Unit 4 - Activities and Processes

You are serving on a comprehensive dental school visit. Yesterday you completed an hour interview with the chair of the department, Dr. Competency. Today you have another such interview scheduled. This morning prior to the initial meeting of the site visit team, the chair of the team calls you aside to speak with you.

"Dr. Site Visitor, at my briefing with Dean Black at the end of the day yesterday, he indicated that Dr. Competency came to him to discuss the interview you had yesterday. Dr. Competency was frustrated because he felt your questions suggested you had not carefully read the self-study. You asked questions that had been thoroughly answered in it. Additionally, he was somewhat distressed that you seemed inattentive to his responses, looking aimlessly away, and doodling on your notepad. Finally, Dr. Competency told Dean Black that later in the day you had discussed with faculty members the concerns he had about them, and the manner in which they conduct their courses. I realize that you have another interview with Dr. Competency today, and wanted to alert you to the concerns expressed in order that you might attempt to address them with him."

Assuming Dr. Competency's impressions are unfounded, (which surely they are!) how would you 'recover' his confidence as you begin the interview with him today?

Objectives

After reading the materials in this unit and answering the questions included, the Site Visitor will be able to:

1. Identify and apply the basic data collection approaches used by Site Visitors to verify information

2. Analyze situations for appropriate behavior of Site Visitors

Although you may be assigned specific evaluation responsibilities, you should be aware of all aspects of the program during your visit. Observation and note-taking should be an ongoing process by all site visitors, and this information should be included in the debriefing.

Look closely at all of the facilities and equipment. Careful observation can provide you with insight into the students' and faculty's routine, interpersonal relationships, and quality of teaching and supervision - in short, the everyday workings of the program. Remember, however, your presence has an effect on the program "heightened normalcy"; therefore, you will want to observe the structural characteristics of the program. For example, if the faculty and administrative offices are in a distant building you may be prompted to ask questions regarding their availability in the clinic and supervision of students and staff as well as their ability to provide counseling and assistance if needed.

The team should include observation of the following:

• direct patient care areas: clinics, supply, reception/accounting, emergency treatment, radiology, sterilization
• faculty areas: offices, labs
• student areas: study facilities, locker room/lounge
• educational support: classrooms, libraries, media

All interviews are designed to exchange information about a person or program and to get and/or give information. The most common method of gathering and verifying information on-site will be through the interview process.

Interviews should be structured; if you follow the structure suggested below you maximize the time on-site to gather the information needed for your report.

1. Be prepared: A first, critical step in conducting a successful interview is to be prepared. It is imperative that you have read the self-study and have a thorough knowledge of it. Among the most distressing and embarrassing things that can occur (for you and the Commission) is to ask questions that are clearly addressed in the self-study documents. You will lose credibility with your hosts if it becomes apparent that you have not adequately prepared for the visit by reading the self-study which they worked long and hard to compile.

Identify the points you want to cover in each interview ahead of time. When reviewing the self-study, look for problems, discrepancies and areas where more information or clarification is needed. Develop a system of issue organization or categorization that you are comfortable using on-site. You may want to use the standards as main headings, and list your questions underneath the headings. For example, if you did not find any documentation supporting adequate clinical facilities you might ask a student "Is there an operatory always available when you are assigned to the clinic?"

You will receive an agenda/schedule of conferences with a list of the respective individuals involved in the program. Organize the questions by conference type before the sessions begin.

Remember, your time with each group of individuals will be very short. You will have little opportunity for reflection. Questions unasked are often opportunities lost because it is usually difficult to meet again with the same people.

1. Explain who you are and why you are there. Begin each session with introductions and a statement about the purpose of the site visit, which is to review the program and determine to what extent it meets the Accreditation Standards. Include a comment about interviewing as a means to gather additional information that will be used to develop a fair, accurate report to the Commission. It is also important to reconfirm that it is the Commission that will ultimately determine accreditation status based on the materials submitted by the institution and the site visit report, not the visiting committee.

Confidentiality should be emphasized in each interview. Stressing the seriousness of the Commission's and Site Visitors' commitment to confidentiality is helpful in making interviewees more comfortable.

