There has been tremendous growth in dental

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1 Quality Considerations in Dental Education in India Mandeep S. Virdi, M.D.S. Abstract: Undergraduate dental education programs have grown tremendously in India over the last five to six decades, mainly in the private sector, putting significant pressure on resources including faculty. This has raised concerns about the quality of dental education in the country. This article examines the concept of quality as applicable to higher education. It provides a roadmap for application of quality concepts, including steps for improving the effectiveness of teaching and applying Total Quality Management to dental education. It also makes suggestions for college-level and structural-level changes to meet the requirement of improved quality, which includes the addition of dental education as a subject in postgraduate dental programs. Dr. Virdi is Professor, Department of Pediatric Dentistry, PDM Dental College and Research Institute, Haryana, India. Direct correspondence and requests for reprints to him at Department of Pediatric Dentistry, PDM Dental College and Research Institute, Sarai Aurangabad, Bahadurgarh, Haryana , India; phone; mandeepsingh74@gmail.com. Keywords: undergraduate dental education, quality in higher education, TQM, India Submitted for publication 4/2/11; accepted 6/19/11 There has been tremendous growth in dental education in the last five to six decades in India. In 1950, there were only three government-run dental colleges with a total of 100 entering students. The growth in the facilities was slow and steady until the 1980s, when the total colleges offering dental education rose to twenty-two with a total of 1,330 entering students. Of these, seventeen colleges were run by the government, and five were in the private sector. In the next decade, the number of colleges rose to fifty-five twenty-four government and thirty-one private with a total of 3,510 entering students. These numbers soon rose: to 206 colleges, thirty-one run by the government and 175 private, with a total of 15,560 entering students. 1 According to the Dental Council of India (DCI), the present number of entering dental students for the thirty-nine government and 288 private sector dental colleges is 23,150. The phenomenal growth in dental education in a relatively short span of time has had its impact on resources. The DCI continues to regulate dental education in the country, including making recommendations to the Ministry of Health and Family Welfare. This is done after carrying out inspections of the facilities and faculty to ensure compliance with its guidelines for starting and continuing education in dental colleges. The sheer pressure of expansion has raised concerns about the quality of dental education in the dental colleges in the academic 2 and public arenas. 3 The DCI guidelines establish the requirements of qualified faculty for dental colleges, defining the number of professors, readers, senior lecturers, and lecturers for various dental disciplines and other faculty members. Most of the teachers from the level of senior lecturer to professor are postgraduates in various dental disciplines. Science postgraduates are, however, permitted to teach basic science courses. There is no formal training in educational pedagogy for the dental postgraduates who form the basic pool of dental educators. There is no formal induction process or mentoring of the new postgraduates who join dental colleges as faculty members. It is assumed that since dental education is a professional course with a high degree of emphasis on clinical and laboratory work as part of the training, clinicians trained in the academic and clinical aspects of the dental specialties will also serve as good teachers. Concepts of Quality in Organizations Quality in organizations is based on a negotiation among stakeholders to recognize, as far as possible, their needs. These needs are to be translated into the objectives of the organization, fulfilling the needs of the consumers. The consistent realization of these objectives is defined as quality. 4 The International Standards Organization (ISO) describes quality control as concerning the operational means to fulfill quality requirements. Quality assurance aims at providing confidence in the fulfillment of quality objectives within the organization and externally to 372 Journal of Dental Education Volume 76, Number 3

