Unit 3 - Roles and Responsibilities

Roles and Responsibilities of Visiting Committee Members

You are an assistant professor at State University, a position you have held for the past five years. As a result of some of the excellent clinical research you have done in your discipline, which has earned you considerable respect among your colleagues, last year you were nominated and named to be a Site Visitor for the Commission on Dental Accreditation. Your credentials are currently being organized for presentation to your department chair for promotion to the rank of associate professor and the granting of tenure.

You returned yesterday from your first site visit, a multi-program visit where you served as the site visitor of the advanced dental education program in your discipline. Having eagerly anticipated the visit, it proved to be as enjoyable and exciting as you had thought.

The program you visited had many deficiencies. You felt as if you had been very fair and objective, and that you had communicated with empathy, but also very honestly with the program director. While he was disappointed in the results, he had complimented you on your professionalism at the exit interview.

The camaraderie of the site visitors was strong, and you were impressed with the careful, thoughtful, and methodical manner in which the team conducted its work; and the leadership of the chair. Your assessment of our personal performance was strong, and you feel good about how you represented the Commission. You had the most significant challenge of the discipline-specific Site Visitors.

Today you are off to a noon departmental meeting. After a discussion of the various items on the agenda, and before closing the meeting, your department chair looks at you and says: "Dr. Site Visitor, tell us about the program at Big City University. They certainly do not have much of a reputation. How could they have an accredited program, as they have lost over half their faculty in the last year? I hear by the grapevine that the students are up in arms! Tell us what you found out about the place!"

What do you do? How do you respond to your Department chair?

As you learn more about your role as a Site Visitor, perhaps the most important thing to remember is that the success of the visit depends on YOU. You are the eyes and ears of the Commission on Dental Accreditation. Your analysis and written site visit report are critical to the success of the entire accreditation process. The Commission relies on the information in the self-study and your report to formulate its decision about the accreditation of programs. This report also becomes a reference document for the next regularly scheduled site visit five to seven years in the future.

The successful site visitor:

• evaluates objectively
• gathers facts
• evaluates data
• acts confident and professional
• understands the faculty's point of view
• is accurate but tactful in conveying program strengths and weaknesses
• observes confidentiality
• reports actual or perceived conflict of interest to the commission before the site visit

General Comments

• Site Visitors serve as fact-finders for the Commission and are expected to be thorough, objective and cooperative with the visiting institution in their conduct of program reviews. An overly critical, negative or judgmental attitude on the part of a Site Visitor is inappropriate and undermines the value of the accreditation process.
• Site Visitors must assess programs according to the established accreditation standards and not according to their personal preferences or biases. While it is often helpful for site visitors to offer suggestions based on personal experience, institutions must clearly understand that programs are evaluated objectively according to pre-established standards.
• Site Visitors must regard all information obtained before and during the visit as confidential. Materials provided to a Site Visitor for the evaluation (e.g., applications and supporting documentation) should be destroyed after the Commission has considered the site visit report.
• Site Visitors must NOT accept social invitations from host administrators during the accreditation site visit. The function of the visit is program evaluation and review.
• Site visitors must remember that accreditation standards are deliberately broad to enable each program to interpret them within its own particular environment. The Site Visitor can assist the institution by exploring and suggesting alternative methods of meeting standards. However, neither the Commission nor its Site Visitors can dictate the specifics of how an institution responds to recommendations, since there are many ways in which most requirements may be met. Site Visitors should never discuss details about the operation of their own accredited programs.

The entire accreditation process is based upon integrity. This includes fair and impartial judgments, protection of confidentiality and the avoidance of any real or perceived conflict of interest. Confidentiality does not end with the site visit.

As a program reviewer, you have had access to a great deal of confidential material. You must not divulge that information to anyone at any time. This discretion is critical to maintaining the integrity of the Commission and its activities as perceived by the programs it accredits. If programs believe they cannot reveal confidential information to the Commission without having it made public, the entire voluntary accreditation process will fail. Only free and open sharing of information allows the process to succeed.

To remind you of the seriousness of the accreditation process and of its commitment to protect confidentiality, the Commission requires all Site Visitors and other external participants to sign an "Agreement of Confidentiality". By signing the agreement annually, you indicate that you understand the Commission’s policy on confidentiality and agree to abide by it.

