Accreditation Seminar

November 12, 2020

Webinar

1

Housekeeping Items

Moderator

Webinar Etiquette

Schedule/Breaks

Lunch

CE Credit

- Attendance

- Post Test

- Survey

Joint Review Committee on Education in Radiologic Technology

• Established in 1969

• Autonomous since 1994

• 708 accredited programs

• Recognized by USDE and CHEA

• Specialized and Institutional Accreditor

• Title IV

JRCERT Mission Statement

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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.

Board of Directors

Bette Schans, Ph.D., R.T.(R), FASRT - ChairLorie Zelna, M.S., R.T.(R)(MR) -1st Vice Chair

Julie Lasley, Ph.D., R.T.(R)(T)

2nd Vice ChairChad N. Hensley, III, M.Ed., R.T.(R)(MR)Secretary/Treasurer

Beverly J. Felder, M.P.A.

Tracy L. Herrmann, M.Ed., R.T.(R)

Jason W. Stephenson, M.D.

Lisa Schmidt, Ph.D., R.T.(R)(M), CRT

Mahsa Dehghanpour, Ed.D., CMD

JRCERTProfessional Staff

Leslie F. Winter, M.S., R.T.(R)

Chief Executive Officer

Traci Lang, M.S.R.S., R.T.(R)(T)

Executive Associate Director

Jennifer Michael, Ed.D., R.T.(R)

Assistant Director

Tricia Leggett, D.H.Ed., R.T.(R)(QM), FASRT

Director of Instructional Design and Technology

Brian Leonard, M.B.A., R.T.(R)

Accreditation Specialist

Jason Mielcarek, M.A.M.Ed.

Accreditation Assistant

Tim Ebrom, M.S.

Accreditation Assistant

JRCERTSupport Staff

Teresa Cruz

Finance Manager

Paul Luhn, B.A.

Information Technology Administrator

Angie Mielcarek

Senior Executive Assistant

Janet Murzyn

Accreditation Services Coordinator

Janet Luczak, B.S.

Administrative Assistant

Joanne Sauter, B.M., B.A.

Administrative Assistant

Meagan Cruz

Office Assistant

JRCERT Program Statistics (January 2020)

Radiography– 604

Radiation Therapy - 71

Magnetic Resonance - 14

Medical Dosimetry - 19

2019

Accreditation Awards

8 Year – 705 Year – 323 Year – 8Probation -6

Website Resources

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Website Resources

Website Resources

Website Resources

Website Resources

Website Resources

Activity Update

• Full Standards Revision

• Updates available on the JRCERT Web Site

• Final Draft Approved at April 2020 Board Meeting

• Fully implemented January 1, 2021

• Site Visit Checklist (Program & Faculty)• Flat Fee of $900 per site visitor

• Program responsible for site visitor hotel expense

• Invoices can now be paid online

Activity Updates

• COVID-19 Update

• USDE Updates

• CHEA Update

• AHRA Update and newest Board Member

• Solicitation for BoD Nominations: ASRT and ACERT

• DE Guide

• 2021 Standards: Flip Books

• LINK Continuing Education courses

Resources Update

Interim Report Module

Interim Report Checklist

JRCERT Accreditation (Student Focused)

Outcomes Assessment

Understanding of Program Effectiveness Data

Calculating Program Effectiveness Module

Portal Instructional Videos (under FAQs)

2021 Standards Resources Update

Example Assessment Plans

Breast Imaging Policy Template

Example Curriculum Maps

Program Effectiveness Templates for Website

MR Safety Screening Protocol Information

Portal Update: Narratives & Documentation

• Narratives in the portal are capped to 3,000 characters per response

• Documentation uploaded to the portal is capped at 15 documents per response.

• Professional staff reserve the right to return the self study report back to the program to comply with these requirements

This Photo by Unknown Author is licensed under CC BY-ND

LINK Learning Innovation Networking Knowledge

Accreditation

• 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

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.

Peer Review (Site Visitors)

Various Roles/ Who are you?

Institutional Official (Dean, Assessment, IE)

Program Directors Clinical Coordinators Faculty Clinical Instructors Practitioners

Representative (Face) of the JRCERT

Foundational concept in higher education accreditation

Successful Traits

Clear Analytic Thinking

Diplomacy/ Personable

Detective Skills

Clear Writing Skills

Good Communication Skills

Supportive of the

Accreditation Process

Questions

• Questions about anything we’ve covered so far?

• Website?

• Resources?

• JRCERT overview?

This Photo by Unknown Author is licensed under CC BY

SELF- STUDY REPORT

Initial Accreditation

Continuing Accreditation

Initial Accreditation

1st: Programs must provide

Institutional accreditation

State authorization to

offer post-secondary level

education

Qualified Program

Director and Clinical

coordinator (if applicable)

Appropriate Clinical Settings

Initial Accreditation

2nd: Portal Access

Pay initial application fee

Access to Portal

Documentation for all clinical settings to be recognized

Documentation for program officials to be recognized

Completion of Self Study Report (6-month submission timeframe)

Continuing Accreditation Timeline

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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

Continuing Accreditation Timeline

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JRCERT Report of Findings within 3 months

Program response to the JRCERT within 6-8 weeks

Board of Directors Meeting

Accreditation award letter

Progress Report or Interim Report –if applicable

Expectations

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Demonstration of compliance with standards & objectives

Self-evaluation of

program

Identification of strengths

and weaknesses

Plan for addressing identified

issues

STANDARDSThere are 6 standards. Each standard is titled and includes a

narrative statement supported by specific objectives. Each objective, in turn, includes the following clarifying elements:• Explanation – provides clarification on the intent and key details

of the objective.

