1. SITE VISITOR WORKSHOP May 12, 2107 Chicago, IL
Jay Hicks, Ed.D., R.T.(R)
Executive Associate Director

3. Joint Review Committee on Education in Radiologic Technology
Established in 1969
Autonomous since 1994
710 accredited programs
Recognized by USDE and CHEA
Specialized and Institutional Accreditor
Title IV
1969 – ASRT and ACR commissioned the JRCERT within the structure of allied health education accreditation provided by the AMA’s Council on Medical Education.  The JRCERT, incorporated in 1971, assumed the duties for site visits and evaluation of educational programs in the radiologic sciences. In 1976, the AMA’s CME delegated Allied Health Education accreditation to the newly created Committee on Allied Health and Educational Accreditation (CAHEA) – ASRT House of Delegates requested that the JRCERT Board of Directors develop an action plan and timetable for the withdrawal of JRCERT from its collaborative relationship with CAHEA and establish itself as the only recognized accrediting agency of educational programs for the radiographer and radiation therapist. AMA established Commission on Accreditation of Allied Health Education Programs (CAAHEP), JRCERT Board did not wish to join, wrote USDE petition and gained initial(interim) approval Jan 1994.

4. Who Are We? :
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.

5. Board of Directors
Laura S. Aaron, Ph.D., R.T.(R)(M)(QM), FASRT - Chair Tricia D. Leggett, D.H.Ed., R.T.(R)(QM) - 1st Vice Chair Bette Schans, Ph.D., R.T.(R), FASRT - 2nd Vice Chair Laura Borghardt, M.S., CMD - Secretary/Treasurer

6. Board of Directors
Beverly J. Felder, M.P.A Julie L. Lasley, Ph.D., R.T.(R)(T) Lisa F. Schmidt, Ph.D., R.T.(R)(M), CRT(R) Jason W. Stephenson, M.D. Loraine D. Zelna, M.S., R.T.(R)(MR)

7. Activity Update(s) Full Standards Revision
We will be seeking YOUR input throughout the revision
Accreditation Management System (AMS)
Survey of Evaluation of Portal
Web Page Revision

8. Update(s)

9. Update(s)
Pulse Newsletter

10. Accreditation Defined Types
Verifying that programs meet the standards established by the profession, peers, and other special interest groups.
Evaluated by peers
Promotes programs to reflect, identify, improve, critique
Provides assurance that program is committed to excellence and providing quality education
Access to Federal and State funds, Transferability

11. Peer Review (Site Visitors)
Foundational concept in higher education accreditation
Representative (Face) of the JRCERT
Various Roles/ Who are you?
Institutional Official (Dean, Assessment, IE)
Program Directors
Clinical Coordinators
Faculty
Clinical Instructors
Practitioners

12. Site Visitors Current ~ 200 (250) Roles Team Chair (74)
Team Member (74)
Apprentice (57)
Pending Seminar (43)
Educators
Practitioners
Academicians
Administrators
Distance Education Experience

13. Clear Analytic Thinking Diplomacy/ Personable
Successful Traits
Clear Analytic Thinking
Diplomacy/ Personable
Detective Skills
Clear Writing Skills
Good Communication Skills
Supportive
of the
Accreditation Process

14. JRCERT Accreditation Criteria
Accreditation Policies
Standards for an Educational Program in
Radiography
Radiation Therapy
Magnetic Resonance
Medical Dosimetry

15. Accreditation Process
Application/Self Study Report due within 6 months
Site Visit scheduled within 6 months
Report of Site Visit Team Findings due within 1 month
Report of Findings due within 3 months
Program response to Report of Findings due within 6-8 weeks
~Monthly Board Meeting
Flowchart

16. Accreditation Actions
Probationary Accreditation
Administrative Probationary Accreditation
Withholding Accreditation
Withdrawal of Accreditation
Voluntary
Involuntary
ACCREDITATION -- Accreditation is awarded to an existing or a new program, following the accreditation review process, for various lengths of time based on the degree of compliance with the relevant accreditation standards.
PROBATIONARY ACCREDITATION--- Probationary Accreditation may be awarded when an accredited program is subsequently determined not to be in substantial compliance with the relevant accreditation standards. Probationary Accreditation is usually limited to one (1) year. It may not extend beyond two (2) years
ADMINISTRATIVE PROBATIONARY ACCREDITATION -- Administrative Probationary Accreditation may be awarded for a maximum of ninety (90) days -when a program does not comply with one (1) or more of the following administrative requirements for maintaining accreditation:
Policy

17. Accreditation Award Levels
Initial
3 year maximum
W/Wo progress report
Continuing
8 year maximum
5 years w/wo progress report
3 years w/wo progress report
Probation