Unless otherwise indicated, all meetings and site visit materials, all information obtained on-site, all protected patient health information, and all discussions related to program or institution accreditation are confidential. And, please remember that confidentiality has no expiration date - - it lasts forever!

Perception is also important when considering conflict of interest. Conflict of interest can be real or perceived, and both should be avoided. The institution has the opportunity prior to the site visit to request different Site Visitors if there is some question regarding conflict of interest. They receive a list of the Site Visitors prior to the visit and may request to remove one or more people from the list if they perceive or anticipate a conflict of interest. As a Site Visitor, you also have an obligation to consider whether you have connections with a particular program or institution that make it inappropriate to serve on the evaluation team.

Examples of conflict of interest include but are not limited to a visitor who:

• is a graduate of a program at the institution;
• has served on the program’s visiting committee within the last seven (7) years;
• has served as an independent consultant, employee or appointee of the institution;
• has a family member who is employed or affiliated with the institution;
• has a close professional or personal relationship with the institution/program or key personnel in the institution/program which would, from the standpoint of a reasonable person, create the appearance of a conflict;
• manifests a partiality that prevents objective consideration of a program for accreditation;
• is a former employee of the institution or program;
• previously applied for a position at the institution within the last five (5) years;
• is affiliated with an institution/program in the same state as the program’s primary location;
• is a resident of the state; and/or
• is in the process of considering, interviewing and/or hiring key personnel at the institution.

Other conflicts may be less obvious. If you are not sure whether a conflict exists, call and discuss your concerns with Commission staff. If a conflict of interest is not reported by the site visitor, the Commission might have to discard the results of a site visit and conduct another visit, a situation that would be damaging to the integrity of the accreditation process and expensive. On an annual basis, the Commission requires that all Site Visitors agree to and sign a Conflict of Interest Statement to ensure compliance.

Additional information regarding confidentiality and conflict of interest can be found in the Commission’s Evaluation and Operational Policies and Procedures (EOPP) Manual.

Review and Practice 3.1:

Would any of the following conditions be perceived as a conflict of interest? Explain your answer. If you are unsure, what would you do to clarify?

• You and the program director used to work in the same institution 10 years ago.
• Your child plans to go to the dental school that you will be visiting next year.
• You worked closely with several of the institution's faculty on an external committee three years ago.

The Commission uses several structured forms to facilitate and promote consistency in its on-site evaluations of programs. A description of these accreditation instruments is included below. Understanding these instruments will facilitate your role as a Site Visitor.

• Application for Initial Accreditation: This document is used by programs that are developing, have not enrolled students/residents, and wish to obtain accreditation by the Commission. The document is completed by the sponsoring institution and provides basic information about the program to be reviewed, including a description of its administration, staffing, facilities, curriculum and resources. It also contains supporting documentation relative to these areas (i.e., affiliation agreements, Biosketches, schedules, etc.). The purpose of the Application is to convey basic program information to the Commission by demonstrating that the program is developing or has developed according to the standards established by the Commission.
• Self-Study Report: In accord with the Self-Study Guide (Appendix 3.5), a program’s self-study report is completed by the sponsoring institution and summarizes findings of the program’s self-evaluation. Educational programs accredited by the Commission must undergo periodic self-evaluation to retain their accreditation status. By requiring self-evaluation the Commission ensures that accreditation will not consist solely of an outside agency assessing the adequacy of a program, but that it will also ensure institutional self-examination. By undergoing a self-study prior to Commission visits, institutions will also be better prepared for on-site evaluations.The self-study involves a program analysis in terms of the accreditation standards and an assessment of total education program effectiveness. It includes a review of all activities relative to its stated institutional purposes and objectives, and a realistic appraisal of its achievements and deficiencies. The self-study process permits a program to measure itself qualitatively prior to evaluation by a visiting on-site committee of peers from dental education and the profession.
• Site Visitor Evaluation Report (Appendix 3.6): The Site Visitor Evaluation Report (SVER) is used to summarize the visiting committee’s findings on each aspect of the program. The SVER follows the order of the standards and requires responses to statements that reflect the accreditation standards. This report is the document you will use to record your findings during the site visit. It is the basis for the written site visit report with its suggestions and recommendations. This written report and the institutional response to it are the documented basis for Commission action.
• Data Profile is a compilation of information about the program as reported by the program in its Annual Survey (Appendix 3.7) for the past five years. This data should be used to verify the information provided in the self-study report.

