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Commission on Dental Accreditation

Self-Study Guide forThe Evaluation of anEndodonticsEducation Program


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Self-Study Guide forThe Evaluation of an

Endodontics Education ProgramCommission on Dental AccreditationAmerican Dental Association

211 East Chicago Avenue

Chicago, Illinois 60611312/440-4653www.ada.org

Copyright 2013

Commission on Dental AccreditationAmerican Dental Association

All rights reserved. Reproduction is strictly prohibited without prior written permission.

Document Revision History

Endodontic Self-Study Guide

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Date Item Action

July 31, 2008 Accreditation Standards for AdvancedSpecialty Education Programs in Endodontics

Adopted

January 1, 2009 Accreditation Standards for AdvancedSpecialty Education Programs in Endodontics

Implemented

January 30, 2009 Addition of American Board of EndodonticsDefinition of Prospective Board Candidate

Adopted andImplemented

January 30, 2009 Revisions to Language Common to AllSpecialties (Preface, Definitions of Terms, andStandards 1, 4 and 5)

Adopted

July 1, 2009 Revisions to Language Common to AllSpecialties (Preface, Definitions of Terms, andStandards 1, 4 and 5)

Implemented

July 31, 2009 Revised Policy on Major Change andAccreditation of Off-Campus Sites


February 5, 2010 Revised Intent Statement for Standard 2-4.1 Adopted, Implemented

August 6, 2010 Policy Revisions (Major Change, Off-CampusSites, Authorized Enrollment Increases)

Adopted

January 1, 2011

August 5, 2011

Policy Revisions (Major Change, Off-CampusSites, Authorized Enrollment Increases)Deletion of intent statement to Standard 2-4

Implemented


August 5, 2011 Revised Policy on Program Changes Adopted andImplemented

February 3, 2012 The Joint Commission Equivalency Statement AdoptedAugust 4, 2012

August 10, 2012

January 31, 2013

January 31, 2013

The Joint Commission Equivalency StatementRevised Mission Statement

Revision to Policy on Accreditation of Off-Campus SitesRevised Compliance with Commission Policiessection (Complaints)

ImplementedAdopted and

ImplementedAdopted andImplementedImplemented


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TABLE OF CONTENTS

Contents

Contents...........................................................................................................................................4INTRODUCTION TO THE SELF-STUDY GUIDE.....................................................................5POLICIES AND PROCEDURES RELATED TO THE EVALUATION OF ADVANCEDSPECIALTY EDUCATION PROGRAMS....................................................................................7ORGANIZING FOR THE SELF-STUDY....................................................................................10INSTRUCTIONS FOR COMPLETING THE SELF-STUDY.....................................................11TITLE PAGE.................................................................................................................................14GENERAL INFORMATION........................................................................................................15PREVIOUS SITE VISIT RECOMMENDATIONS.....................................................................16COMPLIANCE WITH COMMISSION POLICIES.....................................................................17PROGRAM EFFECTIVENESS....................................................................................................18STANDARD 1 INSTITUTIONAL COMMITMENT/PROGRAM EFFECTIVENESS..........19STANDARD 2 - PROGRAM DIRECTOR AND TEACHING STAFF......................................22STANDARD 3 FACILITIES AND RESOURCES...................................................................26STANDARD 4 - CURRICULUM AND PROGRAM DURATION............................................30

BIOMEDICAL SCIENCES......................................................................................................33CLINICAL SCIENCES.............................................................................................................34TEACHING...............................................................................................................................38

STANDARD 5 - ADVANCED EDUCATION STUDENTS/RESIDENTS................................39ELIGIBILITY AND SELECTION...........................................................................................39EVALUATION.........................................................................................................................40DUE PROCESS.........................................................................................................................40

RIGHTS AND RESPONSIBILITIES.......................................................................................41STANDARD 6 RESEARCH......................................................................................................42SUMMARY OF SELF-STUDY REPORT...................................................................................43REQUIRED APPENDIX INFORMATION.................................................................................45

STANDARD 3 FACILITIES AND RESOURCES...........................................................47SELECTED EXHIBITS................................................................................................................51

ENDODONTICS.......................................................................................................................59PROTOCOL FOR CONDUCTING A SITE VISIT.....................................................................66


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INTRODUCTION TO THE SELF-STUDY GUIDE

The Self-Study Guide is designed to help an institution succinctly present information about itsadvanced specialty education program in preparation for an evaluation visit by the Commission onDental Accreditation. It is suggested that the institution initiate the self-study processapproximately 12 months prior to completion of the Self-Study Report. The primary focus of the

self-study process should be to assess the effectiveness of the educational program in meeting (1)the programs stated goals and objectives and (2) the Commissions Accreditation Standards forAdvanced Specialty Education Programs in Endodontics.

The Self-Study Report should be a concise, yet thorough, summary of the findings of the self-study process. The Commission hopes that the self-study will be a catalyst for programimprovement that continues long after the accreditation process has been completed. In itsopinion, this is a more likely outcome if there is thorough planning, as well as involvement ofstudents/residents and administrators in the self-study process. Most programs will concentrateupon questions germane to the Commissions Accreditation Standards. Nevertheless, the benefitsof self-study are directly related to the extent to which programs evaluate their efforts, not simply

in light of minimal standards for accreditation, but also in reference to the programs stated goalsand objectives as well as standards for educational excellence. Conclusions of the self-study mayinclude qualitative evaluation of any aspect of the program whether it is covered in the Self-StudyGuide or not. Programs must respond to all questions included in the Self-Study Guide. Theresponses should be succinct, but must in every case provide or cite evidence demonstratingachievement of objectives in compliance with each of the Accreditation Standards.

For the educational program, the self-study provides an opportunity to:

1. Clarify its objectives as they relate to:

a. Preparation of endodontists;

b. Expectations of the dental profession and the public in relation to theeducation of endodontists; and

c. The programs general educational objectives.

2. Candidly and realistically assess its own strengths and weaknesses in light of its own statedobjectives.

3. Internalize the process and engage in the kind of self-analysis essential to effectiveplanning and change.

4. Provide the basis for a more informed and helpful site visit related to the real issues

including the strengths and weaknesses of the program.*

*Adapted and summarized from Role and Importance of the Self-Study Process inAccreditation, Richard M. Millard, President, Council of Postsecondary Accreditation (July 25-26, 1984)

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For the Commission and visiting committee, the self-study process should:

1. Ensure that the program has seriously and analytically reviewed its objectives, strengthsand weaknesses.

2. Provide the site visitors the basic information about the program and the programs best

judgment of its own adequacy and performance, thus providing a frame of reference tomake the visit effective and helpful to the program and the Commission.

3. Ensure that the accrediting process is perceived not simply as an external review but as anessential component of program improvement.

4. Ensure that the Commission, in reaching its accreditation decisions, can benefit from theinsights of both the program and the visiting committee.

The Self-Study process and report are not the following :

A self-study is not just a compilation of quantitative data. Such data may be a prerequisite fordeveloping an effective self-study, but such data in themselves are not evaluative and must not beconfused with a self-study.

A self-study is not or should not be answers to a questionnaire or a check-off sheet. While aquestionnaire may be probing, it is essentially an external form and does not relieve the responderof the critical review essential to self-study. A check-off list based on the CommissionsAccreditation Standards can be helpful in developing the self-study but does not reveal theconditions or rationale leading to the answers -- again both the organizing activity and the criticalanalysis are missing.

A self-study is not or should not be a simple narrative description of the program. While such a

description is necessary, the self-study should go beyond such description to an analysis ofstrengths and weaknesses in light of the programs objectives, as well as develop a plan forachieving those objectives that have not been fully realized. It should be emphasized that, whilethe self-study is essential to the accrediting process, the major value of an effective self-studyshould be to the program itself. The report is a document, which summarizes the methods andfindings of the self-study process. Thus, a self-study report written exclusively by a consultant oran assigned administrator or faculty member is not a self-study.