18. Compliance Timeframe Program length 2 year or longer 1 year
24 months
18 months
Failure to demonstrate compliance within the specified time period will result in Involuntary Withdrawal of Accreditation.
Procedure A

19. Transparency
Policy 10:700 – Disclosure of Accreditation Status

20. STANDARDS

21. Understanding the Standards
Explanation
Required Program Response
Possible Site Visitor Evaluation Methods

22. Using the Standards

23. Position Statement Mammography
The JRCERT has determined programs must make every effort to place a male student in a mammography clinical rotation if requested; however, programs will not be expected to attempt to override clinical site policies that restrict mammography rotations to female students. Male students should be advised that placement in a mammography rotation is not guaranteed and, in fact, would be very unlikely. To deny mammography educational experience to female students, however, would place those students at a disadvantage in the workforce where there is a demand for appropriately educated professionals to address the needs of patients. It is noted that the same clinical site policies that are in place during the mammography educational rotations are most likely applicable upon employment, thus limiting access for males to pursue careers in mammography.
Position Statement found under Programs & Faculty/Program Resources

24. Basis for Interpretation of Standard One – Objective 1.2
Current imaging practices in mammography have resulted in minimal employment opportunities for males.
Less than 1% of the ~50,000 R.T.(M) are male

25. Radiography, Radiation Therapy, and Medical Dosimetry
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.
Interpretation found under Programs & Faculty/JRCERT Standards

26. Radiography, Radiation Therapy, and Medical Dosimetry
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)
Interpretation found under Programs & Faculty/JRCERT Standards

27. Magnetic Resonance 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.

28. Magnetic Resonance
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)

29. Radiography, Radiation Therapy, and Medical Dosimetry
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.

30. Radiography, Radiation Therapy, and Medical Dosimetry
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)
Interpretation found under Programs & Faculty/JRCERT Standards

31. Standards: Additional Areas to Address
Sponsorship
Consortium
Cooperative Agreement
Substantive Changes
Policy
Curricular Tracks
Distance
Part-time

32. Planning a Site Visit JRCERT You
Accreditation Services Coordinator – Janet Murzyn
Site Visit Scheduling Form
Planning Assignments
Conflict of Interest
Willingness to Serve
Communicate with ASC
Conflict of Interest
Assignment to Team
COI – must address any real or perceived conflict of interest.

33. Assignment to Team Minimum of 2 11.603A
Sponsorship
Minimum of 2
11.603A
Geographic
Conflict of Interest
Apprentice
State Reps
Assignment to
Team
State Reps – 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
COI -- Any potential conflict or concerns should be discussed with JRCERT staff

34. Preparing for Site Visit – Tools
Standards
Interpretations
JRCERT Correspondence
Self-Study Review Letter
Previous Report of Findings
Award Letter
Self-Study Report
Website
Site Visitor Policies
Accreditation Policies s
Professional Staff
Pre-SV Conference Call

35. Roles and Responsibilities
Need solid foundational knowledge of Standards
Review Self-Study Report & JRCERT Correspondence
Understand Accreditation Process and SV Policies
Consult w/ Chair (roles/assignments)
Maintains Confidentiality
Provide input to Chair
Contribute to team’s collective findings (Gather Evidence, Assess each Obj., Determine compliance)
Complete Expense Voucher and Peer Survey
Review ROF for accuracy, contact staff if needed

36. Roles and Responsibilities – Chair specific
Interact with PD and Develop Agenda
Communicate with Member(s) and Acts as Spokesperson on Visit
Develop action plan for SV and coordinates roles w/ Member(s)
Assure Confidentiality
Synthesize Evidence
Contact JRCERT Office for assistance
Summarize Evidence, Compliance, Strengths, Improvements
Complete RSVTF in AMS (Policy – 30 days)
Complete Expense Voucher and Peer Survey
Review ROF for accuracy, contact staff if needed

37. The Site Visit
12 wks
8-6 wks
4 wks
2 wks
SITE VISIT
12 – weeks, assignment letter and Portal access to all materials
8-6 weeks – make travel arrangements… Program to make Hotel
4- weeks – Chair to send in agenda
2 weeks – Pre SV conference call w/ professional staff.