Each member of the site visit team has a defined role during the visit; however, it is also valuable to understand the process as a whole to better understand individual roles.

In preparation for the visit, you are expected to:

• Become thoroughly familiar with all materials submitted by the institution. Aspects of the program that appear deficient or require further clarification should be identified during this review. If specific materials you think would be useful are excluded from the report, make a request for the materials through the site visit team Chair/Staff Representative . He/She will contact the institution and ask for a response before the visit. The program may send the materials or have them available at the time of the visit.
• Become thoroughly familiar with relevant Accreditation Standards and the Site Visitor Evaluation Report.
• Determine whether appointments have been scheduled with the individuals you wish to interview.

During the visit, Site Visitors are expected to:

• Meet with other member(s) of the visiting committee and/or Commission staff the evening before the site visit to review the agenda and materials for the visit.
• Follow the suggested agenda that has been developed by the program and the site visit team chair/Staff (Appendix 3.8 – Sample Site Visit Schedule ). The site visit is organized to follow the division of labor and general sequence of site visit activities specified in the agenda as closely as possible.
• Conduct interviews.
• Tour the physical facilities related to your area. Off-campus clinical facilities may be visited if a significant portion of each student’s/resident’s educational experience is provided at that site. (See Policy on Off-Campus Sites in EOPP)
• Review records and documentation, for example:
  • patient records (to be reviewed onsite only)
  • inpatient and outpatient statistics
  • records of numbers and types of procedures performed
  • course outlines
  • objectives for courses and off-service rotations
  • records of clinical supervision of residents/students
• Debrief program administrators at the end of each day. The staff representative or chair of the visiting team usually conduct this.
• Prepare a draft of your section of the written report.
• Conduct final conferences. The chair or staff representative usually conducts this meeting. Upon conclusion of the evaluation, Site Visitors must inform the program administrators (Dean, Director, Chairperson, etc.) of their findings. The final conference is of critical importance and must never be eliminated or slighted. No site visitor should leave a program without providing a thorough debriefing.

It is also necessary to meet briefly with the appropriate institutional administrator(s) (President, Chancellor, Deans, etc.). They must be informed of the committee’s findings at the time of the site visit.

After the visit, Site Visitors are expected to:

• Participate in completing a collaborative SVER for the site visit team. Only one report, a collaborative effort, should be submitted by the chairman/staff representative to the Commission office. Site Visitors should ensure that they have all information pertinent to these assignments before leaving the site. Contact with the institution, program and/or faculty regarding the visit is prohibited after the site visit is concluded.
• Submit travel reimbursement form. Per diem and travel expenses will be reimbursed following receipt of the completed reimbursement paperwork and appropriate receipts. Policy on Volunteer Travel
• Within one month of the visit, a post-site visit evaluation form will be e-mailed to the visiting committee. Please submit the post site visit evaluation form to the Commission office.
• Review and return to the Commission office the written draft report with comments, by the requested date. (Commission staff prepares the preliminary draft report based on the report completed by the Site Visitors. The draft is sent to Site Visitors for review and comment to ensure that it accurately reflects their findings. Site Visitors should retain a copy of their evaluation report to facilitate this process. The approved written draft is then forwarded to the institution for review and comment.)
• Following the site visit, Site Visitors will be provided instructions on the appropriate destruction of all site visit materials.
• The team’s approved written report, along with comments and additional information from the institution, is considered by the Commission and its Review Committee(s) at a regularly scheduled meeting. The institution will be notified of the Commission’s action within 30 days following the Commission meetings.

Review and Practice 3.2: Summarize the general responsibilities of all site visitors prior to the visit, during the visit, and after the visit.

