Unit 5 - Report Writing

You are a Site Visitor on a comprehensive dental school site visit; your second such experience. In your role you have accompanied the basic science Site Visitor on two of his interviews, one on the first day of the visit and another today, the second day.

Yesterday you began to sense that the Site Visitor was applying the standards in an overly prescriptive manner. That sense was confirmed today. He seemed to be going significantly beyond the expectations set forth in the standards. Certainly he was applying expectations that were in excess of what you had observed the basic science Site Visitor apply at the previous visit of which you were a part.

Yesterday at the executive session at the close of the day, he suggested that the basic science curriculum has significant problems, and was critical of the faculty and their instruction. Today you are in a luncheon executive session, and he is speaking, "I am very distraught by what I see in the basic science curriculum. It is certainly not in keeping with my standards for what constitutes an excellent curriculum. I will present 8 recommendations to you today, and am anticipating another 4-6 to emerge this afternoon."

You realize that the final site visit report to the Commission must represent the consensus of the team, and be affirmed by the entire visiting committee. Based on your interviews, you believe the basic science curriculum is adequate, meeting all of the standards, with the exception of potentially one.

What do you do or say at this time?

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

1. Explain the purpose of the Site Visit Evaluation Report (SVER) and its relationship to the narrative report produced by the site visit team
2. Trace the development and dissemination of the site visit report
3. Recognize and write an accurate and complete recommendation with supporting narrative
4. Recognize appropriate responses to other site visit team members during development of the team's report

View Appendices for Site Visit Documents

The final site visit report is integral to the accreditation process; it is developed and disseminated as follows:

1. Individual site visitors draft sections of the team preliminary site visit report during executive sessions of the site visit.
2. The team draft report is given to the Commission on Dental Accreditation (CODA) staff if staff is present) before leaving the site or is mailed to staff by the site visit chair/staff representative within 3-5 days following the visit.
3. Commission staff consolidates the team draft report into the preliminary draft site visit report.
4. The edited report is sent to visiting committee members for review, comment and approval.
5. After approval is obtained, CODA staff forwards a letter and the preliminary draft report to the chief executive officer (president) of the institution and the chief administrative officer (dean, program director, chief) of the academic or administrative unit that sponsors the program. Distribution of the draft report to faculty is the prerogative of the administrators, but it is recommended in the cover letter.
6. The institution has 30 days to submit a response to the report; the response report may include factual issues and or differences in perception to CODA staff, and may report changes made since the site visit until the deadline provided (either Dec. 1 or June 1).
7. The appropriate Review Committee and the Commission consider the visiting committee's approved draft report and any institutional response.
8. The Commission determines the program’s accreditation status and transmits the final site visit report to the institution along with a letter documenting the program’s accreditation status and any remaining recommendations for which compliance must be demonstrated.

The Site Visit Evaluation Report (SVER) is used to guide site visitors when verifying a program's compliance with standards and policies. Understanding the SVER (Appendix 5.1) is key to developing an accurate narrative report. The SVER lists the "must" statements contained in the Accreditation Standards and asks site visitors to verify compliance with the “Program Changes,” "Third Party Comment", "Complaint," “Distance Education,” and other CODA policies.). The statements should be considered as true or false: YES = true, NO = false. An answer must be provided for each statement based upon information obtained from the self-study and through the site visit.

Rather than asking questions, that can seem more abstract/theoretical, statements are used. Statements are direct and straightforward

• Positive Response in the SVER

If, based on the information obtained, you can make a statement of fact about the program and affirm the statement is TRUE indicate YES. When you indicate YES to statements within the SVER, you have two options:

1. Move to the next question without comment. In your estimation, statements marked YES meet the accreditation standards and no further comment is necessary.
2. You can make a suggestion for improvement. Suggestions are made when the program meets accreditation standards; however, compliance could be enhanced. The program is under no obligation to respond to suggestions.

