Accreditation Seminar

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November 7, 2014Chicago, Illinois

CE Documentation Process Attendance Sheets

Completion of session

CertificatesEmailed to participants

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Before We Start…

JRCERT Mission Statement

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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 Directors

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Debra J. Poelhuis, M.S., R.T.(R)(M)

• Chair

Laura S. Aaron, Ph.D., R.T.(R)(M)(QM), FASRT

• 1st Vice Chair

Stephanie Eatmon, Ed.D., R.T.(R)(T), FASRT

• 2nd Vice Chair

Darcy Wolfman, M.D.

• Secretary/Treasurer

Board of Directors

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Laura Borghardt, M.S., CMD

Susan R. Hatfield, Ph.D.

Tricia Leggett, D.H.Ed., R.T.(R),(QM)

Jason L. Scott, M.B.A., R.T.(R)(MR), CRA, FAHRA

Executive Staff

Leslie F. Winter CEO

Jay Hicks Associate Director

Kelly Ebert Assistant Director

Professional StaffBarbara Burnham Special Projects

Coordinator

Tom Brown Accreditation Specialist

Traci Lang Accreditation Specialist

Jacqueline Kralik Accreditation Specialist

Program Statistics (October 2014)

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Radiography

618

Radiation Therapy

74

Magnetic Resonance

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Medical Dosimetry

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2014 Accreditation Actions (January-October)

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Total Considerations -

324

Interim Reports - 134

Initial -6

Progress Reports - 24

Continuing - 77

Other – 83

2014 Accreditation Awards (January – October)

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8 Year – 52

Probation – 9

5 Year – 11

2 Year – 1

3 Year –3

Involuntary Withdraw – 3

JRCERT Activity Update

Learning Modules

JRCERT Accreditation (Student Focused)

Interim Report Modules

Outcomes Assessment

Understanding of Program Effectiveness Data

Resources - Website

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Standards JRCERT professional

staff Broadcast emails JRCERT Policies and

Procedures

All accreditation related forms can be found under Program & Faculty on Web site (www.jrcert.org)

Self-Studies & Interim Reports should be sent to the office on USB flashdrive

Forms

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Forms

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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

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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

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Expectations

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Demonstration of compliance with standards & objectives

Self-evaluation of program

Identification of strengths and weaknesses

Plan for addressing

identified issues

Group Exercise 1

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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

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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:

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For each Objective:

Explanation

Required program response

Possible site visitor evaluation methods

STANDARDS

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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

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Standard Response

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Strengths

Concerns

Plan for Addressing Concern(s)

Progress

Constraints

STANDARDS

SITE VISIT

Dates are determined after the Self-Study is reviewed

Site Visit Scheduling Form

Program notified by JRCERT Accreditation Services Coordinator

Site Visit

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Purpose of the Site Visit

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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

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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

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Two (2) days

Tour sponsoring institution (classrooms, learning resources, etc)

Visit selected clinical sites

Interviews with administration, faculty, clinical instructors, and students

Site Visit

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Pre-exit Interview Meeting with Program Director

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REPORT OF FINDINGS (ROF)

The Official Report is based on:

Report of Findings

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Self Study Report

Report of Site Visit Team Findings

Staff review of relevant materials

Official Report

Group Exercise 2

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ROF Group ExerciseStandard One, Obj. 1.7

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... . . The JRCERT is a step in the grievance policy.

ROF Citation

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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 1.1, 1.2, 1.3, 1.4, 1.5, and 1.6. The program is not in compliance with Objective 1.7.

• The program is not in compliance with the following: Objective 1.7 – Assures that students are made aware of the JRCERT Standards for an Accredited Educational Program in Radiography and the avenue to pursue allegations of non-compliance with the Standards.

Program Response to ROF

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Narrative

• Describe the procedures for making the students aware of the JRCERT contact information and the Standards.

Assurance

• Provide updated policy and assurance that students have been made aware of the update.

Be concise, but complete Provide narrative and documentation Evidence of implementation is important Response is submitted to mail@jrcert.org Must be signed by the CEO or President

**Direct questions to JRCERT Professional Staff member that developed the ROF.

Program Response to ROF

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Previous ROF Current ROF Current Award Letter Program’s response to current ROF Staff recommendation

Package for Board Consideration

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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

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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:

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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

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Interim Report Modules ◦ http://www.jrcert.org/programs-faculty/learning-modules/

Interim Report Checklist ◦ http://www.jrcert.org/interim-report-checklist/

Resources

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•Objective 1.10

•Objective 2.9

•Objective 4.1

•Objective 4.2

•Objective 4.4

•Objective 4.5

•Objective 4.6

Interim Report Objectives

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•Objective 5.1

•Objective 5.4

•Objective 5.5

•Objective 6.1

•Objective 6.2

•Objective 6.5

Group Exercise 3

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Compliance for Supervision

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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

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Provide Representative Samples – Completed or Blank copies are acceptable.

Document…Document…Document.

mail@jrcert.org www.jrcert.org

Contact Information

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20 North Wacker Drive, Suite 2850

Chicago, IL 60606-3182

(312) 704-5300

THANK YOU!!

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for supporting excellence in education and

quality patient care through programmatic

accreditation.