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Position Papers

(As approved by the 2003 House of Delegates)

	Statement on Peer Review

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Cost, appropriateness, utilization, and quality of health care services are of increasing concern to the providers, consumers, and purchasers of health care. Recent growth in the magnitude of expenditures for health care has caused greater scrutiny of providers than in past years.

Review activities in dentistry are not new. A variety of mechanisms have been tried. Among them are the analysis of postoperative complications, state examining boards, formal review systems in clinics, society grievance procedures, and the quality assessment and assurance activities of government and insurance carriers. However, the development of utilization review, cost control, and quality assurance mechanisms has proceeded much more rapidly in the hospital than in ambulatory care. Medicare, Medicaid, the recent growth of managed care, and other types of third-party programs have accelerated that trend.

More recently, the dental profession, government, and insurance carriers have begun to address review activities in dental care. The government and insurance sectors have emphasized utilization review and quality assurance activities. While most professional activities have been in response to these stimuli, groups such as the American College of Dentists, American Society of Oral and Maxillofacial Surgeons, and Academy of General Dentistry have developed innovative self-assessment approaches. A number of dental and public health clinics have also implemented new quality review and patient grievance procedures. At present, much remains to be done in the development of review activities that are well coordinated and based on professionally accepted standards of care. However, professional involvement is growing.

Dentistry has become increasingly involved in peer review activities, and dental education institutions and programs are required by the Commission on Dental Accreditation to include quality assurance activities as part of their patient care programs. Further, dental education institutions and programs have increased their instruction in peer review activities. Dental education institutions and programs should include in their curricula instruction in peer review. In the establishment of a peer review instruction program, the following principles should be followed:

1. Review should be performed and supported by professionals.
   
2. Review should be performed in an impartial and objective manner.
   
3. Review should be based on professionally established and agreed-upon criteria.
   
4. Review should include appropriate and meaningful participation by lay individuals.
   
5. Review should be performed primarily for the purpose of improving performance and to implement sanctions only as a last resort.
   

It is hoped such instruction will provide new practitioners with the knowledge, appreciation, and understanding they need to encourage their active and informed participation in peer review activities.

In addition to knowledge and understanding, instruction in peer review offers the opportunity to learn skills of working with other practitioners, to analyze one’s own and others’ provision of dental care, to deal with insurance and government carriers, to learn about the administrative and accountability requirements of public programs, and to learn the actual clinical skills of detailed evaluation of care. Also, instruction in peer review should include development in the student of integrity and honor in service and protection of the public.

As dental education institutions and programs explore the inclusion of new utilization review and quality assurance activities in the instructional program, certain experiences such as the following may be considered helpful and appropriate preparation for practice where review activities are ongoing or in development:

1. Student participation in the development and modification of professionally developed criteria for the evaluation of clinical services.
   
2. Instruction in the need, concepts, and principles of peer review, including the principles of third-party payment, insurance programs, managed care plans, and present professional standards used to review organization programs.
   
3. Introduction of students to the practice of peer review in preclinical years.
   
4. Establishment of peer review panels, which include students, to assess the appropriateness and quality of service provided by students in dental education institutions and programs. For example:
   1. Periodic postoperative review of treatment procedures to assess treatment.
      
   2. Treatment seminars with emphasis on review of preoperative and postoperative treatment.
      
   3. Continued development of a viable program of professional ethics.
      
   4. Seminar discussions of effective approaches to dealing with inadequate performance disclosed through peer review.
      
   
   

	Freedoms and Responsibilities of Individuals and Institutions

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It is for the general well-being of society that academic institutions have been established for the pursuit of truth, the transmission of knowledge, and public service. Dental schools are set in universities, while allied dental education programs are set in a variety of institutions, from community colleges to dental schools and universities. Institutions of higher education accept the dual principle of autonomy with responsibility in academic matters. The degree of autonomy and the rights and freedoms enjoyed by the academic community are those that have been established by common agreement between academicians and their governing boards. While other elements of society may influence academic policy, only members of the governing boards have the responsibility for determining that which is appropriate to their mission. To relinquish this responsibility does not serve the public interest.

