Assessment Review Committee Report Health Sciences Division- Support Units

1. 2013 Institutional Planning, Assessment, and Research Institutional Planning, Assessment & Research Assessment Review CommitteeReportHealth Sciences Division- Support Units • Patricia Fazzone, DNSc, MPH, RN • May 5, 2014 2010 Institutional Planning, Assessment & Research 1

2. Mentoring/Review Process • Dr. Patricia Fazzone, ARC Chair, recruited members who are“PERSONS EXTRAORDINAIRE”: • Dr. Michael Kennedy, PhD, MHA, FACHE- Allied Health • Ms Jennifer Muir- Executive Director Finance- CON • Ms Susan Morrissey- Assessment Expert IPAR, was assigned to our ARC, and is truly a “PERSON EXTRAORDINAIRE” 2010 Institutional Planning, Assessment & Research

3. Mentoring/Review Process • The Chair assigned units based upon members’ expressed expertise and interest, and upon need. Each member served as a Primary or Secondary reviewer on the assigned units. • The group met three times in person: Once in the formative stage, and twice during the process • Group members maintained ongoing conversation with the ARC Chair and/or secondary reviewer/ Susan Morrissey when indicated, in an effort to facilitate mentoring of unit personnel

4. Mentoring/Review Process • Numerous units had little if any assessment report entered at the time of the first meeting of the ARC • A number of the units had little to no experience with TracDat, or with writing meaningful outcomes, means of assessment, criteria for success, linking results to outcomes...if any results were even reported; and almost all did not report any followup • All members of the ARC vigorously, tenaciously, professionally, and patiently provided extensive, ongoing mentoring to their respective units • Two units had so much turnover in personnel that the early mentoring had to focus on basic questions such as: • “what is it specifically that you do?” • “what are three things about which you are most concerned, or interested in that need monitoring?”

5. 2012-13 Component Data 2013 Institutional Planning, Assessment & Research

6. Data Visualization 2013 Institutional Planning, Assessment & Research

7. 2012-13 Best Practices – “Closing the Loop” • Outcome: Containment and Management of Waste- The Office of Prospective Health will minimize radiological and biomedical waste exposure by ensuring proper containment and management of waste according to local state and federal regulatory guidelines. • Means of Assessment: Radiation Safety - Radiation monitors through site surveys and inspections. (Attach check list) http://www.ncradiation.net/regs/Chapter%2011_2013_10.pdf • N. C. Regulations for Protection Against Radiation http://ncradiation.net/all_rules/15ahome.htm 2010 Institutional Planning, Assessment & Research

8. 2012-13 Best Practices – “Closing the Loop” • Criterion for Success: 100% compliance. Checklists are used evaluate the site conditions. • Results and Actions Taken: 2012-2013 • We analyzed annual waste trends (increases and decreases of waste generated). Once the bulk of the radioactive waste we collected over a 17 year period was removed from the facility, we designed a new waste handling facility and decommissioned the old area, exterior cargo containers. The new facility is now in a permanent building. The area includes a locked gated fence which gives us more control in securing the area from the public view, reduced the chance of damage by acts of nature, and reduced the overall footprint of the waste handling area. Success for meeting criteria was unable to be determined due to lack of data. 2010 Institutional Planning, Assessment & Research

9. 2012-13 Best Practices – “Closing the Loop” • Actions Planned for Next Reporting Year: • Obtain feedback from clinics and department. • Through education and training efforts the pounds and costs are visibly reduced. • Vendor refresher training for Environmental Health and Safety Techs every 3 years (DOT required). • Environmental Health and Safety Techs observational log for pickup. • Vendor audit of our waste practices. • Record-keeping of manifest. • North Carolina Department of Environment and Natural Resources (NCDENR) recommendation for biomedical wast (Section .1200 Medical Waste Management Rules. • Team will use the newly developed check list under related documents. 2010 Institutional Planning, Assessment & Research

10. 2012-13 Best Practices – “Closing the Loop” • Means of Assessment: Tracking of medical waste by vendor's manifest that reflects the total pounds of material. During this reporting period, the waste vendor changed the billing from price per pounds to price per box. Therefore, we were not able accurately calculate the reduction. (See attached document regarding regulations under Relate Document) • Related Documents: • FACILITY BIOLOGICAL WASTE CHECKLIST.docx • Results and Actions Taken: Infection Control and Biological Safety perform annual inspections of clinical and laboratory sites to physically open biowaste containers to observe the contents. Our Environmental Health and Safety Hazard Material Technicians also inspect these sites during their daily waste pickups and document the findings on a checklist. Unit identified that data were insufficient to measure exposures with current vendor manifest. Began to develop a checklist to collect data. 2010 Institutional Planning, Assessment & Research

11. 2012-13 Best Practices – “Closing the Loop” • Actions Planned for Next Reporting Year: Team identified the insufficient ability to measure waste containment and exposure and developed visual review process and check list. See related document under Means of Assessment. Will utilize document in 2014-2015. 2010 Institutional Planning, Assessment & Research

12. Substantive Changes • Program/Unit: Prospective Health • Description and Justification of Changes: Everything changed for this unit. Personnel were fairly new. No one knew TracDat; everyone agreed the existing outcomes were not meaningful, and the means of assessment and criteria for success did not always match the outcome, nor give meaningful data. Overall documentation and tracking of waste management and other key areas of responsibility were insufficient to assure high quality and compliance with outside agency requirements. Highly concerned, the team at Prospective Health worked closely with the ARC to address critical areas for monitoring, and make major changes to the unit outcomes to address the critical areas to assure quality and safety in areas of waste management and immunizations of key personnel. • Of particular note is the more strategic monitoring of waste management, and the development of a new checklist that will assist the unit with monitoring and documenting compliance with internal, external and regulatory requirements. • Describe how change(s) is/are designed to improve student learning, program quality, or unit performance in response to the previous year’s assessment results. 2010 Institutional Planning, Assessment & Research

13. Rubric and Review Process Feedback • The Rubric worked well for the ARC members, once everyone felt comfortable with using the format. Unit leadership and personnel were not versed in the rubric, and were not very experienced with the assessment process. Any recommendations for change in the rubric were voiced by the ARC Chair at IAAC meetings. The issues the ARC team experienced had little if anything to do with the rubric, and everything to do with the level of conceptual and working knowledge of the unit personnel regarding assessment and reporting, and some units’ commitment to the process. • The ARC members provided very intensive support to the units during the process. The level of labor intensity, time commitment, and frustration with several units’ lack of training and development in assessment, and periodic complacency despite ARC members’ commitment and efforts, has raised questions for ARC members. We will meet again at the end of May or beginning of June, 2014 to discuss how we move forward with our units. 2010 Institutional Planning, Assessment & Research