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Eur J Dental Education - 2007 - Jones - Quality Assurance and Benchmarking An Approach For European Dental Schools
Eur J Dental Education - 2007 - Jones - Quality Assurance and Benchmarking An Approach For European Dental Schools
Eur J Dental Education - 2007 - Jones - Quality Assurance and Benchmarking An Approach For European Dental Schools
Dental Education
Abstract: This document was written by Task Force 3 of DentEd and its appendices, were unanimously supported by the ADEE at
III, which is a European Union funded Thematic Network working its General Assembly in 2006. As there must be more than one
under the auspices of the Association for Dental Education in road to achieve a convergence or harmonisation standard, a
Europe (ADEE). It provides a guide to assist in the harmonisation number of appendices are made available on the ADEE website.
of Dental Education Quality Assurance (QA) systems across the These provide a series of ‘toolkits’ from which schools can ‘pick
European Higher Education Area (EHEA). There is reference to and choose’ to assist them in developing QA systems appropri-
the work, thus far, of DentEd, DentEd Evolves, DentEd III and the ate to their own environment. Validated contributions and
ADEE as they strive to assist the convergence of standards in examples continue to be most welcome from all members of
dental education; obviously QA and benchmarking has an the European dental community for inclusion at this website. It is
important part to play in the European HE response to the realised that not all schools will be able to achieve all of these
Bologna Process. Definitions of Quality, Quality Assurance, requirements immediately, by definition, successful harmonisa-
Quality Management and Quality Improvement are given and put tion is a process that will take time. At the end of the DentEd III
into the context of dental education. The possible process and project, ADEE will continue to support the progress of all schools
framework for Quality Assurance are outlined and some basic in Europe towards these aims.
guidelines/recommendations suggested. It is recognised that
Quality Assurance in Dental Schools has to co-exist as part of Key words: dental curriculum; quality assurance; quality in
established Quality Assurance systems within faculties and education; dental education; benchmarking; DentEd.
universities, and that Schools also may have to comply with
existing local or national systems. Perhaps of greatest import- ª 2007 The Authors. Journal Compilation ª 2007 Blackwell
ance are the 14 ‘requirements’ for the Quality Assurance of Munksgaard
Dental Education in Europe. These, together with the document Accepted for publication, 21 November 2006
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Jones et al.
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Quality assurance and benchmarking
whilst quality assurance aims at providing confidence subjected to both internal and external scrutiny,
in this fulfilment, both within the organisation and and/or should be orientated according to inter-
externally to customers and authorities. Quality man- national benchmarks. In the latter instance, it is
agement includes quality control and quality assur- helpful to have a ‘benchmark’ against which to
ance, as well as the additional concepts of quality measure the performance. The reported outcomes
policy, quality planning and quality improvement. of assessment should be carefully considered and
Quality management operates throughout the QA acted upon by a clearly defined process.
system. An important overall test of whether all of the 3. A system for internal quality assurance should be in
Quality systems are being effective in a dental educa- place by which the improvements identified conse-
tional environment might be as follows: initially quent to assessment (both internal and external) can
students are appropriately selected for entry to a be considered, then actions agreed, acted upon and
school which has modern clinical and teaching facil- implemented.
ities. They are then exposed to training of a high 4. Subsequently, it is helpful to review those changes
quality within the modern teaching environment, the which have been implemented to be sure that they
students being sufficiently supported so as to achieve have achieved the desired effect in bringing about
the appropriate competencies at the appropriate both change and improvement.
milestones throughout the Quality Assured curricu- Quality management should be an ongoing,
lum. They then graduate at the end of 5 years as a dynamic process, as well as forming an essential,
Dentist of a comparable standard against recognised and integral, part of every function in the dental
national and European benchmarks. Thus, all aspects school and hospital. There are different methods
of quality management in a dental school (and the available for quality evaluation. However, decision-
associated clinical facility, for example a hospital) making processes and implementation opportunities
should come together to efficiently produce consis- may vary between schools and thus, not all recom-
tently high quality dentists in a resource, time and mendations may necessarily lead to immediate
cost-effective manner. improvement. Perhaps, the most important point is
to have a clear system for Quality Assurance and
Improvement built into the management structure of a
dental school (and hospital). Ideally it should be a
Quality processes continuous repetitive process, selectively bench-
Quality is assessed in order to determine whether it marked and with appropriately timed internal and
meets the standard set and to lay the basis for external validation included in the cycle. The key
improvement. However, quality assessment per se is outcomes of improvement should never be assumed
no guarantee of quality improvement. In the dental to have been achieved just by implementing change
school/hospital environment, quality assessment can but should be checked against what was intended, in a
be seen as consisting of two interrelated processes further process of review and follow-up.