Academic freedom is vested in individual faculty members. The faculty member has a right to extend and disseminate knowledge in his or her area of competence in accordance with the adopted mission of his or her institution. By sustaining academic freedom for its members, an educational institution maintains its integrity and vitality. In return, the faculty must zealously guard the university’s reputation for objectivity and honesty. The educator has an obligation to exercise critical self-discipline and judgment in fulfilling these special academic responsibilities.

Dental educators are, in addition to being academicians, an integral part of the dental profession. They aspire to achieve the common good through the highest education, communication, and reason. All elements of the profession should exercise good judgment and pursue a course of cooperation in discharging their individual responsibilities to society.

Dental education institutions and programs serve as bridges between the fundamental scientific foundation of the profession and its translation into the health care of the American public. Like other components of the university and other institutions of higher education, dental education institutions have autonomy with responsibility in academic matters. At the same time, their responsibility for health professions education places them in a unique position regarding external influences. For example, licensing and regulation of dental practitioners are vested in authorities outside the university, and those authorities can influence the education process through their rules and regulations.

Various other external agencies seek to influence academic policy and to determine what may and may not be taught and what may and may not be investigated by academicians. Such actions abridge institutional freedom and limit the institutions’ prerogative of determining how best to serve the public interest. Professional societies, consumer groups, licensing boards, and other governmental bodies share with educators the responsibility for representing the public interest and for acting in a manner that will improve the profession’s service to the public. Encouraging investigation and innovation through orderly processes effect positive changes and enhance the quality of oral health care. The university and other institutions of higher education are the appropriate foci for these activities.

ADEA calls upon faculties, administrators, and governing boards of institutions of higher education to identify any external pressures that may be brought to bear on dental and allied dental education and to reaffirm by their pronouncements and their actions that such pressures will not be permitted to alter the fundamental mission of this segment of higher education. External agencies need to be reminded that, while faculties must consider outside influences, those faculties, under the aegis of their governing boards, have the ultimate responsibility for the educational process. The principles of institutional autonomy and academic freedom are not negotiable.

	Statement on Health Care Programs

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ADEA believes that the health needs of the public require a health care system that provides access to care for all Americans and effective preventive and therapeutic treatment at a cost that is affordable. ADEA considers universal access to care a fundamental goal to be achieved in any restructuring of the health care system. ADEA recognizes that this goal may be achieved through federally funded, federally mandated, or private programs, and/or a combination thereof. ADEA believes that federal funds must be included where no other funding is forthcoming to finance basic health care benefits.

Basic Oral Health Care
To maintain and improve general health, oral health services must be an integral component of all health care financing and delivery systems. The development and health of the craniofacial region have a direct bearing on general health and well-being and are a basic element in the quality of life.

ADEA strongly supports basic oral health care benefits for all persons. These benefits should include the provision of acute and primary care. Acute care is emergency care to treat pain, eliminate infection, and treat life-threatening conditions, as well as treatment of traumatic injuries. Primary care includes diagnostic, preventive, restorative, endodontic, periodontal, and surgical services. It also includes prosthodontic care to restore essential function.

ADEA recognizes that important groups of patients require extensive care because of developmental defects and acquired anomalies impairing function, as well as chronic conditions that have oral manifestations. ADEA believes that the scope of basic health care benefits must be sufficiently broad to provide rehabilitative benefits as part of the basic benefit package for these persons.

Dental Education’s Role in Ensuring Access
Dental education plays a pivotal role in ensuring access to effective health care through the provision of care, training, and research. Thus, ADEA supports the incorporation of this national resource into the nation’s health care system. To this end, health care reimbursement should include compensation to health care institutions for the teaching costs associated with the provision of oral health care.

Provision of Care
Dental education institutions, which include schools of dentistry, hospital dental programs, and allied health programs, are a resource in the local community, the state, and the region. Schools of dentistry provide comprehensive dental care in a setting that offers the benefits of a large interdisciplinary group of generalists and specialists, an active education program, and a research component. This environment affords unique opportunities for a variety of patients, including groups who may not otherwise have access to oral health care in the community. Practitioners in the state often refer patients with more unusual problems to dental schools because the school can offer care that is often not possible in a private practice setting.

