .19.92.- 9.3 . .
I Table 2 Complaint Resolution Timeliness
of Sample Complaints Received
by the Board
July 1988 through June 1992
Closed Cases. . . . . . . . . . . . . . . . .
Table 3 Act ion Taken Aga i nst Repeat Of fenders
For Complaints Received
January 1986 through August 1992. . . . . . .
The Office of the Auditor General has conducted a performance audit of
the Arizona State Board of Dental Examiners, under the provisions of
Laws 1990, Chapter 218, Section 22, which authorizes the review and
specifically directs the Auditor General to evaluate the performance of
the Board in handling consumer complaints. This is the fourth
performance audit of the Board conducted by the Auditor General.
The Board is responsible for regulating the practice of dentistry in the
State. The Board consists of eleven members: six licensed dentists, two
licensed dental hygienists, and three laypersons. The Board licenses
approximately 2,600 dentists and 1,500 hygienists, and c e r t i f i e s 14
denturists. The Board also conducts investigations, hearings, and
proceedings concerning violations, and disciplines violators. During
fiscal year 1991- 92, the Board received 239 complaints.
The Role of the Board
Traditionally, the role of the Dental Board is to protect the public.
Over 50 years ago, the Arizona Supreme Court stated:
The purpose and the only j u s t i f i c a t i o n of the various statutes
regulating the practice of medicine in i t s different branches is
to protect the public against those who are not properly
qualified to engage in the healing art .... ( Battv v. Arizona
State Dental Board, 57 Ariz. 239, 254, 112 P. 2d 870 ( 1941) ).
However, over the past 13 years, our audits have repeatedly found the
Board needs to be more effective in f u l f i l l i n g i t s role.
The Board is statutorily empowered to protect the public in two ways:
through licensing those qualified to practice dentistry and regulating
the conduct of licensees. However, in , each of the three previous
performance audits, we found that the Board was not taking appropriate
disciplinary actions or adequately handling consumer complaints in order
to regulate licensees.
In the 1979 Sunset audit and a 1981 follow- up audit, we found that the
Board had not f u l f i l led i t s mandate to protect the pub1 ic against
incompetent dental practitioners. Again in 1987, we found that the Board
continued to have problems in responding to consumer complaints and
regulating licensees. In 1990, the Legislature mandated that we perform
this special audit to determine the adequacy of the Board's handling of
consumer complaints. As with the previous audits, we found the Board
s t i l l needs to improve how i t addresses consumer complaints.
Staffina and Budaet
For fiscal year 1991- 92, the Board was authorized eight full- time
equivalent ( FTE) positions ( see Table 1). The Board staff includes an
Executive Director, an enforcement manager, an administrative o f f i c e r , an
investigator ( dentist), an administrative secretary, and clerk typists.
The Board recently added an administrative assistant position. Also, a
half- time legal assistant position has been approved and w i l l be f i l l e d
in January 1993.
The operations of the Board are supported by 90 percent of the licensing
fees i t collects, which are deposited into the Dental Board Fund. The
remaining 10 percent of these fees are remitted to the State General
Fund. Board expend i tures i ncreased from $ 346,108 i n 1990- 91 to $ 386,756
in 1991- 92. The Board has been appropriated $ 467,300 for fiscal year
1992- 93.
STATEMENT OF FTEs AND ACTUAL AND BUDGETED EXPENDITURES
( unaud i t ed )
FTE Positions
Personal Services
Emp l oyee Re l at ed
Professional and Outside Services
Travel, In- State
Travel, Out- of- State
Equ i pmen t
Other Operating
1990- 91
( actual 1
1991- 92
( actual 1
( a) Amount includes $ 40.000 f o r the Impaired Dentist Program.
Source: Arizona Financial Information System reports for Fiscal. Years
Ended June 30, 1991 and 1992, and the State of Arizona
Appropriations Report for Fiscal Year 1992- 93.
Audit S a x e
The scope of our audit is defined by Session Laws 1990, Chapter 218,
Section 22:
No sooner than eighteen months after the effective date of this
act, the auditor general shall conduct a performance audit of
the state board of dental examiners to determine the adequacy of
the board's handling of consumer complaints.
In response to this directive, we present findings in each of the
following four areas:
The Board's timeliness in handling consumer complaints
The adequacy of the complaint investigations process
Theadequacy of disciplinaryactions
Whether changes are needed to the requirements for f i l i n g complaints
To further assist us in our review of the complaint handling process, we
u t i l i z e d a panel of three retired dentists. Each of these dentists, who
volunteered their assistance, has over 20 years' dental experience in
private practice. The panel's work i s presented in Finding II.
This audit was conducted in accordance with government auditing standards.
The Auditor General and staff express appreciation to the Board of Dental
Examiners and i t s staff for their cooperation and assistance throughout
the audit.
On September 4, 1990, a woman f i l e d a complaint against a
dentist alleging that he had pulled several of her teeth without
her permission. The Board staff notified her in a September 17,
1990, letter that she needed to provide additional information.
She returned the requested information 8 days later. The Board
staff did not request her records from the dentist u n t i l April
15, 1992, over 18 months later. On October 9, 1992, over two
years after the complaint had been received, the Board voted to
dismiss the woman's complaint.
The Board's excessive delay in handling this case is not an isolated
incident. Complaint handling is currently so backlogged that unless
changes are made, a complaint f i l e d today w i l l not l i k e l y be resolved for
one and one- half years. This backlog of complaints has been increasing
since 1990, when several events slowed the complaint handling process
enough to cause a large accumulation of cases. Although the Board is
making attempts to improve complaint handling, more aggressive measures
are needed to address the backlog.
Backloa of Complaint Cases
Is Seriouslv lmpactina Com~ laint Handling
The backlog of complaints is seriously impacting the Board's complaint
handling process. Since 1990, the Board has failed to resolve most
complaints in a timely manner. The cases have become so backlogged that,
at the current rate, the backlog w i l l take years to eliminate.
ColnDlaint handlina untimely - The Board has not resolved most complaints
in a timely manner. We reviewed a sample of 150 complaints received by
the Board between July 1988 and June 1992.(') Of the 150 complaints we
( 1) We randomly selected 30 cases received by the Board i n each of the l a s t f i v e years f o r
review. A l l 1988 cases reviewed were received a f t e r July 1, 1988, and a l l 1992 cases
were received p r i o r t o July 1, 1992. A l l case examples, including the one above, were
derived from t h i s sample.
reviewed, 93 had been closed and 57 were s t i l l open. As shown in Table
2, the closed cases took up to 18 months to resolve. In addition, 12 of
the 57 open cases had been open more than one year. Further, as of July
1992, none of the 1992 cases we reviewed had been heard by the Board.
JULY 1988 THROUGH June 1992ta)
Total Time Required
To Resolve k l a i n t ( b )
Less than 150 days
150 days to 6 months
6 to 9 months
9 to 12 months
12 to 18 months
Total Number of Closed Cases
Number of Closed Cornplaint Cases( c)
- 1988 1989 - 1990 1991
7 16 4 0
8 7 6 0
14 6 6 0
0 0 6 0
- 1 - 0 - 6 - 6
-- 30 -- 29 - 28 - 6
( a) None of the 1992 cases i n our f i l e review were closed on the date the case was
( b) This time i s measured from the date the complaint was received by the Board to the
date of the Board meeting i n which the Board issued i t s findings i n the case.
( c) A case was considered closed when the Board issued i t s findings on the case.
Source: Auditor General staff review of complaint f i l e s conducted during
July 1992.
Because of the delays in resolving complaints, the Board has failed to
meet statutory requirements for complaint handling. Arizona Revised
Statute $ 32- 1263.02 requires that the Board issue i t s findings on a
complaint within 150 days of the i n i t i a t i o n of an investigation.(')
( 1) The investigator or informal interview o f f i c e r must investigate the charges and make
w r i t t e n recomnendations to the Board within 90 days. The Board then has 60 days to
issue i t s preliminary findings on the complaint.
Although the Board generally complied with the 150- day time l i m i t in
1989, it exceeded the statutory time l i m i t for most cases received in
1990 and 1991. Of the 28 cases received in 1990 in which the Board took
action, only 4 cases ( 14 percent), were resolved within 150 days. None
of the 1991 cases we sampled were resolved within the 150- day period.
The untimeliness of the Board's complaint handling process is also shown
by the f o l l ow i ng case examp l es :
Case 1 - On February 25, 1991, a patient f i l e d a complaint against a
dentist concerning the quality of care received. The patient was
evaluated by two dentists who reported their results to the Board on
March 28, 1991. A t the time of our f i le review, Board staff had not
completed their report on this evaluation, over 15 months after
receiving the results.
