Consistency in Accreditation ASPA April 4, 2011

1. NAACLS Consistency in AccreditationASPA April 4, 2011 Department of Medical Laboratory Science Rush University Herb Miller, Ph.D.

2. Questions to answer from A Program Director’s View • When you took the role, what was reality? • What is your current relationship with the agency? • What roles have you had with the agency? • What were your expectations in working with the agency? • Training, customer support, self-help resources, interpretation and application of standards, communication and application of policies and procedures related to program review.

3. Questions to answer from A Program Director’s View • How was consistency a factor in your activities? • Identify areas in which you were engaged in improving consistency, how you supported others in same position. • Were there any surprises about areas that could have been more consistent?

4. History Scope of Responsibilities with NAACLS • Program Director: St. Mary of Nazareth Hospital 1974-1975 • Attended the first NAACLS workshop for Accreditation (and several others over the years) • Associated Program Director Rush University 1975 to 1996 • Program Director Rush 1996 to present • Chairman and Program Director 2001 to present • Associate Dean, Graduate Programs 2009 to present

5. History Responsibilities with NAACLS • NAACLS Paper Reviewer throughout 1980’s to present • Site Visitor 1990’s to present • Volunteer Consultant for self-study preparation • Personally have completed 6 self-studies for Rush • I strongly encouraged a digital format for many years. We now have one. • Our process is very detailed and there have been NO surprises except the amount of work involved.

6. NAACLS • Primary aspects of the NAACLS programmatic accreditation process are: • (1) the self-study process; • (2) the paper and site visit process; • (3) evaluation by a review committee, and • (4) evaluation by the Board of Directors. Evaluation is based on Standards, which are the minimum criteria used

7. NAACLS • The review committees are comprised of educators and practitioners representing their respective disciplines. • Members are appointed by the Board of Directors for staggered terms to assure continuity on the committee. • The chairman and vice chairman are elected annually by committee members

8. Accreditation Process • The Review by the Program Review Committee Based on the review of Paper Review Report, the Program’s Response to the Paper Review Report, the Site Visit Report, and the Program's Response to the Site Visit Report, the Program Review Committee makes determinations as to the compliance, marginal compliance or non compliance of a program with the Standards and recommends accreditation actions to the NAACLS Board of Directors.

9. Accreditation Process • Review by the NAACLS Board of Directors Based on the recommendations of the Program Review Committee, and with review of consistent application of the Standards and to insure that decisions are not arbitrary, capricious or otherwise inconsistent with the Standards, performs all accreditation actions of awarding, withholding and withdrawing.

10. A Program Director’s Expectations • Training and help with the Self-Study: • NAACLS provides workshops at national meetings for program directors and accreditation volunteers. • There is a guide for preparation of the self-study on-line with a detailed matrix for each standard component of the study. • Newsletters highlighting various accreditation standards and education issues are sent to Program Directors.

11. A Program Director’s Expectations • Expectations: for paper review • Paper reviewer check list is available on-line to Program Directors. • Paper review is returned to the Program Director for comments and the opportunity is given to add any missing materials before the Site Visit.

12. A Program Director’s Expectations • Site Visit Expectations: what to expect for the Site Visit? • The Site Visit check list is available on-line to Program Directors. Responsibilities for the director, site-visit team leader and team member are given. Suggested itineraries, sample questions and other details for the visit are also available on-line

13. NAACLS • Excellent support from Office Staff throughout all steps of the process is provided. • There are Consultant Volunteers identified for program support and help throughout the process.

14. Publication Examples • Standards • Self Study Template • Directions For Using and Submitting The Electronic Self-Study • Guide to Accreditation • Paper Reviewer Report • Site Visit Report • Volunteer Manual and Annual Report

15. Consistency ??My Opinion • YES • with all published requirements, guidelines, review processes and across all programs accredited.

16. Problems Concerns Surprises • Very detailed process, but considering the detailed nature of the profession, this is not surprising. • Check lists ensure standardization of content reviewed. Yes-No Format • We do not submit progress reports between accreditations as do some accrediting organizations. • We are finally digital ! • The PROCESS is expensive and time greedy, but Thorough and Objective.

17. RUSH QUESTIONS QUESTIONS ? QUESTIONS

18. THANK YOU

19. Additional Informational Slides

20. Accreditation Process • NAACLS is an autonomous, nonprofit organization established in 1973 as the successor to the American Society for Clinical Pathology (ASCP) Board of Schools. • ASCP and the American Society for Clinical Laboratory Science (ASCLS) are sponsoring organizations of NAACLS.

21. NAACLS • The American Association of Pathologists' Assistants (AAPA), the National Society for Histotechnology (NSH) and the Association of Genetic Technologists (AGT) are participating organizations. • NAACLS is recognized by the Council for Higher Education Accreditation (CHEA).

22. NAACLS • NAACLS conducts various functions of programmatic accreditation including: • (1) drafting and reviewing Standards for the operation of specialized programs; • (2) selecting and training knowledgeable volunteers to review Self-Study Reports and serve as site visitors;

23. NAACLS • (3) selecting representatives to serve on the review committees and the Board of Directors, and • (4) granting accreditation awards based on a program's self-study and site visit processes.

24. Accreditation Process • Development of Program/Initial Processes letter of intent, a completed initial application, payment of an initial application fee, and approval of a preliminary report. • The Self-Study Process program is the program's own self-evaluation • The Paper Review Process The paper Reviewer evaluates the Self- Study based on the standards (check list)

25. Accreditation Process • The paper reviewer is the earliest outside source to review the adequacy of compliance. • The program receives the Paper Review Report and is directed to develop a Paper Review Response. • The Response attempts to clarify issues • identified in the Paper Review, and perhaps to develop new policies and procedures to address • the concerns noted.

26. Accreditation Process • The Site Visit Process Site visits are fact-finding journeys. The objective of a site visit is to verify and supplement information presented in the self-study and the Response to the Paper review • The program receives the Site Visit Report and is directed to develop a Site Visit Report Response.

27. Publication Examples Unique Standards and Documentation Required for Accredited of: • CLS/MT Programs • CLT/MLT Programs • HTL Programs – Histologists • HT Programs – Histotechnicians • DMS – Diagnostic Molecular Scientists • CG – Cytogenetic Technologists • Path A – Pathologists’ Assistant • PBT – Phlebotomists • CA- Clinical Assistant