1. 1 AEIRS July 15, 2015 San Antonio, Texas

2. CE Documentation Process  Attendance Sheets Completion of session  Certificates Distributed to participants 2

3. 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.

4. Laura S. Aaron, Ph.D., R.T.(R)(M)(QM), FASRT Chair Stephanie Eatmon, Ed.D., R.T.(R)(T), FASRT 1 st Vice Chair Tricia Leggett, D.H.Ed., R.T.(R),(QM) 2 nd Vice Chair Darcy Wolfman, M.D. Secretary/Treasurer

5. 5 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, FAHRALoraine D. Zelna, M.S., R.T.(R)(MR)

6. Leslie F. Winter CEO Jay Hicks Executive Associate Director Traci LangAssistant Director

7. Barbara Burnham Special Projects Coordinator Tom Brown Accreditation Specialist Jacqueline Kralik Accreditation Specialist Brian Leonard Accreditation Specialist

8. 8 Radiography 620 Radiation Therapy 75 Magnetic Resonance 10 Medical Dosimetry 17

9. 9 Total Considerations - 378 Interim Reports - 151 Initial -9 Progress Reports - 29 Continuing - 80 Other – 109

10. 10 8 Year – 59 Probation – 5 5 Year – 13 2 Year – 2 3 Year – 6 Involuntary Withdraw – 3

11. Learning Modules JRCERT Accreditation (Student Focused) JRCERT Accreditation (Student Focused) Interim Report Modules Interim Report Modules Outcomes Assessment Outcomes Assessment Understanding of Program Effectiveness Data Understanding of Program Effectiveness Data Effective May 2, 2016 Flat fee of $900 per site visitor Flat fee of $900 per site visitor Program responsible for direct billing of hotel Program responsible for direct billing of hotel

12. 12  Standards  JRCERT Policies and Procedures  Broadcast emails  JRCERT Professional Staff  The Pulse COMING SOON:  Assessment Tools Corner

13.  All accreditation related forms can be found under Program & Faculty on Web site (www.jrcert.org)www.jrcert.org  Self-Studies & Interim Reports should be sent to the office on USB flashdrive 13

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17.  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 17

18.  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 18

19. 19 Demonstration of compliance with standards & objectives Self- evaluation of program Identification of strengths and weaknesses Plan for addressing identified issues

20. For each Objective:  Explanation  Required program response  Possible site visitor evaluation methods 20

21.  Narrative ◦ Objective 1.5: Describe how the program assures security and confidentiality of student records, etc.  Assurance ◦ Objective 1.6: Submit section of Student Handbook to confirm program has a grievance policy.  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. 21

22. 22 StrengthsConcerns Plan for Addressing Concern(s) ProgressConstraints

23.  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 23

24.  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. 24

26.  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. 26

27.  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) 27

28.  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

29.  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

30.  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

31.  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) 31

33.  Dates are determined after the Self-Study is reviewed  Site Visit Scheduling Form  Program notified by JRCERT Accreditation Services Coordinator 33

34. 34 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

35. 35 Minimum of 2 Conflict of interest Geographic considerations Sponsorship considerations Apprentice participation

36.  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 36

37.  Two (2) days  Tour sponsoring institution (classrooms, learning resources, etc)  Visit selected clinical sites  Interviews with administration, faculty, clinical instructors, and students 37

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40. The Official Report is based on: 40 Self Study Report Report of Site Visit Team Findings Staff review of relevant materials Official Report

41. 41..... The JRCERT is a step in the grievance policy.

42. 42 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.

43. 43 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.

44.  Be concise, but complete  Provide narrative and documentation  Evidence of implementation is important  Response is submitted to mail@jrcert.orgmail@jrcert.org  Must be signed by the CEO or President **Direct questions to JRCERT Professional Staff member that developed the ROF. 44

45.  Previous ROF  Current ROF  Current Award Letter  Program’s response to current ROF  Staff recommendation 45

46.  Based on review of program package  Determined by Board of Directors  Types: ◦ Initial – 18 months minimum/3 year maximum ◦ Continuing:  8 years  5 years with/without progress report  3 years with/without progress report  probation 46

47. 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.

49.  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 49

51. 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 51

52.  Interim Report Modules ◦ http://www.jrcert.org/programs-faculty/learning-modules/ http://www.jrcert.org/programs-faculty/learning-modules/  Interim Report Checklist ◦ http://www.jrcert.org/interim-report-checklist/ http://www.jrcert.org/interim-report-checklist/ 52

53. Objective 1.10 Objective 2.9 Objective 4.1 Objective 4.2 Objective 4.4 Objective 4.5 Objective 4.6 53 Objective 5.1 Objective 5.4 Objective 5.5 Objective 6.1 Objective 6.2 Objective 6.5

54. 54  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.

55. 55  Provide Representative Samples – Completed or Blank copies are acceptable.  Document…Document…Document.

56. mail@jrcert.orgmail@jrcert.org www.jrcert.orgwww.jrcert.org 142 20 North Wacker Drive, Suite 2850 Chicago, IL 60606-3182 (312) 704-5300

57. 57 for supporting excellence in education and quality patient care through programmatic accreditation.