ADEA supports the provision of federal and state grants to dental education institutions to establish and enhance primary oral health care training through residency programs in general dentistry (General Practice Residency and Advanced Education in General Dentistry programs), geriatric care, pediatric dentistry, and dental public health. These residency programs provide trained oral health care providers who are needed to ensure access in underserved areas such as rural communities, as well as to geriatric, handicapped, developmentally disabled, high risk, and other medically compromised patients. To facilitate access, ADEA supports the establishment of grants to dental education institutions and programs to offset the cost of providing care to unserved and underserved groups.

ADEA believes that student aid programs are also important mechanisms for improving access to all groups for their health care needs. Thus, ADEA supports National Health Service Corps scholarships and loan forgiveness for practitioners who serve in this or similar programs.

Education and Training
Practitioners who are skilled in diagnosis, risk assessment, and treatment are essential to the provision of oral health care. The role of dental education institutions and programs in preparing an adequate supply of practitioners who have the skills necessary to provide effective primary care is a fundamental part of the health care system.

Practitioners must be prepared to interpret and assimilate new knowledge and apply it appropriately to patient care. ADEA, therefore, advocates grants that will enhance the education process and improve the effectiveness of education in the health professions.

Faculty who are skilled teachers and researchers are needed to educate future practitioners and to generate the new knowledge for future innovations in patient care. Therefore, ADEA supports grants for development of current and new faculty, such as training grants to acquire new skills in patient care, research, and administration.

ADEA believes that the number of minority graduates of dental education institutions and programs should better reflect their representation in the population, and supports programs that will achieve that goal. Faculty role models are critical to the professional development of minority students, and ADEA advocates grants for programs that enhance the development of minority faculty. Additionally, ADEA endorses efforts that result in improving the health of minority and underserved persons.

ADEA recognizes the important contribution that accredited programs in the allied health fields of dental hygiene, dental laboratory technology, and dental assisting make to the nation’s oral health. ADEA strongly supports initiatives that encourage enrollment, support students who are enrolled, and improve the effectiveness of allied dental health education programs.

Indebtedness of dental graduates directly affects decisions to enter professional practice and the nature of those practices. ADEA believes that minimizing the indebtedness of graduates is a responsibility that should be shared with the institution, through efforts to control the cost of education, and the public through state and federal funds to support education. Consequently, ADEA supports programs that provide grants and low-cost, need-based loans to students. In addition, ADEA urges direct public support for dental education.

The retention and graduation of practitioners from disadvantaged groups are goals that are important for the public’s health. Since the indebtedness of disadvantaged students, including minority students, is commonly higher than the average of all students, ADEA supports grant and loan forgiveness programs for disadvantaged persons and minorities, with preference given to those who elect to pursue careers in dental education and research to provide care for underserved populations.

Research
Biomedical research is critical to the health of the nation. Both basic and clinical research has led to improvements in oral health. Further improvements will be the result of continued efforts to produce new knowledge in the prevention and treatment of oral diseases. ADEA believes that allocation of resources for biomedical research must receive a high priority.

ADEA believes that there is a need for research in the effectiveness of allied dental, predoctoral, and postdoctoral health professions education as well as an examination of strategies for maintaining and assessing continuing competency of health professionals, including issues surrounding licensure and credentialing. ADEA, therefore, supports funding for educational research.

Similarly, research in health services has increased knowledge in the area of the effectiveness of treatment and health care delivery. The impact of this research will contribute to cost containments and improved quality of care, as well as to an understanding of barriers to access. Therefore, ADEA supports funding for oral health services research.

Definition of Interdisciplinary Education
Interdisciplinary health professions education is an educational process providing students of the health professions with experience across professional disciplinary lines as they acquire knowledge and skills in subject areas required in their respective educational programs. Interdisciplinary education should enable students to achieve higher levels of effectiveness and efficiency in certain subject areas than those that would occur if each discipline were taught separately, and it is intended to encourage more efficient use of facilities, faculties, and learning resources among all disciplines. The process provides the student opportunity to interact with students in other health professions disciplines, provides a broader scope and higher quality learning experience, and involves more than one health professions school.