Case 2 - On January 4, 1991, a man f i led a complaint with the Board
involving the quality of his bridgework. The Board began to
investigate his complaint on December 5, 1991, 11 months later. On
January 21, 1992, the man was examined by two dentists as part of the
Board's investigation. However, his case was not heard by the Board
u n t i l June 5, 1992, almost one and one- half years, after he f i led the
Case 3 - On November 6, 1990, a woman f i led a comp la i n t aga i ns t a
dentist concerning a root canal that the dentist had allegedly done
four times. On December 17, 1990, she participated in a c l i n i c a l
evaluation in which two dentists examined her. Board staff prepared
a report on the evaluation 10 months later on October 15, 1991. The
Board voted to dismiss the woman's complaint on December 13, 1991,
over one year after she f i l e d the complaint.
Large backloa cannot be resolved in the near future - Under cur rent
conditions, the large backlog of complaint cases could take years to
resolve. As of December 31, 1992, the Board had 333 open cases . ( ' I The
backlog of over 300 cases is the equivalent of over one year's worth of
complaints ( the Board received 258 cases in 1992).
( 1 Open cases were defined as cases where no i n i t i a l Board a c t i o n had been taken. I f an
action had been taken, but the case was pending f u r t h e r Board a c t i o n , t h e case was not
included i n the back1 og f i g u r e s .
I f the Board hears 60 new cases per meeting ( 20 percent more than it is
currently handling)(') and receives a consistent number of new cases ( 20
per month), i t w i l l not be able to eliminate the backlog u n t i l June
1995. Further, hearing 60 cases per meeting on a regular basis w i l l be
challenging, since the Board's best performance in recent years was in
1989 when i t heard an average of 52 cases per Board meet i ng , rang i ng up
to 65 complaints at one meeting.
Several Factors Have
Contributed to the
Growina Backlog
After previous performance audits revealed problems in the Board's
complaint handling process, the Board appeared to be making improvements
in the process in 1989. However, in 1990, case handling became untimely
and the current backlog began to develop. Several events in 1990 may
have contributed to the Board's untimely complaint handling, including
settlement of a lawsuit, turnover i n s t a f f , lack of a complaint tracking
system, and the Board's slow response to a decreasing number of cases on
meeting agendas.
Improvements made followincl ~ revious report - A 1987 audit conducted by
our Office noted the following deficiencies in the timeliness of the
Board's complaint handling process:
Many complaints received by the Board required excessive time to
resolve and exceeded the statutory time limits.
The Board often did not obtain needed records or complete
investigative reports in a timely manner.
The Board did not have a complaint tracking system and could not
adequately monitor the status of i t s complaints.
( 1) The Board took i n i t i a l a c t i o n on 48 complaints i n August 1992, 63 complaints i n
October 1992, and 34 complaints i n December 1992, f o r an average of 49 cases per Board
In response to our 1987 report, the Board made some improvements in i t s
complaint handling process. One of these improvements was a complaint
tracking system, which began tracking complaints received in July 1988.
In addition, the Board was able to handle cases in a more expedient
manner. In our sample, 16 of the 30 cases from 1989 were resolved in
less than 150 days, which is more than double the 7 cases in 1988.
Untimely case handl ina beaan in 1990 - Although the Board's t imel iness in
handling complaint cases improved in 1989, i t slowed significantly in
1990. As shown in Table 2, page 6, the number of 1990 cases resolved in
less than 150 days declined to four. Also, the amount of time for
handl ing 1990 cases increased over the amount of time for handl ing 1989
cases. For example, our review indicated that 14 of the 1990 cases were
unresolved for more than 9 months compared with only one case in 1989.
As resolution of these cases extended into 1991, the cases received in
1991 became backlogged to the point where none of the closed 1991 cases
we reviewed were resolved in less than 12 months.(')
Several factors may have contributed to untimeliness - Several events
beginning in 1990 contributed to the excessive untimeliness of complaint
cases previously described. One significant event in 1990 was the
settlement of a lawsuit brought against the Board by the Arizona State
Dental Association ( ASDA). Evidence presented by ASDA indicates one of
the primary objectives of the lawsuit was to have the Board remove i t s
Chief Investigator, who had been with the Board 10 years, c i t i n g bias
against i t s members. Although the o f f i c i a l settlement of the lawsuit did
not stipulate his removal, according to the former Chief Investigator, he
resigned from his position based, in part, on the pressure generated by
the ASDA l awsu i t . ( 2)
( 1) At the time of our review, 15 of the 1991 cases remained open; these cases had been
pending from 6 to 12 months.
( 2) The former Chief Investigator also a t t r i b u t e d his resignation to an investigation by
the Department of Admini stration, i n i t i a t e d imnediatel y a f t e r the lawsuit settlement,
which encompassed several allegations s i m i l a r to those made by ASDA i n i t s lawsuit.
The investigation f a i l e d to substantiate these allegations.
The resignation of the Chief lnvestigator was only the beginning of
turnover in management and investigative s t a f f , which contributed to the
delays in complaint processing. Disruptions caused by the following
changes also impacted timeliness:
8 The Board has had three different Executive Directors since 1990.
The Chief lnvestigator position was vacant for eight months. During
this time, the Executive Director f i l l e d in and the complaint
handling process slowed further. Later, the Chief lnvestigator
position was converted to an administrative position f i l l e d by a
layperson, rather than a dentist.
8 The Board has had three different investigators in the last two
In 1990, the Board abandoned i t s computerized complaint tracking system
and has had no method for tracking complaints since that time.(')
Without a tracking system, the Board does not readily know the status of
complaints and cannot determine the next step in the complaint handling
Another factor contributing to the delays in complaint handling was the
Board's slow response to obvious signs that cases were becoming seriously
backlogged. The Board and i t s management staff should have been aware of
the backlog in complaint handling because the number of cases prepared
for the Board meetings declined significantly. The Board's agendas
averaged 52 cases per Board meet i ng i n 1989 compared to 31 and 23 cases
per Board meeting in 1990 and 1991, respectively. A t the June 1991 Board
meeting, the Board staff presented only 5 new cases to the ~ o a r d . ( ~ )
Again, in February 1992 the Board had only 11 cases on the agenda for an
i n i t i a l action. At both meetings, the Board minutes do not indicate the
Board was aware of the low number of cases on the agenda.
( 1) Current administrators are unsure of the reasons the complaint tracking system was
( 2) The Board also handled 8 cases involving p e t i t i o n s f o r review or rehearing, 3 cases
i n v o l v i n g a c t i o n needed on a Hearing O f f i c e r ' s recomnendations, and 1 case involving
consideration o f a c t i o n on a previous Board order. Since these cases had previous
Board action, we did not count these as cases which would reduce the Board's backlog.
Chanaes Are Needed
to Handle Backlog
Although recent efforts to improve timeliness have been made, they are
not sufficient to handle the backlog of cases created by previous delays
in processing complaints. The Board must take additional aggresive
measu res to hand l e i t s back l og of cases.
Efforts made to improve complaint ~ rocessinq - The Board has recently
taken steps to change the complaint process to make i t more timely.
The Board changed the scheduling of the c l i n i c a l evaluation procedure
to expedite the evaluation process and f a c i l i t a t e the Board obtaining
evaluation results in a more timely manner. Under the new scheduling
approach, the evaluation is performed at a c l i n i c and results are
given to Board staff immediately after the evaluation.
The Board has u t i l i z e d temporary clerical assistance to handle some
complaint processing tasks, such as scheduling c l i n i c a l evaluations
and investigative interviews, and preparing notices.
The Board engaged a part- time paid consultant to assist the
investigator with investigative reports. The consultant, who is a
dentist, worked 184 hours for the Board in June, July, and August
1992. The Board has also requested another full- time investigator in
the 1993- 94 budget request.
The Board has contracted to have a computerized complaint tracking
system developed.
Temporarv emeraencv measures should be taken - To el iminate the backlog
of cases, the Board should take aggressive actions. As previously shown,
the Board cannot clear the backlog at i t s current rate.
As a f i r s t step, the Board should hire additional temporary investigators
( dentists) and clerical personnel. The Board recently added one
temporary clerk and one temporary part- time investigator. However, to
eliminate the backlog, the Board w i l l need to increase the amount of
temporary help. Based on comparisons with the Arizona State Board of
Nursing and the Arizona State Board of Osteopathic Examiners, we estimate
that the Board needs three to four additional ful I- time investigators for
one year to address the backlog.(') Based on i t s current workloads, we
estimate that the Board would need two additional clerical staff for one
year to support the additional investigative positions. The estimated
cost of the investigators would be $ 120,000 to $ 160,000 and the
additional clerical help would cost $ 32,000.(~)
The Board's present budget allocation does not provide sufficient monies
to fund the needed positions. To cover the expense of additional help,
the Board should consider proposing legislation to collect an emergency
surcharge on dental l icenses in order to raise the addi t ional revenue, as
the Arizona State Board of Nursing did i n 1988. We estimate a $ 75
surcharge per licensed dentist would be necessary and recommend the
surcharge be b i l l e d separately to a l l licensed dentists with appropriate
sanctions for fai lure to pay by a certain date.( 3)
( 1 ) These estimates are based on the Board modifying i t s current i n v e s t i g a t i v e process,
eliminating i t s use of comi ttees to investigate complaints, and instead re1 ying upon
trained s t a f f investigators to pursue complaints ( see Finding 11).