Conclude the introductions by thanking the participants for their time. This sets the tone for the interview and clearly delineates roles of those present.

1. Take notes. It is critical to take notes before, during and after the interview. Accuracy is essential, and it is easy to forget what was learned from one session to the next. There are times when it is necessary to corroborate information learned in an interview with another individual or group. It is important not to forget to follow-up on any such question or issue at a later time, if indicated. Each Site Visitor should assume responsibility for gathering information. Do not assume that another Site Visitor will obtain the necessary information.

2. Use a non-directive approach with open-ended questions to introduce every new topic. The non-directive approach involves very little structure. Open-ended questions that require the respondent to answer with more than a "yes" or "no" are used. Encourage participants to talk openly. Below are some important points about the non-directive, open-ended approach:

• Questions should be broad and unstructured, indicating the topic to be discussed.

• Use of open-ended questions will help to establish rapport.

• Open-ended questions are most effective in getting at threatening and/or embarrassing material.

• The non-directive approach is useful in learning about attitudes and feelings.

• Maintaining control and balance of the interview may be difficult.

• Obtaining information in a timely manner requires diligence.

• Follow-ups, probes and restating will allow movement in a specific direction.

Examples of open-ended non-directive questions:

• "Tell me how you develop your instructional objectives."

• "How do your students score in the basic science portion of the National Board exam?"

• "Explain how the didactic instruction complements the experiences provided in the clinic.

• "How often does the faculty meet?" For additional questions that may be useful during your interview see Appendix 4.1.

1. Use a directive approach with closed questions when you need specific details. The "directive" interviewing approach is highly structured. It is most useful when you know where you want the interview to go and what you want to accomplish.

• It is an efficient method for collecting a great deal of information.

• It is not recommended if you do not know what kind of information is needed.

• This approach may become very mechanical and too specific with the potential for superficial answers.

Although open-ended questions provide more discussion, there are times when you need to use closed questions. A closed question is useful in limiting the other person's talking. For example,

• How many amalgams do students complete?

1. Use follow-ups or probes to obtain more information. If you feel you need more information, ask an additional question using words like "how" or "why." Sometimes encouragement is necessary for further discussion.

2. Guide the interview process. Do not allow the interview to turn into a gripe session. Keep participants focused on the issues.

3. Paraphrase and summarize information. Before you go on to the next topic, paraphrase or summarize the information you have obtained. This gives you and the person you are interviewing the opportunity to verify that you have an accurate understanding about the issue in question.

People to Interview

• Administrators. They are an important, but not the sole source of information about the program.

• Faculty. Determine the role each member of the teaching staff plays in the program. What do they teach? When do they teach? How do they teach it? Also, ask specific questions about clinical supervision and staff input into the conduct of the program and evaluation processes.

• Students and Residents. You will have opportunities to talk with students and residents. They will have been notified of your visit. Depending on the discipline you are reviewing, there may be an open student session that usually has a large attendance. This will be an excellent chance to hear major concerns and have them confirmed or rejected by the majority of students. An interview with class officers or representatives or other small group of students provides the opportunity to become more specific and to ask follow-up questions. Students are always a good source of information, but it is important to put them at ease before the interview begins by explaining that everything they tell you is confidential. As in the case of all interviews, you must confirm any information obtained through other sources.

A key skill to interviewing is listening. You should develop active listening techniques. Active listening is being aware of a respondent’s total communication effort – verbal and nonverbal communications, and acting in a way that the person interprets as attentive and concerned. The listener cannot be planning his/her next response or question while the person is talking. The key to being a good listener is to want to listen. This requires discipline.

 Use the following to help develop your active listening skills:

1. Assume the interview will be interesting. 

2. Concentrate on the content of the respondent’s message. 

3. Listen for central themes, as well as specific facts. 

4. Communicate your interest by nodding and making frequent eye contact. 

5. Don’t plan your response while the other person is talking. 

6. Paraphrase the respondent’s remarks to double-check understanding and to demonstrate your full attention. 

7. Don’t interrupt or finish sentences for the respondent. 

If you and another Site Visitor are conducting an interview together, make sure you listen to each other, not just to the respondent. This display of mutual respect will enhance your credibility.