38. 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

39. Conducting a Successful Visit
Opening Session
Reiterate Confidentiality Statement
Explain Purpose
Review/Revise Agenda
Role of SVT (not the official report)
Allow CEO or Chief Academic Officer to welcome you to Institution
Meet with variety of stakeholders (PD, CC, FT/PT, CIs, RDA, Staff, Students, Alumni)
Tour Campus
Communicate
Time Management is critical
Do not compare to your program

40. Conducting a Successful Visit
Be objective: Your role is to observe, analyze, and report
Listen more than you talk.
Have a positive attitude and tone in the interviews; do not express views that could be interpreted as a bias about program content and outcomes.
Remind those you interview that what you hear is confidential!
Focus on important issues related to accreditation standards, avoid small problems.
Be thorough, ask the same questions of many people to get a balanced view of the situation.
The Chair’s willingness to communicate with the PD during the SV is very important. Misunderstandings can be corrected quickly and arrangements for additional information can be made sooner than later.
Stay on schedule.
Prepare as much of the RSVTF as possible on campus. (AMS – related).
Reprinted w/ Permission: Planning Accreditation Board, SV Manual 2013

41. Interviews JRCERT Sample Questions (SV Resources) Establish Rapport
Group vs. Individual
Evaluate Responses and Explore Further, if needed
Remain Neutral
Know When to Move On

42. Communication Verbal and Nonverbal Keep communication lines open
If question/concern arises during an interview, explore further with multiple people – Not an automatic citation
Listen

43. Developing the RSVTF Begins Night 1 Collaborative Agreement
Explanatory
Well-Organized
Coherent

44. The RSVTF Is a legal document
Professional in presentation and format
Complete
Provides as much detail as necessary for areas of noncompliance, suggestions, &/or kudos.
Is not prescriptive
Avoids individual names, superlatives, and personal opinions
Should be proofed and edited for typographical &/or grammatical errors and overall accuracy.

45. Writing Evidentiary Statements
Poor Example: 3.2 – The program does not follow the current curriculum.
Better Example: 3.2 – The program’s current curriculum does not provide for assurance that students are receiving sectional anatomy instruction.
Best Example: 3.2 – The program is not in compliance with Objective It has been determined that the program does not include any introductory knowledge to sectional anatomy as defined in the current American Society of Radiologic Technology (ASRT) curriculum – Human Structure and Function section. It is apparent that the program considers completion of the College’s Anatomy & Physiology I and II courses as having met this curricular requirement. The information provided in the program’s master plan of education, including the BIOL syllabi do not corroborate this.

46. Pre-Exit Summation Program decides who attends
Final opportunity to clarify any misconceptions
No Surprises before Final Summation
Thorough explanations of citations and/or suggestions
Provide candid and constructive feedback
Rationale
What next – Accreditation Timelines

47. Final Exit Summation Reemphasize
SVT maintained confidentiality of all records
Only report of site visit team’s findings
Program has opportunity to clarify any negative findings upon receipt of official report of findings
Timeframe (briefly)
Thank the institutional and programmatic officials
Strengths, Opportunities for Improvements, Noncompliance

48. Final Exit Summation Do not rush the summation
Maintain decorum and control of summation
Emphasize to institutional officials that the full report has been thoroughly explained to the PD
Emphasize that communication ceases with SVT
Know when to say goodbye!

49. Wrap up and After Submit official RSVTF w/n 4 weeks (P. 11.600)(Chair)
Through the AMS Portal
Include current Assessment plan - via to
Any other backup - via to
Expense Voucher - via to
Itemized receipts
No alcohol
Tips = ≤20%
Peer Evaluation – Surveymonkey
Review Report of Findings for inaccuracies or misinterpretations

50. Always Remember … Contact the office for assistance. mail@jrcert.org

51. For supporting excellence in education
And your Continued Support of Programmatic Accreditation.

52. Accreditation
Accreditation is the process of voluntary, external peer review in which a nongovernmental agency grants public recognition to an institution or specialized program of study that meets established qualifications and complies with educational standards, as determined through initial and subsequent periodic evaluations.

53. Types of Accreditation
Institutional
Regional
Accredit public and private nonprofits and degree-granting two- and four- year institutions
National (Faith-related or Career-related)
Accredit religiously affiliated and doctrinally based institutions, mainly nonprofit and degree-granting
Accredit mainly for-profit , career-based, single purpose institutions , degree and non-degree
Programmatic (specialized)
Accredit specific programs, professions, and freestanding schools.

56. Assignment Letter

57. Assignment Letter

58. Travel Arrangements

59. Sample Agenda

60. Chicago City College – South Loop Radiologic Technology Program
SITE VISIT AGENDA
Chicago City College – South Loop
Radiologic Technology Program
Chicago, Illinois
February 15-16, 2016
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 Professor
Bossier Parish Community College Michigan County College
Bossier City, LA Silo, MI
Cell Phone: Cell Phone:
2/14/16
3:30 pm Pick up site visitors at airport
Abe arrives on American Airlines Flight 2960 at 2:45 pm
Mickey arrives on United Airlines Flight 452 at 3:15 pm

61. 2/15/16
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

62. 2/16/16
Day Two :30 am Pick up Site Visitors at Hotel
8:00 am Meet with 2nd Year Students
9:00 am Meet with Program Officials
10:00 am Telephone Conference Call to Veterans Administration Hospital
and General Hospital
10:30 am Meet with Program Officials
12:00 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