A thorough review of the institution's self-study is essential in your preparation for the site visit. Experienced site visitors offer the following suggestions to ensure that you are well prepared for the visit when you arrive:

1. Review the accreditation standards first. It is a good idea to review the accreditation standards and the Site Visitor Evaluation Report (SVER) before you look at the self-study so that you have the Commission's standards in mind as you review the program description.
2. Cleanse your biases. It is important to be as objective as possible when you review the self-study. Avoid assumptions based on the nature of the sponsoring institution. Try to understand the program on its own terms. Above all, don't expect the program you review to be structured like your program.
3. Read the self-study as though it were a textbook, not a novel. First, read the self-study straight through to get an understanding of how it all fits together. Then read it again. Be active rather than passive. Underline, highlight, take notes and formulate questions as you read. Remember that your goal is not just to familiarize yourself with the program, but to understand it well enough so that you can discuss it intelligently with program personnel. Note essential information, especially mission, goals, philosophy, and institutional effectiveness; in addition focus on:

Names of key program personnel:

• dean and administrators
• department chair(s)
• course directors
• key faculty
• people you will interview
• enrollment
  
  

Statistical short list:

• clinical board results
• national board scores
• certification board results
• senior survey results
• curriculum data
• job placement rates
• maintained compliance with previous recommendations
  
  

Program structure:

• who teaches basic sciences
• distribution of preclinical courses
• when does clinical experience begin
• how is the clinical program structure
  
  

Unique features:

• nature of patient population
• areas of emphasis
  
  

This information should be readily accessible. If you've done your homework, you should not have to consult the self-study repeatedly on-site to remember basic program characteristics.

4. Formulate questions about the program based on the self-study. What SVER questions can’t you answer from the self-study? What aspects of the program do you need to know more about? Are there major discrepancies in the self-study and its supporting documentation? What are the apparent problem areas?
5. Categorize questions under broad topic areas. The site visit schedule will provide information about which you will interview. List questions by interview session, so that you will ask each group all of the pertinent questions. Finding individuals a second time to ask missed or forgotten questions is very difficult due to the busy schedule for the visit. You should be able to locate your questions easily.
6. Keep the big picture in mind. Try not to nitpick or focus on minor discrepancies. You can avoid this by listing questions in priority based on the SVER form. You must have answered ALL of the SVER questions by the end of the site visit, including the narrative responses related to outcomes assessment and program effectiveness. You must also note the program's compliance with the complaint and third party comments policies.
7. Even though you've read the book, you have to see the movie. Some program directors are more skilled at preparing self-studies than others. Do not assume that a poorly written self-study reflects a weak program or that a well-written self-study reflects a strong program. Information not provided in the self-study must be obtained on site. There may be more (or less) going on in the program than is reflected on paper. That's why you are conducting a site visit!

Review and Practice 3.3: How do you evaluate your portion of the self-study if it is very different from your own institution or from the one you attend?

At the conclusion of the site visit there may be at least two final conferences scheduled (there may be more than two), one with the program administrators and one with the President of the institution. The chair of the visiting team or staff representative conducts the final conference. Individuals present during these conferences differ depending on the type of program visited and the preferences of the institutional administrators.

The final conference with the program’s chief administrator (Dental Dean or Program Director) as well as any other individuals he or she wants present is scheduled first. The meeting with the administrator(s) of the sponsoring institution (Chancellor/Provost/President/CEO) usually takes place immediately following the final conference. Unit 6 of the training manual contains a complete overview of the final conferences and presentation of findings.

Site visits differ in length depending on size and number of programs being reviewed at each institution. Visits to a dental school/college are usually accomplished in 2.5 days. Visits to allied dental programs range in time from 1.5 to 2.5 days. Visits to advanced programs in non-dental school settings are one to two days.

Dental school/college site visit teams usually include six site visitors, a chairperson, and Commission staff. Additional team members are added if there are multiple graduate or allied programs and/or a number of external sites. Advanced and allied education visits to a single program will usually include two site visitors, one of whom serve as chair/staff representative, and may include a Commission staff. Advanced and allied education visits to multiple programs concurrently will usually have one site visitor for each program area and Commission staff. During allied education visits, a dentist or national association of dental laboratories site visitor will also be included.

The program director and the site visit team chair/staff representative establish the site visit schedule. A sample schedule can be found in Appendix 3.8. Site Visitors should arrive the evening before the visit for a pre-visit meeting with the site visit team. Every attempt is made to follow the sequence and maintain the time frames in the schedule. Evening meetings are held to review the day’s activities and prepare for the next day. Departure from the site follows the final conferences.

