Site Visitor WorkshopNovember 9-10, 2015

Chicago, Illinois

Revised: 7/8/14

JRCERT Mission Statement

The JRCERT promotes excellence in education and elevates the 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 Staff

Tom Brown Accreditation Specialist

Jacqueline Kralik Accreditation Specialist

Brian Leonard Accreditation Specialist

Program Statistics (November 2015)

Radiography

613

Radiation Therapy

74

Magnetic Resonance

10

Medical Dosimetry

17

JRCERT Activity Update

Learning Modules • What is 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

THE ACCREDITATION PROCESS

Application/Self Study Report due within 6 months

Site Visit scheduled within 6 months

Report of Site Visit Team Findings due upon completion of Exit Summation

Report of Findings due within 3 months

Program response to Report of Findings due within 6-8 weeks

Following the “Greetings” Letter:

BOD Deliberation/Award Levels

• 3 year maximum• With or without progress reportInitial

• 8 year maximum• 5 years with progress report• 3 years with progress report• Probation

Continuing

Compliance TimeframeProgram length

2 year or longer

1 year

Compliance Timeframe

24 months

18 months

Failure to demonstrate compliance within the specified time period will result in Involuntary Withdrawal of Accreditation.

SITE VISIT OVERVIEW

Site Visitors are…

VeryImportant

People

Why Am I Doing This?

Learning experience

Benefit to both you and your program

Potential for enhanced respect from peers

Frequent flyer points

Clear Analytic Thinking

Diplomacy/ Personable

Detective Skills

Clear Writing Skills

Talents Required

Good Communication Skills

Supportive of the

Accreditation Process

Purpose of the Site Visit

AssessEvaluate

Validate

The Role of the Site Visitor

Assess the program in relation to STANDARDS & objectives

Review the program’s mission statement and goals resources and activities policies and procedures

Tools of a Site Visitor

Standards:►Radiography

► Radiation Therapy

► MR

► Medical Dosimetry

Application /Self-study Report► Review Letter

Report of Previous Site Visit Team Findings & Other Official Correspondences

JRCERT Policies and Procedures

Web Site JRCERT Professional

Staff

Site Visitor (Hidden) Page A great wealth of SV information is

available at this hidden page of our Website

http://www.jrcert.org/site-visitor-hidden-information/

Team AssignmentMinimum of 2

(State Representative – NY, NJ, WV, KY, NE,

CA)

Conflict of interest

Geographic considerations

Sponsorship considerations

Apprentice participation

Contractual Agreements JRCERT has contracts in Nebraska,

Kentucky, New Jersey, New York, and West Virginia to share confidential programmatic information.

Representatives from these states could also participate in any announced or unannounced site visits

Conflict of Interest

Credibility is extremely important

Any potential conflict or concerns should be

discussed with JRCERT staff

JRCERT Site Visitor Responsibilities

Review Self-study Report AND review letter

Study STANDARDS

Understand accreditation process & site visitor policies and procedures

Familiarize yourself with your role and assignments

Provide input to the team chair

Contribute to the team’s collective decisions

Review ROF for accuracy and report inaccuracies to the assigned JRCERT staff

Responsibilities of Team Chair

Contact Program Director & plan agenda

Communicate with team members

Assure confidentiality

Perform assessment

Analyze evidence & determine the facts

Assess the program in relation to each objective of each STANDARD

Determine how the program’s efforts affect the effectiveness of the program

Complete the RSVTF via the AMS

SITE VISIT AGENDAChicago City College – South Loop

Radiologic Technology ProgramChicago, Illinois

February 15-16, 2013

SITE VISITORS:Abe Lincoln, M.Ed., R.T. ( R ) Mickey Mouse, M.S, R.T.(R)

(CT)Team Chair Team Member Radiography Program Director Associate ProfessorBossier Parish Community College Michigan County CollegeBossier City, LA Silo, MICell Phone: 888-867-5309 Cell Phone: 888-555-4226

2/14/13 3:30 pm Pick up site visitors at airport

Abe arrives on American Airlines Flight 2960 at 2:45 pmMickey arrives on United Airlines Flight 452 at 3:15 pm

2/15/13 7:30 am Pick up Site Visitors at Hotel 8:00 am Introductory Meeting with Radiography Program

Faculty and Other Administrative Personnel 8:30 am Campus Tour [Classroom(s), Laboratory, Faculty

Offices, Library, and Student Services] 9:30 am Meet with Campus Admission’s Director and

Registrar 10:00 am Meet with Program Personnel 11:00 am Meet with 1st Year Students 12:00 pm Lunch with Clinical Instructors 12:30 pm Individual Meetings with Clinical Instructors 1:30 pm Tour Clinical Facilities: Northwest Hospital and

Craig T. Johnson Memorial Hospital 3:00 pm Return to Program and Meet with Program

