Consistency in AccreditationASPA April 4, 2011

Department of Medical Laboratory Science

Rush University

Herb Miller, Ph.D.

NAACLS

RUSH

Questions to answer from A Program Director’s View

When you took the role, what was reality? What is your current relationship with the agency? What roles have you had with the agency? What were your expectations in working with the

agency?– Training, customer support, self-help resources,

interpretation and application of standards, communication and application of policies and procedures related to program review.

RUSH

Questions to answer from A Program Director’s View

How was consistency a factor in your activities? Identify areas in which you were engaged in

improving consistency, how you supported others in same position.

Were there any surprises about areas that could have been more consistent?

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History Scope of Responsibilities with

NAACLS Program Director: St. Mary of Nazareth Hospital

1974-1975 Attended the first NAACLS workshop for

Accreditation (and several others over the years) Associated Program Director Rush University 1975

to 1996 Program Director Rush 1996 to present Chairman and Program Director 2001 to present Associate Dean, Graduate Programs 2009 to present

RUSH

History Responsibilities with NAACLS

NAACLS Paper Reviewer throughout 1980’s to present

Site Visitor 1990’s to present Volunteer Consultant for self-study preparation Personally have completed 6 self-studies for Rush I strongly encouraged a digital format for many

years. We now have one. Our process is very detailed and there have been

NO surprises except the amount of work involved.

RUSH NAACLS

Primary aspects of the NAACLS programmatic accreditation process are:– (1) the self-study process;– (2) the paper and site visit process; – (3) evaluation by a review committee, and– (4) evaluation by the Board of Directors.

Evaluation is based on Standards, which are the minimum criteria used

RUSH NAACLS

The review committees are comprised of educators and practitioners representing their respective disciplines.

Members are appointed by the Board of Directors for staggered terms to assure continuity on the committee.

The chairman and vice chairman are elected annually by committee members

RUSH Accreditation Process

The Review by the Program Review Committee

Based on the review of Paper Review Report, the Program’s Response to the Paper Review Report, the Site Visit Report, and the Program's Response to the Site Visit Report, the Program Review Committee makes determinations as to the compliance, marginal compliance or non compliance of a program with the Standards and recommends accreditation actions to the NAACLS Board of Directors.

RUSH Accreditation Process

Review by the NAACLS Board of Directors

Based on the recommendations of the Program Review Committee, and with review of consistent application of the Standards and to insure that decisions are not arbitrary, capricious or otherwise inconsistent with the Standards, performs all accreditation actions of awarding, withholding and withdrawing.

RUSH

A Program Director’s Expectations

Training and help with the Self-Study: – NAACLS provides workshops at national

meetings for program directors and accreditation volunteers.

– There is a guide for preparation of the self-study on-line with a detailed matrix for each standard component of the study.

– Newsletters highlighting various accreditation standards and education issues are sent to Program Directors.

RUSH

A Program Director’s Expectations

Expectations: for paper review– Paper reviewer check list is available on-line to

Program Directors.– Paper review is returned to the Program

Director for comments and the opportunity is given to add any missing materials before the Site Visit.

RUSH

A Program Director’s Expectations

Site Visit Expectations: what to expect for the Site Visit?– The Site Visit check list is available on-line to

Program Directors. Responsibilities for the director, site-visit team leader and team member are given. Suggested itineraries, sample questions and other details for the visit are also available on-line

RUSH NAACLS

Excellent support from Office Staff throughout all steps of the process is provided.

There are Consultant Volunteers identified for program support and help throughout the process.

RUSH Publication Examples

Standards Self Study Template

– Directions For Using and Submitting The Electronic Self-Study

Guide to Accreditation Paper Reviewer Report Site Visit Report Volunteer Manual and Annual Report

RUSHConsistency ??

My Opinion

YES

– with all published requirements, guidelines, review processes and across all programs accredited.

RUSH Problems Concerns Surprises Very detailed process, but considering the detailed

nature of the profession, this is not surprising. Check lists ensure standardization of content

reviewed. Yes-No Format We do not submit progress reports between

accreditations as do some accrediting organizations.

We are finally digital ! The PROCESS is expensive and time greedy, but

Thorough and Objective.

QUESTIONS

QUESTIONS

QUESTIONS ?QUESTIONS ?

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Additional Informational Additional Informational SlidesSlides

RUSH Accreditation Process NAACLS is an autonomous, nonprofit

organization established in 1973 as the successor to the American Society for Clinical Pathology (ASCP) Board of Schools.

ASCP and the American Society for Clinical Laboratory Science (ASCLS) are sponsoring organizations of NAACLS.

RUSH NAACLS

The American Association of Pathologists' Assistants (AAPA), the National Society for Histotechnology (NSH) and the Association of Genetic Technologists (AGT) are participating organizations.

NAACLS is recognized by the Council for Higher Education Accreditation (CHEA).

RUSH NAACLS

NAACLS conducts various functions of programmatic accreditation including:

(1) drafting and reviewing Standards for the operation of specialized programs;

(2) selecting and training knowledgeable volunteers to review Self-Study Reports and serve as site visitors;

RUSH NAACLS

(3) selecting representatives to serve on the review committees and the Board of Directors, and

(4) granting accreditation awards based on a program's self-study and site visit processes.

RUSH Accreditation Process

Development of Program/Initial Processes

letter of intent, a completed initial application,

payment of an initial application fee, and approval of a preliminary report.

The Self-Study Process

program is the program's own self-evaluation The Paper Review Process

The paper Reviewer evaluates the Self- Study based on the standards (check list)

RUSH Accreditation Process

The paper reviewer is the earliest outside source to

review the adequacy of compliance. The program receives the Paper Review Report

and is directed to develop a Paper Review Response.

The Response attempts to clarify issues identified in the Paper Review, and perhaps to

develop new policies and procedures to address the concerns noted.

RUSH Accreditation Process

The Site Visit Process

Site visits are fact-finding journeys. The objective of a site visit is to verify and supplement information presented in the self-study and the Response to the Paper review

The program receives the Site Visit Report and is directed to develop a Site Visit Report Response.

RUSH Publication ExamplesUnique Standards and Documentation Required

for Accredited of: CLS/MT Programs CLT/MLT Programs HTL Programs – Histologists HT Programs – Histotechnicians DMS – Diagnostic Molecular Scientists CG – Cytogenetic Technologists Path A – Pathologists’ Assistant PBT – Phlebotomists CA- Clinical Assistant