Transcript Slide 1

May 8, 2015
Chicago, Illinois
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CE Documentation Process

Attendance Sheets
Completion of session

Certificates
Distributed to participants
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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.
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Laura 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
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)
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Leslie F. Winter
CEO
Jay Hicks
Executive Associate
Director
Traci Lang
Assistant Director
Barbara Burnham Special Projects
Coordinator
Tom Brown
Accreditation Specialist
Jacqueline Kralik Accreditation Specialist
Brian Leonard
Accreditation Specialist
Radiography
619
Radiation
Therapy
76
Magnetic
Resonance
8
Medical
Dosimetry
18
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Total
Considerations 378
Initial -9
Continuing - 80
Progress Reports 29
Interim Reports - 151
Other – 109
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8 Year – 59
5 Year – 13
3 Year – 6
2 Year – 2
Probation – 5
Involuntary
Withdraw – 3
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Learning Modules
• JRCERT 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
 Standards
 JRCERT
professional
staff
 Broadcast emails
 JRCERT Policies and
Procedures
COMING SOON:
 The Pulse
 Assessment Tools
Corner
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 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
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
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
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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
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Demonstration
of compliance
with standards
& objectives
Selfevaluation of
program
Identification
of strengths
and
weaknesses
Plan for
addressing
identified
issues
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For each Objective:
Explanation
Required program response
Possible site visitor evaluation methods
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
Assurance

Narrative

Assurance and Narrative
◦ Objective 1.6: Submit section of Student Handbook to confirm
program has a grievance policy.
◦ Objective 1.5: Describe how the program assures security and
confidentiality of student records, etc.
◦ Objective 4.2: Submit section of Student Handbook that
contains the pregnancy policy and describe how the policy is
made known to students.
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Strengths
Concerns
Plan for Addressing Concern(s)
Progress
Constraints
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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

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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.
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
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.
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
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)
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

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.
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
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)
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

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.
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
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)
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 Dates
are determined after the Self-Study
is reviewed
 Site
Visit Scheduling Form
 Program
notified by JRCERT
Accreditation Services Coordinator
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• Application material
Validate • Self-study Report
• Program’s personnel, facilities and resources in
support of its mission and goals
Evaluate
Assess
• Relationship between program efforts and
requirements of objectives
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Minimum
of 2
Apprentice
participation
Sponsorship
considerations
Conflict of
interest
Geographic
considerations
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 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
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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
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The Official Report is based on:
Self Study
Report
Report of
Site Visit
Team
Findings
Staff
review of
relevant
materials
Official
Report
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... . . The JRCERT is
a step in the
grievance policy.
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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.
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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.
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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.
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Previous ROF
 Current ROF
 Current Award Letter
 Program’s response to current ROF
 Staff recommendation

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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
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Program Length
Compliance Timeframe
2 year or longer
24 months
1 year
18 months
Failure to demonstrate compliance, or identify
mitigating circumstances within the specified
time period, will result in Involuntary
Withdrawal of Accreditation.

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
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Required of programs with maximum
accreditation award
–
• basic program information
• elements of Standards One, Two, Four, Five, and Six
 Board of Directors’ Accreditation action –
 includes
• 8-year award maintained or
• award reduced and review process expedited
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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/
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•Objective
1.10
•Objective 5.1
•Objective
2.9
•Objective 5.4
•Objective
4.1
•Objective 5.5
•Objective
4.2
•Objective 6.1
•Objective
4.4
•Objective 6.2
•Objective
4.5
•Objective 6.5
•Objective
4.6
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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.
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Provide Representative Samples – Completed or Blank
copies are acceptable.
Document…Document…Document.
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20 North Wacker Drive,
Suite 2850
Chicago, IL 60606-3182
(312) 704-5300
[email protected]
www.jrcert.org
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for supporting excellence in education and
quality patient care through programmatic
accreditation.
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