Several weeks before the site visit you will receive:

• A letter confirming your appointment to the visit, the date of the visit, the hotel accommodations plus air travel information;
• The self-study report from the program;
• Information and statistics from the Commission;
• An agenda listing the personnel and activities that are scheduled for the visit. To ensure prompt reimbursement, travel reimbursement and receipts should be completed and returned with the appropriate documentation as soon as you return from your visit.
  

• Will conduct a briefing session with the entire visiting committee relative to the philosophy of the Commission on the approach, purpose and methodology of the conduct of the site visit on the evening prior to the first day of the site visit;
• Will be responsible for the continual reinforcement of the above concepts during the course of the site visit and for monitoring continually the conduct of the site visit;
• Will brief visiting committee members as to their role as a fact-finding and reporting committee and the appropriate protocol during the course of the site visit; including what is expected of each member in terms of kinds of activities and relative to the report of findings and conclusions and recommendations, with adequate background rationale for making recommendations and enumerating strengths and weaknesses in the education program being evaluated;
• Will lead all assigned conferences and executive sessions;
• Will serve as liaison between the visiting committee members and the dental administration and the executive administrators of the institution;
• Will make specific and special assignments to individual visiting committee members relative to evaluating and reporting on specific matters and sections of the site visit report, e.g. administrative organization, faculty, library facilities and resources, research program, facilities and equipment, admission process, hospital program(s), student achievement;
• Will be responsible for ensuring that consultants/site visitors fully understand their responsibility for reporting adequately, but succinctly, in their area of expertise (finance, curriculum, basic sciences, clinical sciences and national licensure);
• Will consult with the dental administration at regular intervals to discuss progress of the visit;
• Will be responsible, during executive sessions with visiting committee members, for the separation of recommendations from suggestions–focusing upon the recommendations which are to be included in the site visit report which are considered to be major, critical and essential to the conduct of the education program(s); suggestions for program enhancement are to be included as part of the narrative of the report; and
• Will be responsible for the preparation of a written summary of the visiting committee’s conclusions, findings, perceptions and observations of the program(s)’ in the form of suggestions and recommendations, as appropriate, for oral presentation during the exit interview with the Dean, and for presentation of an abbreviated summary during the exit interview with the institution’s executive administrators.
• Will assess institutional effectiveness including:
  • Assessment of the school’s mission statement;
  • Assessment and evaluation of the school’s planning, and achievement of defined goals related to education, patient care, research and service;
  • Assessment of the school’s outcomes assessment process; and
  • Evaluation of the school’s interaction with other components of higher education, health care education or health care delivery systems.
  • Will assess the effectiveness of faculty and staff including:
    • Assessment of the number and distribution of faculty in meeting the school’s stated objectives;
    • Assessment of the school’s faculty development process;
    • Assessment of the school’s faculty governance;
    • Assessment of the school’s measurement of faculty performance in teaching, patient care, scholarship and service; and
    • Assessment of the school’s promotion and tenure process.

Will confer with the sponsoring institution’s chief financial officer(s) and the dental administration and its financial manager to assess the adequacy of the full spectrum of finance as it relates to the dental school including:

• Assessment of the operating budget and budgeting process;
• Assessment of all sources of revenue (state, federal, tuition and fees, practice plans, etc.);
• Evaluation of the maintenance of the facilities and learning resources to support the school’s mission and goals;
• Assessment of the school’s compliance with applicable regulations;
• Assessment of the resources for planned and/or future renovations and/or new construction; and
• Assessment of the school’s resources as they relate to its mission and goals.

Will examine the education program and the educational support services including:

Admissions

• Assessment of admission criteria
• Assessment of admission policies and procedures
• Assessment of student body diversification

Instruction

• Assessment of course syllabi and outlines as related to the school's defined competencies
• Assessment procedures for student due process

Curriculum Management

• Evaluation of the goals of the dental education program
• Evaluation of the program's competencies and assessment of the competencies
• Evaluation of the integration of behavioral and biomedical sciences with the clinical sciences
• Evaluation of all courses with respect to the defined competencies
• Assessment of the school's ongoing curriculum review process
• Assessment of the school's patient care experiences in terms of meeting the school's defined competencies

Behavioral Sciences

• Evaluation of behavioral sciences relating to patient centered care
• Assessment of patient population diversity and student competency in interpersonal and communication skills