• Required Program Response – requires the program to provide a brief narrative and/or documentation that demonstrates compliance with the objective.

• Possible Site Visitor Evaluation Methods – identifies additional materials that may be examined and personnel who may be interviewed by the site visitors at the time of the on-site evaluation to help determine if the program has met the particular objective. Review of additional materials and/or interviews with listed personnel is at the discretion of the site visit team.

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Required Program

Response

• Objective 1.6 (2021 Standards): • The program publishes program

effectiveness data (credentialing examination pass rate, job placement rate, and program completion rate) on an annual basis.

• Assurance• Provide the hyperlink for the program’s

effectiveness data webpage.

• Provide samples of publications that document the availability of program effectiveness data via the JRCERT URL address from the program’s website.

Required Program

Response

• Objective 1.4 (2021 Standards)• The program assures the

confidentiality of student educational records.

• Narrative• Describe how the program maintains

the confidentiality of students’ educational records

Required Program

Response

• Objective 5.4 (2021 Standards)• The program assures that medical

imaging procedures are performed under the appropriate supervision of a qualified radiographer.

• Assurance and Narrative• Describe how the supervision policies

are made known to students, clinical preceptors, and clinical staff.

• Describe how supervision policies are enforced and monitored in the clinical setting.

• Provide policies/procedures related to supervision.

• Provide documentation that the program’s supervision policies are made known to students, clinical preceptors, and clinical staff.

2021 Standards: Example Required Response• Required Program Response (As outlined in Standards):

• • Describe how the supervision policies are made known to students, clinical preceptors, and clinical staff.

• • Describe how supervision policies are enforced and monitored in the clinical setting.

• • Provide policies/procedures related to supervision.

• • Provide documentation that the program’s supervision policies are made known to students, clinical preceptors, and clinical staff.

Narrative Provided by Program for Self-Study or Interim

Report*:

Students are made aware of Clinical Supervision policy during

program orientation (Exhibit: Orientation Agenda). The

Supervision policy is published in the Radiography Student

Handbook (Exhibit: Handbook Page 19), and students are required

to sign forms stating their understanding of these policies (Exhibit:

Student Signatures 2016-2020). Clinical Instructors are informed

of the Supervision policy at an in-service conducted by the

Program’s Clinical Coordinator. Each Clinical Instructor/Preceptor

is supplied with a job description and signs a form for the Program

stating that they have been in-serviced and understand these

policies (Exhibit: CI Inservice Form). The supervision policy is also

reviewed annually with all Clinical Instructors during the annual

Advisory Committee meeting (Exhibit: Advisory Committee

meeting PowerPoint). The Clinical Coordinator assures that each

Clinical Setting covers the program’s Supervision Policy annually at

department meetings (Exhibit: Clinical Setting Meeting minutes).

Monitoring and enforcement of appropriate supervision of

students is carried out by the Program Clinical Coordinator and

Clinical Faculty. Each Clinical Education Center is routinely visited

by a Program Faculty every semester. These visits assure that

Clinical Instructors and Clinical Staff are supervising students

appropriately (Exhibit: Clinical Visit Summaries).

Standard Summary

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Strengths

Opportunities for improvement

Plan for addressing opportunities

Progress

Constraints

AMS View of Self-Study

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AMS View of Self-Study

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AMS View of Self-Study

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AMS View of Self-Study

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AMS View of Self-Study

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Self-Study Preparation Process Considerations

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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

Things to Consider:

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DO NOT ASSUME THE JRCERT ALREADY HAS

MATERIAL OR DOCUMENTS

BE SO CONCISE THAT THE SVT DOES NOT GUESS.

INVOLVE FACULTY IN THE PROCESS.

Questions?

Self-study process questions?

SITE VISIT:Scheduling

PurposeTeam Assignment

Pre-Site Visit CommunicationOn-Site Evaluation

Site Visit: Scheduling

• Dates are determined after the Self-Study is reviewed

• Site Visit Scheduling Form

• Program notified by JRCERT Accreditation Services Coordinator

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Site Visit: Purpose

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• Application material

• Self-study Report

Validate

• Program’s personnel, facilities and resources in support of its mission and goals

Evaluate

• Relationship between program efforts and requirements of objectives

Assess

SV Team Assignment

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Minimum

of 2

Conflict of interest

Geographic considerations

Sponsorship considerations

Apprentice participation

Communications During Site Visit

• 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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This Photo by Unknown Author is licensed under CC BY-NC-ND

Site Visit

• 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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This Photo by Unknown Author is licensed under CC BY-NC-ND

This Photo by Unknown Author is licensed under CC BY-NC-ND

Pre-exit Interview Meeting with Program Director

REPORT OF FINDINGS

(ROF)

Report of FindingsThe Official ROF is based on:

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Self Study Report

Report of Site Visit

Team Findings

Staff review of relevant materials

Official Report

ROF with citation

ROF Citation

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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 4.1, 4.2, 4.3, 4.7, and 4.8. The program is not in compliance with Objectives 4.4, 4.5, and 4.6.

