Accreditation requirements for dental public health programs



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4.4.0 Resident Issues



Requirement
4.4.1 Residents must have rights, responsibilities, and privileges comparable with those of other residents at the institution.
Policies must exist concerning resident representation on appropriate committees.
The program must have methods to identify and address resident concerns.
Documentation Required


  1. Provide copies of documentation supplied to residents describing their rights, responsibilities and privileges. Comment on the adequacy of facilities available for resident use (i.e. learning resources, lounge, cafeteria, washrooms, lockers, health clinic, day care, etc.).

  2. Attach as an appendix, policies concerning resident representation on appropriate committees.

  3. Describe the process(es) in place to identify and address resident concerns.


Requirement
4.4.2 There must be an institutional policy which provides for due process for residents with respect to grievances.
Documentation Required
Describe or attach as an appendix, the institution policy that provides for due process if a resident has a grievance.
Requirement
4.4.3 Residents must have an opportunity to participate in the evaluation of the teaching effectiveness of faculty members.
Documentation Required
Describe resident participation in the evaluation of the teaching effectiveness of faculty members.
Requirement
4.4.4 Resident membership and participation in provincial/national dental and dental specialty organizations should be encouraged.
Documentation Required
Describe how resident membership and participation in provincial/national dental and dental specialty professional organizations is encouraged.
Requirement
4.4.5 Counselling and health services must be available to all residents.


Documentation Required
Describe how residents access counselling and health services.
Requirement
4.4.6 Prior to admission, residents should receive information concerning expected costs of the program. This information should include estimates of living expenses and educational fees.
Documentation Required
Describe how residents are provided with information related to the costs of graduate education and provide as an appendix, a copy of the information provided to residents.
NOTE:

Requirement 5 is only applicable if the program utilizes clinical facilities for Epidemiological or Research Activities.


5.0 CLINIC ADMINISTRATION




5.1.0 Clinic Operations



Requirement


      1. There must be an individual identified as responsible for patient relations, clinical care and clinic administration of the clinic. The director or equivalent must have access to relevant faculty decision-making groups and should have appropriate committee appointments. This individual must have effective working relationships with other administrators.


Documentation Required
Identify the director of the clinic or equivalent at the institution and attach his/her job description. Describe his/her access to relevant faculty decision-making groups. Describe how he/she has effective working relationships with other administrators.
Requirement
5.1.2 Patient treatment records must be comprehensive and adequate for teaching purposes.
Documentation Required
Provide as an appendix, a copy or screenshot of a blank patient treatment record.
Provide confirmation that patient authorization for his/her chart to be reviewed as part of the accreditation process has been obtained.


5.2.0 Health and Safety Provisions



Requirement
5.2.1 Written policies and procedures relating to quality assurance to ensure the safe use of ionizing radiation must be in place and be compliant with applicable regulations for radiation hygiene and protection. Mechanisms must be in place to monitor compliance of these policies and protocols by faculty members, staff and residents. The design and construction of radiology facilities must provide adequate protection from ionizing radiation for the patient, operator and others in close proximity. The program must ensure that it is in compliance with provincial and federal regulations relating to radiation protection. Where provincial or federal regulations are not in force, the program must show evidence that radiography equipment is routinely inspected to ensure the safe use of ionizing radiation, and that the radiology facilities are designed in such a way to ensure that occupational and public exposure is not in excess of the current recommendations of the International Commission on Radiological Protection (ICRP).
In addition, the program must identify a radiation protection officer and have in place a quality assurance program that includes daily monitoring of radiographic quality.
Radiographs must be prescribed based on the specific needs of the patient taking into account the existence of any current radiographs. Radiographs must be exposed solely for diagnostic purposes, not to achieve instructional objectives.
Documentation Required


    1. Attach as an appendix, a copy of the job description of the radiation protection officer.

    2. Provide on site copies of policies and protocols related to the prescription of radiographs.

    3. Provide an on site a copy of the quality assurance program used at the institution.

    4. Provide on site reports of the radiation safety inspections undertaken since the last accreditation survey.


Requirement
5.2.2 Policies and/or protocols must exist relating to Fire and Safety Procedures, Hazardous Materials and Waste Management, Infection Control and Medical Emergency Procedures. Such policies and/or protocols must be consistent with related elements of the didactic program, related regulation, legislation and bylaws of the various jurisdictions and must be readily available for faculty members, staff and residents. Mechanisms must be in place to monitor compliance of these policies and protocols by faculty members, staff and residents.