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POLICIES AND PROCEDURES RELATED TO THE EVALUATION OFADVANCED SPECIALTY EDUCATION PROGRAMS

The Commission has established a seven-year site visit cycle for accreditation review for alldisciplines except oral and maxillofacial surgery, which has a five-year cycle. Every effort ismade to review all existing dental and dental-related programs in an institution at the same time.

However, adherence to this policy of institutional review may be influenced by a number offactors, e.g., graduation date established for new programs, recommendations in previousCommission reports, and/or current accreditation status.

The purpose of the site evaluation is to obtain in-depth information concerning all administrativeand educational aspects of the program. The site visit verifies and supplements the informationcontained in the comprehensive self-study document completed by the institution prior to the siteevaluation.

As stated in Instructions for Completing the Self-Study Report, one copy of the completed Self-Study Report should be sent directly to each member of the visiting committee at least 60 days

prior to the date of the visit. Names and addresses of the members of the team will be provided tothe institution approximately two to three months ahead of the visit. In addition, one copy of allself-study materials is to be submitted to the Commission office 60 days in advance of the visit.NOTE: If a Commission staff member is serving on the visiting committee, the Commissionshould receive one copy of the self-study report for this individual and a second copy for theprograms files.

Third Party Comment Policy: The program is responsible for soliciting third party commentsfrom students/residents and patients that pertain to the Standards or policies and procedures usedin the Commissions accreditation process. An announcement for soliciting third party commentsis to be published at least ninety (90) days prior to the site visit. The notice should indicate thatthird party comments are due in the Commissions office no later than sixty (60) days prior to thesite visit. Please review the entire policy on Third Party Comments in the Commissions EOPP:Evaluation and Operational Policies and Procedures manual.

Complaints Policy: The program is responsible for developing and implementing a proceduredemonstrating that students/residents are notified, at least annually, of the opportunity and theprocedures to file complaints with the Commission. Additionally, the program must maintain arecord of student/resident complaints received since the Commissions last comprehensive reviewof the program. Please review the entire policy on Complaints in the Commissions EOPP:Evaluation and Operational Policies and Procedures manual.



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Student Identity Verification Requirement For Programs That Have Distance Education Sites:Programs that offer distance education must have processes in place through whichthe program establishes that the student who registers in a distance education courseor program is the same student who participates in and completes the course orprogram and receives the academic credit. Programs must verify the identity of astudent who participates in class or coursework by using, at the option of the

program, methods such as a secure login and pass code; proctored examinations;and/or new or other technologies and practices that are effective in verifyingstudent identity. The program must make clear in writing that processes are usedthat protect student privacy and programs must notify students of any projectedadditional student charges associated with the verification of student identity at thetime of registration or enrollment.

Site Visitor Requests for Additional Information: Visiting committee members are expected tocarefully review the completed self-study reports and note any questions or concerns they mayhave about the information provided. These questions are forwarded to Commission staff (or staffrepresentatives), compiled and submitted to the program director prior to the visit. The requestedinformation is provided to the team members either prior to the visit or upon their arrival to theprogram. Site visitors will have a copy of the institutions most recent Annual Survey.

Site Visit Committee Composition: The Commission on Dental Accreditations accreditationprogram is accomplished through mechanisms of annual surveys, site evaluations and Commissionreviews. The visiting committees are assigned to review advanced dental education programs bythe Commission Chairman. The visiting committees are composed, as appropriate, ofCommission staff representatives who are responsible for coordinating the visit and preparing thesite visit report, and Commission-appointed site visitors in advanced specialty education who haveexpertise in their respective areas.

For advanced education site visits, the Commission urges the program to invite a representative

from the dental examining board of the state in which the program is located to participate withthe committee as the State Board representative. This representation; however, must be at therequest of the institution/program being evaluated. State Board representatives participate fully insite visit committee activities as non-voting members of the committee. State Boardrepresentatives are required to sign the Commissions Agreement of Confidentiality.

After the Site Visit: The written site visit report embodies a review of the quality of the program.It serves as the basis for accreditation decisions. It also guides officials and administrators ofeducational institutions in determining the degree of their compliance with the accreditationstandards. The report clearly delineates any observed deficiencies in compliance with standardson which the Commission will take action.

The Commission is sensitive to the problems confronting institutions of higher learning. In thereport, the Commission evaluates educational programs based on accreditation standards andprovides constructive recommendations, which relate to the Accreditation Standards andsuggestions, which relate to program enhancement.

Preliminary drafts of site visit reports are prepared by the site visitors, consolidated by staff into asingle document and approved by the visiting committee. The approved draft report is thentransmitted to the institutional administrator for factual review and comment prior to its review bythe Commission. The institution has a maximum of 30 days in which to respond. Both theEndodontic Self-Study Guide

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visiting committees approved draft report and the institutions response to it are considered by theCommission in taking the accreditation action.

The site visit report reflects the program as it exists at the time of the site visit. Anyimprovements or changes made subsequent to a site visit may be described and documented in theprograms response to the preliminary draft report, which becomes part of the Commissions

formal record of the programs evaluation. Such improvements or changes represent progressmade by the institution and are considered by the Commission in determining accreditation status,although the site visit report is not revised to reflect these changes. Following assignment ofaccreditation status, the final site visit report is prepared and transmitted to the institution. TheCommission expects the chief administrators of educational institutions to make copies of theCommission site visit reports available to program directors, faculty members and others directlyconcerned with program quality so that they may work toward meeting the recommendationscontained in the report.

Commission members and visiting committee members are not authorized, under anycircumstances, to disclose any information obtained during site visits or Commission meetings.The extent to which publicity is given to site visit reports is determined by the chief administratorof the educational institution. Decisions to publicize reports, in part or in full, are at the discretionof the educational institution officials, rather than the Commission. However, if the institutionelects to release sections of the report to the public, the Commission reserves the right to make theentire site visit report public.

Commission Review of Site Visit Reports: The Commission and its review committees meettwice each year to consider site visit reports, progress reports, applications for accreditation andpolicies related to accreditation. These meetings are usually in winter and summer. Reports fromsite visits conducted less than ninety (90) days prior to a Commission meeting are usually deferredand considered at the next Commission meeting.

Notification of Accreditation Action: An institution will receive the formal site visit report,including the accreditation status, within thirty (30) days following the official meeting of theCommission. The Commissions definitions of accreditation classifications are published in itsAccreditation Standards documents.

Additional Information: Additional information regarding the procedures followed during the sitevisit is contained in the Commissions publication, Evaluation and Operational Policies andProcedures. The Commission uses the Accreditation Standards for Advanced Specialty EducationPrograms as the basis for its evaluation of advanced specialty education programs; therefore, it isessential that institutions be thoroughly familiar with this document.



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ORGANIZING FOR THE SELF-STUDY

The self-study should be comprehensive and should involve appropriate faculty and staffthroughout the institution.

When feasible, it is suggested that a committee, with appropriate faculty representation, be

selected to assist the program director with the self-study process. This committee should beresponsible for developing and implementing the process of self-study and coordinating thesections into a coherent self-study report. It may be desirable to establish early in the processsome form or pattern to be used in preparing the sections in the report in order to provideconsistency.

The committee should have assistance with preparing and editing the final self-study report.Appropriate faculty and other institutional representatives (e.g., learning resources staff,financial/budget officers, counselors, admissions officers, instructional design staff) should beinvolved in the process to ensure that the Self-Study Report reflects the input of all individualswho have responsibility for the program.

