1. Creating the Self Study

2. Required Materials Guide to Approval (add link) Glossary of Terms (add link) Sponsoring institution fact sheet (add link) Clinical facility fact sheet for appropriate program (add link) Didactic faculty fact sheet (add link) Documentation for Standards 9A and 9C (add link) Checklist for phlebotomy equipment (add link) Self Study Review Report form for approved programs (add link)

3. Learning Outcomes Upon completion of this instructional unit and review of additional resources, the learner shall be able to: 1. Describe the self study process. 2. Follow the instructions for preparing the self study report. 3. Identify the organization of the self study report. 4. Identify the information for each clinical affiliate that should be included in the self study report. 5. Identify the curriculum information that should be included in the self study report.

4. Self Study Process Primary aspect of the accreditation process Self review of internal policies, functions, resources, and external relationships Demonstration of the program's compliance with the standards

5. Self Study Process Evaluate the program before the site visit Take remedial action if aspects don't meet the standards Enhance positive aspects of the program

6. Program Director Responsibilities Is responsible for supervising the self study process Submitting the self study report

7. Conducting the Self Study Process The program director may conduct the self study in the following sequence: 1. Organize at least one committee of representatives from interested groups. 2. Familiarize committee with NAACLS documents. 3. Make assignments 4. Gather committee evaluations of the program 5. Prepare the self study report 6. Have committee members and administrators review

8. Self Study Forms There are several forms that must be included in the self study report. These include: - Sponsoring institution fact sheet - Clinical facility fact sheet for each clinical affiliate site NOTE: the second page of this form is the clinical instructor information -Didactic faculty fact sheet for the program director and all didactic faculty -Documentation for Standards 9A and 9C. -Checklist for phlebotomy equipment. The program director must ensure that all of the forms are complete and accurate.

9. Submitting the Self Study Three copies to the NAACLS office The self study report can be submitted via hard copy or in the electronic format.

10. Self Study Format If the self study is submitted via hard copy, please follow these instructions: 1. Use 8.5 x 11 inch paper, single sided, single spaced. 2. If excerpts from sources are pertinent to the self study report, duplicate the information and cite the sources. 3. Number each page in sequence. 4. Use dividers to separate the report by standard. 5. Place documentation to support the narrative for each standard directly following the narrative. 6. Do not use paper clips or staples. Do not spiral bind the report. A three ring binder may be used. 7. Place all of the clinical affiliate information at the beginning of the report in alphabetical order.

11. Organizing the Self Study The program director should organize the self study.

12. Clinical Affiliate Information Clinical facility fact sheet (for phlebotomy programs, the second page of this form is the clinical instructor information) Signed, current clinical affiliation agreement Equipment used for student instruction except for TJC, CAP, COLA, and CLIA accredited settings Facility specific required textbooks Access to periodicals Instructional resources Objectives and evaluations utilized exclusively by the facility Rules and policies unique to the facility that governs student behavior Safety features for those settings not accredited by TJC, CAP, COLA, and/or CLIA

13. Electronic Submission Electronic self study template (add link for template instructions)

14. Curriculum Content All program curriculum must be included in the self study It is recommended that program directors use the documentation form for standard 9A and 9C It is recommended that program directors use the checklist for phlebotomy equipment.

15. Learning Assessment 1 The purpose of the self study is(are): a. a primary aspect of the accreditation process b. involves programmatic self review of internal policies c. demonstrates program's compliance with the standards d. all of the above

16. Learning Assessment 2 The self study may be submitted electronically a. true b. false

17. Learning Assessment 3 The clinical affiliate information should include: a. the clinical facility fact sheet b. a copy of the current, signed affiliation agreement c. a list of phlebotomy equipment for a setting not accredited by TJC, CAP, COLA and/or CLIA d. all of the above

18. Learning Assessment 4 NAACLS approved programs are required to have a site visit. a. true b. false

19. Learning Assessment 5 All curriculum information must be included in the self study report including a cross referencing of objectives/evaluation items with the appropriate NAACLS competencies. a. true b. false