Central to the objective of interdisciplinary health manpower education is the availability to the health professions student of a learning atmosphere that will stimulate the future practitioner to perform in interactive groups with an understanding of the roles of each discipline and the relationship of the roles to one another in the delivery of health services.

To encourage the implementation of interaction in future practice, it is necessary that each health professions discipline provide fundamental principles early in the curriculum and reinforce them later not only by observing role models but also by emphasizing efficient and effective approaches to the solution of health problems. Interdisciplinary education among schools of the health professions and other schools should prepare future practitioners to work in the "team" approach toward the delivery of health services and should encourage more effective approaches to the organization and delivery of health services.

	Due Process for Students in Dental Education

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Introduction
The protection of students’ rights through due process is a continuing concern in dental education because of the educational processes unique to dentistry. Dental and allied dental students are required to assume clinical responsibilities before they complete their professional education. Faculty members must, therefore, evaluate the ability of students to assume these responsibilities. This evaluation, which includes assessments of personal and professional judgment, ethical integrity, and clinical skills, is often based in part on subjective interpretation and opinion. Because of the nature of these assessments, it is particularly important that students be ensured due process in the resolution of disputes arising from evaluations of professional performance. Due process is a legal concept expressed in the Fifth and Fourteenth Amendments to the U.S. Constitution. The amendments provide that neither the federal government nor a state shall "deprive any person of life, liberty, or property without due process of law." The Supreme Court has indicated that the fundamental requisite of due process is the opportunity to be heard.

Dental education institutions and programs should provide due process to its students in the interest of fairness. The basic principle of a fair and objective hearing should be accorded the student in appropriate situations. If the school intends to pursue charges of misconduct against a student, the concept of due process requires: 1) a notice and listing of specific charges, 2) a notice of the right to a hearing, 3) the opportunity to be present and to hear and rebut the evidence at such a hearing, 4) the opportunity to present a defense, and 5) the opportunity to appeal the decision. Clearly, a formal set of procedures must be identified by the institution to ensure that these opportunities are available. The following guidelines will assist dental education institutions and programs in either establishing or reviewing an existing set of procedures designed to ensure due process.

Procedural Guidelines for Due Process—Nonacademic Matters
The following sequential procedures should provide the basis for individual schools to develop or review their policy and procedural statements concerning the due process afforded students in nonacademic matters:

1. Specific responsibilities and rights of students must be clearly stated and published for student and faculty information. The statement must provide the standards expected of students in both academic and nonacademic matters. The institution has the obligation to clarify those standards of behavior that it considers essential to its educational mission and consistent with the code of ethics of the profession. Any specific rules shall represent a reasonable regulation of student conduct; the student shall be as free as possible from imposed limitations that have no direct relevance to the student’s education or to the standards of the profession. The determination of performance that constitutes violations of the standards of conduct shall be formulated with student participation and published in advance. Offenses shall be clearly defined.
   
2. The school shall establish a tribunal or hearing committee appropriate to its organizational structure to serve as the judicial body to ensure due process for students under the published regulations (developed by procedures suggested in 1) concerning student conduct. Essential elements are as follows:
   1. The charge of the committee, its jurisdiction, and its authority shall be formulated and communicated to faculty and students.
      
   2. The hearing committee should be empowered to make decisions regarding the disposition of cases involving alleged violations of the standards and regulations.
      
   3. The committee shall include student members selected by students.
      
   4. A faculty or student member who is directly or indirectly involved in the particular case being heard shall be automatically excused from the hearing and consideration of the matter.
      
   
   
3. A pending action shall not prevent the student from continuing in the academic program unless extraordinary circumstances exist. A student may be suspended from the school for reasons relating to his or her physical or emotional safety and well-being or the safety of other students, faculty, patients, or university property. Such emergency authority shall be vested in the dean of the school or other appropriate academic authority.
   
4. A prehearing may be established to permit the resolution of the issues prior to the commencement of a formal hearing. The informal proceeding must be clearly described as an initial step in the total hearing process, and the results of such an informal proceeding must be documented. Often such a proceeding is the most appropriate manner in which to resolve an existing problem and may save time and expense. In the event that this informal process is unsuccessful, the formal proceedings should follow.
   