"Whenever two people meet there are really six people present. There is each man as he sees himself, each man as the other person sees him, and each man as he really is." - - William James

In addition to observing, interviewing, and listening we all engage in nonverbal communication. There are elements of nonverbal communication that we should be aware of, recognize, interpret and control. Obviously, we cannot control the nonverbal behaviors of others, but we can learn to be careful observers of others and even more important, we can control our own nonverbal behaviors.

This section will focus on three nonverbal behaviors - eye contact, body language and vocal effectiveness. As a site visitor it is important that you are cognizant of the unspoken messages sent by you and others during a site visit.

Eye Contact

Strong eye contact tells others you are honest, confident, friendly and cooperative. Conversely, lack of eye contact may be interpreted as dishonesty, self-consciousness, hostility or competitiveness. Obviously, you want to be perceived as the former! To help you avoid nonverbal pitfalls, the three most common problems with eye contact are listed below.

1. Looking away or down as you speak. This indicates a lack of confidence in your own message. If you don't think your message is relevant, accurate or interesting, why should your listener? Look directly at your listener, especially at the beginning and end of your message.
2. Looking away or down as the other person speaks. This gives a strong message of boredom or hostility. Again, look directly at the speaker, especially at the beginning and end of the message.
3. Looking for longer than 15 seconds. Although eye contact is essential to your image, you can overdo it and give a hostile impression. Look away briefly; think of it as a pause in the eye "conversation."

It is extremely difficult to evaluate your own eye contact behavior. Your best route to improvement is to ask for honest feedback from people you trust (who probably have strong eye contact or you wouldn't trust them!).

Body Language

Second only to eye contact in importance, is body language which gives a strong message on how you feel about yourself, others and the topic under discussion. The following guidelines will help you project an image of concern and confidence.

1. Relax. A relaxed posture builds rapport because it is associated with honesty and confidence. It also encourages others to be relaxed, open and honest.
2. Face the other person squarely and lean forward in your chair. This shows interest and makes it easier to pick up nonverbal cues.
3. Keep an open body posture. Folded arms gives others a message of defensiveness and potential hostility.
4. Don't fidget. Smoothing your hair, twisting coat buttons, pulling lint off your jacket, drumming your fingers or shuffling papers aimlessly all spell nervousness and/or boredom to your listeners.
5. Stay at the same height as the other person. If the person is seated, sit down. If the person is standing, stand. This will help keep your conversation on an equal footing.
6. Always ask before you invade a person’s territory. Your position as a site visitor requires access to files, reports, offices, clinics, etc., that "belong" to other people. Tread carefully or risk resentment from the "owner" of the space or object.

Voice Effectiveness

How you speak is as important as what you say. Tape record yourself in a speaking situation for at least five minutes, and check yourself on the following points:

1. Which verbal fillers ("ers," "ums," "you knows") do I need to eliminate?
2. Is my speech smooth or choppy? Do I pause at the ends of ideas and sentences or in the middle of them where pauses are inappropriate?
3. Do I have variety in pitch, or do I tend to fall into a monotone or a repeated "sing-song" pitch pattern?
4. Is the volume appropriate -- neither too loud nor too soft?
5. Is the rate appropriate -- neither slow nor rushed?

On-site data collection and verification includes written materials as well as information gleaned from interviews and observations. Although you have received the written self-study, it is important to clarify information that may be unclear in the documents you received. For verification purposes, ask to see copies of syllabi, course materials, sample evaluation forms, charts, schedules and other forms that show ongoing patterns of documentation. For example, you might ask to see:

• Copies of a course outline and materials. Are the goals, objectives, evaluation criteria, etc. clearly and consistently communicated to students?
• A clinic schedule. Does the schedule accurately reflect the activities? Are students allowed adequate time to meet accreditation and program requirements?
• Sample evaluation forms. How often are students evaluated? Have the students seen the completed evaluations? Are they evaluated qualitatively and quantitatively? Are evaluations based on course/clinical objectives?
• Active patient records. Are medical histories updated? Are events appropriately documented? Is the timeliness of treatment monitored? Are appropriate signatures included? How often are the records reviewed?

