Accreditation Seminar

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May 8, 2015Chicago, Illinois

CE Documentation Process Attendance Sheets

Completion of session

CertificatesDistributed 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 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

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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 StaffBarbara Burnham Special Projects

Coordinator

Tom Brown Accreditation Specialist

Jacqueline Kralik Accreditation Specialist

Brian Leonard Accreditation Specialist

Program Statistics (April 2015)

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Radiography

619

Radiation Therapy

76

Magnetic Resonance

8

Medical Dosimetry

18

2014 Accreditation Actions

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Total Considerations -

378

Interim Reports - 151

Initial -9

Progress Reports - 29

Continuing - 80

Other – 109

2014 Accreditation Awards

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8 Year – 59

Probation – 5

5 Year – 13

2 Year – 2

3 Year – 6

Involuntary Withdraw – 3

JRCERT Activity UpdateLearning Modules

• JRCERT Accreditation (Student Focused)

• Interim Report Modules

• Outcomes Assessment

• 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

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Standards JRCERT professional

staff Broadcast emails JRCERT Policies and

ProceduresCOMING SOON:

The Pulse Assessment Tools

Corner

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

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

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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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

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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

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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

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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

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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

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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

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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 1

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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

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.

Group Exercise 2

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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.