5. Any student charged with violation of nonacademic standards of conduct shall be given written notice that states the grounds for disciplinary action. This written notification to the student should contain the following elements:
   1. A statement of the charge or charges against the student, referring to the specific institutional rule that allegedly has been violated.
      
   2. A statement of the date, time, and place of the hearing on the charges. Sufficient time (specified) must be made available to the student to prepare a defense.
      
   3. A statement that the student has the right to be present at the hearing.
      
   4. A statement that the student may, if desired, submit a written response to the specific charges set out in the notice letter. If a written response is to be submitted, it shall be forwarded to the committee within a specified time period.
      
   5. A statement that the student may request a review of his or her student file by appointment in advance of the hearing.
      
   6. Notification to the student that the identity of any witness(es) to be called on his or her behalf at the hearing should be provided to the committee within a specified time period prior to the actual hearing date. The committee must notify the student of any witness(es) it intends to call at the meeting.
      
   7. A statement of the institution’s policy on representation by an attorney.
      
   8. A statement to the student that he or she has the right to remain silent to avoid self-incrimination.
      
   9. A copy of the school’s procedures and policy of due process attached to the letter of notice.
      
   
   
6. The school must establish a procedure to ensure due process and fairness during the proceedings of the hearing committee. To meet this objective, the following steps are recommended:
   1. The committee chair shall recommend for the committee’s approval a procedural sequence appropriate to each case. The committee chair shall be vested with the authority to rule on specific procedural decisions.
      
   2. The student is entitled to appear at the hearing to hear summary statements of the accusations, to provide the committee supporting oral and documentary information, to make opening and closing statements, to call witnesses on his or her behalf, and to rebut any information presented by the institution.
      
   3. The student does not have the right to be present during deliberations of the committee.
      
   4. The committee may question the student and summon, present, and reasonably question any witness.
      
   5. The results of the committee hearing, excluding deliberations, shall be made available to the student upon request within a reasonable period of time.
      
   6. The student’s adviser, if present, shall be permitted to counsel the student and may be given reasonable opportunity by the committee chair to speak on the student’s behalf. This adviser shall not be permitted to question or examine witnesses or committee members unless specifically requested or allowed to do so by the chair.
      
   7. All aspects of the hearing shall be kept private in order to preserve confidentiality unless a public hearing is requested by the student and approved by the committee.
      
   8. In its deliberations, the committee shall consider only the evidence that is presented at the hearing.
      
   9. Burden of proof of the charges rests with the institution.
      
   10. The chair of the committee shall submit the findings of fact and decision of the boards to the dean of the dental school or equivalent administrator in writing and without undue delay, along with all documents and records considered in the matter. The decision will specifically address the question of disciplinary action and shall set out in reasonable detail the reasons underlying the decision. Where the decision is not unanimous, a minority report may be submitted. The dean or equivalent administrator should consider the decision of the committee as well as the entire record of the case and should implement the decision in the matter as promptly as possible by notifying the accused student in writing. The decision of the hearing committee should be considered final, subject to the student’s ultimate right to appeal to the appropriate university officials.
       
   
   
7. The school should publish in its catalog, student handbook, or similar publications the policies and procedures that ensure the rights and responsibilities of students. If a challenge of the actual rule or regulation occurs, it should be referred to the appropriate institutional governing body that established the specific rule or regulation.
   

It should be noted that once a university establishes and publishes such procedures and rules concerning due process, it is bound to abide by its own regulations. The decisions made by the faculty and administration concerning disciplinary matters that do not follow their own prescribed due process procedures may be considered invalid. There are two possible exceptions to the follow-the-rule principle: 1) if the student knowingly and freely agrees to waive his or her right to the original rule and procedures, and 2) when changes in the procedures could not be considered as a disadvantage to the student.

	Footnotes

 
When used in this document, "dental education" refers to all aspects of academic dental, allied dental, and advanced dental education unless otherwise indicated. Likewise, the term "dental educator" refers to dental and allied dental faculty, and the term "institution" refers to the academic unit in which the educational program is housed.

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