( 2) The Board currently pays approximately $ 20 per hour f o r the d e n t i s t investigator
position, f o r a t o t a l of $ 40,000 per investigator annually. The Board currently pays
approximately $ 8 per hour f o r temporary c l e r i c a l help, f o r a t o t a l of $ 16,000 per
clerk annually.
( 3) A surcharge of $ 75 per licensed d e n t i s t would raise approximately $ 195,000.
Using temporary personnel to prepare cases should dramatically increase
the volume of cases for the Board to review. With such an increase, the
caseload may become too burdensome for the Board to handle at i t s
bi- monthly meetings. Two alternative approaches should be considered for
easing the Board's abi l i ty to handle the increase.
The Board could hold monthly meetings temporarily u n t i l the backlog
is resolved, or
The Board could consider requesting legislation to allow i t to form
two separate panels, each containing at least one hygienist and one
layperson . ( I )
While the Board works to resolve the backlog, i t should issue a quarterly
report to the Legislature on the status of complaint cases, including the
number of cases received, pending, and adjudicated. This would provide
the Legislature with a means for monitoring the Board's progress u n t i l
the backlog of cases is resolved.
1. To eliminate the backlog of cases, the Board should
Seek additional funding for temporary personnel by requesting a
supplemental appropriation funded through a surcharge on a l l
Use the additional funding to hire four temporary investigators
and two temporary clerical s t a f f .
Consider alternative approaches to hearing cases, including a
panel approach or more frequent Board meetings.
( 1) The State Liquor Board has s t a t u t o r y a u t h o r i t y ( A. R. S. § 4 - l l l [ D ] ) to allow the
Chai rman to designate panels to hold hearings and take di sci p l i nary actions against
i t s licensees. The State Board of Pardons and Paroles also has statutory a u t h o r i t y
( A. R. S. 531- 401CII) to work i n panels of three to hear cases.
2. The Board should implement a complaint tracking system to ensure
timely processing of cases.
3. The Legislature should consider the following:
Requiring quarterly reports from the Board on the status of the
back l og
Providing the Board with authority to use two panels to hold
hearings on complaints
Providing the Board with the authority to assess an emergency
surcharge on i t s licensees
The Board should improve i t s complaint investigation process. The
current process results in fragmented and incomplete investigations and
is poorly perceived by some participants. Revising the process could
ensure complete investigations and improve public perceptions.
Limitations of
Current Process
The Board's current investigation process is hampered by i t s reliance on
committees to investigate complaints. Through the use of committees, the
process lacks the comprehensive nature of a regulatory investigation and
results in incomplete investigations that are poorly perceived by some
complainants and licensees.
C m it tee a ~ ~ r o a ctho invest iaat ions - The Board's invest igat ion process
relies on the use of committees to collect and analyze information and
evidence in complaint cases. In most complaint investigations, the Board
uses two separate committees, a Clinical Evaluation Committee and an
Investigative Interview committee.(') A brief description of each
committee and how it functions follows.
Clinical Evaluation Connittee consists of two volunteer dentists who
examine the complainant in order to evaluate the adequacy of the
dental work. Board practices do not allow evaluators to review the
patients' dental records, and the evaluators are instructed not to
discuss their findings with the complainant. The committee's
findings are then summarized in a report prepared by the Board's
staff investigator.
( 1 ) C l i n i c a l evaluations are routine1 y performed i n cases i n v o l v i n g qua1 i t y o f dental
care complaints. Further, although s t a t u t e s a l l o w the Board t o conduct an informal
i n t e r v i e w ( s i m i l a r t o the i n v e s t i g a t i v e i n t e r v i e w except t h a t a Board member i s
required t o preside over the panel), the m a j o r i t y of cases are assigned t o
i n v e s t i g a t i v e i n t e r v i e w s .
lnvestiaative lnterview Committee consists of two volunteer dentists
and a layperson who s i t as a panel and hear testimony from the
complainant and licensee. ( During the investigative process, this
is the only opportunity for each party to present his or her side of
the case.) Other evidence, including the findings of the Clinical
Evaluation Committee and the complainant's dental records, may also
be reviewed. The proceeding i s held much l i k e a hearing; a tape
recording is made, and each party is sworn in and given a limited
amount of time to present their case. The committee deliberates the
case before the parties, formal ly indicating thei r findings of facts
and conclusions regarding any statutory violations and
recommendations for disciplinary actions. A summary report of the
proceeding is compiled by the Board's staff investigator ( who does
not participate in the investigative interview) and forwarded to the
Board for i t s consideration.
lnvestiaations ~ rocess results in incomplete and substandard
investiaations - The use of committees to gather evidence results in a
fragmented and inefficient process. Unlike most boards that use
investigators to conduct investigations, the Dental Board relies
primarily on the investigative interview to collect and review evidence,
and reach conclusions on whether a dentist has violated dental
regulations. Thus, the process does not ensure that sufficient
information, facts, and evidence have been obtained prior to a meeting to
recomnend case action. For example, although the investigative interview
is generally the f i r s t opportunity the complainant has to explain his or
her complaint, and the dentist has to respond to the complaint, the
committee generally reaches a conclusion by the end of the interview,
without further work to address the points raised during the interview.
In addition, the Board's vehicle for gathering further evidence, i t s
investigator, is assigned the clerical responsibilities of transcribing
the interview tapes, and preparing written reports for the Board.
The Investigative Interview Committees' investigations are often
incomplete or problematic. With the assistance of our consultants, we
identified several deficiencies in complaint investigations as a result
of the inadequate work of the Investigative lnterview committee assigned
to the case. These deficiencies include:
Ignoring findings of the c l i n i c a l evaluation when deliberating the
facts of the case
e Omitting evidence presented by the complainant or the records in the
Neglecting to obtain pertinent evidence, including testimony from
complainants and pretreatment X- rays
Failing to address the primary allegations of the complaint
Procedural errors, including recommendations inconsistent with the
statutes, and incomplete and inaccurate reporting of findings
The following case examples demonstrate the problems with the
investigative interview process.
Case - In June 1990, a man filed a complaint alleging that a
dentist had failed to properly diagnose his periodontal condition.
More than a year later, an lnvestigative lnterview Committee heard
the case, but did not take testimony from the complainant because the
Board had failed to notify him of the hearing. Acting on the
committee's recommendation, the Board dismissed the complaint.
However, when appealing the Board's decision, the complainant
explained that he was also concerned about the orthodontic treatment
he had received from the dentist. A clinical evaluation conducted
after the appeal found the dentist's orthodontic work to be deficient.
b e n t - Under the Board's current investigative process, obtaining
evidence and input from the parties involved is limited to a single
opportunity at the interview. In this case, although the complainant
had significant additional information to present to the Board, he
was never interviewed by the Board before it reached a decision.
Consequently, the man was forced to appeal the Board's decision and
require the Board to initiate a new investigation, which took place
more than one and one- half years after the man filed the complaint.
Case Two - A woman filed a complaint alleging that a dentist had
diagnosed unnecessary root canal treatment and then pressured her in
an effort to have the work performed. A clinical evaluation
confirmed the complainant's allegations, finding that a root canal
was indeed not necessary. Despite these findings, as well as
statements indicating their own doubts about the licensee's
explanation of his diagnosis, the Investigative lnterview Committee
recommended dismissing the complaint. Additionally, records of the
hearing indicate that committee members never questioned the dentist
about pressuring the complainant to accept treatment.
Conment - This case i l lustrates not only the Investigative lnterview
Committee's failure to consider pertinent evidence, but also its
failure to address a primary allegation in the complaint.
Case Three - In August 1990, the Board received a complaint from a
woman that included several allegations, among them inadequate crown
and bridgework, and obtaining a fee by misrepresentation. In hearing
the case, the Board noted several deficiencies in the investigation
performed by the lnvestigative lnterview Committee, disregarded the
committee's recommendation to dismiss the complaint, and instead
ordered sanctions against the licensee. The licensee appealed the
Board's decision, and the Board ordered a new investigation, with
specific instructions to evaluate the allegations regarding fees.
However, the Board found that a second lnvestigative lnterview
Committee failed to evaluate the fee- related allegations, and ordered
a third lnvestigative lnterview Committee to review the complaint.
A t i t s April 1992 meeting, the Board accepted the recommendations of
the third committee and took disciplinary actions against the dentist.
Cornnent - The Board, by i t s statements, recognized the incomplete and
inadequate investigations conducted by the lnvestigative lnterview
Committees in this case, particularly a f t e r instructing the
Committees to investigate specific allegations. Further, this case
i l l u s t r a t e s the inefficient and inconvenient nature of the current
investigations process, which took more than a year and one- half to
resolve this complaint.