based on both internal and external evaluation. In a
well-developed and mature process, results and rec-
ommendations from internal and external evaluations
should be used in an integrated way to drive the
A famework for QA
improvement of education and produce graduates of a In the context of Higher Education, Vroeijenstijn (10)
consistently high quality. Within educational quality introduced a framework for quality assurance that
improvement, four strongly correlated components includes both internal and external elements. The
can be distinguished: external process is built on, and is preceded by, the
1. There should be clear goals and objectives for a internal process.
curriculum. Similarly, there should be objectives Internal evaluation comprises monitoring, student
and standards set for the educational methods evaluation and a method of school (and hospital) self-
employed and also the systems and staff being evaluation. Some system of external peer review is
used for delivery. All of these need to be clearly included.
identified to develop an appropriate system of In such a framework as that proposed, the following
assessment. objectives can be identified:
2. There should be clear methods for the evaluation 1. Accreditation – usually an external quality evalua-
of all courses and also the modules from which tion by which an outside body formulates the
the curriculum is built. Ideally, these should be criteria and standards (a benchmark) against which
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Jones et al.
the institution and the program will be assessed. 1966 (12) with its further development by Starfield in
Improvements are usually aimed at fulfilling 1973 (13). This conceptual framework includes three
criteria for accreditation. dimensions:
2. Accountability – this usually considers the appro- 1. Structure – relating to the facilities, equipment,
priate use of resource and would include an personnel and organisation available for provision
assessment of the value for money. Benchmarking of care,
by some method is usually fundamental to this 2. Process – referring to actual provision of care,
process, which may be based on an external 3. Outcome – denoting effects of care on patient’s
evaluation. Any resultant improvement would health status.
usually be in the form of increased efficiency. Each of these dimensions and the dynamics of the
3. Self-regulation (and autonomous systems) – where relations between them can be assessed separately
quality management comprises internal and exter- (or in combination) in relation to the quality of care
nal evaluations with linked internal procedures for provided in dental schools and hospitals. Again,
improvement. This is aimed at maintaining high they are all fundamental to the development of an
educational standards in an independent, academic appropriate environment for dental education and
institution. form an important part of the overall mechanism of
It is apparent that all of these objectives are of QA.
paramount importance in achieving a good system for In the case where patient treatment is performed
quality management in dental schools. within a hospital environment, the QA management
A different approach, which is based on the ISO system of the hospital, as well as the corresponding
9000 series or related guidelines, differs between national regulations, should apply.
process evaluation/accreditation and programme
accreditation (11):
1. Process evaluation involves the control of processes
within an institution (e.g. the University), by which
Definition of terms
the necessary quality level within this institution is Requirements – A requirement is a binding or
evaluated and controlled. This process evaluation/ mandatory policy and, in this document, it is also a
accreditation is normally performed by an external ‘best practice’.
institution/group of experts. Recommendations (guidelines) – A recommenda-
2. Programme evaluation/accreditation involves the tion or guideline in the EU is not binding or manda-
control of each single teaching programme within tory, and in this document constitute suggestions for
the University. This may be performed by external the improvement of practice.
or internal peer review.
3. External process evaluation/accreditation and ADEE requirements
Internal programme evaluation/accreditation can The following requirements originally were devel-
be combined. For Dentistry, international bench- oped through work in an earlier Task Force and
marks (e.g. as those set up by ADEE) can be have been considered and supported in a DentEd/
implemented as part of the process, and thus, such ADEE workshop in Athens in 2005. Subsequently,
benchmarks are required for, and are relevant to, they have been carefully considered and subject to
internal evaluation/accreditation. minor amendment by the authors within Task Force
However, perhaps self-regulation is the most funda- 3. They are strongly supported by all members of
mental component. It can be seen as the basis for Task Force 3, who believe them to be fundamental
achieving robust quality management, which will to achieving a high quality, modern, dental educa-
encompass all of the key processes in a dental school tional QA system that is fit for purpose in the 21st
(and hospital), including education, research and also century. They were unanimously supported by the
patient care and protection. General Assembly of the ADEE in Krakow in
There are also several perspectives to quality of care. September 2006.