There is a paradox in being a Site Visitor; you have to remain open-minded, while at the same time reach definitive conclusions about a program. If there are discrepancies, you need to probe more deeply. Is the problem one of record-keeping or is there a deficiency in the education provided? Sometimes it is necessary to go back and ask some additional questions of an individual you have already interviewed.

It is important to tell the faculty, department chair or administrator that there is a discrepancy that you would like to resolve. Don't play cat and mouse. Work together until you are satisfied that you have accurate information. Don't leave until you are confident with your assessment.

If problems of verification persist, you should explain the deficiency in your report and make a recommendation that the deficiency be corrected.

There is the potential for differences in perception and attitude between you, the Site Visitor, and the faculty, students/residents/fellows and administrators during the site visit:

These perceptual differences create challenges during data collection. To overcome them, you must:

1. Reiterate the role of the Site Visitor. Explain your function. You are a fact finder. You will conduct interviews and look at documentation.
2. Be pleasant but not patronizing. Don't be too close or chummy, but also not too distant or stand-offish. Let it be known that you appreciate the professionalism of the institutional personnel.
3. Be prepared. It is essential that you have read the self-study. You need to have a first question prepared in advance for each interview. Your goal is to give the faculty or administrator an opportunity to describe that part of the program and tell you about how it fits into the overall program and its objectives.
4. Be thorough but not picky. Review with the faculty the kinds of documentation you need to see. You are seeking reasonable assurance that standards are being met. It is your job to separate the significant from the extraneous.
5. Be firm but flexible. You are not the star of the show, but you are the director. Stick to the prearranged schedule, because other members of the visiting committee and institution depend on it. Improvise if necessary to get the job done.
6. Identify and avoid potential prejudice. Go to the site visit with an open mind. It is always a good idea to travel light; leave the excess baggage generated by the rumor mill at home. Giving the appearance of being open-minded helps you to be open-minded.
7. Use the interviews to probe issues that resulted from reviewing the self-study report. Start with more general questions and gradually narrow the focus. Ask the faculty to explain ambiguous or contradictory responses in the self-study.
8. Control the flow of interviews. Don't allow long monologues. Tell the interviewees that you are very much interested in what they are saying, but since your time is limited, you have to proceed systematically.
9. Answer questions openly, honestly and succinctly. Maintain confidentiality; don't pass along information given to you in confidence.
10. Be empathetic. Try to put yourself in the administration's, students' and faculty members' places.

Review and Practice 4.1

Identify examples of open and closed, paraphrasing, summarizing, and probing questions.

Interviewing Strategies to Use For:

The "Yupper" - "Noper"

The "Yupper – Noper" answers as many questions as they can with short one to two word answers. They block the flow of information because they feel threatened, insecure or shy. If respondents believe that the interview will be used to evaluate them personally, they will edit their responses to protect themselves. Establishing trust is your first priority. Respondents must know that you will not pass judgment on their personal worth no matter what their answers may be or what information they provide. Building empathy is your second priority. Respondents must feel free to admit that they have forgotten, are confused, or need to check their facts for accuracy. Showing interest is your third priority. Occasionally, a person is "just not much of a talker" and must be drawn out and encouraged to talk.

Strategies to use during interviewing include:

• Use open questions – A closed question can be answered by a few words. An open question requires at least a sentence in response.
• Be an active listener – Stay at the same height as the respondent, face him or her squarely, keep an open body posture, make frequent eye contact, smile and nod.
• Echo central phrases – Repeat portions of the respondent's answer to encourage additional information.
• Be willing to wait for responses – Often when a respondent does not answer immediately, we become uncomfortable with the silence and rush in with a follow-up question. Sit, wait, give the respondent time to collect his or her thoughts. Silently count to 15 or 20, if you feel uncomfortable with the silence.
• Compliment even minor cooperation – Make a note of a positive comment and refer to it later in the interview to encourage the respondents.