Poor ~ e r c e ~ t i o n s- In addition to i t s impact on the quality of
investigations, the Board's investigation process is poorly perceived by
some complainants and licensees. To identify participant concerns with
the Board's complaint handling process, we spoke with 19 complainants and
12 licensees who had either contacted our Office or were referred to us.
Their concerns, summarized below, primarily involve the a c t i v i t i e s of the
Clinical Evaluation and lnvestigative lnterview Committees.
Committee bias - Many complainants we spoke with believe the
lnvestigative lnterview Committees are biased. These be1 iefs stem
from different experiences ranging from evidence not being accepted
and testimonies being interrupted, to the licensee and the panel
conversing p r i o r t o the interview. Some complainants f e l t the panel
had reached a conclusion on their case before the interview.
Rude and insultina behavior - Some complainants indicated they were
treated rudely or insulted by committee members. Complainants also
stated they were made to feel inferior, and committee members
appeared to be bored and uninterested during the interview.
Member qualifications auestioned - Some licensees f e l t the
lnvestigative lnterview Committee members were not qualified to hear
their cases. It was indicated that the committee members were
untrained in the subject specialty area of dentistry. The
appropriateness of a lay committee member participating in
discussions involving technical issues was also questioned.
Time limitations on testimonies - Some complainants we spoke with
cited instances during investigative interviews in which time
limitations were placed on their testimonies, preventing them from
presenting information pertinent to their case. Although the
Board's Executive Director indicated time limitations are not
imposed, an introductory statement read at the beginning of each
interview indicates that participants have only five minutes to
present their testimony.
Disclosure of information - Many complainants expressed concern
about their i n a b i l i t y to obtain information generated during the
investigation process, particularly the results of the c l i n i c a l
evaluation. By statute, Board investigative materials are
confidential to the public, including complainants, but are
available to licensees involved in complaints, enabling them to
establish a defense against the allegations. Complainants, who
consider themselves a party in the complaint process, often feel
this limited disclosure of information is unfair. The Board's
actions may also contribute to this perception of unfairness since
i t does not routinely inform complainants of the reasoning behind
the distribution of this information.
Through our work, we identified a c t i v i t i e s by Investigative Interview
Committees that might tend to support the concerns expressed by the
complainants and licensees we spoke with. Summaries of these instances
Case One - While attending an investigative interview, we observed
two committee members repeatedly t e l l i n g a complainant that her
testimony regarding fee information from her dentist's office was
" wrong" and that she misunderstood what she was told. This
transpired despite the fact that neither the licensee nor his office
staff had been present at the interview, and therefore could not
have been the source of information to contradict the complainant's
test i mony .
Case Two - A t the conclusion of an investigative interview, we
overheard the committee chairman comment that the complainant in the
case, who had not attended the interview, was " not playing with a
f u l l deck," adding that he had previously treated the complainant as
a patient. These comments, along with the committee member's prior
relationship with the complainant, create serious questions about
the objectivity of the committee member.
Case Three - In i t s written report transmitted to the Board for use
in i t s deliberation of the case, an Investigative Interview
Committee included as a finding of fact that " the patient w i l l never
be happy ." The Board, apparent ly recognizing the i nappropr iateness
of this statement, deleted i t from the final findings in the case.
Revisina the Process Could Ensure
Corn~ lete lnvesti~ ations and lrn~ rove
Public Perce~ tions
The Board should revise i t s complaint investigations process to ensure
the completeness of investigations and improve public perceptions. I t
could do so by eliminating the use of committees to investigate
complaints and replacing committees with staff investigators.
Wdifv investigative process - To improve its investigative process, the
Board should eliminate the use of investigative interviews and rely on
trained staff investigators to pursue complaint cases. Several Arizona
healthcare regulatory boards utilize staff investigators. For example,
the Boards of Medical Examiners, Osteopathic Examiners, and Nursing all
use staff investigators to pursue complaint allegations. Each board has
investigators licensed in their respective medical field, who are
assigned overall responsibility for the investigation of the case,
including the gathering and analysis of necessary evidence, interviewing
the parties relevant to the complaint, and formulating recommendations
for Board action.
In fact, a 1989 statutory change empowered the Board to revise its
investigative process and begin using investigators. During the 1989
legislative session, A. R. S. 532- 1263.02 was amended to eliminate the
Board's specific ability to use " investigative committees" and authorized
the use of " investigators" to handle complaints. Despite this statutory
change, the Board has continued to rely on investigative committees.
Beyond potentially improving the quality of investigations, the use of
investigators could benefit the Board in several ways. First, by
eliminating the investigative interview from the complaint process, the
Board would remove a major source of complainant and licensee perceptions
of unfairness. Second, investigators familiar with cases could ensure
the more efficient use of clinical evaluations, rather than the Board's
current approach of sending most quality of care complaints for
evaluation. Finally, the use of investigators creates a convenient and
efficient mechanism for the Board to request additional investigatory
work, rather than its current time- consuming practice of referring
complaints back through the committee approach of investigating cases.
To improve its complaint investigative process, the Board should
eliminate its use of committees to investigate complaints, and instead
rely upon trained staff investigators to pursue complaints.
FINDING Ill
The Board should take actions to address problem dentists and improve i t s
deliberation procedures. Specifically, the Board should increase i t s
efforts to take disciplinary actions against licensees who have
repeatedly violated the dental statutes. In addition, the Board needs to
improve i t s procedures for deliberating cases to ensure that disciplinary
actions are upheld.
Board Needs To
Increase Efforts Aaainst
Repeat Violators
The Board should increase i t s efforts to take disciplinary actions
against licensees who repeatedly violate the dental statutes. Although
the Board has sufficient statutory power to act against repeat offenders,
i t has been reluctant to enforce s t i f f e r penalties. The Board's failure
to adequately monitor repeat offenders may contribute to this problem.
Statutory authority - The Board has adequate statutory authority to take
action against licensees who repeatedly violate the standards. Arizona
Revised Statutes ( A. R. S.) 032- 1263 empowers the Board to take
disciplinary action against any licensee for unprofessional conduct. In
turn, A. R. S. 932- 1201.18 defines unprofessional conduct as including,
" gross malpractice or repeated acts constituting malpractice." Finally,
the Board is granted a wide range of disciplinary actions, from censure
and rest i t u t i on to l i cense suspens i on and revoca t i on.
Re~ eat offenders - To evaluate the Board's response to problem licensees,
we identified 14 dentists who had accumulated numerous complaints and
disciplinary actions over a long period of time, or several complaints in
a short period of time ( see Table 3, page 22). The significance of the
number of complaints becomes more prominent when considering that in
1991, more than 90 percent of the dentists licensed in Arizona had no
complaints f i l e d against them.
2 1
Rece i ved
- 46
Complaints With
Discipl inary
Act i ons
( a) This includes e i g h t cases ordered t o fonnal hearing t h a t have not y e t been heard.
Source: Auditor General staff analysis of complaints received by the
Board from January 1986 through August 1992. Complaint
informat ion obtained from Board records for individual
Board reluctant to act - Whi le the Board has the authority, i t has been
reluctant to act against repeat offenders. For example, in a review of
l icenses revoked by the Board since 1988, we were unable to identify any
dentists whose licenses were revoked for repeated acts of malpractice or
for the number of complaints and/ or disciplinary actions taken by the
Board against their license. In addition, of the 14 licensees identified
in Table 3, at the time of our review, the Board had initiated an e f f o r t
to remove the license of only one of these dentists.(') The following
examples of dentists listed in Table 3 i l l u s t r a t e the Board's reluctance
to pursue action against repeat offenders.
( 1) However, even t h i s action i s not expressly r e l a t e d t o the number and frequency o f
v i o l a t i o n s comni t t e d by t h e l i c e n s e e ( see D e n t i s t B example, page 23).
2 2
Dentist D received 12 complaints over the last seven years. The
Board found the licensee had comnitted a violation in four of these
complaints, including three complaints involving inadequate
dentures. Despite previous disciplinary actions that included a
total of 21 hours of continuing education in denture work, a l l four
of the most recent complaints f i led against the dentist ( received in
the last three years and s t i l l open at the time of our review)
concern inadequate dentures.
Dentist F received 10 complaints in the last seven years, six of
which were found to involve a violation. Although four of the six
complaints with a violat ion concern inadequate oral surgery, and
three were acted upon by the Board at the same meeting, beyond
imposing censure and administrative penalties, the Board has done
nothing to r e s t r i c t t h i s licensee's practice of dentistry in Arizona.