Suggested Timetable for Self-Study:

Months Prior to Visit

12 Appoint committee and resource persons; Assign sections of self-study toappropriate faculty-resource persons; Develop action plan and report format

10 Sections of report are analyzed and developed by assigned individuals

7 Faculty and review tentative reports

6 Committee prepares rough draft of self-study document

5 Draft document is reviewed institution-wide

4 Self-study document finalized and duplicated

3 Solicit comments in accordance with the Policy on Third Party Comments foundin the Commissions Evaluation and Operational Policies and Procedures manual.

2 Final self-study document forwarded to Commission and members of the visitingcommittee 60 days prior to date of the scheduled visit.

Staff Assistance/Consultation: The Commission on Dental Accreditation provides staffconsultation to all educational programs within its accreditation purview. Programs may obtainstaff counsel and guidance at any time.

Policies and Procedures for Site Visits: These policies and procedures are included at the end ofthis Self-Study Guide.



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Self-Study Format: As noted in the instructions with this Self-Study Guide, this is a suggestedapproach to completing a self-study report. All institutions should be aware that the Commissionrespects their right to organize their data differently and will allow programs to develop their ownformats for the exhibits requested in the appendix sections of the Guide. However, if theprograms proposed format differs from that suggested in the Self-Study Guide, the program

should contact Commission staff for review and approval prior to initiating the self-study process.This procedure will provide assurance to the program that its proposed format will include theelements considered essential by the Commission and its visiting committees.

INSTRUCTIONS FOR COMPLETING THE SELF-STUDY

Background: The Self-Study for advanced specialty education programs was designed to mirrorthe Site Visitor Evaluation Report Form and provide a listing of documentary evidence thatsupports the programs answers to each question. All questions are based on a specific muststatement of the Accreditation Standards for Advanced Specialty Education Programs in

Endodontics. The number of the standard upon which the question is based is noted in parenthesisafter each question.

Before answering each question, the program should read the corresponding standard in order todetermine the intentof the standard. Then, after answering the question, the program is requiredto identify the documentary evidence on which it supports its answer. In this manner, the selfstudy process becomes evidence-based in demonstrating compliance with each accreditationstandard. Intent statements are presented to provide clarification to the advanced specialtyeducation programs in endodontics in the application of and in connection with compliance withthe Accreditation Standards for Advanced Specialty Education Programs in Endodontics. Thestatements of intent set forth some of the reasons and purposes for the particular Standards. Assuch, these statements are not exclusive or exhaustive. Other purposes may apply.

Additionally, the program is required to attach appendix information. This appendix informationis identified after the questions. Exhibits containing charts are provided to assist the program inpresenting important program information data. It should be noted that documentary evidencemay include required appendix information where appropriate. The exhibits included are intendedas samples, and some may not be applicable to the program.

With this new self study process, the interviews and on-site observations during the site visit takeon a more important role in that this is the place within the process that the program providesadditional description of its compliance with accreditation standards, that is not evident from theanswers to the Self-Study questions and required appendix information. A final summary

containing assessment of selected issues that are related to the institution, patient care, and theprogram completes the self-study process.

Instructions: The following general instructions apply to the development of the advancedspecialty education programs self-study report:

1. It is expected that information collected during the self-study will be presented in the orderthat the sections and questions occur in the Guide. The sections of the report shouldculminate in a qualitative analysis of the programs strengths and weaknesses. Keep in



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mind that the programs written responses must provide the Commission and its visitingcommittee with enough information to understand the operation of the programs.

2. The suggested format for preparing the report is to state the question and then provide thenarrative response. A copy of the Self-Study Guide is available on a word processingprogram (IBM compatible-Microsoft Word) from the Commission office.

3. All questions posed in the Guide should be addressed. In the event that a program haschosen to meet a particular standard in a manner other than that suggested by the questions,please so indicate and explain how the program complies with the Standards. There is noneed to repeat at length information that can be found elsewhere in the documentation.Simply refer the reader to that section of the report or appended documentation, whichcontains the pertinent information.

4. The completed self-study document should include appropriately tabbed sections; pagesshould be numbered. (The page numbers in the completed document are not expected tocorrespond to the page numbers in this Guide).

5. The completed document should include:

a. Title Page .

b. General Information Sheet(s).

c. Table of Contents: The table of contents should include the general informationsheet(s), previous site visit recommendations, compliance with Commissionspolicies, sections on each of the 6 Standards, the summary of the Self-Study Reportand any necessary appendices; page numbers for each section should be identified.

d. Self-Study Report: The Commission encourages programs to develop a self-studyreport that reflects a balance between outcomes and process and that produces anappropriately brief and cost-effective Self-Study Report. The supportivedocumentation substantiating the narrative should not exceed what is required todemonstrate compliance with the Standards. Take note where documentation isdesignated to be available on-site rather than attached to the report.

e. Summary: At the completion of the report, a qualitative assessment is required.Actions planned to correct any identified weaknesses should be described. It issuggested that the summary be completed by the program director with assistancefrom other faculty and appropriate administrators.

6. The programs documentation for CODA (self-study, application, or reports to CODA, forexample) must NOT contain any patient protected health information. If an institutionnevertheless provides the Commission and/or Commission site visitors with materialscontaining patient protected health information (PHI), such materials must be in electronicform and encrypted as outlined by the most recent breach notification regulations related tothe Health Insurance Portability and Accountability Act of 1996 (HIPAA).

In addition, most states have enacted laws to protect sensitive personally identifiableinformation (PII) such as social security numbers, drivers license numbers, credit card



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numbers, account numbers, etc. Before sending documents such as faculty BioSketches(see Exhibit 3.3) to CODA, institutions must fully redact the following PII: social securitynumbers, credit or debit card numbers, drivers license numbers or government-issued IDnumbers, account numbers, health information, taxpayer ID, and date of birth.

7. In addition to the number of paper copies requested, please be advised that the Commission

requires that all accreditation correspondence/documents/reports and related materialssubmitted to the Commission for a programs permanent file be done so electronically.The Electronic Submission Guidelines will assist you in preparing your report. If theprogram is unable to provide a comprehensive electronic copy of the self-study document,the Commission will accept a paper copy and assess a fee to the program for converting thedocument to an electronic version.

Please be advised that the Commission requires that all accreditationcorrespondence/documents/reports and related materials submitted to the Commission for aprograms permanent file be done so electronically. The attached Electronic SubmissionGuidelines will assist you in preparing your report. If the program is unable to provide acomprehensive electronic document, the Commission will accept a paper copy and assess a fee perdiscipline self-study document to the program for converting the document to an electronicversion.

A summary of the self-study documentation that must be provided to the visitingcommittee prior to the visit and additional information which must be available on-site islisted under Resources/Materials Available On-Site of the Protocol For Conducting aSite Visit section of the Self-Study Guide.



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TITLE PAGE

Sponsoring Organization:

(Dental School/Hospital, Other, e.g., Consortium)Street Address:

City, State & Zip Code:

Chief Executive Officer

(University President/Chancellor)

or Hospital Administrator:

Telephone Number: ( )

Fax Number: ( )

E-Mail Address:

Signature________________________________________________________________Date________________________________________________________________Dental School Dean or

Chief of Dental Service:

_


Fax Number: ( )E-Mail Address:

Signature__________________________________________________________Date__________________________________________________________Program Director:

_


Fax Number: ( )

E-Mail Address:

Signature _________________________________________________________Date__________________________________________________________Endodontic Self-Study Guide

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I have seen and reviewed the completed Self-Study Guide (and required appendixinformation) that will be used in an upcoming site visit to this institution.