• The program is not in compliance with the following:

• Objective 4.4 – Assures that medical imaging procedures are performed under the direct supervision of a qualified radiographer until a student achieves competency.

• Objective 4.5 – Assures that medical imaging procedures are performed under the indirect supervision of a qualified radiographer until a student achieves competency.

• Objective 4.6 – Assures that students are directly supervised by a qualified radiographer when repeating unsatisfactory images.

Program Response

to ROF

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Narrative

• Describe the procedures for making the students, CIs, and staff award of supervision policies.

Assurance

• Provide updated policies and assurance that students, CIs, and staff have been made aware of the update.

Program Response

to ROF

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Be concise, but complete

Provide narrative and

documentation

Evidence of implementation is

important

Response is submitted thru

the Portal

E-mail sent to the CEO or President

for electronic signature.

Questions about the Portal? Refer

to Portal Helps/You Tube

videos and FAQs.

**Direct questions to JRCERT Professional Staff member that

developed the ROF.

AMS -Program Response to ROF

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Program Response to ROF

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Package for Board Consideration

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Previous ROF

Current ROF

Current Award Letter

Program’s response to current ROF

Staff recommendation

Accreditation Award Levels

❖Based on review of program package

❖Determined by Board of Directors

• Initial:• Withhold

• 18 months (minimum)

• 3 year (maximum)

• Continuing:• 8 years (maximum)

• 5 years with/without progress report

• 3 years with/without progress report

• Probation

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Compliance TimeframeProgram 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.

PROGRESS REPORTS

Progress Report

Program Officials Should:

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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

INTERIM REPORTS

Interim Report

Required of programs with maximum

accreditation award

➢Includes :

• basic program information

• elements of Standards Two, Five, and Six

➢Board of Directors’ Accreditation action:

• 8-year award maintained or

• award reduced and review process expedited

Resources

• Interim Report Modules • https://www.jrcert.org/programs-

faculty/learning-modules/

• Interim Report Checklist • https://www.jrcert.org/interim-

report-checklist/

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Interim Report Objectives

•Objective 1.1*

•Objective 1.6*

•Objective 2.1

•Objective 2.2

•Objective 5.1

•Objective 5.2

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•Objective 5.3

•Objective 5.4

•Objective 6.2

•Objective 6.3

•Objective 6.4

•Objective 6.5

*no response needed, website will be reviewed to confirm compliance

Compliance for SLO data: Analysis and

Sharing

• Describe:

• examples of changes that have resulted from the analysis of student learning outcome data and discuss how these changes have maintained or improved student learning outcomes.

• the process and timeframe for sharing student learning outcome data results with its communities of interest.

• Provide:

• actual student learning outcome data and analysis since the last accreditation award.

• documentation of an action plan for any unmet benchmarks.

• documentation that student learning outcome data and analysis is shared in a timely manner. 72

Extra Considerations

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Large quantity materials: provide representative samples

Document…Document…Document.

Questions?

Site Visit, ROF, Board Consideration, Progress Reports, Interim Reports?

This Photo by Unknown Author is licensed under CC BY-ND

STANDARDS

Radiography

• Standard One - Accountability, Fair Practices, and Public Information

The sponsoring institution and program promote accountability and fair practices in relation to students, faculty, and the public. Policies and procedures of the sponsoring institution and program must support the rights of students and faculty, be well-defined, written, and readily available.

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Standard 1.1

At a minimum, the sponsoring institution and/or program must publish policies, procedures, and/or relevant information related to the following:

• Admission and transfer of credit policies;• tuition, fees, and refunds;• graduation requirements;• grading system;• program mission statement, goals, and

student learning outcomes;• accreditation status;• articulation agreement(s);• academic calendar;• clinical obligations;• grievance policy and/or procedures.

Questions regarding Standard One

Radiography

• Standard Two - Institutional Commitment and Resources

The sponsoring institution demonstrates

a sound financial commitment to the program by assuring sufficient academic, fiscal, personnel, and physical resources to achieve the

program’s mission.

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Questions regarding Standard Two

General JRCERT Questions?

Please let us know of any questions we can answer for you.

Standard 35 objectives

Standard 3Objective 3.1 –The sponsoring institution provides an adequate number of faculty to meet all educational,

accreditation, and administrative requirements.

• Faculty workload: Institutional policies and practices for faculty workload and release time must be consistent with faculty in other comparable health sciences programs in the same institution.

• Full Time Clinical Coordinator requirement: A full-time equivalent clinical coordinator is required if the program has more than fifteen (15) students enrolled in the clinical component of the program. The clinical coordinator position may be shared by no more than four (4) appointees.