Dentist B received 15 complaints in the seven- year period. Although
only four complaints resulted in disciplinary actions, the Board has
ordered eight complaints to a formal hearing, including two ordered
by the Board more than three years ago for allegations of
"... conduct or practice constituting a danger to the health, welfare
or safety of the patient or the public." Regardless of this record,
the Board took no action to l i m i t this licensee's p r i v i lege to
practice dentistry u n t i l August 1992, when i t summarily suspended
his license for working for a company not under the supervision of a
licensed dentist and for failure to maintain and provide dental
records for his patients.
lnadeauate trackinfa may contribute to reluctance to act - One possible
reason for the Board's reluctance to act against repeat offenders could
be the result of i t s failure to adequately track violations and
disciplinary actions. Since 1989, the Board has failed to track
violations and disciplinary actions taken against licensees. Therefore,
the Board does not have a comprehensive record of the nature of the
violations committed by these licensees or a record of recent
disciplinary actions ordered against them. Without this information, the
Board is unable to establish a pattern of violations that would lead them
to take stronger actions.
Board Nee& to lm~ rove
Deliberation Procedures
In instances where the Board takes disciplinary actions, i t needs to
improve the procedures i t follows when deliberating cases to ensure that
i t s disciplinary actions have an adequate basis. Recent court rulings
have questioned the Board's deliberation process and resulted in the
reversal of disciplinary actions taken by the Board. Despite these
events, the Board continues to use questionable procedures when
deliberating cases.
Recent court rul inas - Two recent court ru l ings have seriously quest ioned
the process the Board follows when deliberating complaint cases. In both
cases, the courts concluded that the Board failed to support i t s
decisions to amend the findings and conclusions of the lnvestigative
lnterview Committee with " substantial evidence." Therefore, the courts
reversed the disciplinary action ordered by the ~ oard.(') Summaries of
the two cases and the courts' decisions follow.
Case One - A patient f i l e d a complaint with the Board alleging that
a dentist had charged excessive fees. An Investigative Interview
Committee found no basis for the allegation and recommended that the
complaint be dismissed. The Board ignored the committee's
recommendations and rendered i t s own findings and conclusions,
censuring the dentist for " inadequate practice management."
On review, the superior court found that the record in the case
contained no substantial evidence to support the Board's
conclusions. Because the court also found that the Board lacked the
statutory authority to censure the dentist for inadequate practice
management, i t reversed the Board's order against the dentist. On
appeal by the Board, the State Court of Appeals upheld the superior
court's ruling.
Case Two - A patient f i l e d a complaint with the Board, alleging
unsafe practices by a dentist. An lnvestigative lnterview Committee
found no evidence to support the allegations and recommended that
the complaint be dismissed. When hearing the case, the Board
decided to adopt new findings of fact that substantially changed
those submitted by the lnvestigative lnterview Committee. Based on
these new findings, the Board concluded that the dentist's conduct
was unprofessional and ordered restitution of fees paid by the
patient .
After reviewing the record, the superior court found that the Board,
without further investigation, improperly changed the findings of
fact, and that these changes were unsupported by " substantive
( 1) I n a d d i t i o n t o t h e r e v e r s a l o f i t s d i s c i p l i n a r y actions, the Board's f a i l u r e t o
p r o p e r l y d e l i b e r a t e these cases r e s u l t e d i n d i r e c t f i n a n c i a l loss t o the State. For
example, i n the f i r s t case, t h e S t a t e must pay the d e n t i s t more than $ 7,600 i n
a t t o r n e y ' s fees and expenses. Furthermore, these costs do n o t i n c l u d e the expenses
i n c u r r e d by the Attorney General's Office t o defend the Board.
reliable evidence." The court further concluded that the Board's
actions were " arbitrary and capricious" because the Board relied on
a weak record of evidence to support i t s new findings of fact and
expressed a desire not to investigate the case further. The court
ordered the Board to either adopt the findings of fact and
recommendations made by the Investigative lnterview Committee or
reinvestigate the case " . . . i n order to appropriately resolve the
case and to make an informed decision."
Board continues to use auest ionable procedures - The Board cont i nues i ts
practice of amending investigative findings and conclusions without using
appropriate evidence. A t the same meeting that the Board was informed of
these court rulings against it, the Board ordered disciplinary actions in
three cases involving the same dentist in the second court case described
above. A review of the deliberation process followed by the Board in
these cases indicates i t s continued failure to use substantial evidence
when deciding cases. For example, in two of the three cases, the Board
did not accept the recommendations of the Investigative lnterview
Committee and imposed a disciplinary action without stating on the record
what evidence was used to reach i t s conclusion. In a third case, despite
significant evidence from the Investigative lnterview committee, the
Board again reversed the committee's dismissal recommendation and imposed
a disciplinary action based upon a single photograph of the patient.
Further, the meeting records indicate the Board mentioned the evidence
used to support i t s determination only after i t s Assistant Attorney
General and Executive Director reminded i t to do so.
The Board should
1. Pursue appropriate levels of disciplinary action against licensees
who repeatedly violate the standards of professional practice.
2. Develop a system to track violations and disciplinary actions against
licensees and use this information to determine when stronger
enforcement actions are needed.
3. Establish clear policies to guide i t when hearing complaint cases to
ensure that appropriate evidence is obtained to support i t s
disciplinary actions.
The Board's requirements for f i l i n g a complaint create an unnecessary
burden on the public. By eliminating certain f i l i n g provisions, the
Board could streamline i t s complaint f i l i n g process.
Filina Requirements
Are Burdensome
The Boardvs procedures for f i l i n g complaints act as a deterrent. When a
complainant contacts the Board to f i le a complaint ( either by telephone
or l e t t e r ) , the Board normally sends the complainant a complaint form
and requests that the complainant complete the form and return i t to the
Board. Before returning the form to the Board, the complainant must
have the form " verified," as required by A. R. S. 532- 1263.02 and defined
in $ 32- 1201, as signing the form before a notary or an authorized Board
employee. In addition, the Board requires that the complainant complete
the " Authorization For Release of Information and Records" portion of
the form, which i t later uses in requesting dental records.
This process is an unnecessary burden for complainants. Although many
complainants have already taken the time to write a l e t t e r t o the Board
detailing their concerns, their complaint letter is returned to them
with a Board complaint form, which they then must complete, have
" verified," and return to the Board. Further, i f the complaint
involves more than one dentist or patient, a separate form must be
completed for each dentist or patient. The process of i n i t i a t i n g an
investigation is delayed u n t i l the form is received. Because of the
inconvenience of f i l i n g a complaint, some complainants may not bother to
return the complaint form. Through our review, we identified the
following instance in which the process created a problem for a
A woman sent a notarized complaint form to the Board with concerns
about the treatment provided to her, her spouse, and her child by
two dentists operating from one dental practice. The Board sent the
woman six forms to complete ( because two dentists were involved, two
forms were required for each person treated). The woman did not
return the forms.
Other Medical Boar&
Do Not Have Similar Reauirements
Other medical regulatory boards with similar enforcement
responsibilities do not require complaints to be " verified," nor do they
require complainants to provide authorization for the release of their
records. For example, the Board of Nursing, the Board of Medical
Examiners, and the Osteopathic Board w i l l i n i t i a t e a complaint
investigation based on a letter received from a complainant. These
boards are not required to perform the extra step of obtaining a
Itverified" complaint. Further, the boards do not require complainants
to provide authorization for the release of their records. Instead,
they request records based upon their statutory investigative powers,
and i f records are not provided they use their subpoena powers to obtain
the needed information or records. Because the Dental Board already has
the authority to request and subpoena the records necessary to conduct
i t s investigations, i t could discontinue the practice of requiring
complainants to provide authorization for release of their records.
1. The Legislature should consider amending A. R. S. § § 32- 1263.02 and
32- 1201 to eliminate the requirement that complaints be " verified."
2. The Board should discontinue requiring complainants to complete an
authorization for release of records and instead rely on i t s
investigative and subpoena powers as granted in A. R. S. $ 32- 1263.02.
Comments On
The State Board Of Dental Examiners'
The following response was received from the State Board of Dental
Examiners. Normally we meet with an agency prior to receiving their
response to c l a r i f y wording and update data as needed. Because the Board
did not accept our offer to meet and discuss the report draft, we did not
have the opportunity to identify and make a l l needed c l a r i f i c a t i o n s u n t i l
after receiving their reponse. We have placed an * within the margins
of the Board's response to identify where we have revised our report to
update data or address their concerns.
5060 North 19 Avenue, Suite 406 Phoenix, Arizona 85015
Telephone ( 602) 255- 3696
January 13, 1993
Douglas R. Norton
Auditor General
State of Arizona
2700 North Central, Suite 700
Phoenix, Arizona 85004
Dear Mr. Norton:
This is in response to your letter of December 3, 1992 forwarding
a preliminary draft report of the performance audit conducted by
your office of the Arizona State Board of Dental Examiners.
Enclosed is the Board's response to the draft audit.
Unfortunately, the Board was unable to review the draft, develop a
response, and then schedule a meeting with the audit staff. The
timing of the submittal of the draft report, directly before the
start of the December holidays, did not provide sufficient time for
the review and the development of the response by the Board prior
to any meeting. Consequently, the response is forwarded in the
absence of any discussion of the draft with the audit staff.
