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Accreditation Seminar
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November 7, 2014Chicago, Illinois
CE Documentation Process Attendance Sheets
Completion of session
CertificatesEmailed to participants
2
Before We Start…
JRCERT Mission Statement
3
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
6
Medical Dosimetry
17
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 [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
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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.
[email protected] www.jrcert.org
Contact Information
142
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.