• Clinical Preceptors: A minimum of one clinical preceptor must be designated at each recognized clinical setting. The same clinical preceptor may be identified at more than one site as long as a ratio of one full-time equivalent clinical preceptor for every ten (10) students is maintained.

Standard 3Objective 3.2 – The sponsoring institution and program assure that

all faculty and staff possess the academic and professional qualifications appropriate for their assignments.

Position Modality Qualifications

Program Director Radiography ARRT(R)

Radiation Therapy ARRT(T)

Magnetic Resonance

ARRT(MR), preferred: If the PD does not hold MR credential, CC required and must hold credential

Medical Dosimetry Medical Dosimetrist Certification Board (MDCB) certification

Proficient in curriculum design, evaluation,

instruction, program administration, and academic advising

3 Years Clinical experience in the

profession

2 years experience as an instructor in a JRCERT accredited program

Master’s degree

Standard 3Objective 3.2 – The sponsoring institution and program

assure that all faculty and staff possess the academic and professional qualifications appropriate for their assignments.

Position Modality Qualifications

Clinical Coordinator Radiography ARRT(R)

Radiation Therapy ARRT(T)

Magnetic Resonance

ARRT(MR), preferred: If the PD does not hold MR credential, CC required and must hold credential

Medical Dosimetry Medical Dosimetrist Certification Board (MDCB) certification

Proficient in curriculum development, supervision,

instruction, evaluation, and academic advising

2 years clinical experience in the

profession

1 year experience as an instructor in a JRCERT accredited program

Bachelors Degree

Standard 3Objective 3.2 – The sponsoring institution and program

assure that all faculty and staff possess the academic and professional qualifications appropriate for their assignments.

Position Modality Qualifications

Full Time Didactic Faculty

Radiography ARRT(R)

Radiation Therapy

ARRT(T)

Magnetic Resonance

ARRT(MR)

Medical Dosimetry

Medical Dosimetrist Certification Board (MDCB) certification

Proficient in course development,

evaluation, instruction, and academic advising

2 Years Clinical experience in the

profession

Bachelors Degree

Standard 3Objective 3.2 – The sponsoring institution and program

assure that all faculty and staff possess the academic and professional qualifications appropriate for their assignments.

Adjunct Faculty

Holds academic and/or professional credentials appropriate to the subject

content area taught

Knowledgeable of course development, instruction, evaluation,

and academic advising

Standard 3Objective 3.2 – The sponsoring institution and program

assure that all faculty and staff possess the academic and professional qualifications appropriate for their assignments.

Clinical Preceptor

Proficient in supervision, instruction, and evaluation

Documents 2 years’ clinical experience in the professional

discipline

Holds current credential/registration in specific

modality

Standard 3Objective 3.2 – The sponsoring institution and program assure that

all faculty and staff possess the academic and professional qualifications appropriate for their assignments.

Clinical StaffHolds current

credential/registration in specific modality

Standard 3Objective 3.3 – The sponsoring institution and program assure the

responsibilities of faculty and clinical staff are delineated and performed.

This objective outlines the minimum responsibilities that must

be performed for each of the recognized positions.

Example: Program Director

Program Director

Professional development

Budget planning

Program accreditation

and assessment

Program operations

Leadership

Standard 3

Objective 3.4

The sponsoring institution and program assure program faculty performance is evaluated and

results are shared regularly to assure responsibilities are

performed.

Minimally evaluated and shared once a year

Concerning results must be shared and discussed

as soon as possible

Prerogative of the program to evaluate the performance of clinical

preceptors who are employees of clinical

settings

Standard 3Objective 3.5 – The sponsoring institution and/or program

provide faculty with opportunities for continued professional development.

•Opportunities on institutional campus

•Faculty should not be expected to use personal leave time to attend professional development activities external to the sponsoring institution

Standard 49 objectives

Standard 4Objective 4.1 – The program has a mission statement that

defines its purpose.

• Clearly define the purpose and intent of the program

• Supports the mission of the institution

• Evaluated minimally every three years

• Engage faculty and communities of interest in the reevaluation

Standard 4Objective 4.2 – The program provides a well-

structured curriculum that prepares students to practice in the professional discipline.

•Well-structured curriculum is guided by a master plan of education

• Curriculum should promote: • Competent clinical practice

• Ethical decision making

• Situational assessment

• Strong patient care skills

• Effective communication

• Knowledge of advancing profession

Standard 4Objective 4.2 – The program provides a well-structures

curriculum that prepares students to practice in the professional discipline.

R •ASRT

T •ASRT

MR •ASRT

MD •AAMD

➢ Expansion of curriculum beyond minimum is required of programs at the bachelor degree or higher

➢ Innovative approaches to method of delivery is encouraged

distance educationPart-time/evening tracksService learningInterprofessional developmentand more

➢ Is there something innovative your program has implemented?

Standard 4Objective 4.3

All clinical settings must be recognized by

the JRCERT.

