Concerns about Accredited Programs and Facilities

Area: Accreditation
Subject: Concerns about accredited programs and facilities policy
Board Approved date: June 2023

1. Introduction

1.1. This document sets out the Commission on Dental Accreditation (CDAC) policy for considering concerns about accredited programs or facilities.

1.2. CDAC welcomes concerns about accredited programs and facilities as one source of information which can help ensure that programs and facilities continue to meet CDAC Accreditation Standards.

1.3. Due to legal constraints, CDAC will consider complaints out of scope when they pertain to:

1.3.1. the individual practice of a health care professional (CDAC will instead refer complainants to the appropriate regulatory body)

1.3.2. situations where legislation exists to address the issue

1.3.3. situations where legal action has been initiated against the accredited program or facility.

1.4. Complaints about CDAC are addressed separately in CDAC ‘Complaints Policy’.

2. Definition of a Concern

2.1. For the purpose of this policy, CDAC will investigate concerns about an CDAC accredited program or facility which meets the definition of a ‘systemic complaint’ in the Management of complaints guidance:

‘A systemic complaint [is information] which may evidence some systemic matter that could signify a failure of a program or provider to meet accreditation standards.’

2.2. CDAC will not consider ‘personal complaints’:

‘A personal complaint [is where] the complainant seeks to have a matter investigated and addressed so as to bring about a change to their personal situation. This could include, for example, matters such as selection, recognition of prior learning/experience, training post allocation, assessment outcomes or dismissal from training.’

2.3. CDAC normally expects that concerns have been raised with the program or facility first. Many concerns about accredited programs or facilities will not raise any issues about a program or facility’s ongoing accreditation and can be most effectively handled by the program or facility and/or escalated to other appropriate bodies. It is expected that a complainant(s) will provide evidence that this step has been taken.

3. Process

3.1. CDAC is committed to handling concerns about programs and facilities in a proportionate and transparent manner that ensures fairness to both complainants and program or facility.

3.2. CDAC will follow this process when a concern is received.

Acknowledgment

Concerns will normally be made in writing. All concerns will be recorded. CDAC will acknowledge receipt of the concern and provide information about the process that will be followed.
Where a complainant is unable to put their complaint in writing because of a disability, CDAC will put in place any reasonable adjustments. Assessment
The concern will be assessed by the Executive Director (ED) and Director of Operations, to consider whether the concern should be investigated further because it appears to bring into doubt whether an accredited program or facility continues to meet the Accreditation Standards. Further information may be requested from the complainant if necessary. Advice may also be sought from the Chair of the appropriate (i.e., Dentistry, Dental Hygiene, Dental Assisting or Facilities and Residencies) Accreditation Review Committee (or another Committee if appropriate).
Where it is determined that a concern meets the definition of a ‘personal complaint’ or is otherwise of a minor nature such that it does not raise any issues which might reasonably bring into doubt whether the program or facility concerned meets the Accreditation Standards, CDAC will write to the complainant to explain its assessment and the matter will be closed. Where appropriate, the complainant may be directed to other concerns and complaints procedures.

Investigation

If it is determined that there may be issues which bring into doubt whether the program or facility concerned meets the Accreditation Standards, the ED and Director of Operations will determine the scope of the subsequent investigation required. CDAC may contact the complainant to request further information and/or contact other individuals or organisations if they are able to provide information.
CDAC will contact the program or facility to discuss the concerns that have been raised. The program or facility will be provided with a copy of/information about the concern raised and invited to send written comments in response.

Consideration by an Accreditation Review Committee

An investigation report comprising the original concern, any other information gathered in the investigation, the program or facility’s response and a recommended outcome will be considered by the appropriate CDAC Accreditation Review Committee. There are three possible outcomes:
- No action. The Accreditation Review Committee is satisfied that no further action is required to ensure the Accreditation Standards are met. This will be an appropriate outcome where the investigation has not substantiated the concerns raised the Committee concludes that the issues raised do not affect compliance with the Accreditation Standards; or where the program or facility has already taken corrective action and no further ongoing monitoring is required.
- Monitoring requirement. The Accreditation Review Committee is satisfied that the Accreditation Standards continue to be met but requires further information as part Concerns about Accredited Programs and Facilities Policy June 15, 2023 3 of program or facility monitoring to ensure that issues raised in the investigation are addressed. This will be an appropriate outcome where, for example, a program or facility is putting in place changes to a program or facility as a result of the concern and further assurance is required of their implementation and effectiveness.
- Targeted review. The Accreditation Review Committee has concerns that a program or facility may not be meeting the Accreditation Standards and determines that a targeted review by an CDAC Accreditation Site Visit Team is required. A targeted review would focus on the standard or standards that may not be fully met. The targeted review will be either a paper-based assessment or a site visit, determined by the nature of the concerns, the standards in question and the appropriate tool to achieve the required level of assurance.

The program or facility and complainant will be informed of the outcome.

Concerns Received Before a Site Visit

If the concern relates to a program or facility for which a site visit is shortly due to take place (i.e., within 6 months), it may be appropriate (subject to the steps outlined in assessment and acknowledgement above) for that concern to be shared with the Accreditation Site Visit Team reviewing the program. This means the concern would be considered alongside other evidence gathered at the visit to inform the Site Visit Team’s assessment of the program against the Accreditation Standards.
If the ED and Director of Operations consider this to be an appropriate course of action, the complainant will be notified of the intention to handle their concern in this way. If the concern is handled in this way, the program or facility will also be sent a copy of / information about the concern and invited to submit any further information in response. The complainant will be sent a copy of the published report of the site visit.

4. Anonymous Concerns

4.1. There may be occasions when CDAC receives concerns about a program or facility which are made anonymously.

4.2. CDAC will be limited in the action it can take in relation to concerns received anonymously, as this limits further investigation.

4.3. CDAC will assess whether there is sufficient basis to investigate the concern further, taking into account the need for the program or facility to be able to respond to the concerns raised. In many cases, the concern will be recorded but no further action will be taken.

4.4. However, there may be occasions where it would be appropriate and proportionate to investigate an anonymous concern. This includes, for example, where it is possible to gather documentary evidence which might support the concern; and/or where the same or similar concerns about a program or facility are raised by multiple complainants.

5. Timeliness and Prioritisation

5.1. CDAC aims to:

acknowledge all concerns within five working days of receipt; and
keep complainants informed about likely timescales and updated at regular intervals about the progress of any investigation.

5.2. The assessment of concerns will consider whether a concern indicates a high potential risk to public safety. If a concern indicates a high potential risk, the ED and Director of Operations may decide to expedite the investigation and, with the agreement of the Chair of the appropriate Accreditation Review Committee (or another Committee if appropriate), escalate the matter to an out-of-session meeting of the Accreditation Review Committee.

5.3. The timescales for any targeted review required will also be influenced by the Accreditation Review Committee’s assessment of the potential risk.

6. Notification to the Regulatory Authority

6.1. Where an initial assessment by the relevant Accreditation Review Committee of a concern indicates a high potential riskⁱ to public safety, the Regulatory Authorities of the applicable profession will be notified promptly. In addition, in all matters where the Accreditation Review Committee determines that a monitoring requirement or targeted review is necessary, CDAC will notify the Regulatory Authorities of the applicable profession of its decision and the eventual outcome.

ⁱ A high-risk issue is one that could/is reasonably likely to result in the graduation of students who are not safe and competent practitioners.

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