GENERAL INFORMATION

a. What is the length of the program? month

b. How many full-time students/residents are currently enrolled in the program peryear?

c. How many part-time students/residents are currently enrolled in the program per yea

d. What is the programs CODA-authorized base number enrollment?

e. The program offers a certificate degree or both

f. What other programs does the organization sponsor? Indicate whether each programis accredited. Indicate which programs are accredited by the Commission on DentalAccreditation.

g. If the program is affiliated with other institutions, provide the full names and addresseof the institutions, the purposes of the affiliation and the amount of time eachstudent/resident is assigned to the affiliated institutions.

h. What is the percentage of the students/residents total program time devoted to eachsegment of the program?

biomedical sciences %

clinical Sciences %

teaching %

research %

other (specify) %

%

Total = 100%

i. (For Endodontics program) What is the total faculty/student/resident ratio of the program?j. (For Endodontics programs.) What is the number of endodontic cases per

student/resident?



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For the clinical phases of the program, indicate the number of faculty members specificallyassigned to the advanced education program in each of the following categories and theireducational qualifications:

TotalNumber

# Board Certified # EducationallyQualified*

# Other**

Full-time

Half-time

Less thanhalf-time

* Individual is eligible but has not applied to the relevant Board for certification.**Individual is neither a Diplomate nor Candidate for board certification by the relevantcertifying Board.

Verify the cumulative full-time equivalent (F.T.E.) for all facultyspecifically assigned to this advanced education program. For example:a program with the following staffing pattern one full-time (1.00) +one half-time (0.50) + one two days per week (0.40) + one half-day perweek (0.10) would have an F.T.E. of 2.00.

Cumulative F.T.

PREVIOUS SITE VISIT RECOMMENDATIONS

Using the programs previous site visit report, please demonstrate that the recommendationsincluded in the report have been remedied.

The suggested format for demonstrating compliance is to state the recommendation and thenprovide a narrative response and/or reference documentation within the remainder of this self-study document.

* Please note if the last site visit was conducted prior to the implementation of the revisedAccreditation Standards for Advanced Specialty Education Programs (January 1, 2000), somerecommendations may no longer apply. Should further guidance be required, please contactCommission on Dental Accreditation staff.



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COMPLIANCE WITH COMMISSION POLICIES

Identify all changes which have occurred within the program since the programs previoussite visit, in accordance with the Commissions policy on Reporting Program Changes inAccredited Programs.

Changes have a direct and significant impact on the programs potential ability to comply with theaccreditation standards. These changes tend to occur in the areas of finances, programadministration, enrollment, curriculum and clinical/laboratory facilities, but may also occur inother areas. Failure to report in advance any increase in enrollment or other change, using theGuidelines for Reporting Program Changes, may result in review by the Commission, a specialsite visit, and may jeopardize the programs accreditation status. The program must reportchanges to the Commission in writing at least thirty (30) days prior to a regularly scheduled semi-annualReview Committee meeting. The Commission recognizes that unexpected, changes may occur. If anunexpected change occurs, it must be reported no more than 30 days following the occurrence.Unexpected changes may be the result of sudden changes in institutional commitment, affiliatedagreements between institutions, faculty support, or facility compromise resulting from natural

disaster. Failure to proactively plan for change will not be considered unexpected change.Depending upon the timing and nature of the change, appropriate investigative proceduresincluding a site visit may be warranted. For enrollment increases in advanced specialty programsthe program must submit a request to the Commission one (1) month prior a regularly scheduledsemiannual Review Committee/Commission meeting. For the addition of off-campus sites, theprogram must report in writing to the Commission at least thirty (30) days prior to a regularlyscheduled semi-annual Review Committee meeting. See the Policy on Enrollment Increases InAdvanced Specialty Programs and the Policy on Accreditation Of Off-campus Sites for specificinformation on these types of changes.

Provide documentation and/or indicate what evidence will be available during the site visit todemonstrate compliance with the Commissions policy on Third Party Comments.

The program is responsible for soliciting third party comments from students/residents andpatients that pertain to the Standards or policies and procedures used in the Commissionsaccreditation process. An announcement for soliciting third party comments is to be published atleast ninety (90) days prior to the site visit. The notice should indicate that third party commentsare due in the Commissions office no later than sixty (60) days prior to the site visit. Pleasereview the entire policy on Third Party Comments in the Commissions EOPP Evaluation andOperational Policies and Procedures manual.

Provide documentation and/or indicate what evidence will be available during the site visit todemonstrate compliance with the Commissions policy on Complaints.

The program is responsible for developing and implementing a procedure demonstrating thatstudents/residents are notified, at least annually, of the opportunity and the procedures to filecomplaints with the Commission. Additionally, the program must maintain a record ofstudent/resident complaints received since the Commissions last comprehensive review of theprogram. Please review the entire policy on Complaints in the Commissions EOPP: Evaluationand Operational Policies and Procedures manual.

Provide documentation and/or indicate what evidence will be available during the site visit todemonstrate compliance with the Commissions policy on Distance Education.Endodontic Self-Study Guide

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Programs that offer distance education must have processes in place through which the programestablishes that the student who registers in a distance education course or program is the samestudent who participates in and completes the course or program and receives the academic credit.In addition, programs must notify students of any projected additional student charges associatedwith the verification of student identity at the time of registration or enrollment. Please read the

entire policy on Distance Education in the Commissions EOPP: Evaluation and OperationalPolicies and Procedures manual.

PROGRAM EFFECTIVENESS

Program Performance with Respect to Student Achievement:Provide a detailed analysis explaining how the program uses student achievement measures,such as national assessment scores, results of licensure or certification examinations and/or

employment rates to assess the programs overall performance. In your analysis, provideexamples of program changes made based on student achievement data collected and

analyzed.



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STANDARD 1 INSTITUTIONAL COMMITMENT/PROGRAMEFFECTIVENESS

(Complete each question by inserting an x in the appropriate box and identifying documentation

in support of your answer. Appendices A-F are also required for this section. Note: requiredappendix information may serve as documentary evidence where appropriate.)

1. Has the program developed clearly stated goals and objectivesappropriate to advanced specialty education, addressingeducation, patient care, research and service? (1)

YES NO

Documentary Evidence:

2. Are planning for, evaluation of and improvement of educationalquality for the program broad-based, systematic, continuous anddesigned to promote achievement of program goals related toeducation, patient care, research and service? (1)

YES NO


3. Does the program document its effectiveness using a formal andongoing outcomes assessment process to include measures ofadvanced education student/resident achievement? (1)

YES NO

Intent: The Commission on Dental Accreditation expects each program to define its owngoals and objectives for preparing individuals for the practice of endodontics and that one ofthe program goals is to comprehensively prepare competent individuals to initially practiceendodontics. The outcomes process includes steps to: (a) develop clear, measurable goals andobjectives consistent with the programs purpose/mission; (b) develop procedures forevaluating the extent to which the goals and objectives are met; (c) collect and maintain datain an ongoing and systematic manner; (d) analyze the data collected and share the results with

appropriate audiences; (e) identify and implement corrective actions to strengthen theprogram; and (f )review the assessment plan, revise as appropriate, and continue the cyclicalprocess.


4. Are the financial resources sufficient to support the programs YES NOEndodontic Self-Study Guide

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stated goals and objectives? (1)

Intent: The institution should have the financial resources required to develop and sustainthe program on a continuing basis. The program should have the ability to employ anadequate number of full-time faculty, purchase and maintain equipment, procure supplies,reference material and teaching aids as reflected in annual budget appropriations. Financial

allocations should ensure that the program will be in a competitive position to recruit andretain qualified faculty. Annual appropriations should provide for innovations and changesnecessary to reflect current concepts of education in the advanced specialty discipline. TheCommission will assess the adequacy of financial support on the basis of currentappropriations and the stability of sources of funding for the program.