The Rambler

This person won't stop talking. He or she includes endless detail, jumps to topics unrelated to the site visit or subject currently being discussed. He or she insists on taking the longest route possible to any conclusion, occasionally constructing new "roads" en route! This person not only taxes your patience, but wastes valuable time.

Strategies to use during the interview include:

• Interrupt – Whenever possible, try to interrupt without being rude. Wait for the rambler to pause for breath.
• Summarize – After interrupting, summarize the point briefly or echo a central phrase of the respondent's.
• Focus the question – Without pausing yourself, ask a follow-up question that is more specific or closed to try to limit the response. You may have to limit the interview to a series of "yes/no" questions.

The Hostile/Defensive Interviewee

The hostile interviewee assumes you are "out to catch or trip up" him or her. They immediately become defensive and may become aggressive.

Strategies to use during the interview include:

• Stay calm – Don't let defensiveness be contagious. Speak slowly; don't raise your voice, and keep your body posture relaxed.
• Paraphrase to show understanding – Slow the pace of the conversation by paraphrasing the comments of the interviewee and ask if you have understood correctly. Restating major points will demonstrate your willingness to listen and correct inaccuracies.
• Stay positive – Compliment the program or interviewee about something you have heard, read or observed. Be sincere.
• Avoid using the words "you" or "your" – These words make program deficiencies seem like personal deficiencies and contribute to a defensive atmosphere. Rather than saying "you don't" or "you reported," say "the program doesn't" or "the self-study reported."

The Puppy Dog or "Yes Man"

The puppy dog or "yes man" respects you, admires you, desires to please you and wants to be "your best friend!" His or her main goal is to give you the right answer. The "yes man's" right answer is whatever answer he or she thinks you want to hear. With an outward appearance of complete cooperation, the "yes man" may be responsible for as much inaccurate information as other difficult interviewees.

Strategies to use during the interview include:

• Avoid leading questions and adjectives – Ask question using neutral language and strong adjectives that may give the respondent a clue as to the answer you expect. Ask for facts.
• Monitor your nonverbal behavior – Be aware of how you communicate nonverbally. The "yes man" may be able to predict your expected response by your inadvertent body language signals.
• Use a "laundry list" approach – If you need to give choices, include both positive and negative items in the list so the respondent cannot avoid any negative responses if they are accurate.

The Whiner/Complainer

This person is not happy with their personal situation and brings this attitude to the interview. They are usually seeking sympathy and support for their position.

Strategies to use during the interview include:

• Stay neutral – Be careful not to justify or "feed into" the complaints of the interviewee with facts, opinions, or information from previous interviews.
• Don't sympathize or reassure – Sympathize only by paraphrasing the complainer's remarks; do not offer reassurance in a manner that might be taken out of context later.
• Ask for facts – Ask questions that focus on the facts and issues related to the standards.

The Smooth Talker

This type of person may have access to the specific information you need, but reveals only generalities – perhaps in an attempt to present a positive image. Do not waste time on trying to gain the information or on wondering why the respondent is not being cooperative.

Strategies to use in the interview include:

• Narrow your questions quickly – Focus on the specific facts you would like to verify. Ask questions using a list approach.
• Seek alternative sources of information – Minimize the time spent on trying to get information from this person. Go through the issues you had identified as important, but do not probe if you decide that this person is not providing the depth of information needed.

Review and Practice 4.2:

Indicate whether these are appropriate (A) or inappropriate (I) approaches to gaining more information and explain why it is appropriate or inappropriate. Then rewrite the inappropriate examples as appropriate information gathering tools.

1. "Of course you agree that..."
2. "How would you describe your relationship with your immediate superior and your subordinates?"
3. "That's terrible! I don't see how you stand it."
4. "What is your perspective on…"
5. "It really tests your patience, doesn't it?"
6. "I must admit this is the worst case I have seen in four years."
7. "How are you applying the guidelines?"
8. "It sounds like this situation has made your job more difficult."
9. "May I assume you are applying the guidelines as directed?"
10. "Do you evaluate faculty every year using a standardized format?"