Quality of care is an integral part of clinical training However, for many, these requirements may be
and the running of the university/hospital clinics. only an aspiration, at least for a time. To fully achieve
Varieties of models/approaches have been presented these requirements there will be a need for appropri-
to structure and conceptualise the assessment of, and ate local, national and European support. The appen-
factors related to, quality of care. The most enduring dices to this document are found on the DentEd III
of these seems to be that described by Donabedian in and ADEE websites (14) and are intended to support
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Quality assurance and benchmarking
those taking the initial steps towards achievement of 10. Feedback from patients and support staff (nurses,
these goals, by providing a ‘toolkit’, and, in time receptionists, etc.) is an important tool and can be
perhaps, a network of expertise, to support the used in the assessment of the quality of care
progress of European schools towards the meeting of provided by both students and staff.
these requirements. 11. Any quality improvement method employed
1. Quality management can only be implemented should ensure that outcomes from the feedback
when the explicit goals and objectives of all of the and review mechanisms are communicated to
functions of a dental school are clearly defined. A teachers, students, graduate and postgraduate
well-described curriculum, the basic DentEd III/ trainers. This fosters an ethos of transparency,
ADEE ‘Profile & Competencies for the New Eur- continued professional development and life-long
opean Dentist’ (15) and the DentEd III/ADEE learning.
‘Curriculum Structure & European Credit Transfer 12. All of those involved in, and associated with,
System for European Dental Schools’ (16) and also learning and teaching should receive a regular
this current document could form the basis for this formal appraisal based on documentation that
process. might include a personal portfolio. This will
2. Every dental school (and hospital) should pursue identify training and development needs, whilst
explicit quality management, improvement and identifying good practice for dissemination. There
enhancement. Of course, quality management should be a strategy and associated budget for the
is a much wider issue than purely relating to development of all staff involved in learning and
the curriculum. It includes teaching, research, teaching.
clinical care, professionalism/‘fitness to practise’ 13. There should be a properly documented period of
and also includes the physical facilities and ‘educationally related’ training for all new (and
infrastructure. returning) teaching staff with clear guidelines and
3. Quality is the responsibility of everybody, inclu- achievable targets. This should form part of the
ding all those involved in dental education, inclu- overall strategy for the training and development
ding members of the dental support staff and of staff.
students. Ideally, patients should also have some 14. The management and committee structure within
means of input into the QA process. the Dental School, Hospital and the providers of
4. Appropriate Quality systems should be an integral other ‘clinical support’ training facilities should
part of all of the activities at a dental school (and include systems for quality assurance and
hospital). It should not be purely an administra- improvement at every level.
tively led ‘paper’ exercise.
5. Schools should have critical self-evaluation sys- Recommendations
tems in place with an appropriate (and consistent) 1. Every school should carry out, on a regular cyclical
documented method of analysis. basis, internal quality assessment and review of the
6. Assessment of quality should be systematic, peri- provision of the teaching programmes and aca-
odic and cyclical in nature. It is suggested that, as demic structure. This process should be overseen at
an ideal, an annual appraisal of teaching pro- the appropriate level within the University or an
grammes is undertaken along with a periodic (e.g. equivalent body.
5-year) review. 2. The University, or equivalent body, should ensure
7. Continual quality management processes and their that a larger periodic quality assessment (a review)
outcomes should always be documented properly. of the undergraduate dental programme should
8. Student feedback, obtained through appropriate take place – this might, for example, be approxi-
evaluation mechanisms and teacher/student liai- mately every 5 years. Ideally, the individuals mak-
son meetings (or forums), are an essential compo- ing up assessment panels should be drawn from
nent of quality improvement. those in cognate discipline areas but should also
9. Feedback from recent graduates on how the dental include external representation of experts from
undergraduate programme has facilitated their other dental teaching institutions.
ability to work as dental care providers should 3. There should be some periodic assessment of the
be included amongst the tools available for QA. provision by, for example, a national body to
The views of employers or postgraduate trainers ensure consistency amongst dental schools in the
about the graduates (from the school) can also be state/country. Ideally, this external periodic
of enormous value. review process should include the use of external
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Jones et al.
assessors (which could be representatives from requirement will be further reviewed at their next
other dental schools in the same state/country meeting in London in 2007.