Officials 5:00 pm Return to Hotel

2/16/13 7:30 am Pick up Site Visitors at Hotel 8:00 am Meet with 2nd Year Students 9:00 am Meet with Program Officials10:00 am Telephone Conference Call to Veterans

Administration Hospital and General Hospital 10:30 am Meet with Program Officials12:00 pm Lunch/Work on Exit Summation 2:00 pm Exit summation with program director 2:30 pm Exit summation 3:15 pm Depart for Airport

ASSESSMENT

Expectations•Explicit•Public

Evidence•Systematic collection•Interpretation•Matches expectations

Explain•Use information•Document•Improve performance

Assessment

Outcomes: Measurement Tool:

Benchmark: Results: Analysis/ Action Plan:

1. Student will select appropriate technical factors.

Simulated lab competency Q6

Ave score 2.5

(3 pt scale)

2.75 Benchmark met. For the past 2 years this result has increased: 2008/9-2.5, 2009/10-2.65. This could be attributed to the increase in laboratory sections resulting in a lower faculty to student ratio.

Psychomotor evaluation Q12

Ave score2.5

(3 pt scale)

2.45 Benchmark not met. Results for 2008/9-2.65, 2009/10-2.7. There was a decrease in the average for the past two(2) years. Initiate an additional review exercise prior to the student’s next clinical assignment. Will continue to monitor this benchmark

Assessment Plan 2010-2011Mission: To produce competent, entry-level radiographers.Goal: Graduates will be clinically competent.

Outcomes Assessment: Data Analysis

Identify benchmarks metSustained effortMonitoring Evaluate benchmarks

Identifying benchmarks not metTargets for improvementStudy the problem before trying to solve it!Evaluate benchmark

Outcomes: Measurement Tool:

Benchmark: Results: Analysis/ Action Plan:

1. Student will select appropriate technical factors.

Simulated lab competency Q6

Ave score 2.5

(3 pt scale)

2.75 Benchmark met. For the past 2 years this result has increased: 2008/9-2.5, 2009/10-2.65. This could be attributed to the increase in laboratory sections resulting in a lower faculty to student ratio.

Psychomotor evaluation Q12

Ave score2.5

(3 pt scale)

2.45 Benchmark not met. Results for 2008/9-2.65, 2009/10-2.7. There was a decrease in the average for the past two(2) years. Initiate an additional review exercise prior to the student’s next clinical assignment. Will continue to monitor this benchmark

Assessment Plan 2010-2011Mission: To produce competent, entry-level radiographers.Goal: Graduates will be clinically competent.

Outcomes Assessment: Communicating Results

The process of drawing conclusions and

improvements resulting from assessment

should be open to all those who are likely to

be affected by the results; the communities

of interest.

Outcomes Assessment: Reporting Results

On assessment plan

On separate document

Show dates

Should facilitate comparisons

Outcomes: Measurement Tool:

Benchmark: Results: Analysis/ Action Plan:

1. Student will select appropriate technical factors.

Simulated lab competency Q6

Ave score 2.5

(3 pt scale)

2.75 Benchmark met. For the past 2 years this result has increased: 2008/9-2.5, 2009/10-2.65. This could be attributed to the increase in laboratory sections resulting in a lower faculty to student ratio.

Psychomotor evaluation Q12

Ave score2.5

(3 pt scale)

2.45 Benchmark not met. Results for 2008/9-2.65, 2009/10-2.7. There was a decrease in the average for the past two(2) years. Initiate an additional review exercise prior to the student’s next clinical assignment. Will continue to monitor this benchmark

Assessment Plan 2010-2011Mission: To produce competent, entry-level radiographers.Goal: Graduates will be clinically competent.

Patient Communication Form

Benchmark: 80

2011 – 82.6 2010 – 83.0 2009 – 84.7 2008 – 87.5 2007 – 90.8

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 policies and procedures that are in compliance with Nuclear Regulatory Commission regulations and state laws as applicable.

Radiography, Radiation Therapy, and Medical Dosimetry

39

Interpretation: All students who participate in using equipment in a energized laboratory or clinical environment must be monitored for radiation exposure, including by 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

40

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

41

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

42

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

43

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

44

Standards: Additional Areas to Address

Sponsorship• Consortium• Cooperative

Agreement

Substantive Changes• Policy 11.400

6.6

Distance Education Integrity of Distance Education Courses

Protect Student Privacy Verification of students participation, completion &

receiving credit Disclose cost

Student Learning Outcomes Traditional vs Distance

Program Publications

Curriculum Well-Structured Appropriately Sequenced Team must observe a portion of at least one course

Equitability Resources Advisement Faculty

Learning Environment Classrooms Laboratories

Learning Resources & Student Services

Available to Distance Students Advisement

THE SITE VISIT

Preparing for the Visit Travel arrangements

lowest coach airfare personal auto rental car stay over

Coordinate travel schedules: Team chair & program officials

Arrive early evening before site visit Departure should allow time for thorough

presentation of exit summation

Initial Team Meeting

Clarify any concerns regarding your role as a team member

Familiarize yourself with program effectiveness concept

Review agenda & determine potential questions for interview

Required Program Response

Provide:

The program must provide/ make available materials verifying achievement of desired outcome.