It must also be pointed out that, in the opinion of the Board, the
report does not accurately reflect the operations of the Board's
complaint processing program. While the Board will agree that a
backlog of cases has developed, the reasons stated in the audit are
inaccurate. Further, we believe that the audit is prejudiced
against the Board. Examples that support this belief are contained
in the response.
Please feel free to call me at 867- 9844 or Mark Steinberg,
Executive Director of the Board, if you have any questions or
require additional information.
President of the Board
The Arizona State Board of Dental Examiners has eleven members and
consists of six dentists, two hygienists, and three consumer
representatives. The Board is a citizen run agency. Although
members receive modest compensation for each meeting, they spend
many hours assisting the Board in a variety of activities as well
as preparing for each meeting without any compensation. The Board
process is an excellent example of citizen participation in the
public's business.
No one would argue with the audit findings that the Board is faced
with significant delays in processing and resolving complaints
against licensees. However, the major disagreement with the audit
concerns the reasons for the delays and the recommendations on the
case processing procedures.
The audit report faults the complaint processing system for the
delay. This is where the Board strongly disagrees with the
conclusions contained in the audit report. It appears that the
auditors found the Board's procedures to be unique and, therefore,
suspect. The audit recommendations are based, not on facts
demonstrated in the report, but on subjective statements
unsupported by facts. As such, they have no place in an audit
report. The Board's procedures are not at fault and should not be
abandoned to be replaced by a staff- based investigative system. The
Board previously used a staff- based system that proved to be
costly, cumbersome, and ineffective.
The Board also believes the audit report does not reflect
accurately its current procedures, staffing, or operations. The
report covered a period of major problems, but does not include a
period of rapid progress in the management of the complaint
processing system. In brief, the audit report was outdated as it
was being prepared.
The Board's complaint processing procedures includes the
participation of over 120 volunteer dentists from around the state
who serve as investigators. This process will be described further
in this response. The audit faults the Board, in part, for using
this volunteer- based process because other boards do not use such
a process. This does not appear to be a sufficient reason to
change the Dental Board's complaint investigation system.
In fact, the volunteer- based investigation system is the very core
of the Board's operations and could be emulated by other state
boards with similar responsibilities. Its strength is its broad
based involvement of many practicing dentists who volunteer their
time and expertise. The Board does not depend on just one or two
state employees. The broad- based professional representation
results in the development of an unbiased community standard of
practice for dentistry.
Response to Performance Audit
Page 2
In addition, the cost savings of a volunteer- based system are very
significant. The state could not afford the costs associated with
paying for the services of the volunteers, including the many
specialists, that provide their expertise on a regular basis.
The audit was conducted over a four and half month period with the
assistance of at least seven audit and dental professional
participants. The Board has had less than 30 working days to
respond to the draft audit report.
The audit report states that three dentists volunteered their
assistance with the audit. It is unclear what the qualifications
of these dentists were to evaluate the Board's performance. It did
not appear that these dentists were licensed by Arizona or if they
had any previous board or peer- review experience. It is also
unknown if they had been disciplined by the state in which they
were licensed. The Auditor General should provide this information
to the Board as part of the audit.
The techniques for conducting evaluations of dental treatment
performed by other dentists is not included in the standard
training for dentists. There is a certain degree of training
required and it is questionable whether or not these non- Arizona
licensed dentists had the qualifications necessary to evaluate the
performance of the Board or any other dentist. The Board provides
training programs to its consultants on dental evaluation
techniques, the laws governing dentistry in Arizona, and operations
of the Board. The training is given before the dentist evaluates
the treatment of others.
The report also relies on subjective statements, not facts to
support a recommendation. The audit includes the following
statements on Page 18: " some" or " many complainants believe" or
" some indicated" or " some licensees felt...." These are subjective
statements, not facts. Consequently, they should not be included
in the audit as they cannot be compared to the total number of
people involved in the process. Further, in the absence of any
identification, it is impossible to determine what bias may be
included. Beliefs or feelings, in addition, are not facts and
cannot be used to determine recommendations. This situation is a
clear indication of the bias and inadequacy of the audit.
The audit states that it was conducted in accordance with
government auditing standards. The Board requests a description of
the specific standards for this report. The report has been
reviewed by the members and staff of the Board as well as two
independent auditors. It is the conclusion of all reviewers that
the report is biased and does not provide an accurate and helpful
description of the Board. Further, the report does not describe in
a factual manner any pattern of problems. It just states what is
obvious: There is a backlog of complaint cases.
Response to Performance Audit
Page 3
The first section of the draft report begins with a description of*
a case filed with the Board in September of 1990. In the absence
of more detailed information, it is difficult to accurately
identify the case. However, the case appears to be one where
suspension or revocation of the dentist's license was possible.
Therefore, as required, the Board forwarded the matter to the
Office of the Attorney General for a formal hearing under the
provisions of the Arizona Administrative Procedures Act. This
hearing has not been held. The scheduling of the formal hearing
remains outside the control of Board, but the case is symptomatic
of a more general problem.
The Board has experienced ongoing difficulty in obtaining adequate
legal assistance from the Office of the Attorney General in a
timely, consistent, and accurate manner. There are over 15 cases
awaiting the scheduling of a formal hearing by the Attorney
General's staff. The Board has repeatedly requested action on
these cases, but to no avail. To suggest that the Board is remiss
in its handling of the case is not correct.
As previously stated, there is no question that the Board has a
backlog of complaint cases awaiting final disposition. However,
the reasons for the backlog are not those stated in the audit
report. In addition, the Board recognized the problem and is
taking " aggressive" measures to expedite the process.
Several factors contributed to the backlog of complaint cases. The
contributing factors were related to staffing and administrative
problems, not of the process used by the Board to investigate
During 1990, the members of the Board discovered that the Executive
Director and the chief staff dentist were carrying out their
responsibilities in an totally inappropriate manner. There were
allegations of misuse of funds, nepotism, sexual harassment, and
other improper activities. When the involved staff were confronted
with the allegations, with the advice of counsel, they resigned.
The draft audit report states that the Board's staff dentist
claimed he resigned under pressure from the State Dental
Association. This statement does not reflect the reasons for the
resignation and is not confirmed by other individuals involved with
this matter. Clearly, it is irresponsible for the audit to have
included these statements without any collaboration other than a
footnote that implies the dentist in question was truthful.
Response to Performance Audit
Page 4
In fact, the Department of Administration investigation referenced
in the footnote does not support this inference. The report
supports some of the allegations. The self- promoting and
unverified statements of a former employee have no place in the
audit report.
Following the termination of the dentist involved in the above
referenced matter, the Board proceeded to employ a new dentist.
Unfortunately, the new dentist experienced critical health problems
which resulted in his untimely death. This situation resulted in
further delays in the processing of cases and was beyond the
Board's ability to quickly rectify. A new Executive Director was
hired, however, this individual resigned to return to her home
state. Again, this left the Board in a position of not being able
to respond in a timely manner until new staff was hired. This is
not to suggest that the Board was unaware of the growing problem.
The problems related to staffing are not an excuse, but rather
represent the facts the Board has had to deal with. Such problems,
unfortunately, are not uncommon, but the impact is more significant
when faced by a very small agency such as the Board.
A new and highly qualified staff dentist was hired but was
immediately summoned for jury duty and assigned to a month- long
trial. Subsequently, a new Executive Director was hired and a
number of steps were then implemented to deal with the complaint
process and the backlog of cases. This was accomplished with the
assistance of the dentist, when he returned from fulfilling his
obligations as a juror, and a part- time dental consultant.
Additional steps have also been taken to improve the effectiveness
of the process. These steps are discussed throughout this
The audit alleges that the Board handles " about 40 cases" per Board *
meeting. This is not an accurate reflection of the Board's current
procedures. At the August two- day meeting, 64 cases were heard.
An additional 77 were heard at the October two- day meeting and
another 64 at the December meeting. Eighty cases are scheduled for
the February two- day meeting. At this rate, the Board can be
expected to eliminate the backlog and become current by the fall of
The draft report alleges on Page 10 that the Board abandoned its
computerized tracking system in 1990. Current staff were unaware
of the tracking system until the former staff dentist who developed
the system came to the Board's offices and tried to obtain
additional compensation for making it work. A complaint tracking
system was not fully developed. The staff dentist who resigned
( and was inappropriately paid over regular compensation to develop
such a system) is the only person who claims the system was
adequate. It was not adequate and of no use to the Board.
Response to Performance Audit
Page 5
The arrangement for this work was done without the knowledge or
authorization of the Board and contributed to the resignation of
the then Executive Director and staff dentist. The arrangement was
possibly illegal and the work certainly inadequate. It was
The Board recognized the need for a new automated information
system to handle all the Board's needs and one that included a
complaint case tracking component. In the absence of such a
system, it is impossible to manage its licensure information and
complaint cases with any acceptable level of effectiveness.