Practice Management

• Evaluation of the school's competencies in oral health care management and delivery

Ethics and Professionalism

• Evaluation of the school's competencies in ethical, legal and regulatory concepts

Information Management and Critical Thinking

• Assessment of the use of critical thinking and problem solving
• Assessment of the utilization of information technology

Student Services

• Assessment of student counseling, due process, student advocacy, financial aid including student loan repayment information, and student health services

Will work closely with curriculum consultant/site visitor to ensure consistency of evaluation and assessment. During the formal and informal evaluation of the basic sciences, the consultant/site visitor will conduct personal interviews with students, faculty and departmental chairpersons and during the assessment will focus on:

Biomedical Sciences

• Assessment of the school's stated competencies in terms of foundational knowledge for clinical competencies
• Assessment of the depth, scope and quality of instruction

Research Program

• Evaluation of the school's research program as it relates to its mission and goals
• Evaluate student opportunities for research
• Evaluate faculty opportunities to engage in research

1. Within the limitations imposed by the length of the site visit, will examine and evaluate the preclinical and clinical portions of the predoctoral dental education program and activities in terms of the details of what is occurring in these areas and assess the quality of the education and experiences provided to students to prepare them for dental practice.
2. Will work closely with the curriculum Site Visitor to ensure consistency of evaluation and assessment.
3. During the formal and informal evaluation of the preclinical and clinical sciences, will conduct personal interviews with students, faculty and departmental chairpersons and during the assessment will focus upon:

• Assessment of the school's ability to provide adequate patient care experiences to all students
• Evaluation and assessment of student attainment of competency Assessment of student competency in providing basic life support

Patient Care Services

• Evaluation and assessment of the dental school's quality assurance system including:

Standards of care, patient care and patient record review, mechanism to determine treatment deficiencies, outcomes and corrective measures

• Evaluation of the school's delivery of comprehensive care
• Evaluation of written statement of patient rights
• Evaluation of the school's patient access to dental emergencies
• Evaluation to the school's policies on the safe use of ionizing radiation
• Evaluation of the school's policies and procedures on infection and biohazard control and the disposal of hazardous waste
• Evaluation of the school's policy on patient confidentiality

During the formal and informal evaluation of the clinical program, will conduct personal interviews with students, faculty and departmental chairpersons and during the assessment will focus upon:

• stated objectives;
• adequacy of instruction;
• appropriateness of subject matter;
• intra/extra-mural experiences;
• student clinic requirements;
• student performance evaluation mechanisms;
• sterilization of instruments;
• patient care policies;
• laboratory tests for patients;
• patient physical examinations; and clinic administration.

Disciplines include: Advanced Dental Education Programs in Dental Public Health, Endodontics, Oral and Maxillofacial Pathology, Oral and Maxillofacial Radiology, Oral and Maxillofacial Surgery, Orthodontics and Dentofacial Orthopedics, Pediatric Dentistry, Periodontics, Prosthodontics (Combined and Maxillofacial), Advanced Education in General Dentistry, General Practice Residency, Oral Medicine, Orofacial Pain, and Dental Anesthesiology.

Advanced education program site visitors will utilize the site visitors’ evaluation report form for their respective area, conduct personal interviews with Program Directors, faculty and students, and assess the advanced education program focusing upon:

• administration and staff;
• admissions procedures;
• physical facilities and equipment;
• didactic program (biomedical, lecture, seminar and conference program)
• clinical program;
• evaluation of residents;
• research activities and requirements;
• library resources;
• intra/extra-mural experiences;
• hospital program; and
• teaching conducted by residents.

An assessment of the strengths and weaknesses of the advanced education program is based upon the published accreditation standards for each respective program.