2 customers and statutory authorities. Quality management system Standard ISO 9001:2008 specifies requirements for a quality management system. It requires that an organization demonstrate its ability to consistently provide products including services that meet customer and applicable statutory and regulatory requirements. It also aims to enhance customer satisfaction through the effective application of the system, including processes for continual improvement of the system and the assurance of conformity to customer and applicable statutory and regulatory requirements. 5 The concept of quality has been introduced widely at the school level in the developed countries, which have attempted to apply similar concepts to higher education including medical and dental education. A large body of literature on quality in education published since the 1980s 6 has studied the concept of quality in education with the hope that results similar to those in manufacturing and service industry will be achieved in improving the quality of education with benefits to the stakeholders. Professional associations, agencies, and universities have taken steps to introduce the concepts of quality in education including medical and dental education. 7,8 After the European Union issued guidelines for quality assessment and quality education in higher education, Task Force 3 DentalEd III under the auspices of the Association of Dental Education in Europe (ADEE) produced a document to assist in harmonization of Dental Education Quality Assurance (QA) systems across the European Higher Education Area. 4 It is recognized that quality learning can be achieved only through quality teaching. 9 The elements of a quality system presuppose the availability of fairly objective tools for the measurement of the effects of its implementation. An assessment of effectiveness for U.S. dental schools addressed three methods: student assessment, peer assessment, and self-assessment of faculty. 10 This study reported that the best effectiveness measure that will overcome weaknesses of these three methods individually is by triangulation of all of them, but that only about 19 percent of participating dental schools used triangulation, whereas peer assessment and student assessment were reported to be used by 78 percent and 81 percent respectively. In 2009, the General Assembly of the ADEE approved the profile and competences expected for graduating European dentists. 11 A related document describes major competences and supporting areas of knowledge a graduating dentist should have acquired as a benchmark for quality assurance purposes. 12 These documents suggest use of competence to be the measure of quality, supporting the use of a competence-based curriculum. Techniques such as active teaching 13 and blended animated teaching pedagogy 14 in practice for improving quality and efficiency of teaching have been reported. Quality in continuing medical education too has been reported. 15 The revitalization of U.S. dental education has been dealt in details identifying the needs for the changes, its drivers, and roadmap for moving ahead. It is emphasized that dental education should move away from merely treatment of diseases and move towards the application of current developments. Otherwise, dentistry may be taken over by medical professionals and nurses, making dental professionals redundant. 16 Applying Quality Concepts to Dental Education To address concerns about the quality of expanded undergraduate dental education in India, efforts in all directions need to be made so that it is not affected adversely and the gains from the expanded size of the profession are made available to the community in a desirable manner. It would also ensure that the reputation of the profession is not compromised. Few immediate steps can be taken at the college level, but the steps that will have a far-reaching impact will have to be taken mainly in the medium to long range. They may need certain structural changes in the dental education system both at the undergraduate level, which is the area of immediate attention, and the postgraduate level, which provides the pool of educators and teachers for undergraduate dental education. Short-Term Improvements The immediate steps that can be taken by Indian dental colleges will be towards improving the effectiveness of undergraduate dental education. These can include increasing use of articulated teaching with the assistance of audiovisual devices, recording both classroom lectures and clinical sessions, and making them available on the Internet so that students who are not able to understand the matter in one exposure have the opportunity of going over it in their own time and as many times as they feel. The teaching material from various colleges can be shared March 2012 Journal of Dental Education 373

3 for cross-cultivation of useful ideas in pedagogy and content design. Feedback on students performance or assessment of their learning needs to be shared in an interactive manner individually. This will help the students to identify the areas where they need additional efforts and guidance so that they can make efforts in the right direction. The relevance of the basic science courses needs to be stressed during the coursework, and efforts need to be made to relate the same with the clinical subjects. This can be done by asking clinicians to take some lectures at appropriate stage so that they can make students appreciate the importance of the basic science courses and the important foundation they are going to provide in their later years of dental training. The induction of students in dental care at least in data collection and analysis can be started from the first year. 16 The teaching would be considered complete only when all three stages of it the ability to recall, comprehend, and apply the knowledge in their professional life are achieved. The students tend to learn what they are examined for in a relatively short span of time. To ensure that students learn all aspects of a complete education, the assessment assignments and tests need to be designed to cover all these aspects rather than the ability to recall the facts made known to them. The start can be made from the local level and move on to external or university examinations in a relatively short span of time to cover relevant facets of education. Mid- to Long-Term Improvements In the second stage, steps need to be taken to increase the clinical exposures and practice of the student during their training. Most of the newer private sector dental colleges are located in rural or semi-urban areas and have comparatively small catchment areas of patients, affecting the availability of an adequate number of cases to students for clinical exposure/practice. The fact that patients have to pay for treatment in some of the dental colleges makes them weigh whether they should go to private practice where they can develop a personal bond with the dentist or come to a dental college where mainly student dentists will be working on them. Further, the pressure on the members of the faculty to engage in research and project work in order to grow professionally affects the availability of teachers to guide the students during their clinical work. The situation is further attenuated due to the fact that a significant number of members of the faculty in the newer dental colleges have their private practices to tend to after the college time. The other steps to improve quality of education should include improving the quality of teachers. Postgraduate students in dental faculties should have the option to choose an academic or purely clinical stream of education. Those who choose the academic stream should have exposure to education pedagogy, which should be continued as a part of continuing education for the dental faculty members. The postgraduate dentistry colleges should set up departments of dental education with professionals in education who should conduct the pedagogy course, help faculty to develop educational audiovisual training aids, and improve their teaching methods by systematically collating and monitoring feedback from students. The use of problem-based learning, evidencebased curriculum, and competence-based education curricula with the application of the latest development of molecular biology, use of oral fluids and tissues for diagnostics purposes, and an approach towards early detection and prevention rather than treating particular diseases needs to be the focus of development of the new approach to dental education. This, coupled with the concepts of quality management, will only prepare dental education for becoming ready to face the challenges of the future, which will be driven by knowledge-enriched patients. 16 TQM for Improving Teacher Quality Felder and Brent 13 examined in detail the application of concepts of Total Quality Management (TQM) to improve teaching quality. They wrote that quality of individual classes can be improved by writing instructional objectives, use of active learning, cooperative learning, assessment and evaluation of teaching quality, and longitudinal study of the proposed instructional methods. Every strategy for effective teaching has a TQM counterpart indicating similarities in effective teaching and TQM. The writing of instructional objectives is the same as to clarity of vision and strategic planning. Student-centered instruction is customer focus. Empowerment is driving out fear. Collaborative or cooperative learning is adopting a new philosophy and teamwork. Assessment is measurement. Benchmarking is continuous improvement. Training and monitoring in human 374 Journal of Dental Education Volume 76, Number 3

