This post below is the first of two contributed to Croakey by leading Australian dental academics, looking at both dental education priorities and equity in dental care. The second part can be read here.

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Professors Estie Kruger,  Laurie Walsh and Marc Tennant write:

Dental education accreditation: What is needed to sustain quality improvement for the next 25 years?

For the last half of the 20th century, Australia had just five dental schools all located in the well established “sandstone universities”. All faced significant stresses in terms of staffing and financial aspects of their operations. Dental student numbers were at their nadir in the early 1990s, a factor that contributed to a workforce shortage of dentists at the turn of the century. While each of the five schools then increased their student intakes, the overall pattern of supply and demand did not change dramatically until the development of additional dental schools.

Over the first decade of the 21st century, there has been a near doubling of the number of dental schools in Australia. Not withstanding this, the discipline remains, in absolute terms, a relative minnow in the Australian tertiary education sector; with 9 schools, less than 250 academics nationally and some 500 graduates each year. In the context of the health professions, these are relatively small numbers compared to pharmacy, nursing or medicine.

The arrangements for ensuring the quality of Australian dental education programs are multilayered. They extend from local quality assurance measures applied within the host university through to professional accreditation organised by the Australian Dental Council (ADC).  Historically, the ADC was a composite body drawn mostly from the State-based dental boards, but now with the advent of a nationalised system (2010 APRHA and National Boards) has had to adapt to new directions.

To date, all dental schools in Australia have participated in the process and their programs undergo accreditation with the ADC, with periodic site visits and increasingly arduous annual reporting requirements.

The ADC was not born from gatherings of dental educationalists, nor did it have its genesis in experts in dental school leadership. It was drawn rather from members of dental boards, professional associations and other groups who had a diverse set of goals but who shared a common interest in compliance; a history that continues to be expressed in the structure and operation of the system now.

In its accreditation processes, the ADC uses guidelines that were originally developed some 15 years ago, with one substantive change over that time; namely the addition of Indigenous health (5-10 years ago).

The guidelines that each school responds to are compliance focused, and relate to pre-determined sets of “norms” across each of some 20 parameters. The newly released re-drafted guidelines retain this philosophy. The overall process re-enforces an attitude of compliance, and arguably stifles innovation and enhancement.

A compliance focus is not about enhancing best quality excellence in systems; rather compliance is a mechanism for risking a fall to the lowest common denominator.

At the core of best practice accreditation philosophy is the focus on quality improvement.  Modern health accreditation systems (e.g. ACHS accreditation, and ISO 9000 quality standards) press towards strategic long-term improvements, with systematic goals of achievement across a range of key evolving focuses.  All these systems reflect a strong emphasis on ongoing, sustainable quality improvement philosophy.

Dental education in Australia is at a turning point.

Dental school numbers and student numbers have both increased, addressing workforce number and distribution issues. The past decade has been unrivalled in terms of the amount of Federal, State and University funds invested into facilities and programs. The next decade, not unsurprisingly, will be a period of consolidation and reaping reward from these community investments.

It is without doubt a period that should be focused on the core of continuous quality improvement and bedding down the reforms of the last decade. It should foster innovations that bring about real improvement in the quality of dental graduates entering the workforce and ensure the sustainability of all dental schools.

The opportunity exists for accreditation of dental education to reorient itself to reflect the modern philosophy of quality and sustainable efforts towards quality enhancement.

As a starting point, the fundamental philosophy of quality improvement should drive a substantive re-engineering of accreditation in Australia. Basing the re-engineering process around the systematic approaches taken in global healthcare over the last 50 years would be a focus to give guidance to the development of a new way forward.

The new way forward should draw upon the core of experienced senior dental academics in the Australasian region. Site-visit team members should all be dental academics with substantive track records in dental education and/or leadership, rather than a collection of people with limited academic or dental school leadership experience. With the relatively small number of schools in the region, there is a need for balance so that rivalries and conflicts of interest are minimized.

It could be strongly argued, consistent with other health disciplines, that experts in dental education (e.g. the Australasian Council of Dental Schools, as the peak body of dental educationalists) should have substantial oversight of a process to re-engineer accreditation processes. To date this peak body has had only a small voice within the ADC governance and processes.

Looking back over the last 15 years, a fundamental philosophy of compliance and rigid reporting has not led to a wellspring of innovation within Australian dental schools. Equally apparent has been the lack of development of substantive quality improvement systems.

A strong argument can be made that the current path is not (or no longer) the right path. It is now out of step with the focus on quality improvement that underpins the rest of the health sector globally.

The accreditation processes used for dental education has languished for 15 years, and the status quo with its compliance-based approach (even in the recently updated form) cannot bring forth a sustained quality improvement movement in Australian dental schools.

What is needed now is a re-engineered system of quality improvement resting on the global advances made in health system accreditation, which have been shown to lead to sustained quality movement evolving over the last half century.

The new approach must be comprehensive, and draw on evidence, including that developed by many national and international accreditation approaches. These systems at their core are founded upon transparent criterion based performance measures with an underlying philosophy of “how to improve” not “licencing to continue”.

Achieving sustained quality improvement in dental education is something that all Australians expect and indeed demand of their health professions and universities –and particularly after a period of substantial investment. Merely tinkering with the current system of professional accreditation will limit the extent to which dental education can flourish over the next 25 years.

Rather than evolution, what is needed now is system revolution, beginning with a wholesale consideration of the underpinning philosophy for dental education accreditation. The fundamental objectives of this re-engineering should not be quality control but sustained quality improvement.

Professor Estie Kruger is a leading dental public health researcher in Australia.  Her primary focus for 20 years has been addressing issues of inequality through research, education and service.  She has been a driving force in graduate dental public health education in Australia.

Professor Laurie Walsh is one of Australia’s leading dental academics, having just completed a decade as Dean of the Dental School at the University of Queensland. He travels widely as an international speaker and has advised dental schools across the world.

Professor Marc Tennant has been, for the last 20 years, addressing issues of inequality in dentistry in Australia through service, education and research.  He has been part of the leadership in developing Australia’s new dental schools in rural and regional Australia.

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