Consequently, the Board authorized and now has an automated system
that allows for tracking of all necessary information including
complaints. The basic licensure information component is
operational and the necessary historical complaint data is
currently being entered into the system. The complete system will
be fully operational by March of 1993.
The report states that at the June 1991 meeting the Board dealt *
with only five cases. This suggests that the Board is lax in
meeting its responsibilities. The minutes of this meeting reflect
a different story. The Board disposed of four times that number of
cases in addition to dealing with a number of other important
matters. These other matters included a detailed discussion and
approval of policies and procedures on a number of subjects related
to the practice of dentistry.
These administrative matters included regulations for continuing
education, the criteria for issuance of a sedation permit, and new
complaint procedure requirements. There is more to the Board's
duties than solely the disposition of complaints, important as that
responsibility is.
The report recommends that three to four additional dentists be
obtained by the Board on a temporary basis. The Board agrees that
additional professional staff is required. A part- time dental
consultant was hired in the spring of 1992. The services of
another temporary dental consultant was recently added and another
is under consideration for a total of three part- time consultants.
In addition, the Board is considering a reorganization plan to add
a second full- time dental position. With an anticipated
reallocation of its budget, the Board believes it can cover the
costs associated with these staff increases out of its current
resources. There is no need for any special assessment as
recommended in the audit report.
Response to Performance Audit
Page 6
The Board has also moved to a two- day meeting schedule, in place of
its one day meeting, every other month. This enhanced schedule
permits the Board to deal with a greater number of cases in a
timely manner. There is no need for splitting the Board into
separate panels. No valid purpose can be served by this
recommendation other than to fracture the process.
The audit recommends quarterly reporting on the complaint process.
The Board already reports on an annual basis. The Board will
report on a more frequent basis to the Governor and the Legislature
on its progress in the absence of any further requirement to do so.
This finding is the very heart of the Board's complete disagreement
with the focus of the audit. The audit report states that the
investigation process is hampered by its reliance on volunteers to
investigate complaints. Nothing in the history of the Board's
operations can support this finding. The audit's statement is an
opinion and not a statement of fact.
The following is a description of the Board's complaint handling
procedures and the response to the audit findings.
Filins of the Complaint: A complaint filed with the Board must be
signed by the patient or a representative and verified. In the
absence of this signature and permission to obtain records, the
Board would not be able to breach the wall of confidentiality of
patient/ doctor records and start the investigation. Further, by
requiring the verified signature, the Board can be assured that the
complaint is being filed by a patient, and not by any unknown
person for a purpose unrelated to dental treatment. For example,
some individuals have attempted to file against their former
employer using the names of patients. By being certain of the
identity of the person making the complaint, the Board can protect
the privacy rights of the patients and the due process rights of
the licensee.
This requirement does not mean that the Board will not investigate
a matter based on a phone call or letter without the identity of
the person making the contact. The Board has initiated its own
investigation and complaints involving drug abuse, mistreatment of
patients, and other such matters.
The Board requests the assistance of local or Federal law
enforcement officials when the subject of the investigation
requires non- dental expertise and involves matters in addition to
direct dental treatment.
Response to Performance Audit
Page 7
Clinical Evaluation: The clinical evaluation is conducted when the
complaint involves a question of treatment. The evaluation is
performed by two volunteer dentists unrelated to the case. If a
specialty treatment area is under review, a fully qualified
specialist in that area is included in the evaluation team. The
audit report is wrong when it states that specialists are not used *
when appropriate.
The procedures used during the clinical evaluation are those in use
by most dental peer- review programs, other state dental boards, and
teaching institutions. They are standard procedures for dental
evaluation. It is clear that the auditors do not have any
familiarity with the accepted procedures for evaluation of dental
treatment. Consequently, they are in error to recommend a
different procedure for clinical evaluations.
The purpose of the clinical evaluation is to obtain an accurate and
current status report of the patient's dental condition. It is
conducted in a manner to avoid any hint of bias. Names are not
used to maintain anonymity. Records and x- rays are included when
necessary. The audit report is in error when it states that they
are not included.
At least two clinical evaluation sessions are scheduled each
month in Phoenix at a local dental clinic that is made available to
the Board at no charge. Evaluations are conducted in Tucson when
required at a local dental office which is also made available to
the Board at no charge.
Investisative Interviews: ~ nvestigative ~ nterviews are conducted
by two dentists, different from those that conducted the clinical
evaluation, and a lay person representing consumers. The dentist
and the patient have the opportunity to present their case in full.
( It is claimed in the report that this is the only opportunity the
parties have to present their case. gain, the report is in error.
Each party may make a presentation to the Board when it considers
the case on the appropriate Board meeting date.)
All relevant records are also reviewed by the three- member panel
and questions asked of all parties. Witnesses may also testify on
behalf of either side. The audit report states that there is a
limit to the time allowed for each party to present their case.
This statement, again is untrue. No time limit is imposed for the
discussion of any relevant matter relating to the complaint. Each
case is schedule for at least one hour. However, some sessions may
last 30 minutes while others have lasted for several hours.
The process and time allotted permits a full discussion of the
issues, a determination of the facts, and the development of
recommendations for consideration by the Board.
Response to Performance Audit
Page 8
The participation of volunteer dentists insures that the process is
fair and based on a standard of practice that is accepted by the
entire dental profession. The alternative to this community- based
approach is to have the Board hire a sufficient number of staff
dentists. This system was tried and failed to provide an
acceptable procedure in terms of fairness. No one wants state
employees making decisions that are best made by independent
professionals with the assistance of consumer representatives.
The audit claims that the panels gathering evidence results in a
fragmented and inefficient process. No evidence to support this
statement can be found in the report. The statement is simply
untrue and is a sign of the auditor's dislike of a system they
failed to understand.
There is no evidence that a staff investigator would be able to
gather any more information or reac'h a different conclusion than
reached by an independent panel. To state otherwise, is an opinion
not substantiated by facts. All relevant and available information
is included in the investigatory process.
There are some patients who object that they cannot bring up issues
and present information that is not under the jurisdiction of the
Board or related to the treatment under question. To allow a non-focused
process would unnecessarily delay the resolution'of cases
and add nothing to the proceedings. This is not a requirement
solely of this Board, but rather one in use by every agency
responsible for conducting investigations. Again, the auditors
failed to understand the need to limit discussion to the matters
before the Board.
The auditors also concluded, with the assistance of their
consultants, there were several deficiencies in the investigations.
The Board questions the understanding of the process on the part of
the auditors, and their dental consultants.
The members of the investigation panel, and eventually the Board,
do not ignore the findings of the clinical evaluation teams. The
evaluations are used by the panels and the Board during the review
of the cases as one of many factors that must be considered. The
process should not be limited to just one factor for the resolution
of the case. It seems strange that the report in one part
criticizes the Board for not having sufficient information and in
another criticizes the Board for considering additional
It is also untrue to state that evidence is omitted. Not all
information that is submitted by a patient is relevant to the case.
If information or material is not relevant, it should not be
included regardless of the claims of a patient or dentist.
Response to Performance Audit
Page 9
The Board does not neglect to obtain pertinent evidence, including
testimony from complainants and pretreatment x- rays as claimed in
the report. The Board does not fail to address the primary
allegation of a complaint. The cases presented to support these
general findings demonstrate that the process works by allowing the
complainant ample opportunity to correct the record by submitting
new and relevant information.
The listing of cases should not be included in the report as they
are not identified in a manner to permit verification of the
description and findings. Further, their selection is questioned.
The report states that the cases reviewed were selected on a random
It is of interest that the selected cases appear to be the most
high- profile and problem cases under consideration by the Board
during the audit period. They clearly do not represent a cross
section of the Board's complaint files. It appears their selection
was predetermined.
The auditors admit they met with a dozen individuals to discuss the
process. The names of the individuals are not provided and the
Board cannot determine the outcome of their cases to determine the
relevancy of their comments. Clearly, this meeting did not include
a cross section of all individuals who filed a complaint. Rather,
it consisted of those individuals with a particular bias against
the Board. This meeting should have never been held under these
non- representative conditions. Audit reports should not base its
findings on " some" or " perceptions." To do so is not part of any
standard audit procedure.
Suffice it to say that not everybody is going to be pleased with
the Board's determinations. Many licensees are upset even when the
complaint against them is dismissed. They object to any
questioning of their professional abilities and to the time lost
from their practice while attending hearings. The Board will
proceed with investigations regardless of any individual's feelings
to the contrary of the need.
Many patients are upset even when the complaint is upheld. They
are unhappy for a variety of reasons which include that the Board
cannot award damages like a civil court or punish the dentist with
a term in jail. The Board's goal is not to make people " happy."
It is to protect the public's health and safety by investigating
complaints and taking appropriate steps to sanction a licensee when
they fail to meet accepted standards of care.
Response to Performance Audit
Page 10
In an effort to deal with the actual and documented mistakes and
problems experienced by patients and licensees with the process,
the Board has increased its training programs and case review
procedures. This will insure that the case files are complete and
handled in a proper and timely manner.