A. Site Visit Chair

• Will function as chairperson/staff representative of visiting committee of consultants/site visitors evaluating the allied dental education programs in dental assisting, dental hygiene and dental laboratory technology;
• Will be responsible for the continual reinforcement of the Commission’s procedures to be used for the site visit and for monitoring continually the conduct of the visit;
• Will brief consultants/site visitors as to their role as a fact finding and reporting committee and the appropriate protocol during the course of the site visit; including what is expected of each consultant/site visitor in terms of kinds of activities and relative to the report of findings and conclusions and recommendations, with adequate background rationale for making recommendations and enumerating strengths and weaknesses in the education program being evaluated;
• Will chair all conferences and meetings of the allied dental visiting committee, as well as those which occur during the visiting committee’s executive sessions;
• Will be responsible for maintaining closely the site visit evaluation schedule;
• Will serve as liaison between the visiting committee and the allied dental visiting committee members;
• Will make specific and special assignments to individual visiting committee members relative to evaluating and reporting on specific matters and sections of the site visit report, e.g. administrative organization, faculty, library facilities and resources, research program facilities and equipment, admissions process, hospital program(s), student achievement;
• Will be responsible for ensuring that consultants/site visitors fully understand their responsibility for reporting adequately, but succinctly, in their area of expertise;
• Will consult with the allied dental administration at regular intervals to discuss progress of the visit;
• Will be responsible, during executive sessions with visiting committee members, for the separation of recommendations from suggestions – focusing upon the recommendations which are to be included in the site visit report which are considered major, critical and essential to the conduct of the education program(s). Suggestions for program enhancement are to be included as part of the narrative of the report; and
• Will be responsible for the preparation of a written summary of the visiting committee’s conclusions, finding, perceptions and observations of program(s) strengths, weaknesses, recommendations and suggestions for oral presentation during the exit interview with the dean, and for presentation of an abbreviated summary during the exit interview with the institution’s executive administrators.

B. Dentist: A dentist is also included, when at all possible, on site visits to dental assisting and dental hygiene programs in settings other than dental schools. An additional dentist consultant/site visitor will be added to dental school visiting committees when multiple programs are to be reviewed.

The role of the dentist team member during allied site visits includes the following responsibilities:

• Take notes during conferences;
• Conduct meeting with advisory committee, when applicable;
• Ensure confidentiality by waiting to begin the meeting until all affiliated school personnel have left the room;
• Introduce the visiting committee to the advisory committee members;
• Thank the members of the committee for meeting with the team and for their interest in and commitment to the specific allied program(s);
• Explain the purpose of the site visit;
• Discuss the Commission’s policy on confidentiality as it applies to the meeting and the entire site visit;
• Begin discussion of the following topics/questions:
  1. How often the committee meets and the purpose or goals of the committee
  2. Strengths/weaknesses of the students
  3. Specific current committee activities and future goals or anticipated activities
• Ensure that all of the questions in the Site Visit Evaluation Report form under Standard 1. Institutional Effectiveness, Community Resources are answered during the meeting;
• Assist Curriculum Consultant/Site Visitor in review of science courses;
• Review clinical courses and clinical evaluation mechanisms;
• Review learning resources – library & audiovisual materials/equipment (It is usually most efficient for this review to be conducted by the dentist consultant/site visitor only.);
• Review documentation in the self-study prior to visit;
• Conduct preclinical, clinical, and/or laboratory observations (on/off campus) with Curriculum Consultant/Site Visitor;
1. Extended campus laboratory facilities
2. Extramural clinical facilities
• Review equipment and instruments using Site Visit Evaluation Report Checklist under Standard 4. Educational Support Services;
• Formulate recommendations and suggestions; and
• After the visit, review and critique preliminary draft of the site visit report.

Disciplines include: Dental Assisting, Dental Hygiene, Dental Laboratory Technology, Dental Therapy, Dental Public Health, Endodontics, Oral and Maxillofacial Pathology, Oral and Maxillofacial Radiology, Oral and Maxillofacial Surgery, Orthodontics and Dentofacial Orthopedics, Pediatric Dentistry, Periodontics, Prosthodontics and Maxillofacial Prosthetics, Advanced Education General Dentistry, General Practice Residency , Oral Medicine, Orofacial Pain, and Dental Anesthesiology

• Uses the Site Visitor Evaluation report (SVER) form for their respective area.
• Assists with identification of off-campus sites to be visited.
• Conducts interviews with program directors, faculty and students/residents.
• Assesses the following aspects of the allied and advanced education program:
  • administration and staff
  • admissions procedures
  • physical facilities and equipment
  • didactic program (biomedical, lecture, seminar and conference program)
  • clinical program
  • evaluation of students/residents
  • research activities and requirements
  • library resources
  • intra/extramural experiences
  • hospital program
  • teaching conducted by students/residents
• Assesses the allied and advanced education program strengths and weaknesses based on the Accreditation Standards.