5. Does the sponsoring institution ensure that support from entitiesoutside of the institution does not compromise the teaching,clinical and researchcomponents of the program? (1)

YES NO


6. Is the advanced specialty education program sponsored by an

institution, which is properly chartered, and licensed to operate andoffers instruction leading to degrees, diplomas or certificates withrecognized education validity? (1)

YES NO


7. If a hospital is the sponsor, is the hospital accredited by anaccreditation organization recognized by the Centers for Medicare

and Medicaid (CMS)? (1)

YES NO N/A


8. If an educational institution is the sponsor, is the educationalinstitution Accredited by an agency recognized by the UnitedStates Department of Education? (1)

YES NO N/A



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9. If applicable, do the bylaws, rules and regulations of the hospitalthat sponsors or provides a substantial portion of the advancedspecialty education program ensure that dentists are eligible formedical staff membership and privileges including the right tovote, hold office, serve on medical staff committees and admit,manage and discharge patients? (1)

YES NO N/A


10. Does the authority and final responsibility for curriculumdevelopment and approval, student/resident selection, facultyselection and administrative matters rest within the sponsoringinstitution? (1)

YES NO


11. Is the position of the program in the administrative structureconsistent with that of other parallel programs within theinstitution? (1)

YES NO


12. Does the program director have the authority, responsibility andprivileges necessary to manage the program? (1)

YES NO


AFFILIATIONS

(If the program is not affiliated with other institutions, please skip to Standard 2.)



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13. Does the primary sponsor of the educational program accept fullresponsibility for the quality of education provided in all affiliatedinstitutions? (1)

YES NO


14. Is documentary evidence of agreements, approved by thesponsoring and relevant affiliated institutions, available? (1)

YES NO


15. Are the following items covered in such inter-institutionalagreements:

a) Designation of a single program director?

b) The teaching staff?

c) The educational objectives of the program?

d) The period of assignment of students/residents?

And

e) Each institution's financial commitment? (1)

YES NO

YES NO

YES NO

YES NO

YES NO

Intent: The items that are covered in inter-institutional agreements do not have to becontained in a single document. They may be included in multiple agreements, both formaland informal (e.g., addenda and letters of mutual understanding).


STANDARD 2 - PROGRAM DIRECTOR AND TEACHING STAFF

(Complete each question by inserting an x in the appropriate box and identifying documentationin support of your answer. Appendices G-Kare also required for this section. Note: requiredappendix information may serve as documentary evidence where appropriate.)

16. Is the program administered by a director who is board certified intherespective specialty of the program, or if appointed after January 1,

YES NO



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1997,has previously served as a program director? (2)

Intent: The director of an advanced specialty education program is to be certified by anADA-recognized certifying board in the specialty. Board certification is to be active. Theboard certification requirement of Standard 2 is also applicable to an interim/acting program

director. A program with a director who is not board certified but who has previousexperience as an interim/acting program director in a Commission-accredited program priorto 1997 is not considered in compliance with Standard 2.


17. Is the program director appointed to the sponsoring institution andhave sufficient authority and time to achieve the educational goalsof the program and assess the programs effectiveness in meetingits goals? (2)

YES NO


18. Does the sponsoring institution appoint a program director:

a) who is a full-time faculty member?

b) whose time commitment is no less than twenty-four hours

per week to the advanced education program in endodontics? (2-1)

YES NO

YES NO

Intent: The intent is to ensure that the program director has sufficient time to participatein all aspects of the program including direct student/resident contact in didactic andclinical activities.


19. Do the responsibilities of the program director include:

a) Development of mission, goals, and objectives for the program?

b) Development and implementation of a curriculum plan?

c) Planning for and operation of the facilities used in theendodontic program?

d) Student/Resident selection unless the program is sponsored by afederal service utilizing a centralized student/resident selection process?

e) Ensuring ongoing evaluation of student/resident performance

YES NO

YES NO

YES NO

YES NO

YES NOEndodontic Self-Study Guide

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and faculty teaching performance?f) Evaluation of teaching program and faculty supervision inaffiliated institutions?

g) Maintenance of records related to the educational program,including written instructional objectives and course outlines?

h) Overall continuity and quality of patient care as it relates toprogram?

i) Ongoing planning, evaluation and improvement of the quality of theprogram?

j) Preparation of graduates for certification by the American Boardof Endodontics? and

k) Ensuring formal (written) evaluation of faculty members at leastannually to assess their performance in the educational program? (2-2)

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

Intent: The intent is to ensure that the program director has complete authority toadminister all aspects of the advanced education program and that all administrativerecords are maintained within the institution and available for the site visitor.


20. Are the number of faculty and the professional education anddevelopment of faculty sufficient to meet the programs objectives and

outcomes? (2-3)

YES NO


21. Is there attending faculty responsible for all clinical activities? (2-4)

YES NO


22. Do attending faculty have specific and regularly scheduled clinicassignments to provide direct supervision appropriate to astudents/residents level of training in all patient care? (2-4.1)

YES NO



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23. Are program directors and full time faculty provided time andresources to engage in scholarly pursuits? (2-5)

YES NO




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STANDARD 3 FACILITIES AND RESOURCES

(Complete each question by inserting an x in the appropriate box and identifying documentationin support of your answer. Appendices L-M are also required for this section. Note: requiredappendix information may serve as documentary evidence where appropriate.)

24. Are institutional facilities and resources adequate to provide theeducational experiences and opportunities required to fulfill theneeds of the educational program as specified in the AccreditationStandards for Advanced Specialty Education Programs? (3)

YES NO


25. Are equipment and supplies for use in managing medical

emergencies readily accessible and functional? (3)

YES NO

Intent:The facilities and resources (e.g.; support/secretarial staff, allied personnel and/ortechnical staff) should permit the attainment of program goals and objectives. To ensurehealth and safety for patients, students/residents, faculty and staff, the physical facilities andequipment should effectively accommodate the clinic and/or laboratory schedule.


26. Does the program document its compliance with the institutionspolicy and applicable regulations of local, state and federalagencies, including but not limited to radiation hygiene andprotection, ionizing radiation, hazardous materials, and bloodborneand infectious diseases? (3)

YES NO


27. Are the above policies provided to all students/residents, facultyand appropriate support staff and continuously monitored forcompliance? (3)

YES NO


28. Are policies on bloodborne and infectious diseases made available YES NOEndodontic Self-Study Guide

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to applicants for admission and patients? (3)

Intent: The program may document compliance by including the applicable program policies.The program demonstrates how the policies are provided to the students/residents, faculty andappropriate support staff and who is responsible for monitoring compliance. Applicable

policy states how it is made available to applicants for admission and patients should arequest to review the policy be made.


29. Are students/residents, faculty and appropriate support staffencouraged to be immunized against and/or tested for infectiousdiseases, such as mumps, measles, rubella and hepatitis B, prior tocontact with patients and/or infectious objects or materials, in aneffort to minimize the risk to patients and dental personnel? (3)

YES NO

Intent: The program should have written policy that encourages (e.g., delineates theadvantages of) immunization for students/residents, faculty and appropriate support staff.


30. Are all students/residents, faculty and support staff involved in the

direct provision of patient care continuously recognized/certified inbasic life support procedures, including cardiopulmonaryresuscitation? (3)

YES NO

Intent: Continuously recognized/certified in basic life support procedures means theappropriate individuals are currently recognized/certified.




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31. Are private office facilities used as a means of providing clinicalexperiences in advanced specialty education? (3)*

YES NO

Intent:Required endodontic clinical experiences do not occur in private office facilities.Practice management and elective experiences may be undertaken in private office facilities.


32. Are the clinical facilities for students/residents in endodonticsspecifically identified and readily available? (3-1)

YES NO


33. Is the design of units suitable for all endodontic clinicalprocedures, including four-handed dentistry? (3-1.1)

YES NO

Intent: The intent isto ensure that students/residents, faculty, and clinical support personnelhave the facilities/resources necessary to conduct the clinical phase of the program; thatclinical operatories and surrounding space are sufficient to perform all endodonticprocedures, including surgery, and to allow for patient comfort, access and space for clinicalsupport personnel and student/resident/faculty maneuverability.