The auditors recommend that the Board revise the complaint
processing procedures by eliminating the volunteer panels and rely
on trained staff. This recommendations assumes that the volunteers
cannot perform as adequately as staff dentists. However, no
documentation or facts are presented in the audit to support this
statement, and the cost would be substantial. It is a conclusion
based on a preconceived opinion. The current procedures of other
Boards are used to support the opinion.
A careful review of the complaint processing procedures and
outcomes of the other Boards demonstrates that they are
experiencing delays as well. The reasons for the delays vary from
Board to Board and are unrelated to the procedures utilized. What
works for one health board may be totally unrealistic for use by
another board. The review of dental care is different from that
used to review nursing care or medical care.
For the great number of cases received by this Board, the treatment
under question is a physical reality subject to review by trained
dentists. The very nature of dental evaluation cannot be turned
over to non- dentists and there is no need to create some new mid-level
of state employees to do what is unnecessary. The volunteer
dentists are effectively performing the evaluation function.
The auditors also claim that the removal of the investigative
interview panels would remove dissatisfaction and poor perceptions
on the part of patients and licensees. No fact or documentation is
presented to support this conclusion. It is an opinion based on
the statements of a few consumers who have not had their cases
upheld or dentists who have been sanctioned. Unsupported opinions
have no place in an audit.
The investigative interview allows a full discussion of the
complaint by all participants. The resulting recommendations are
submitted to the Board for consideration in its deliberations. The
outcome of any particular case may not be to the liking of the
dentist, the patient or both, but it is most often the correct
outcome based on the facts available to the Board. A careful
review of the Board's decisions by qualified and unbiased
professionals will support this position.
Response to Performance Audit
Page 11
The Board has consistently recognized the need to take action
against dentists who violate the dental statutes. Its record on
this matter is clear. During the audit period of 1990- 91, the
Arizona State Board of Dental Examiners had the highest percentage
of cases resulting in some form of disciplinary action in the
nation. No State had a higher rate of actions against licensees
who fail to meet accepted standards of dental care. The Board now
stands third in the nation among all state dental boards.
This record is clear and demonstrates the seriousness with which
the Board carries out its responsibilities. To state otherwise is
again, an opinion that cannot be supported by facts.
The Board has and continues to deal with repeat offenders with
every resource at its disposal. As stated earlier in this
response, the Board has forwarded to the Office of the Attorney
General over 15 cases for the purpose of conducting formal
hearings. These cases were forwarded for Formal Hearing because
revocation of the licenses was requested by the Board.
The Attorney General's office has not scheduled these hearings
after repeated requests to do so by the Board. This failure is not
acceptable to the Board. Consequently, the Board is entering into
an interagency agreement with the Attorney General's office to
provide the Board a full- time Assistant Attorney General to be
assigned to the Board. The Assistant Attorney General will carry
out various duties on behalf of the Board. These duties will
include the holding of the Formal Hearings on an expedited basis.
The Board will pay for these services out of its existing budget.
The chart contained in the audit report on Page 22 presents
information on the complaint process. This chart is a gross
oversimplification of the status of unidentified cases. Therefore,
there is no way the Board can respond in detail. The information
in the chart is not significant. The cases that are presented on
Page 23 also do not present an accurate description of the status
of cases handled by the Board.
The audit states that recent court rulings have questioned the
Board's deliberation process; however, the report does not identify
the cases they referenced. The Board's actions are based on the
legal advice provided by the Assistant Attorney General assigned to
the Board.
Response to Performance Audit
Page 12
During the last 2 years, the Board has been subject to frequent
changes in the assigned staff. This constant rotation has resulted
in inconsistent and poor legal assistance which sometimes has left
the Board in a precarious position. The agreement to obtain full-time
legal counsel will correct this situation in an effective
The actions taken in the cases listed on Page 24 were based on the
advice of the legal counsel then assigned to the Board. This lack
of adequate legal counsel has been addressed above. The cases
should have been listed in a manner that would have permitted the
Board and its counsel to verify the audit's description of the
The audit claims that the complaint filing procedures are
unnecessary and burdensome to the public. This statement is not
supported by any facts and is the uninformed opinion of the
The Board requires that all complaints be signed in the presence of
a notary public or a Board employee. This is not a burden, but it
does insure the accuracy of the identity of the person filing the
The Board also requires the patient's permission to obtain records.
With the identity certain, the Board can obtain records without
violating a patient's right to privacy. The Board has reason to
believe that this procedure goes a long way to eliminate the
possibility that the privacy rights of patients are violated based
on the filing of an improper complaint.
The assurance that the complaint is valid also protects the due-process
rights of dentists. The filing of a complaint and the
resulting investigation would violate the right to due- process if
the complainant is not the actual patient but some other individual
attempting to harass the dentist. The Board understands its
obligation to investigate complaints and that to treat the dentists
in a fair manner that recognizes their rights.
The problem identified on Page 28 of the audit is not sufficient
grounds to eliminate the protection that the current procedure
affords the dentist and the public. Further, the case cited has
nothing to do with the alleged problem. The family submitting this
case was requested to file a complaint for each case.
Response to Performance Audit
Page 13
This procedure is standard practice in all such investigations and
permits a full investigation, including the collection of all
records for each patient and a resolution of each problem on its
own merits. The audit finding is mere speculation unsupported by
any facts.
The audit reports that other health boards do not have similar
requirements. This statement is true. They do not for the reasons
previously stated. The audit offers nothing to support that any
change in the Board's procedures will result in a different outcome
for any one or group of cases.
Again, the recommendations are based on the feelings or opinions of
the auditor. They are not based on any facts and must be
considered irrelevant to the audit.
The Arizona State Board of Dental Examiners, its staff, and
consultants have carefully reviewed the draft audit report. It
agrees with the conclusion that there is a backlog of complaint
cases awaiting review by the Board for final disposition. However,
it strongly disagrees with the findings and recommendations
contained in the audit.
The Board has concluded that the audit is based on speculation and
opinion, not on supportable facts. Further, the Board believes
that the auditors have a strong bias against the Board's procedures
and attempted to discredit them in the absence of any factual
The Board has implemented a number of procedural changes to
expedite the processing of complaints. The Board has increased the
number of clinical evaluation clinic nights to at least 3 per
month. Investigative interview panels now meet on an average of 2
times per week to dispose of as many as 14 cases per week. The
Board now meets for 2- day meetings every other month, in place of
its one day meeting. The Board will deal with as many cases as
necessary to reduce the backlog and keep current with the new cases
that are filed. In addition, the Board will have the assistance of
adequate legal counsel to avoid legal problems and deal with each
case in the proper manner.
All of these steps, plus many others, are permitting the Board to
deal with cases in a timely manner. his will go a long way to
reducing the frustration that many feel when they face delays they
should not have deal with.
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text:
Steve Hofvendahl
Nursery/Fruit Tree Program Manager
With a passion for horticulture and edible landscaping, it was natural that Steve Hofvendahl would find his way to TreePeople. Attracted by our name and signature work in planting and caring for trees across L.A., Steve joined us in 2003 to manage our nursery and Fruit Tree program. He oversees the planting and care for thousands of seedlings, with an emphasis on growing California native plants for our mountain forestry programs. Steve also trains volunteers in pruning and tree care and runs our annual distribution of fruit trees to low-income communities in Los Angeles.
An avid fruit tree enthusiast with more than 100 edible fruiting plants at his Altadena home, Steve is a Master Gardener with the L.A. County and a member of California Rare Fruit Growers (CRFG) and North American Fruit Explorers (NAFEX).

subset: commoncrawl


text:
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text:
By George Chen
The opinions expressed are the author's own.
Let's talk about Italy.
Italy is about art — Leonardo da Vinci, Michelangelo Buonarroti and more names. Italy is about luxury — Prada, Salvatore Ferragamo and more brands. Italy is also about food.
But, right now, Italy is about debt — huge national debt that is putting the entire eurozone or even the rest of the world into market panic. So, who's going to rescue Italy?
Perhaps Chinese investors. They are focused on Italy these days because the deepening debt crisis there has become a negative external factor dragging down the benchmark Hang Seng Index for two straight trading sessions. At the beginning, people were not fully aware of the situation, as some thought Italy could not be Greece.
After all, Italy is the No.3 economy in the euro zone. How can Italy be in crisis? If Italy is in trouble, what about the rest of Europe? Yesterday, I moderated an online forum where a former Trade Commissioner for the Italian government spoke. Mr. Romeo Orlandi, an old China hand, who's now teaching globalisation at the University of Bologna in Italy, said Italy was "too big to fail".
The European Union may find it difficult to work with the current Italian government given political dramas related to Prime Minister Silvio Berlusconi and the highly complex domestic politics in Italy, but one likely scenario is that Italy should survive from the growing debt crisis in Europe if Beijing decides to step in to help.