• Recognized prior to student assignment

• Owned & operated settings on same campus (example) do not need separate recognition

• 1 Clinical preceptor per setting, minimum• Minimum 1 for every 10

students (objective 3.1)

• Observation sites: • Recognition not

necessary• Student may not

assist/perform

LSU Health Shreveport

LSU Ambulatory Care Clinic

Standard 4

Objective 4.4

The program provides timely,

equitable, and educationally valid clinical

experiences for all students.

• Students are not to be used as replacements for employees

• Clinical settings provide wide range of procedures for competency achievement

• Maximum 10 hours of clinic a day

• No clinical assignment on holidays observed by sponsoring institution

• Clinical make-up time permitted during scheduled breaks/terms

• Availability of faculty

• Coverage of liability insurance

• Student-to-clinical staff/equipment ratio:

• (R) – 1:1 Student-to-clinical staff ratio and student-to-physical

resources

• (T) – 1:1 Student-to-therapeutic

devices

• (MR) – 1:1 Student-to-magnet ratio

• (MD) – 2:1 Student-to-medical

dosimetry staff ratio

Standard 4

Objective 4.5

The program provides learning opportunities in

advanced imaging and/or

therapeutic technologies.

Program decides which

advanced/therapeutic technologies

Didactic and/or clinical• Clinical rotations strongly encouraged

Standard 4

Objective 4.6

The program assures an appropriate relationship between program length and the subject matter taught for the terminal award offered.

Program length consistent with terminal award

Standard 4

Objective 4.7

The program measures didactic,

laboratory, and clinical courses in clock hours and/or credit hours through

the use of a consistent formula.

• Calculating assigned clock/credit hours must

• align with institutional policy

• be consistently applied for didactic, laboratory, and clinical courses respectively

• Example Credit hour calculation:

• Didactic credit hour: 1:1

• Laboratory credit hour: 3:1

• Clinical credit hour: 6:1

Standard 4

Objective 4.8

The program provides timely and supportive academic and

clinical advisement to

students enrolled in the program.

• Student advisement should be:

• Formative

• Summative

• Shared in a timely manner

• Written programmatic advisement procedures are encouraged

Standard 4Objective 4.9 – The program has procedures for maintaining

the integrity of distance education courses.

Assurance measures that the students registered

are the students that participate,

complete and receive credit

Example measures taken:

• Secure logins

• Passcodes

• Proctored exams

• Video monitoring

QuestionsQuestions regarding Standards 3 and 4?

Standard Five: Health and Safety

Objective 5.1 (RAD, RTT, MD): The program assures the radiation safety of students through the implementation of published policies and procedures

• ALARA

• Monitor and maintain student radiation exposure data (clinical and energized lab)

• Threshold dose

• Provide students with their exposure report within 30 days of receipt

Objective 5.1 (RAD, RTT, MD) continued

• Pregnancy Policy:• Written notice of voluntary declaration

• Option for written withdrawal of declaration

• Option for student continuance in the program without modification

Objective 5.1 (MR): The program makes available to the students and the public accurate information about potential workplace hazards associated with magnetic fields

• Provide info to the public regarding potential danger of implants or foreign bodies in students

• Safety screening protocol

• Students must notify program if status changes

Objective 5.2 (Rad and RTT): The program assures each energized laboratory is in compliance with applicable state and/or federal radiation safety laws.

• Programs must maintain records of compliance

Objective 5.2 (MD): The program assures that students employ proper safety practices

• Assure that students are instructed in utilization of simulation and treatment equipment and accessories - ALARA

• MRI safety screening and protocol

Objective 5.2 (MR): The program has a published pregnancy policy that is made known to accepted and enrolled female students

• Pregnancy Policy:

• Written notice of voluntary declaration

• Option for written withdrawal of declaration

• Option for student continuance in the program without modification

Objective 5.3 (Rad and RTT): The program assures that students employ proper safety practices.

• More ALARA – assure students are instructed in utilization of equipment, accessories, optimal exposure factors, and proper patient positioning

• Policies regarding safe and appropriate use of energized lab (supervision)

• RAD only – students must not hold image receptors

• RAD only – students should not hold patients when an immobilization method is the appropriate standard of care

• MRI safety screening protocol

Objective 5.3 (MD): The program assures that a credentialed practitioner approves all medical dosimetry calculations and treatment plans prior to implementation.

• Program must develop and publish a policy that clearly delineates this expectation to students clinical preceptors, and clinical staff.

Objective 5.3 (MR): The program assures that students employ proper magnetic resonance safety practices.

• Assure that students are instructed in utilization of imaging equipment, accessories, optimal imaging parameters, and proper patient screening and positioning

• Safety in Zone IV

• Operational laboratory safe and appropriate use

Objective 5.4 – Supervision policies

• Direct Supervision: Student supervision by a qualified technologist/practitioner who:• Reviews the procedure in relation to the student’s

achievement• Evaluates the condition of the patient in relation to the

student’s knowledge• Is physically present during the conduct of the

procedure• Reviews and approves the procedure and/or image

• Indirect supervision: Student supervision by a qualified technologist who is immediately available to assist students regardless of the level of achievement

Objective 5.4 – Supervision Policies

Radiography

• Direct supervision until competency

• Indirect supervision after competency achieved

• Repeat images, surgical, and mobile procedures (including mobile fluoroscopy) must be under direct supervision regardless of level of competency

Radiation Therapy

• All procedures are under

Medical Dosimetry

• Direct patient contact procedur

Magnetic Resonance

• Direct supervision until competen

Objective 5.5 (All modalities): The sponsoring institution and/or program have policies and procedures that safeguard the health and safety of students.