34. Is radiographic or imaging equipment and equipment specific forendodontic procedures readily available? (3-2)

YES NO

Intent: The intent is to ensure that necessary equipment is available in the same clinicarea to image teeth and their surrounding structures to aid in diagnosis and treatment.


*Answer YES if a statement is true, answer NO if a statement is false.



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35. Are lecture and seminar rooms as well as audiovisual aidsavailable? (3-3)

YES NO


36. Are appropriate information resourcesavailable, including accessto biomedical textbooks, dental journals and other sourcespertinent to the area of endodontic practice and research? (3-4)

YES NO


37. Is clinical support personnel sufficient to ensure efficient operationof the clinical program and to provide students/residents with theopportunity to practice four-handed dentistry techniques? (3-5)

YES NO

Intent: The intent isto facilitate efficient delivery of dental care; to enhance the normaloperation of endodontic practice; and to provide a simulated clinical practice environment;(Clinical support personnel is needed to keep from placing an undue burden of additionalduties and responsibilities on the student/resident, potentially compromising the overalleducational objectives of the program.)


38. Is secretarial and clerical support personnel sufficient to permitefficient operation of the program? (3-6)

YES NO

Intent: The intent isto ensure operations of the program are managed in an efficient andexpeditious manner without placing undue hardship on the faculty and students/residents inthe program.




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39. Do program resources exist to support the number ofstudents/residents enrolled? (3-7)

YES NO


STANDARD 4 - CURRICULUM AND PROGRAM DURATION



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(Complete each question by inserting an x in the appropriate box and identifying documentationin support of your answer. Appendices N-T are also required for this section. Note: requiredappendix information may serve as documentary evidence where appropriate.)

40. Is the advanced specialty education program designed to providespecial knowledge and skills beyond the D.D.S. or D.M.D. training

and oriented to the accepted standards of specialty practice as setforth in the Accreditation Standards for Advanced SpecialtyEducation Programs? (4)

YES NO

Intent: The intent is to ensure that the didactic rigor and extent of clinical experience exceedspre-doctoral, entry level dental training or continuing education requirements and the materialand experience satisfies standards for the specialty.


41. Is the level of specialty area instruction in certificate and degree-granting programs comparable? (4)

YES NO N/A

Intent: The intent is to ensure that the students/residents of these programs receive the sameeducational requirements as set forth in these Standards.


42. Is documentation of all program activities ensured by the programdirector and available for review? (4)

YES NO


43. If the institution/program enrolls part-time students/residents, doesthe institution have guidelines regarding enrollment of part-timestudents/residents? (4)

YES NO N/A


44. If the institution/program enrolls part-time students/residents, do they YES NO N/AEndodontic Self-Study Guide

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start and complete the program within a single institution, except whenthe program is discontinued? (4)

DocumentaryEvidence:

45. If the institution/program enrolls students/residents on a part-time basis,does the director of the accredited program ensure that:

a) The educational experiences, including the clinicalexperiences and responsibilities, are the same asrequired by full-time students/residents? and

b) There is an equivalent number of months spent in theprogram? (4)

YES NO N/A

YES NO N/A


46. Does the advanced specialty education program in endodontics encompassa minimum duration of 24 months (104 weeks) of full-time study? (4-1)

YES NO

Intent: The intent is to ensure that during the 104 weeks it is expected that endodontic

students/residents will have a maximum of 8 weeks available for vacations, legal holidays,sick leave and personal time.


47. Is the content of all didactic instruction included in the programcurriculum documented? (4-2)

YES NO


48. Is a formal (written) annual review of the program curriculumconducted? (4-3)

YES NO

Intent: The intent is to ensure that the instructional content continues to meet the programgoals and objectives.

Documentary Evidence:Endodontic Self-Study Guide

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BIOMEDICAL SCIENCES

49. Does instruction in the biomedical sciences provide information

emphasizing principles and recent developments in order to meetthe advanced programs objectives? (4-4)

YES NO

Intent: The intent is to ensure that developing new theories and techniques of endodontictreatment are included in the advanced program curriculum. Instruction should includethe biologic and technical aspects of maintaining, replacing, and enhancing the naturaldentition, including mechanisms for enhanced tissue healing and tissue regeneration.


50. Does instruction emphasize the interrelationships among thebiomedical sciences and their application to clinical practice? (4-5)

YES NO




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51. Is instruction provided in: (4-6)

a) Anatomy (gross and micro) of soft and hard tissues ofthe head and neck?

YES NO

b) Embryology? YES NO

c) Infectious and immunologic processes in oral healthand disease?

d) Pathophysiology of the pulpal/periradicular?

e) Wound healing?

f) Oral medicine and oral pathology?

g) Pharmacotherapeutics?

h) Research methodology and statistics?

i) Neurosciences? and

j) Biomaterials?

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO


CLINICAL SCIENCES

52. Are a minimum of 40% and a maximum of 60% of the total clockhours in a two-year (24 months) program devoted to clinical care?(4-7)

YES NO


53. Is endodontic treatment evidence-based? (4-8)(EBE is theintegration of the best research evidence with clinician expertiseand patient values).

YES NO




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54. Does the educational program provide in-depth instruction andclinical training to achieve proficiency in the following areas: (4-9)

a) Diagnosis, treatment planning and prognosis?

b) Non-surgical and surgical endodontic treatment and

retreatment?

Intent: The intent of instruction and training in surgical endodontictreatment and retreatment is to ensure that students/residents aretrained to provide comprehensive treatment, which may include theremoval of teeth as part of an endodontic treatment plan, e.g.,extractions/replantations or extractions of teeth with vertical rootfractures or other pathosis for which extraction is the preferredtreatment.

c) Outcome evaluation?

d) Radiography and other diagnostic imagingtechnologies?

e) Management of endodontic treatment of medicallycompromised patients?

f) Emergency treatment for endodontic conditions?

g) Management of patients with orofacial pain andanxiety?

h) Preparation of space for intraradicular restorations andcoresin endodontically treated teeth?

i) Communication with patients and health careprofessionals? and

j) Use of magnification technologies?

Intent: The intent is to ensure that students/residents are trained inthe use of instruments that providemagnification and illumination ofthe operative field beyond that of magnifying eyewear. Inaddition

to the operating microscope, these instruments may include, but arenot limited to, the endoscope, orascope or other developingmagnification.

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO


55. Does the educational program provide in-depth instruction and clinicalEndodontic Self-Study Guide

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training to achieve competency in the following areas: (4-10)

a) Vital pulp management?

b) Endodontic management of developing permanent teeth?

c) Endodontic management of traumatic dental injuries? and

Intent: the intent is to ensure that students/residents are trained tomanage all aspects of the endodontic care of teeth with traumatic injuries

d) A variety of endodontic techniques?

YES NO

YES NO

YES NO

YES NO

YES NO


56. Does the educational program provide instruction at the level ofunderstanding and clinical training to the level of exposure in the followingareas: (4-11)

a) Diagnosis and treatment of periodontal disease and defects inconjunction with the treatment of the specific tooth undergoingendodontic therapy; treatment should be provided inconsultation with the individuals who will assume theresponsibility for the completion or supervision of anyadditional periodontal maintenance or treatment?

b) Placement of intraradicular restorations and cores inendodontically treated teeth; when the patient is referred, thistreatment is accomplished in consultation with the restorativedentist?

c) Intracoronal bleaching procedures?

d) Implant dentistry? and

e) Extrusion procedures?

YES NO

YES NO

YES NO

YES NO


57. Does the educational programprovide formal instruction in the



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following areas:(4-12)

a. The history of endodontics?

b. Teaching methodology?

c. Ethics and jurisprudence?

d. Practice management?

e. Risk management? and

f. Medical emergencies?