Documentation Required
Provide as an appendix, copies of the policies and/or protocols outlined in 5.2.2. Describe how these policies and/or protocols are monitored for faculty members, staff and residents.
Requirement
5.2.3 Residents, faculty members and appropriate staff must be encouraged to be immunized against and/or tested for infectious diseases, such as mumps, measles, rubella, tuberculosis and hepatitis B prior to contact with patients and/or infectious objects or materials in an effort to minimize the risk to patients and dental personnel. All individuals who provide patient care must follow standards of risk management.
Documentation Required
Describe steps that are taken to ensure compliance with institutional immunization requirements by residents, faculty members and staff against infectious diseases prior to contact with patients.
Requirement
5.2.4 The program should develop (or adopt provincial policies if applicable) and implement policies and procedures related to individuals who have bloodborne infectious disease(s).
Documentation Required
Provide a copy of the institution’s policies and procedures related to faculty members, staff and residents who have blood borne infectious disease(s).
Requirement
5.2.5 Residents, faculty members and staff involved with the direct provision of patient care must be certified in basic life support procedures.
Documentation Required
Provide documentation that identifies the process used to monitor that all faculty members, staff, and residents are certified in basic life support.


5.3.0 Patient Care and Quality Assurance



Requirement
5.3.1 Policies and/or protocols must exist relating to the following:


  1. Audit of Patient Care

  2. Collection of Patient Fees

  3. Confidentiality of Patient Information

  4. Consultative Protocols

  5. Informed Consent

  6. Patient Assignment

  7. Patient Continuing and Recall Care

  8. Patient Records

  9. Professional Decorum

Such policies and protocols must be written, consistent with related elements of the didactic program and readily available for the residents, staff and faculty members. Mechanisms must be in place to monitor compliance of these policies and protocols by faculty members, staff and residents.


Documentation Required
Provide as an appendix, copies of the policies and/or protocols outlined in 5.3.1. Describe how these policies and/or protocols are monitored for faculty members, staff and residents.
Requirement
5.3.2 The program must have policies and mechanisms in place that provide quality assurance and education for patients about their specialty care and related treatment needs. Patients accepted for dental specialty care must be advised of the scope of care available at the facility and be appropriately referred for procedures that cannot be provided by the specialty program.

The primacy of total dental care for the patient must be well established in the management of the clinical program, assuring that the rights and best dental interests of the patient are protected. The quality assurance process should ensure that the following are in place:





    1. Primary responsibility for total patient care is formally assigned and documented to a single resident.

    2. Patient-centred, comprehensive care, continuing and recall care.

    3. Patient review policies, procedures, outcomes and corrective measures.

    4. Adverse or ineffective outcomes are subject to routine review.


Documentation Required
Describe quality assurance mechanisms in place within the program. Provide evidence that the quality assurance program supports ongoing improvement in comprehensive patient care.
Requirement
5.3.3 Treatment undertaken by residents prior to advancement and graduation must be reasonably expected to be beneficial for the health and care of patients.
Documentation Required
Describe mechanisms that ensure that student educational requirements are beneficial for the health and care of patients.


6.0 RESEARCH AND SCHOLARLY ACTIVITIES



Requirement
6.1 There must be an appropriate commitment to research activity by faculty members teaching in the dental public health program. This responsibility must also involve residents and should have the support of the parent university with respect to finances and facilities. An appropriate balance of faculty member involvement between teaching and research must exist so that the quality of the program is not compromised. Investigations leading to the improvement of the educational program should be included in such research activities.
CDAC believes that there are many worthy research projects, particularly of a public health, clinical or educational nature, which could be undertaken without major funding from external agencies.
Documentation Required


  1. Identify the research and scholarly activity requirements for residents and identify if a thesis/major paper is required.

  2. Attach as an appendix, a list of the research projects/scientific papers that have been completed by faculty members and the graduate residents since the last accreditation survey visit, identifying the name of the investigator and the name, title and affiliation of the staff supervisor.

  3. Attach as an appendix, a list of research affiliations and support mechanisms of the program since the last accreditation survey visit.


7.0 PROGRAM RELATIONSHIPS




7.1.0 Relationships with Other Educational Programs



Requirement
7.1.1 Where other health science programs and/or baccalaureate/graduate/postgraduate educational programs exist efforts should be made to integrate the didactic and clinical aspects of these programs wherever possible and/or appropriate, in order to foster effective working relationships.

Documentation Required
Describe the program’s relationships with other health sciences educational programs that permit residents to develop multidisciplinary working relationships, as appropriate, with other programs and residents.
Requirement
7.1.2 CDAC recognizes the potential value of faculty-based continuing education programs. Such programs should develop resident awareness and appreciation of the necessity for continuing education as a professional responsibility. The demands of continuing education programs must not be allowed to jeopardize the quality of the program.
Documentation Required
Describe how resident awareness and appreciation of the benefits of a faculty-based continuing education program are fostered. Describe how faculty members provide and/or participate in continuing education programs.