1. Open Question, 2.Open Question, 3. Open Question, 4. Open Question, 5. Closed Question, 6. Closed Question, 7. Paraphrase, 8. Paraphrase, 9. Summarize, 10. Probe, 11. Probe, 12. Probe, 13. Probe

1. (I) - leading question, ask as open-ended question, 2. (I) - "double-barreled" question, separate into 2 questions, 3. (I) - don't provide justification for a complaint, make a statement that shows you understand, but do not agree, 4. (A) - open-ended question, 5. (A) - shows you understand his/her perspective, 6. (I) - don’t provide support for a negative statement, 7. (A) - use non-directive, open questions to get the most information, 8. (A) - be empathetic, 9. (I) - using a yes/no questions that leads respondent to easy answer, 10. (I) - try not to provide specifics in questions, ask so respondent can "fill in the blank"

More Sample Open-Ended Questions

• "One of the things we heard was ________; looking at your report _________ why did you feel this happened?"
• "Do you have any difficulties in getting an appropriate number of patients?"
• "What is the structure of the curriculum committee?"
• "What are the subcommittees?"
• "How does the curriculum committee function?"
• "How does information flow back to the departments?"
• "I would appreciate some comment about Steinberg and Zaki."
• "Could you give me a little historical background on ________?"
• "How did ________ work?"
• "How are the basic sciences integrated into the dental curriculum?"
• 'How will mechanisms 'in progress' work?" (Ex: planned rounds)
• "There appears to be some 'tension' between minimum requirements and competency; can you address this?"
• Follow up question - if students completed a numbers competency what keeps them from checking out and not doing more?" (Trying to get at the comprehensive core issue)
• "Walk me through this scenario: There is a 3-unit bridge that's ready to be delivered, but the patient has a $300.00 outstanding bill."
• "How do your students perform on the NERBS?"
• "What are some of the strengths and weaknesses of the comprehensive care model you are using?"
• "Predoctoral program - how do you handle a student who hasn't quite achieved competency?" "How do you do remediation?"
• "Tell me about your responsibilities."
• 'Tell me about the courses you teach."
• "How do you address critical thinking in your course? clinic?"
• "Tell me about your evaluation methods and how they relate to competencies."
• "How do you handle faculty calibration?"
• "Would you comment on how you integrate biomaterials with other dental courses?"
• "Can you describe your policies on implants?"
• "What is your feeling about availability of patients?"
• "Describe your financial situation."
• "What are your program needs?"
• "What are problems you face?"
• "What are your equipment needs?"
• "What are your space needs? (clinic, lab, research, office, etc.)"
• "Do these questions help get at vital information or do they lead faculty/ chairs into thinking accreditation is a way to leverage for something?"
• "How does your faculty practice work?"
• "Can you describe your financial support?"
• "Evaluate the operating facilities."
• "What would you change?"
• "What kind of relationship do you have with anesthesia?"
• "How does 'call' work?"
• "Do you feel your graduate students have adequate support personnel?"
• "Describe your patient population (adequate numbers)."
• "Describe the students' exposure to using conscious sedation (nitrous)."
• "What kind of input do you have into the curriculum?"
• "How are part-time faculty calibrated, developed?"
• "How would you describe the students' experiences in occlusion, splinting?"
• "Describe the process used for oral board exams."
• "How do you as a part timer receive evaluation? From students, residents, other faculty, chairman, etc."
• "How do you feel about your clinical requirements?"
• "What do you think of the program?"
• "Describe your clinical coverage."
• "Do you deal with philosophical differences?"
• "Do you have any concerns with interdepartmental referrals?"
• "How are you evaluated? (process, access to file)"
• "What would you do if you received a negative evaluation? "
• "Do you have an understanding of 'due process'?"
• "When you matriculated were you given a copy of due process?"
• "What are your teaching responsibilities?"
• "What contact do you have with other residents?"
• "How do you feel about courses offered outside the department?"
• "How is your support personnel?"
• "Do you have access to new technology? materials? instruments?"
• "How do you manage, recall, maintenance?"
• "Who is responsible for teaching maintenance?"
• "What is your exposure to precision and semi-precision attachments?"
• "What experiences do you have with implants?"