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO


58. Do students/residents actively participate in seminars orconferences involving literature and textbook reviews? (4-13)

YES NO


59. Do students/residents actively participate in endodontic andinterdisciplinary seminars and conferences evaluating diagnostic

data, treatment plans, treatment procedures, and outcomesassessment? (4-14)

YES NO


60.Does the program include a system for follow-up evaluation ofpatients to enable students/residents to assess the outcome of theirtreatment? (4-15)

YES NO


61.Are comprehensive records of history, diagnosis, and treatmentmaintained for each patient? (4-16)

YES NO



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TEACHING

62.Do students/residents participate in teaching endodontics topredoctoral and/or postdoctoral students/residents? (4-17)

YES NO


63.In a two-year (24 months) program, does this participationexceed10% of the total clock hours? (4-17-1)

YES NO

Intent: The intent is to enhance a students/residents ability to organize and evaluateteaching material, to communicate information to others, and/or to mentor others.Teaching is to be in the specialty of endodontics or other related disciplines, at thediscretion of the program director.


*Answer YES if a statement is true, answer NO if a statement is false



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STANDARD 5 - ADVANCED EDUCATION STUDENTS/RESIDENTSELIGIBILITY AND SELECTION

(Complete each question by inserting an x in the appropriate box and identifying documentationin support of your answer. Appendices U-X are also required for this section. Note: requiredappendix information may serve as documentary evidence where appropriate.)

64. Are dentists with the following qualifications eligible to enter theadvanced specialty education program accredited by the Commissionon Dental Accreditation:

a) Graduates from institutions in the U.S. accredited by theCommission on Dental Accreditation?

b) Graduates from institutions in Canada accredited by theCommission on Dental Accreditation of Canada? and

c) Graduates of international dental schools who possessequivalent educational background and standing asdetermined by the institution and program? (5)

YES NO

YES NO

YES NO N/A


65.Are specific written criteria, policies and procedures followedwhen admitting students/residents? (5)

YES NO

Intent:Written non-discriminatory policies are to be followed in selectingstudents/residents. These policies should make clear the methods and criteria used inrecruiting and selecting students/residents and how applicants are informed of their statusthroughout the selection process.


66. Is the admission of students/residents with advancedstanding based on the same standards of achievementrequired by students/residents regularly enrolled in theprogram? (5)

YES NO N/A




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67. Do transfer students/residents with advanced standing receive an appropriatecurriculum that results in the same standards of competence required bystudents/residents regularly enrolled in the program? (5)

YES NO N

Documentary Evidence: (If yes, as part of the documentary evidence, describe the

policies and methods for awarding advanced standing credit. Indicate the type ofcourses for which advanced standing is granted and the maximum number of creditsthat can be awarded).

EVALUATION

68. Does a system of ongoing evaluation and advancement ensure that,through the director and faculty, each program:

a) Periodically, but at least semiannually, evaluates theknowledge, skills, ethical conduct and professionalgrowth of its students/residents, using appropriatewritten criteria and procedures?

b) Provides to students/residents an assessment of theirperformance, at least semiannually?

c) Advances students/residents to positions of higherresponsibility only on the basis of an evaluation of their

readiness for advancement? And

d) Maintains a personal record of evaluation for eachstudent/resident which is accessible to thestudent/resident and available for review during sitevisits? (5)

YES NO

YES NO

YES NO

YES NO

Intent: (b) Student/Resident evaluations should be recorded and available in written form.(c) Deficiencies should be identified in order to institute corrective measures.(d) Student/Resident evaluation is documented in writing and is shared with the

student/resident.


DUE PROCESS

69. Are there specific written due process policies and procedures for YES NOEndodontic Self-Study Guide

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adjudication of academic and disciplinary complaints, whichparallel those established by the sponsoring institution? (5)


RIGHTS AND RESPONSIBILITIES

70. At the time of enrollment are the advanced specialty educationstudents/residents apprised in writing of the educationalexperience to be provided, including the nature of assignments toother departments or institutions and teaching commitments? (5)

YES NO


71. Are all advanced specialty education students/residents providedwith written information which affirms their obligations andresponsibilities to the institution, the program and programfaculty? (5)

YES NO

Intent:Adjudication procedures should include institutional policy which provides dueprocess for all individuals who may potentially be involved when actions are contemplated orinitiated which could result in disciplinary actions, including dismissal of a student/resident(for academic or disciplinary reasons). In addition to information on the program,

students/residents should also be provided with written information, which affirms theirobligations and responsibilities to the institution, the program, and the faculty. The programinformation provided to the students/residents should include, but not necessarily be limitedto, information about tuition, stipend or other compensation; vacation and sick leave; practiceprivileges and other activity outside the educational program; professional liability coverage;and due process policy and current accreditation status of the program.




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STANDARD 6 RESEARCH

(Complete each question by inserting an x in the appropriate box and identifying documentationin support of your answer.)

72. Do advanced specialty education students/residents engage in

scholarly activity?(6)

YES NO


73. Do students/residents participate in research? (6-1) YES NO

Intent: The intent is to ensure that each student/resident is capable of developing a research

protocol and has an active role in conducting a research project.


74. Are the research experience and results compiled into a documentin publishable format? (6-2)

YES NO




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SUMMARY OF SELF-STUDY REPORT

Summarize in a qualitative appraisal and analysis the programs strengths and weakness.

Note: This summary culminates the self-study report in a qualitative appraisal and analysisof the programs strengths and weakness.

INSTITUTION-RELATED

1. Assess the adequacy of institutional support for the program.

2. Assess whether the program is achieving goals through training beyond pre-doctoral level.

3. Assess whether the program is achieving goals through stated competencies.

4. Assess whether the program is achieving goals through stated proficiencies.

5. Assess whether the program is achieving goals through outcomes.

6. Assess calibration among program directors and faculty in the student/resident evaluationprocess to ensure consistency of the evaluation process.

7. Assess the faculty evaluation process to ensure consistency of the evaluation process.

8. Assess the institutions policies on advanced education students/residents.

9. Assess the institutions policies on eligibility and selection.

10. Assess the institutions policies on due process.

11. Assess the institutions policies on student/resident rights and responsibilities.

12. Assess the adequacy and accessibility, hours of operation and scope of holdings of thesponsoring institutions library resources.

13. Assess the institutional oversight of the quality of training at affiliated institutions.

PATIENT CARE

1. Assess the institutions/programs preparedness to manage medical emergencies.

2. Assess the adequacy of radiographic services and protection for patients, advancededucation students/residents and staff.



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3. Assess the programs capacity for four-handed dentistry.

4. Assess the institutions policies and procedures on hazardous materials, and bloodborneand infectious diseases for patients, advanced education students/residents and staff.

5. Assess how students/residents may be able to apply ethical, legal and regulatory concepts

in the provision, prevention and/or support of oral health care.

PROGRAM-RELATED

1. Assess the students/residents time distribution among each program activity (e.g.,didactic, clinical, teaching, research) and how well it is working

2. Assess the volume and variety of the programs patient pool.

3. Assess the programs student/resident/faculty ratio.

4. Assess the programs student/resident pool.

5. Assess rotations, electives and extramural experiences of the program.

6. Assess the programs record keeping and retention practices.

7. Assess the research activities of the program.



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REQUIRED APPENDIX INFORMATION

STANDARD 1 INSTITUTIONAL COMMITMENT/PROGRAMEFFECTIVENESS/AFFILIATIONS

Appendix A Attach as Appendix A the institutions educational mission andprograms goals and objectives.

Appendix B Attach as Appendix B the programs outcomes assessment plan,outcomes measurements, and outcomes assessment results.(Exhibit 1a)

Appendix C Attach as Appendix C the institutions administrative structure inan organizational chart.

Appendix D - Attach as Appendix D the success rate of graduates on the boardexamination for the last 5 years.