4 resources development is employee training in TQM terms. However, a mere application of TQM to teaching is not going to improve the quality, as the classroom situation is different from an industrial or office environment. TQM is a collective strategy that becomes meaningful if agreed upon and implemented by the staff of an organization. TQM involves combination of sound educational and psychological principles to develop a better approach. The definition of quality within an organization is determined by its true mission, which may be different from the stated mission. The objectives will invariably include maximizing the profits for the entrepreneur and customer satisfaction, which will include the satisfaction of the students. However, there will be need for increased allocation of resources to meet the requirements. Quality is a top-driven concept and works best if all stakeholders know that the top of the organization is interested in improving it. In the case of dental education in India, it will mean that the present regulatory authority (DCI), the educational entrepreneur who is controlling the management of the dental college, and the head of the institution such as the principal or dean have to agree on the improvement of the quality and application of the concepts of TQM. Improving the Quality of Indian Dental Education The following steps are suggested to improve the quality of the undergraduate dental education in India in addition to those stated above. First, faculty and administrators should define the knowledge, skills, and values that the graduates should have at the end of the course in line with the requirements of the regulatory organization. A reference to competence defined by ADEE may be made while defining these parameters for guidance. 4 Second, the faculty should define the instructional methods in consultation with pedagogy experts, select the method of assessment of effectiveness of teaching, and estimate required resources. Problem-based learning, evidence-based learning, and development of a competence-based curriculum should be introduced. 16 Third, the administration must commit to providing the required resources in terms of faculty, support staff, logistics staff, physical resources, tools, and materials to initiate and sustain the quality improvement program in line with the ISO and reports published on the subject by various task forces under the aegis of ADEE. 4,11,12,17 Fourth, a detailed implementation action plan should be developed. Fifth, as the plan is implemented, it should be monitored to identify modifications needed to meet the desired objectives. In addition, lessons may be drawn from the work done by ADEE in documents published on quality assurance 5 and competences for graduating dentists. 11 Conclusions Improvement of quality of undergraduate dental education in India is not only meaningful to all stakeholders in this country but also to other countries, where increasing numbers of health personnel are coming from developing countries like India due to its vast population pool. The immediate steps for improvement can be initiated at the individual college level, and the middle- to long-term changes in the approach to the pedagogy of teaching at the postgraduate level need to be undertaken through the DCI. REFERENCES 1. Mahal AS, Shah N. Implications of the growth of dental education in India. J Dent Educ 2006;70(8): Mahal A, Mohanan M. Medical education in India: recent and long-term trends and their implications. Abstracts Academyhealth Meeting 2005;22(abstract no. 3498). 3. Purandeshwari D. Step up quality of dental education. The Hindu, Sunday, November 10, Jones ML, Hobson RS, Plasschaert AJM, Gundersen S, Dummer P, Roger-Leroi V, et al. Quality assurance and benchmarking: an approach for European dental schools. Eur J Dent Educ 2007;11: International Standard Organization. Quality management systems: requirements. Geneva: International Standard Organization, Quality teaching: the standard, the rationale, annotated bibliography. Oxford, OH: Learingforward, Regional Centre for Development of Quality Management of Education and Training. Quality management framework for postgraduate medical education. Cambridge, UK: National Health Service, Value for high-quality teaching and learning procedure. Melbourne, Australia: Monash University, Hendricson WD, Anderson E, Andrieu SC, Chadwick DG, Cole JR, George MC, et al. Does faculty development enhance teaching effectiveness? J Dent Educ 2007;71(12): Jahangiri L, Mucciolo TW, Choi M, Spielman A. Assessment of effectiveness in U.S. dental schools and value of triangulation. J Dent Educ 2009;72(6): March 2012 Journal of Dental Education 375

5 11. Cowpe J, Plasschaert A, Harzer W, Vinkka-Phuhakka H, Walmsley AD. Profile and competence for graduating European dentist: update Eur J Dent Educ 2010;14: Maogue M, McLoughin CC, Delap E, Lindh C, Schoonheim-Klien M, Plasschert A. Curriculum structure, content, learning, and assessment in European undergraduate education: update Dublin: Association for Dental Education in Europe, Felder RM, Brent R. How to improve teaching quality. Quality Management J 1999;6(2): Hajsadar M. Blended animated teaching pedagogy in practice improving quality and efficiency of teaching and learning. Sunderland, UK: Elesson, Holm HA. Quality issues in continuing medical education. BMJ 1998;316: DePaola DP. The revitalization of U.S. dental education. J Dent Educ 2008;72(2 Suppl): Oliver R, Kersten H, Vinkka-Puhakka H, Alpasan G, Bearn D, Cema I, et al. Curriculum structure: principles and strategy. Eur J Dent Educ 2008;12: Journal of Dental Education Volume 76, Number 3