• Campus safety

• Emergency preparedness

• Harassment

• Communicable diseases

• Substance abuse

Standard Six: Program Effectiveness and

Assessment: Using Data for Sustained Improvement

Objective 6.1: The program maintains the following program effectiveness data

• Five-year average credentialing examination pass rate of not less than 75% at first attempt within 6 months of graduation**• **within the next testing cycle after

graduation for MD programs

• Five-year average job placement rate of not less than 75% within twelve months of graduation

• Annual program completion rate

• Number of grads passing on first attempt compared to number of grads who take exam within six months of graduation

• Within next testing cycle for MD programs

Credentialing examination

pass rate

•Number of grads employed in the radiologic sciences compared to number of grads actively seeking employment

•Not actively seeking:

o Grad fails to communicate with program officials regarding employment status after multiple attempts

o Grad unwilling to relocate

o Grad unwilling to accept employment (Salary/hours/etc.)

o Grad on active military duty

o Grad is continuing education

Job Placement

Rate

•Number of students who complete the program within the stated program length

•Program specifies the entry point

•Do not need to consider students that attrite due to nonacademic reasons:

o Financial, medical/mental health, family reasons

o Military deployment

o Change in major

o Nonacademic withdrawals as defined by the institution.

Program Completion

Rate

Objective 6.2: The program analyzes and shares its program effectiveness data to facilitate ongoing improvement

• Analyze and discuss with faculty prior to sharing with communities of interest

• Analysis must occur at least annually and results of evidence-based decisions must be documented

• Analysis includes actual data compared to expected achievement

• Need to document discussion of analysis including trending of results over time

• If a benchmark is not met, an action plan must be implemented.

Objective 6.3: The program has a systematic assessment plan that facilitates ongoing program improvement.

• Plans must include:• Goals in relation to clinical competency,

communication, and critical thinking;

• Two SLO’s per goal

• Two assessment tools per SLO

• Benchmarks for each assessment method to determine level of achievement

• Timeframes for data collection

• Bachelor’s degrees and higher should consider additional content when developing goals and SLO’s

• Must assess graduate and employer satisfaction (method and timeframes are prerogatives of the program)

Objective 6.4: The program analyzes and shares student learning outcome data to facilitate ongoing improvement

• Use assessment results to promote students’ success and maintain and improve student learning outcomes

• Analyze and discuss with faculty prior to sharing with communities of interest

• Analysis must occur at least annually and results of evidence-based decisions must be documented

• Analysis includes actual data compared to expected achievement

• Need to document discussion of analysis including trending of results over time

• If a benchmark is not met, an action plan must be implemented.

Objective 6.5: The program periodically reevaluates its assessment process to assure continuous program improvement

• Review mission statement, goals, SLO’s and assessment plan

• Assure assessment process is effective in measuring SLO’s

• Evaluation must take place at least every three years and be documented

• Curriculum maps

Questions?

128

129

Take advantage of resources:

Assessment Corner Your institution Google

Click on any assessment resources

What is Assessment?

Assessment is the systematic collection, review, and use of information to improve student learning and educational quality -JRCERT, Standard Five – Objective 5.1 based on Palomba and Banta’s definition (Assessment Essentials, 1999)

Assessment Essentials 2nd Ed (2015)

The process of providing credible evidence of resources, implementation actions, and outcomes undertaken for the purpose of improving the effectiveness of instruction, programs, and services in higher education.

130

What is Student Learning Outcomes Assessment?

•The ongoing process of

1. Establishing clear, measurable, expected SLOs2. Systematically gathering, analyzing, and interpreting

evidence to determine how well students’ learning matches expectations

3. Using the resulting information to understand and improve student learning

4. Reporting on processes and results

131

Assessment Involves:

132

MAKING YOUR EXPECTATIONS EXPLICIT AND PUBLIC

USING THE RESULTING INFORMATION TO DOCUMENT,

EXPLAIN, AND IMPROVE PERFORMANCE

Goal of Assessment?

• Information-based decision making

• “The end of assessment is action”

• Do not attempt to achieve the perfect research design… gather enough data to provide a reasonable basis for action.

Wolvoord (2010)

Pitfalls of Assessment

• Compliance with external demands

• Gathering data no one will use or data that is required (# of comps, dosimeter)

• Making the process too complicated

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Course Grades

• Course grade cannot pinpoint concepts that students have or have not mastered

• Grading Criteria

• Attendance, Participation, Bonus points

• Inter-rater reliability or vague grading standards

• Not holistic

• Do grades have a place in an Assessment program?