1. One representative selected by the institution in consultation with the Commission from two names submitted by the state board of dentistry to the Commission.
2. The state board representative is encouraged to attend all scheduled conferences and executive sessions of the visiting committee.
3. The state board representative participates in the site visit to develop a better understanding of the accreditation process and its role in ensuring the competence of graduates.
4. The dental, advanced dental and allied dental education programs are evaluated against the approved accreditation standards for each respective discipline.

While on-site the state board representative:

• provides assistance in interpreting the state’s dental practice act and/or provides background on other issues related to dental practice and licensure within the state.
• on allied dental education visits: assists the team in assessing the practice needs of employer-dentists in the community and in reviewing those aspects of the program which may involve the delegation of expanded functions.
• on dental school visits: functions primarily as a clinical consultant, working closely with the clinical specialist member(s) who evaluate the adequacy of the preclinical and clinical program(s) and the clinical competency of students.

During their initial site visits, new Site Visitors are teamed with experienced Site Visitors and/or staff who provide guidance on the Site Visitor's role and on interpretation of Commission policies and accreditation standards.

When a consultant/site visitor cannot attend a formal consultant/site visitor training workshop or if it is determined that additional training is warranted, s/he may be requested to attend a site visit as a trainee. The trainee is accompanied by a Commission staff member or staff representative and a comparable experienced consultant/site visitor who provide ongoing training and guidance.

The trainee must sign the Commission’s Agreement of Confidentiality prior to the site visit and must not have a conflict of interest with the institution. The consultant/site visitor trainee, if authorized to participate in the site visit by the institution, receives all self-study materials from the institution and background information from the Commission prior to the site visit.

The trainee participates during all site visit conferences and executive sessions. In the event the chairperson/staff representative of the site visit committee determines that a vote is necessary to make a recommendation to the Commission, the trainee will be considered a non-voting member of the site visit committee.

Commissioners, Review Committee members, public members of the Commission or Review Committees may participate on site visits as observers. The observer must not have a conflict of interest with the institution. This individual must be approved to participate in the site visit by the institution, receives all self-study materials from the institution and background information from the Commission prior to the site visit. This individual participates during all site visit conferences and executive sessions as a non-voting member of the site visit committee. As a participant of the site visit, it is expected that this individual will remain with the designated site visit team members at all times during the visit. The chairperson of the site visit committee has the right to excuse and/or exclude the observer from any or all aspects of the site visit for improper and/or unprofessional behavior.

In order to facilitate a better understanding of the accreditation and site visit processes, any dental education program scheduled for a regularly-scheduled site visit of its program, may request the opportunity to send one administrator or faculty member as a silent observer to a Commission site visit.

Representatives of international programs may also participate as a silent observer on a Commission site visit. The silent observer visit will be scheduled one to two years before the scheduled site visit of the observer’s program. The program being observed has the right to approve the designated observer. Requests for a faculty member or administrator to observe the site visit of another program are managed according to when the observer’s site visit is scheduled. The observer’s program pays all expenses for such an observer.

The observer receives all self-study materials and is allowed to observe all interviews and meetings, but does not attend the briefing at the end of each day. The observer must remain silent during all sessions where university and/or program officials, faculty, staff or students are present at the site visit. The observer is encouraged to ask questions of the visiting committee during executive session meetings only but does not participate in decision-making discussions. As an observer of the site visit, it is expected that this individual will remain with the designated site visit team members at all times during the visit.

All observers must sign the Commission’s Agreement of Confidentiality prior to the site visit. The chairperson of the site visit committee has the right to excuse and/or exclude the observer from any or all aspects of the site visit for improper and/or unprofessional behavior. The chairperson’s decision to remove or exclude an observer from the site visit cannot be appealed.

A representative of the state dental society may attend a comprehensive dental school site visit as a silent observer, if requested by the society and approved by the institution.

Evaluation and Operational Policies and Procedures (PDF)

Policy on Professional Conduct and Prohibition Against Harassment (DOC)

The following links will connect to site visit documents for these specific disciplines:

• Predoctoral Dental Education
• Advanced Dental Education
• Allied Dental Education