7.2.0 Relationships with Health Care Facilities and Other Health Care Agencies



Requirement
7.2.1 The program must have a functional relationship with at least one (1) public health department and provide opportunities for residents to liaise with other agencies that have an impact on the practice of dental public health.
Documentation Required
Describe the relationship between the facility and the various public health agencies, and provide the agreement describing the relationship.
Requirement
7.2.2 The program should also develop functional relationships with other institutional health care facilities, community health programs and health departments to establish an environment which prepares residents to provide care in such health care facilities.
Documentation Required
Describe relationships between the program and other institutional health care facilities, community health programs and health departments. Describe how these relationships establish an environment that prepares residents to provide care in such facilities.

7.3.0 Relationships with Regulatory Authorities and Dental Organizations



Requirement
7.3.1 Residents must be made aware of the regulatory framework for both dental and specialty practice and of the distinct role of regulatory authorities, provincial/national dental and dental specialty organizations. Faculty members should be encouraged to accept positions of responsibility in such organizations and their contributions should be supported and recognized by the program.
Documentation Required


    1. Describe how residents are made aware of the role of regulatory authorities.

    2. Describe how residents are made aware of the role of provincial/national dental and dental specialty organizations.

    3. Describe how faculty members participate in positions in these organizations and how their contributions are supported and recognized by the program.


APPENDIX A Dental Specialty Assessment and Training Program

Accredited dental specialty programs offering a Dental Specialty Assessment and Training Program (DSATP) for dental specialists who graduated from non-accredited programs will be assessed by CDAC. The dental specialty program and the DSATP for dental specialists who graduated from non-accredited programs will be assessed by CDAC conjointly. The accredited dental specialty program will provide the customary documentation in response to the accreditation requirements for the specific dental specialty program; and specific additional information will be requested for the DSATP. CDAC will review the accredited dental specialty program’s educational approach preparing DSATP candidates.


Introduction
CDAC accredited dental specialty programs may admit dental specialists who graduated from non-accredited programs for assessment and additional education and training. CDAC requires that an accredited dental specialty program offering a DSATP be responsible for the assessment of candidates and all educational components of the program. Accredited dental specialty programs may enter into an affiliation agreement with other Dental Faculties/Schools of Dentistry to provide aspects of the DSATP program. However, the certificate of completion of the DSATP must be granted to successful candidates by the Faculty/School of Dentistry accredited dental specialty program.
The Faculty/School of Dentistry offering a DSATP must advise accepted candidates that Institutional policies and regulations apply to them as candidates in the program and that they have the same rights and responsibilities as other residents in the Institution.
The following documentation in relation to CDAC requirements must be provided.
Documentation Required


A1 Institutional Structure

A1.1 Identify the sponsoring Faculty/School of Dentistry and the accredited dental specialty program(s) admitting dental specialists who graduated from non- accredited programs to assess their eligibility for the DSATP.


A1.2 In the event of an affiliation with another Faculty/School of Dentistry; the accredited dental specialty program must provide a copy of the affiliation agreement(s).
A1.3 Identify all sites and affiliated institutions where candidates receive instruction.


A2 Admission to the Dental Specialty Assessment and Training Program

A2.1 Verify that all applicants have completed the Dental Specialty Core Knowledge Exam (DSCKE) as a requirement for admission.


A2.2 Describe the admissions process for applicants to be admitted to the DSTAP.
A2.3 Describe how the applicant’s skills in the specific dental specialty are assessed prior to admission into the DSATP.
A2.4 Complete the following chart for DSATP candidates for the past five (5) years.

Number of candidates who applied to the program.





Number of applicants admitted.




Number of candidates who successfully completed the program.




Number of candidates who passed the NDSE.






A3 Curriculum

A3.1 Describe, with examples, the process used to develop a customized plan for educational experiences for a candidate.


A3.2 Provide an example of a customized educational program. On site, provide further examples of customized educational programs including a description of the ongoing evaluation of the program and any required modifications.

A4 Candidate Evaluation

A4.1 Describe the process to determine that a candidate has successfully completed the customized plan for educational experiences and is eligible to be awarded the certificate of completion.



A5 Resources

A5.1 Identify the faculty members involved in the DSATP, and indicate whether they have a Faculty appointment and have the appropriate qualifications and experiences necessary to teach the candidates in the program.


A5.2 Provide evidence that there is sufficient faculty member coverage to provide the individualized program for each candidate.
A5.3 Demonstrate that the appropriate resources, physical facilities, support staff, and patients are available to offer the program.


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