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Curriculum MapCourses Student Learning Outcomes

SLO 1 SLO 2 SLO 3 SLO 4

RAD 150

RAD 153 I I I

RAD 154 R I I

RAD 232 R R R R

RAD 234 R R

RAD 250 M M M & A M

RAD255 M & A M & A A M & A

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“I” = Introduce“R” = Reinforce, practice“M” = Mastery“A” = Assessed for program assessment

Types of Assessment

Student Learning

What students will do or achieve

• Knowledge

• Skills

• Attitudes

Program Effectiveness

What the program will do or achieve

• Certification Pass Rate

• Job Placement Rate

• Program Completion Rate

• Graduate Satisfaction

• Employer Satisfaction

137

Types of Assessment

Formative Assessment

•Gathering of information during the progression of a program.

•Allows for student improvement prior to program completion.

Summative Assessment

•Gathering of information at the conclusion of a program.

138

139

Mission Statement

Goals

SLOs

MISSION STATEMENT

• Mission Statement - The program's mission statement should clearly define its purpose and scope and is periodically reevaluated.

• Is the program's mission statement consistent with the focus of the institution's mission?

• Is it easily understood?

• Does it reflect what is expected from graduates?

140

141

• broad statements of student achievement that are consistent with the mission of the program

• should address all learners and reflect clinical competence, critical thinking, and communication skills

Goals Should NOT:

142

CONTAIN ASSESSMENT TOOLS

CONTAIN INCREASES IN ACHIEVEMENT

CONTAIN PROGRAM ACHIEVEMENTS

Goals ?

143

The program will prepare graduates to function as entry-level ___.

The faculty will assure that the JRCERT accreditation requirements are followed.

Students will accurately evaluate images for diagnostic quality.

85% of students will practice age-appropriate patient care on the mock patient care practicum.

Student Learning Outcomes

• Specific

• Measurable

• Attainable

• Realistic

• Targeted

144

Student Learning Outcomes

145

Students will __________ _____________.

(action verb) (something)

The JRCERT suggests no more than 6-7 total SLOs.

146

147

KNOWLEDGE

COMPREHENSIONAPPLICATION

ANALYSISSYNTHESIS

EVALUATION

Cite

Count

Define

Draw

Identify

List

Name

Point

Quote

Read

Recite

Record

Repeat

Select

State

Tabulate

Tell

Trace

Underline

Associate

Classify

Compare

Compute

Contrast

Differentiate

Discuss

Distinguish

Estimate

Explain

Express

Extrapolate

Interpolate

Locate

Predict

Report

Restate

Review

Tell

Translate

ApplyCalculateClassify

DemonstrateDetermineDramatizeEmployExamineIllustrateInterpretLocateOperateOrderPracticeReport

RestructureScheduleSketchSolve

TranslateUseWrite

Analyze

Appraise

Calculate

Categorize

Classify

Compare

Debate

Diagram

Differentiate

Distinguish

Examine

Experiment

Inspect

Inventory

Question

Separate

Summarize

Test

Arrange

Assemble

Collect

Compose

Construct

Create

Design

Formulate

Integrate

Manage

Organize

Plan

Prepare

Prescribe

Produce

Propose

Specify

Synthesize

Write

Appraise

Assess

Choose

Compare

Criticize

Determine

Estimate

Evaluate

Grade

Judge

Measure

Rank

Rate

Recommend

Revise

Score

Select

Standardize

Test

Validate

Lower division courseoutcomes

148

KNOWLEDGE

COMPREHENSIONAPPLICATION

ANALYSISSYNTHESIS

EVALUATION

Cite

Count

Define

Draw

Identify

List

Name

Point

Quote

Read

Recite

Record

Repeat

Select

State

Tabulate

Tell

Trace

Underline

Associate

Classify

Compare

Compute

Contrast

Differentiate

Discuss

Distinguish

Estimate

Explain

Express

Extrapolate

Interpolate

Locate

Predict

Report

Restate

Review

Tell

Translate

ApplyCalculateClassify

DemonstrateDetermineDramatizeEmployExamineIllustrateInterpretLocateOperateOrderPracticeReport

RestructureScheduleSketchSolve

TranslateUseWrite

Analyze

Appraise

Calculate

Categorize

Classify

Compare

Debate

Diagram

Differentiate

Distinguish

Examine

Experiment

Inspect

Inventory

Question

Separate

Summarize

Test

Arrange

Assemble

Collect

Compose

Construct

Create

Design

Formulate

Integrate

Manage

Organize

Plan

Prepare

Prescribe

Produce

Propose

Specify

Synthesize

Write

Appraise

Assess

Choose

Compare

Criticize

Determine

Estimate

Evaluate

Grade

Judge

Measure

Rank

Rate

Recommend

Revise

Score

Select

Standardize

Test

Validate

Upper divisionCourse / Program

outcomes

Assessment Measurements

149

The most important criterion when selecting an assessment method is whether it will provide useful information - information that indicates whether students are learning and developing in ways faculty have agreed are important.

(Palomba & Banta, 1999)

Assessment Plan Review

Measurement Tools - Assessment best practices suggest the use, where appropriate, of two or more measurement tools for each SLO.

Measurement from multiple perspectives can often provide a more accurate picture of student learning.