Appendix E - Attach as Appendix E the affiliated institutions that participate intraining students/residents, indicate: (Use Exhibit 1 for eachaffiliated institution used by the program. Make copies of the form asneeded. Number appropriately, e.g., Appendix E1, Appendix E2, etc.)

Appendix F - Attach as Appendix F the names of other programs that rotate

students/residents through this sponsoring organization. Note thepurpose of the affiliation and the time duration.

Have a copy of the organizations by-laws available at the time of the site visit.



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STANDARD 2 PROGRAM DIRECTOR AND TEACHING STAFF

Appendix G - Attach as Appendix G information regarding the programdirectors time commitment. (Use Exhibit 2.)

Appendix H - Attach as Appendix H information regarding the teaching staff.(Use the Exhibits 3.1 and 3.2.)

Appendix I - Attach as Appendix I BioSketch of the program director and allFTE teaching faculty (Use Exhibit 3.3).

Appendix J - Attach as Appendix J monthly attending staff schedules.

Appendix K - Attach as Appendix K a blank faculty evaluation form.



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STANDARD 3 FACILITIES AND RESOURCES

Appendix L - Attach as Appendix L information regarding facilities. (UseExhibit 4.)

Appendix M - Attach as Appendix M information regarding support staff. (UseExhibit 5.)

Have a copy of the institutions infection and hazard control protocol availablefor inspection at the time of the site visit.



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STANDARD 4 CURRICULUM AND PROGRAM DURATION

Appendix N - Attach as Appendix N the percentages of the students/residentstotal program time. (Use Exhibit 6.)

Appendix O Attach as Appendix O students/residents schedules for eachyear of the program. (Use Exhibit 7.)

Appendix P Attach as Appendix P information regarding Biomedical Sciencesinstruction. (Use Exhibit 8.)

Appendix Q Attach as Appendix Q a schedule of department seminars,conferences and/or lectures. Indicate the title or topics and nameand title of the presenter(s) for each seminar, conference and/or

lecture. Also include goals, objectives and course outlines foreach course identified.

Appendix R Attach as Appendix R a schedule of off-service assignments. (UseExhibit 9.)

Appendix S Attach as Appendix S information regarding Admissions. (UseExhibit 10.)

Appendix T Attach as Appendix T information regarding Clinical training.

(Use Exhibit 11.)



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STANDARD 5 ADVANCED EDUCATION STUDENTS/RESIDENTS

Appendix U Attach as Appendix U a brochure, school catalog or formaldescription of the program.

Appendix V Attach as Appendix V a student/resident evaluation form.

Appendix W Attach as Appendix W the specific written due process policiesand procedures for adjudication of academic and disciplinarycomplaints, which parallel those established by the sponsoringinstitution.

Appendix X Attach as Appendix X a copy of the written material given toentering students/residents, describing their rights and

responsibilities to the institution, program and faculty.



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Exhibit 1

AFFILIATIONS

a. Official name of affiliate:

(city, state)

b. Length and purpose of the rotation (number of weeks, hours per week) :

c. Is the institution accredited by JCAHO?

YES NO N/A

If another accrediting body, please list:

d. Distance from the affiliate to sponsoring institution: (miles)

e. One-way commuting time:

f. Indicate why this institution was selected, the nature of training provided to students/residents,teaching staff responsible for conducting the program and supervising students/residents at the institutionand how these educational experiences supplement training received at the sponsoring institution.

g. If affiliation agreements have not been updated to include this program, please provide timetablefor updating the agreement.



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SELECTED EXHIBITS

EXHIBIT 1a

OUTCOMES ASSESSMENT

(Standard 1)

This table provides one example of a format, which may be utilized to present the programs outcomesassessment plan and process. A copy should be made for each of the programs overall goals and objectivan alternative format is used, please be sure it includes the information below.

Overall Goal or Objective #_________:

Overall Goal or Objective

Outcomes AssessmentMechanism

How often conducted

Date to be conducted/

finished by

Results expected

Results achieved

Assessment of results

Program improvement as a

result of data analysis

Date of next assessment



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Exhibit 2

PROGRAM DIRECTOR

Please complete the following chart for all programs being reviewed at this time.

Name ofProgram

DirectorsFirst Init. &Last Name

BoardCertified orpreviouslyserved asProgramDirector andYearAppointed

Yr Appointedto Position

Number of Hrs/wk atSponsoring Institution Breakdown time intofollowing categories:

administration

teaching

research

other

Number ofHrs/wkDevoted toProgram



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Exhibit 3.1

TEACHING STAFF

On the table below, indicate the members of the teaching staff who are scheduled to devote ONE-HALF DAY OR MORE PER WEEK specifically to the program. Indicate whether each staff

member listed is a general practitioner or specialist, the number of hours per week, and thenumber of weeks per year devoted to the program. If the staff member is a specialist, indicate thespecialty and board status. Be sure to include the program director.

Name Discipline/Specialty

Board Status(IfSpecialist)

Hoursper week

Weeksper year

Assignments*

*Use the following codes to indicate assignments:

SCSupervision of students/residents in clinic

TTeaching Didactic Sessions (lectures, seminars, courses)PAProgram Administration



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Exhibit 3.2

TEACHING STAFF

Starting with the individual who has the greatest time commitment to the program, list members ofthe attending staff or consultants who are scheduled to devote LESS THAN ONE-HALF DAY

PER WEEK, BUT AT LEAST ONE-HALF DAY (OR MORE) PER MONTH specifically to theprogram. Indicate whether each individual listed is a general practitioner (GP) or specialist, thenumber of hours per month, and the number of months per year devoted to the educationalprogram. If the staff member or consultant is a specialist, indicate specialty and board status.

Name Discipline/Specialty

Board Status(IfSpecialist)

Daysper month

Weeksper year

Assignments*

*Use the following codes to indicate assignments:

SCSupervision of students/residents in clinicTTeaching Didactic Sessions (lectures, seminars, courses)

PAProgram Administration



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Exhibit 3.3

Commission on Dental AccreditationBioSketch

Do not attach Curriculum Vitae.Print or Type Only

Name:

Current

Institution:

EDUCATIONAL BACKGROUND (Begin with college level)

Name of School, City and StateYr ofGrad.

Certificate or Degree Area of Study

LICENSURE

License (Do not include license number) From (Year) To (Year)

BOARD CERTIFICATION

Certifying Organization Specialty Date certified

CE COURSES TAKEN (last 5 years)

Course Title Course Content and Provider Month and Year

TEACHING APPOINTMENTS (Begin with current)

Name of Institution, City and StateRank

Subjects/Content AreasTaught/Administrative Responsibilities

From(Year)

To(Year)



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CURRENT TEACHING RESPONSIBILITIES

Name of Institution, City, State Course Title Discipline and Level of

Students (Year)

Total Contact Hours Per Year

Didactic Clinic/Laboratory

HOSPITAL APPOINTMENTS (Begin with current)

Name of Hospital City StateFrom(Year)

To(Year)

PRACTICE EXPERIENCE

Location (City and State) Type of Practice From(Year)

To(Year)

MEMBERSHIP, OFFICES OR APPOINTMENTS HELD IN LOCAL, STATE OR NATIONAL DENTAL OR ALLIED

DENTAL ORGANIZATIONS, INCLUDING APPOINTMENTS TO STATE BOARDS OF DENTISTRY AND CODA

Name of Organization Title From(Year)

To(Year)

PUBLISHED WORKS (For the most recent five years, list articles in which you were the principal author that appeared in refereedjournals or text books, by author(s), title, publication, and date)

Author(s) Title Publication Date



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Exhibit 4

FACILITIES AND RESOURCES

For each item listed below, indicate whether the item is located within the dental clinic, outside thedental clinic but readily accessible to it, or not available (check appropriate response).

Facilities, Capabilities/Equipment Wi

spec endo ssg

Documents