1 Wi-Fi Login – 20nconference Password – meeting2015
Jan 17, 2016
1
Wi-Fi
Login – 20nconference
Password – meeting2015
Accreditation Seminar
2
November 9, 2015Chicago, Illinois
CE Documentation Process Attendance Sheets
Completion of session
CertificatesDistributed to participants
3
Before We Start…
JRCERT Mission Statement
4
The JRCERT promotes excellence in education and elevates quality and safety of patient care through the
accreditation of educational programs in radiography, radiation therapy, magnetic resonance, and medical
dosimetry.
Board of DirectorsLaura S. Aaron, Ph.D., R.T.(R)(M)(QM), FASRT
• Chair
Stephanie Eatmon, Ed.D., R.T.(R)(T), FASRT
• 1st Vice Chair
Tricia Leggett, D.H.Ed., R.T.(R),(QM)
• 2nd Vice Chair
Darcy Wolfman, M.D.
• Secretary/Treasurer
Board of Directors
6
Laura Borghardt, M.S., CMD
Susan R. Hatfield, Ph.D.
Bette A. Schans, Ph.D., R.T.(R)
Jason L. Scott, M.B.A., R.T.(R)(MR), CRA, FAHRA
Loraine D. Zelna, M.S., R.T.(R)(MR)
Executive Staff
Leslie F. Winter CEO
Jay Hicks Executive Associate Director
Traci Lang Assistant Director
Professional Staff
Tom Brown Accreditation Specialist
Jacqueline Kralik Accreditation Specialist
Brian Leonard Accreditation Specialist
Program Statistics (November 2015)
9
Radiography
613
Radiation Therapy
74
Magnetic Resonance
10
Medical Dosimetry
17
2014 Accreditation Actions
10
Total Considerations -
378
Interim Reports - 151
Initial -9
Progress Reports - 29
Continuing - 80
Other – 109
2014 Accreditation Awards
11
8 Year – 59
Probation – 5
5 Year – 13
2 Year – 2
3 Year – 6
Involuntary Withdraw – 3
JRCERT Resource Update
Learning Modules
• What is Accreditation? (Student Focused)
• Interim Report Modules
• Outcomes Assessment (Assessment Corner)
• Understanding of Program Effectiveness Data
Effective May 2, 2016
• Flat fee of $900 per site visitor
• Program responsible for direct billing of hotel
Resources - Website
13
Standards JRCERT Policies and
Procedures Broadcast emails JRCERT Professional
Staff The Pulse (News) Site Visitor Checklist Assessment Corner
Assessment: Working Backward
Considerations When Reviewing an Assessment Plan
All accreditation related forms can be found under Program & Faculty/ Program Resources on Web site (www.jrcert.org)
Self-Studies & Interim Reports should be sent to the office on USB flashdrive
Forms
14
Forms
15
Forms
16
SELF- STUDY REPORT
1 year from projected Site visit date, program will receive “Greetings letter”
Self-study submission due in 6 months
Site visit within 6 months of Self-study review
Site Visit Team report submitted to the JRCERT following site visit
Continuing Accreditation Timeline
18
JRCERT Report of Findings within 3 months via E-mail
Program response to the JRCERT within 6-8 weeks
Board of Directors Meeting
Accreditation award letter
Progress Report or Interim Report – if applicable
Continuing Accreditation Timeline
19
Expectations
20
Demonstration of compliance with standards & objectives
Self-evaluation of program
Identification of strengths and weaknesses
Plan for addressing
identified issues
For each Objective:
Explanation
Required program response
Possible site visitor evaluation methods
STANDARDS
21
Assurance◦Objective 1.6: Submit section of Student Handbook to confirm
program has a grievance policy.
Narrative◦Objective 1.5: Describe how the program assures security and
confidentiality of student records, etc.
Assurance and Narrative◦Objective 4.2: Submit section of Student Handbook that
contains the pregnancy policy and describe how the policy is made known to students.
Required Program Response
22
Standard Summary
23
Strengths
Concerns
Plan for Addressing Concern(s)
Progress
Constraints
Involve communities of interest Develop plan for self-study process Involve someone unfamiliar with your program
for clarity Be concise but complete Use samples for exhibits – recommended
organization of the report
Self-Study Preparation Process Considerations
24
Assume the JRCERT already has material or documents
Send Paper Documents! ◦ If your agency will not allow a USB Flash drive to be mailed – contact the
office.
Things NOT To Do:
25
STANDARDS
Standard Four - Health and Safety The program’s policies and procedures promote the
health, safety, and optimal use of radiation for students, patients, and the general public.
Objective 4.1: Assures the radiation safety of students through the implementation of published polices and procedures that are in compliance with Nuclear Regulatory Commission regulations and state laws as applicable.
Radiography, Radiation Therapy, and Medical Dosimetry
27
Interpretation: All students who participate in using equipment in an energized laboratory or clinical environment must be monitored for radiation exposure, including but not limited to simulation procedures or quality assurance.
Adopted by the Joint Review Committee on Education in Radiologic Technology: 04/15(effective 04/15)
Radiography, Radiation Therapy, and Medical Dosimetry
28
Standard Four - Health and Safety The program’s policies and procedures promote the
health and safety for students, patients, and the general public.
Objective 4.1: Makes available to students and the general public accurate information about potential workplace hazards associated with magnetic fields.
Magnetic Resonance
29
Interpretation: Information regarding the potential dangers of implants or foreign bodies in students must be published and provided to students and the general public. Programs must establish a safety screening protocol for all students that assures that students are appropriately screened for magnetic wave or radiofrequency hazards. Programs must describe how they prepare students for magnetic resonance safe practices and provide a copy of the screening protocol.