• Do tools validate one another so that the data is accurate and reliable?

• Are enough measurement tools utilized to assure a valid picture on student achievement?

• Are there too many tools for each SLO and wasting time on collection of data? ~ Are the best tools available being used to measure the SLO? ~ Have they provided results that we believe accurately measure the SLO? ~ Should different tools be considered? ~ Should the existing tool be modified to improve the accuracy and validity of the results provided?

• Large enough sample size from each measurement tool to yield valid results? For example, results from an employer survey to assess critical thinking skills and only two surveys (the “n” number) were returned from a graduating class of fifteen, the data would not be sufficient to provide reliable assessment information from this tool.

• Identify the “n” number, i.e., the sample size when reporting the results. 150

Assessment Plan Review

151• Benchmarks - Programs must set the expectations for how well

the students are learning. If only a section/part of a measurement tool is used, then the program must be able to set a benchmark for that particular subsection of the entire measurement tool. • Is the benchmark consistent with the measurement tool? ~

If the scale is not a 100% scale has the scale being used been clearly identified?

• Benchmarks are reasonable expectations. If, for example, a “passing” benchmark is set at a 75% average for the entire cohort, that would mean some students are performing well below the acceptable “passing” level of 75%. The program may wish to consider setting the performance benchmark higher than the minimum “passing” level.

• Are benchmarks set at reasonable and acceptable levels? ~ Should benchmarks be set higher to reflect the true expectations for student learning? ~ If students are consistently meeting a benchmark, should the benchmark be increased?

• If a benchmark is raised, what must be done to improve the program in order to get the students to that higher level?

• Should we lower a benchmark if the benchmark is not met for several cycles of assessment? Programs should examine results over several cycles for trends, analyze the reasons for any unmet benchmark(s), and make modifications to improve student performance. Programs should “stretch” to reach the highest levels of student achievement possible before deciding to lower a benchmark.

Assessment Plan Review

• Timeframes

• Is the formative assessment timeframe appropriate?

• Summative assessment is used to determine if program graduates are at the achievement level consistent with the program’s mission. Should we establish any different timeframes for summative measurement? ~ Would feedback obtained post-graduation from graduates or employers be valuable in the assessment process?

• Individual Responsible

• Are the individuals responsible for collecting assessment data appropriately identified in the plan?

• Are the individuals identified the best resource or should someone else be identified to perform this task?

• Do these individuals understand the importance of their respective roles in the assessment process?

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Assessment Plan Review Cont.

• Reporting Results - Assessment results should be reported in a format that is correlated with the benchmark. If the benchmark is based upon a Likert scale then the results should be reported using the same scale. “Actual” data must be reported. • Are we reporting “generalizations” rather than actual results? For example,

based on a benchmark: “All students will achieve a minimum 80%,” the results cannot be reported as, “All students received over 80%.” This is not actual data and does not indicate how well the cohort performed. Did the distribution of scores identify multiple students barely exceeding the minimum benchmark, or were scores concentrated at the upper end of the grading scale? If using a class average as the benchmark, report the actual average score.

• When reporting the data, are we also reporting the sample size (“n” number), i.e., the number of data inputs reviewed to determine the reported results?

153

Collect and Trend the Data

154

Report the actual data

• On assessment plan

• On separate document

Should facilitate comparison

• Comparison of cohorts

• Comparison of students attending certain clinical setting

Show dates

Data Analysis

• What does the data say about your students’ mastery of subject matter, of research skills, or of writing and speaking?

• What does the data say about your students’ preparation for taking the next career step?

• Do you see areas where performance is okay, but not outstanding, and where you’d like to see a higher level of performance?

155

UMass-Amherst, OAPA: http://www.umass.edu/oapa/oapa/publications/

Data Analysis

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Identify benchmarks met

• Sustained effort

• Monitoring

• Evaluate benchmarks

01Identify benchmarks not met

• Targets for improvement

• Study the problem before trying to solve it!!

• Evaluate benchmark

02Identify 3 years of data (trend)

03

Assessment Plan Review

• Analysis of Assessment Results – the assessment plan’s value to the department lies in the evidence it offers about overall department or program strength and weaknesses, and in the evidence it provides for change (Wright, 1991).

• What does the data say about the students’ mastery of subject matter?

• Were benchmarks met?

• Are students prepared as graduates of a JRCERT accredited program?

• What are the areas of program strengths?

• What are the areas of program weaknesses?

• Formally documented

157

Ongoing Assessment

158

is cumulative

is fostered when assessment involves a linked series of activities undertaken over time

may involve tracking progress of individuals or cohorts

is done in the spirit of continuous improvement

Closing the Cycle

159

The process of drawing conclusions should be

open to all those who are likely to be affected by the results – the communities

of interest.

Analysis of the assessment data needs to be shared

and formally documented. For example, meeting

minutes from Assessment or Advisory Committee.

Contact Information

mail@jrcert.org www.jrcert.org

20 North Wacker Drive, Suite 2850

Chicago, IL 60606-3182

(312) 704-5300

General JRCERT Questions?

Please let us know of any questions we can answer for you.

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programmatic accreditation.

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