and/or a different state/country). Such assessors In order to achieve a continuous improvement in
should be experienced in visiting curricula/exam- dental education, a proper Quality Management sys-
inations and be prepared to comment on the tem needs to be in place that includes both internal
appropriateness of the programme and its com- assessment and review, different evaluation/accredi-
ponent courses, as compared to other institutions, tation systems with the university and, where applic-
both national and international (e.g. DentEd/ able, the Medical Faculty. There also needs to be, in
ADEE). Some schools feel that there is benefit in place, a method by which responsive change and
including student representatives in this process improvement in the educational process can be
[e.g. Dutch Dental Accreditation Process – Quality achieved. QA does not just apply to the teaching
Assurance Netherland Universities (QANU)]. programme/curriculum, rather it must apply to every
The type of periodic process described could activity of a dental school and hospital including, for
form part of the national course accreditation – example, the suitability of clinical and ICT facilities.
an agreed desirable outcome in the Bologna QA linked to some system of benchmarking and
Declaration. external review is fundamental to achieving the
4. Peer review and student assessment of teaching equalisation of teaching standards across the Euro-
can be a useful tool in the enhancement of pean Union and the wider EHEA. The 14 require-
educational quality. When it is introduced, an ments in this document may not be achieved by all
appropriate mechanism is necessary to address dental schools in Europe immediately and some of the
any teaching deficiencies in a positive manner ‘requirements’ may be more of an aspiration than
through the usual system of staff appraisal, train- others. However, the ‘toolkit’ in the Appendices (14),
ing and development. which will develop further in time, is available to
5. Using appropriate benchmarks, the external provide good examples of ‘how to do it’. The text of
validation of the academic content of proposed this paper is also available on the DentEd III and
new programmes is useful before their implemen- ADEE websites (18).
tation. The authors of Task Force III , DentEd III and ADEE
6. A structured process should be agreed with are confident that all of these ‘requirements’ can be
providers of ‘Outreach’, ‘Extra-mural’, ‘Satellite’ or achieved, in a realistic timescale, within the support-
‘Placement’ dental education and clinical training – ive environment of the ADEE.
for example, in clinics/hospitals remote from the
main teaching institution. The QA processes should
always ‘mirror’ those in the central Dental School or
Hospital. This is particularly important with regard
Acknowledgements
to the access, by students, to appropriate library and The authors wish to acknowledge the financial
IT facilities and also student welfare support. There support of the DentEd III Thematic Network Project
should also be co-ordinated management of the through the European Union Directorate for Educa-
assessment procedures between the centre and the tion and Culture. We would like to acknowledge
satellite. other members of Task Force III who were unable to
attend the meetings of the group but, nonetheless,
were able to make helpful comments and contribu-
tions to this document: Heikki Murtomaa – President
Conclusions of ADEE (Finland); Jacinta McLoughlin, Project
The matters discussed in this document should not, to Co-ordinator, DentEd III (Ireland); Kevin Murphy,
any large extent, be seen as being contentious. To have EDSA (Ireland); June Nunn (Ireland); Jessica Keogh
a process of Quality Assurance and Improvement in (DentEd III Project Administration); Gill Jones
place is a fundamental requirement in any modern (Representing the ‘Dental Team’ view). We especially
organisation. Of course, dental education cannot be an would like to thank Dr. A.I. Vroeijenstijn who, as an
exception to this necessity. In any event, comparable acknowledged external expert in this area of exper-
QA measures are deemed to be necessary in all areas tise, made many valuable contributions. Finally, we
of higher education as a requirement of the European would like to thank the many respondents/schools
Union as first defined by Ministers of the member from 24 countries that contacted us following the
states in Prague in 2001 (17). Progress against this circulation of the draft document. We were able to
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include many of the suggestions and amendments 14. ADEE/Dented III. Task Force 3. ‘Toolkit’ appendices to
received via the consultation process and this helped quality assurance and benchmarking: an approach for
European schools, 2006 (http://adee.dental.tdc.ie/tf3/
to improve, strengthen and achieve unanimous Appendices.doc; http://dented.learnonline.ie).
support for this document at the ADEE 2006 General 15. Plasschaert AJM, Holbrook WP, Delap E, Martinez C,
Assembly. Walmsley AD. Profile and competences for the European
dentist. Eur J Dent Educ 2005: 9: 98–107.
16. Plasschaert AJM, Lindh C, McLoughlin J, et al. Curricu-
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