• Negative Response on the SVER

If you circle NO on the SVER you are indicating the program does not meet the accreditation standard and you must, therefore, make a recommendation. A recommendation includes a stem plus a statement from a Standard.

Example #1 Stem: It is recommended that Body: the program provide adequate and appropriately maintained facilities to support the academic and clinical purposes of the program that are in conformance with applicable regulations.

Remember to include only those aspects of the standard that are not met. The recommendation cannot be prescriptive. It must identify how the program is not in compliance, not what to do to bring the program into compliance.

To support the recommendation, the accompanying narrative must also include answers to the following questions:

• What is required?
• What was found?
• Why is it a problem?

Example #2

Standard: The program must provide adequate and appropriately maintained facilities to support the academic and clinical purposes of the program that are in conformance with applicable regulations.

Through on-site observation of the program facilities f the visiting committee noted there is adequate clinical space for students within every scheduled clinical session. The visiting committee further noted there is a designated sterilization and maintenance area for instruments and equipment; however, the sterilization area does not provide adequate space for preparing, sterilizing and storing instruments. Current infection control guidelines require there be sufficient space to allow for designated contaminated and sterile areas to prevent cross contamination. The visiting committee determined the sterilization area space is not sufficient to allow for separation of sterile and non-sterile work areas.

Stem: It is recommended that

Body: the program provide adequate and appropriately maintained facilities to support the academic and clinical purposes of the program that are in conformance with applicable regulations.

Example #3

Standard: The program must provide clinical experience in orthodontics.

Through review of the self-study document and on-site interviews, the visiting committee determined the program provides instruction in orthodontics. The self-study report indicates students receive clinical experience treating patients that require uncomplicated orthodontic therapy. However, through review of the program’s record of the number and type of clinical procedures performed by individual students, the visiting committee determined some students do not receive experience in orthodontics. Further, the visiting committee did not identify orthodontic faculty scheduled for clinic coverage.

Stem: It is recommended that

Body: the program provide clinical experience in orthodontics.

Other Tips:

• Provide as much detail whenever possible that is relevant or supports the specific issue. Treat each NO as a separate issue and provide a rationale for each.
• Separate one issue from another. If combining two closely related recommendations seems to make sense, staff will combine or "bundle" recommendations.

Do not be concerned about a "report-writing style." It is best to be simple and direct. Use short sentences so your meaning is clear. It may be helpful to read the report aloud. It should be a straightforward and include a detailed explanation of your findings.

When writing the report, keep your audience in mind -- Review Committee members and Commissioners, who do not have first-hand knowledge of the program, must understand the deficiencies well enough to determine whether a recommendation has been met and to recommend/grant an accreditation status. Institutional administrators who may have very limited knowledge about dentistry and dental education must also understand the nature of the concerns.

The report must clearly identify compliance deficiencies with the standards. If you find a deficiency and fail to make a recommendation, the Commission cannot require the institution to correct the problem. Your report is the only record of the site visit. When the Commission meets, it must rely on your report; therefore, it is crucial your report be complete and detailed. Worst case scenario: The report contains hints of major problems in the program, but it does not follow through with clear explanations and recommendations. If the report makes only vague references to problems and deficiencies without making specific recommendations, the Review Committee and Commission will be unable to require specific corrections. It is possible that remaining problems could be left unchanged.

"The premise behind the team report is the site visit team has reached consensus in its findings. The entire site visit team is responsible for the finished report. Each team member must agree with the background statements and recommendations in the report. Consensus building begins during the executive sessions when each site visitor presents their findings to the team. Ideally, before the final executive session, the team will have reached consensus on most findings. If the team is evaluating more than one program team members should discuss potential recommendations and ensure consistent and appropriate application of common accreditation standards.