Describe:

A brief description that demonstrates steps taken to implement a procedure or achieve an outcome.

Standards: Site Visitors’ Use

Prior

• Review the program self-study & other materials supplied by the program.

• Areas to follow up

During

• Outline specific questions that can be asked of each respondent type.

Ending

• Summarize a program’s strengths & concerns.

California Radiography and Therapy Programs Only!!

California radiographers and therapists’ licenses are to be posted in the department. Spot check the names posted with the names

provided on the database listing for that particular facility

Inquire if Radiologists/Oncologists are still supervising students

Opening Session

1. Read Confidentiality Statement

2. Explain purpose

3. Review agenda

Confidentiality Statement

As participants in this accreditation site visit, we are aware that we have access to accreditation information which shall remain confidential. We agree to respect and protect the confidentiality of all accreditation materials, recommendations, suggestions and discussions prior to, during and following this site visit.

Meet with Program Director/Faculty

Program’s mission/goals

Curriculum

Clinical plan

Finish Agenda

Visit clinical sites

Tour campus facilities

Interviews

Interview Strategies Establish the reason for the interview

individual vs. group

Establish rapport assure confidentiality & autonomy listen attentively

Structure the interview start with broad questions fully explore each topic before moving to the

next use open-ended, non-leading questions

Interview Strategies Continued..

Evaluate responses & explore further as necessary: to assure full and accurate information to assure your understanding when answers are not consistent

Respond neutrally to all responses

Know when to move on

Attitudes & the Site VisitYou Program Director

Positive Skeptical

Upbeat Tense

Enthusiastic Defensive

Confident Anxious

Welcome break from your routine

Intrusive/Disruptive

Communication

How can we help you/the school?

What would you like us to include in the report that would be helpful to you?

In my school we do it differently.

This appears to be an excellent program.

Blank check to request the JRCERT’s support resolving other than accreditation issues.

Blank check to request the JRCERT’s support resolving other than accreditation issues.

Big Problem.

No Problem.

What You Say: What They Hear:

Communication What You Say: What They Hear: This is a beautiful program. No Problem.

This is a model for other schools.

No Problem.

Your reputation is well known. No Problem.

In my school, we do it the same way.

No Problem.

And the BIGGIE…

Pre-exit Interview Meeting with Program Director

Report of Site Visit Team Findings

Confidentiality & exit

statements

Accreditation

cycle

Objectives assessment Strengths Suggestions

The Exit Summation: Be Prepared

Thank your host.

Take your time.

Read confidentiality statement.

List the strengths of the program.

Go through each of the STANDARDS.

Any objective with which the site visitors had concerns relative to compliance with the STANDARDS

The Exit Summation-For Each Standard:

Be specific.

Be complete.

Maintain professional demeanor.

Do not ask the program director to help you write the report.

Maintain control.

The Exit Summation: Considerations

And . . .

It’s not over until it’s over.

Know the accreditation process.

Know when to stop talking.

Finishing Up

Complete:1. Try to email/mail any additional information to

office within 7 days (Policy = 4 weeks)

2. Expense voucher

3. Evaluation of other team members * Will be emailed to you after RSVTF is received in

office.

After the Site Visit

The Site visitor has no further contact with program

Each site visitor receives copy of ROF letter report any inaccuracies/misinterpretations to JRCERT

Observations The visit team is a TEAM. The team chair is the spokesperson and in charge

of the visit assuring evaluation is: Focused on outcomes Comprehensive and thorough Fair

The team is entrusted with the highest form of professional confidence.

More Observations

It is important to display a receptive attitude to the program’s philosophy, mission, and goals.

Time management during the visit is critical.

The JRCERT staff is available for assistance if problems or concerns arise before, during, or after the visit.

Be on timeBe a

contributing team member.

Maintain objectivity.

Do your homework.

Focus on STANDARDS & program’s effectiveness.

Helpful Hints

Maintain confidentiality.

Avoid measuring program by your

program’s practice

Do not be drawn into irrelevant

discussions

Concentrate on accuracy and fairness

Be conscientious

of costs

Helpful Hints

Thank You

Be sure you have signed attendance sheet Please, complete evaluations Please turn in your name badges

THANK YOU!!

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for supporting excellence in education and

quality patient care through programmatic

accreditation.