Adopted by the Joint Review Committee on Education in Radiologic Technology: 10/14 (effective 10/14)
Magnetic Resonance
30
Standard Four - Health and Safety The program’s policies and procedures promote the
health, safety, and optimal use of radiation for students, patients, and the general public.
Objective 4.3: Assures that students employ proper radiation safety practices.
Radiography, Radiation Therapy, and Medical Dosimetry
31
Interpretation: Programs must establish a safety screening protocol for students having potential access to the magnetic resonance environment. This assures that students are appropriately screened for magnetic wave or radiofrequency hazards. Programs must describe how they prepare students for magnetic resonance safe practices and provide a copy of the screening protocol, if applicable.
Adopted by the Joint Review Committee on Education in Radiologic Technology: 10/14 (effective 10/14)
Radiography, Radiation Therapy, and Medical Dosimetry
32
SITE VISIT
Dates are determined after the Self-Study is reviewed
Site Visit Scheduling Form
Program notified by JRCERT Accreditation Services Coordinator
Site Visit
34
Purpose of the Site Visit
35
Validate
•Application material
•Self-study Report
Evaluate
•Program’s personnel, facilities and resources in support of its mission and goals
Assess
•Relationship between program efforts and requirements of objectives
SV Team Assignment
36
Minimum
of 2
Conflict of interest
Geographic considerations
Sponsorship considerations
Apprentice participation
Team chair contacts program director to establish agenda
Communications shift from Professional Staff to Team Chair
Following visit, communication shifts back to the JRCERT office
Communications During Site Visit
37
Two (2) days
Tour sponsoring institution (classrooms, learning resources, etc)
Visit selected clinical sites
Interviews with administration, faculty, clinical instructors, and students
Site Visit
38
Pre-exit Interview Meeting with Program Director
39
REPORT OF FINDINGS (ROF)
The Official Report is based on:
Report of Findings
41
Self Study Report
Report of Site Visit Team Findings
Staff review of relevant materials
Official Report
Group Exercise 1
42
ROF with citation
43
ROF Citation
44
Based on the documentation submitted by the program and the findings of the site visit team, the program appears to be in substantial compliance, at the time of the site visit, with Objectives 4.1, 4.2, 4.3, 4.7, and 4.8. The program is not in compliance with Objectives 4.4, 4.5, and 4.6.
• The program is not in compliance with the following:• Objective 4.4 – Assures that medical imaging procedures are performed
under the direct supervision of a qualified radiographer until a student achieves competency.
• Objective 4.5 – Assures that medical imaging procedures are performed under the indirect supervision of a qualified radiographer until a student achieves competency.
• Objective 4.6 – Assures that students are directly supervised by a qualified radiographer when repeating unsatisfactory images.
Program Response to ROF
45
Narrative
• Describe the procedures for making the students, CIs, and staff award of supervision policies.
Assurance
• Provide updated policies and assurance that students, CIs, and staff have been made aware of the update.
Be concise, but complete Provide narrative and documentation Evidence of implementation is important Response is submitted to [email protected] Must be signed by the CEO or President
**Direct questions to JRCERT Professional Staff member that developed the ROF.
Program Response to ROF
46
Previous ROF Current ROF Current Award Letter Program’s response to current ROF Staff recommendation
Package for Board Consideration
47
Based on review of program packageDetermined by Board of DirectorsTypes:◦Initial – 18 months minimum/3 year maximum◦Continuing:
8 years 5 years with/without progress report 3 years with/without progress report probation
Accreditation Award Levels
48
Compliance Timeframe
Program Length
2 year or longer
1 year
Compliance Timeframe
24 months
18 months
Failure to demonstrate compliance, or identify mitigating circumstances within the specified time period, will result in Involuntary Withdrawal of Accreditation.
PROGRESS REPORTS
Make the connection between initial recommendation and narrative in Report of Findings
Understand first response was inadequate in some way
Contact professional staff for clarification Be clear
Provide documentation; evidence of implementation important
Progress Report - Program Officials Should:
51
INTERIM REPORTS
Required of programs with maximum accreditation award
includes – • basic program information
• elements of Standards One, Two, Four, Five, and Six Board of Directors’ Accreditation action –
• 8-year award maintained or • award reduced and review process expedited
Interim Report
53
Interim Report Modules ◦ http://www.jrcert.org/programs-faculty/learning-modules/
Interim Report Checklist ◦ http://www.jrcert.org/interim-report-checklist/
Resources
54
•Objective 1.10
•Objective 2.9
•Objective 4.1
•Objective 4.2
•Objective 4.4
•Objective 4.5
•Objective 4.6
Interim Report Objectives
55
•Objective 5.1
•Objective 5.4
•Objective 5.5
•Objective 6.1
•Objective 6.2
•Objective 6.5
Compliance for Supervision
56
Describe how students, clinical instructors, and clinical staff are made aware of the supervision requirements.
Describe how the program’s supervision requirements are monitored and enforced in the clinical education setting.
Provide representative samples of instruments (e.g., clinical evaluations, student surveys) that document the monitoring and enforcement of supervision policies.
Provide copies of memos to students, clinical instructors, and clinical staff; and/or meeting minutes that document discussion of the supervision requirements.
Extra Considerations
57
Provide Representative Samples – Completed or Blank copies are acceptable.
Document…Document…Document.
[email protected] www.jrcert.org
Contact Information
142
20 North Wacker Drive, Suite 2850
Chicago, IL 60606-3182
(312) 704-5300
THANK YOU!!
59
for supporting excellence in education and
quality patient care through programmatic
accreditation.