Presenting Your Findings to Your Fellow Team Members

When presenting your part of the report to the visiting committee, you should:

1. Avoid arguing. Present your position as clearly as possible. Use as much data as possible. Listen to others' reactions and consider them carefully before you respond.
2. Do not get into a win/lose situation. Look for the most acceptable alternatives.
3. Do not capitulate just to avoid conflict or reach agreement. Be cautious when agreement comes too easily. Explore soundness of reason. Analyze.
4. Avoid conflict-reduction techniques like voting, averaging or coin flipping. Do not make deals with a dissenting member of the site visit team.
5. Seek out differences of opinion. Use differences as opportunities to increase the group's chances of arriving at good decisions.

Providing Constructive Feedback to Fellow Team Members

1. Focus on the report, not the writer.

DO: "I think we need to move this recommendation into the suggestion section."

DON'T: "Can't you tell the difference between a recommendation and a suggestion?"

1. Discuss what is written, rather than why it is written.

DO: "I think we need to focus on whether the report accurately represents what occurred at the time of the site visit."

DON'T: "You don't want to give a critical report because the program director is a friend of yours!"

1. Be specific. Give examples.

DO: "The first sentence of this paragraph would read more clearly if it were divided into two sentences. Also, we should use more active verbs and fewer passive verbs."

DON'T: "This paragraph should be rewritten completely."

1. Give feedback immediately; don't wait.

DO: "Let's discuss your last statement."

DON'T: "Let's go back to what you said concerning a suggestion three sections ago."

1. Stress the benefits of improved copy, rather than the problems with existing copy.

DO: "If we can make this recommendation more clear, I know we'll see significant improvement in the program."

DON'T: "With a recommendation this vague, the program probably won't improve at all."

1. Keep comments short and to the point. This is not the time for extended discussion. The program has the opportunity to respond to the site visit report.
2. Focus your feedback on the amount of information that the presenter can use, rather than on the amount you want to give.

Responding to a Challenge of Your Views

1. Stay calm. Don't get defensive. Always recognize that a challenge of your ideas is not a reflection on your worth as a site visitor.

DO: "I appreciate your willingness to tell me this."

DON'T: "Criticism, criticism, criticism! That's all I hear!"

1. Listen carefully, be interested, and don't interrupt. If you show respect for others' ideas, they will show respect for yours. Also, if people are stressed, airing views without interruption will give them a chance to unwind and cool off.

DO: "Um hum... I see... Anything else?"

DON'T: "Now, wait a minute! I can explain! You see..."

1. Don't repeat the negative comments of others. For example, if someone says your report is biased:

DO: "Not at all."

DON'T: "Biased? I'm not biased. How can you say I'm biased?"

1. Begin your rebuttal with a "bridging" statement.

DO: "I can see why you would be concerned."

"I used to feel that way myself."

"You're right, that was certainly the case five years ago."

1. Don't disagree immediately with other people's ideas. Wait until after you have discussed points of agreement.

DO: "I can see that we agree on the first three points in our recommendation. However, on the fourth point, I would like to discuss further..."

DON'T: "Absolutely not! The fourth point must..."

1. If the challenge is general or unclear, ask for clarification or examples. For example, if you are told that you are overly critical of a program.

DO: "In which recommendation have I been too critical?"

DON'T: "I am not being overly critical!"

1. If someone attacks you, rather than your ideas, calmly point out that the discussion will proceed more productively if everyone limits comment to the report, not the people.

DO: "I am sorry you feel that way. Now, if we can return our discussion to the report..."

1. Summarize the challenge and apply active listening techniques. "So you are worried that..."
2. Avoid "dummy" messages. Don't use statements implying that anyone who doesn't understand or agree with you must be a bit dense, i.e., a "dummy." Phrases to watch for: "But we all know...," "It's obvious..., It's easy to see...," "Surely you remember...," and "I've told you repeatedly..."

The following document libraries are available:

• Download Documents for Advanced Site Visits
• Download Documents for Allied Site Visits
• Download Documents for DDS/DMD Site Visits