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RCAP Protocol

RCAP Protocol. Recommended Materials. RCAP Reference Manual Programs Review Committees’ Handbook. Learning Outcomes. Upon completion of this unit of instruction and review of additional resources, the learner shall be able to:

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RCAP Protocol

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  1. RCAP Protocol

  2. Recommended Materials • RCAP Reference Manual • Programs Review Committees’ Handbook

  3. Learning Outcomes Upon completion of this unit of instruction and review of additional resources, the learner shall be able to: • Document the makeup of the RCAP members and their roles and duties • Determine how one becomes a RCAP member • Identify the NAACLS staff and their roles • Comprehend the meeting process

  4. Learning Outcomes Upon completion of this unit of instruction and review of additional resources, the learner shall be able to: • Describe the voting process and how a motion is pulled for discussion • Recognize instances when a RCAP member should be absent or abstain from discussions of and voting for a motion • Identify the role of quality assurance in the RCAP process

  5. Learning Outcomes Upon completion of this unit of instruction and review of additional resources, the learner shall be able to: • Recognize meeting etiquette • Recognize the necessity for confidentiality and avoiding conflict of interests while an RCAP member • Determine the outcome of multiple absences or significant change in professional status of a RCAP member

  6. Review Committee for Accredited Programs (RCAP) Role • Reviews programs for accreditation • CLS/MT • Clinical laboratory scientists/medical technologists • CLT/MLT • Clinical laboratory technician/medical laboratory technician • HTL • histotechnologist • HT • histotechnician • DMS • Diagnostic molecular scientist • CG • Cytogenetic technologist • PathA • Pathologists’ assistant

  7. RCAP Role • Forwards accreditation recommendations to the Board of Directors (BOD) • Develops and implements operational policies and procedures for accreditation

  8. RCAP Membership • 24 members that represent appropriate professions of clinical laboratory science, pathology and education • 6 CLS/MT educators (university and hospital based) • 6 CLT/MLT educators • 2 HT/HTL educators • 2 DMS educators • 2 CG educators or practitioners

  9. RCAP Membership • 2 PathA educators or practitioners • 1 four year educator – generalist • 1 two year educator – generalist • 1 clinical pathologist • 1 anatomic pathologist

  10. RCAP Membership • A BOD liaison is assigned to the committee • This individual: • Attends each meeting • Transmits information from and takes information back to the BOD • The committee is run by 3 officials/officers • Chair, Vice chair, and Chair in Waiting • Each year the chair in waiting is elected from the committee members • The officials traditionally serve one year in each position and advance to the next position after the fall BOD meeting • The Vice chair takes roll and records the minutes of the meeting

  11. RCAP Membership • Individuals are elected to the committee by the BOD • NAACLS puts out a call for nominations as positions become available • 3 members traditionally rotate off the committee after the summer meeting • Individuals may be nominated by another or can be self-nominated • If elected, the individual is invited to attend the next regularly scheduled meeting • Traditionally the 4 year term begins after the next scheduled summer meeting • Members can be elected to a maximum of 2 successive full terms

  12. RCAP Duties • Attend two multi-day (1-3 days) meetings each year • The summer meeting is usually face to face • The winter meeting is via teleconference • Make recommendations to the BOD regarding program accreditation • Respond to the committee’s chair, subcommittee’s chair, member, BOD or staff questions or proposals on various topics • Make recommendations on policies and procedures • Review revisions of the Standards, guides and manuals • Elect officers

  13. RCAP Duties • Serve as readers to submit and present recommendations on assigned programs to be evaluated by the committee • Return the completed motion to the discipline specific NAACLS staff member by the established deadline • Review progress reports for initial programs and programs with deficiencies • Review all meeting motions and minutes for corrections prior to the meeting • Review all discussion items prior to the meeting • Track citations of the Standards, during the meeting, for quality assurance purposes

  14. RCAP Duties • Members may also be asked to: • Serve on ad hoc subcommittees • Serve on standing subcommittees, as needed or assigned, • Standards revision • Program conversions • Preliminary reports for new programs • Program position changes such as the program director • Serve as discipline lead person for a specific discipline • Present NAACLS workshops or seminars • Write articles for the NAACLS News • Provide assistance to programs

  15. RCAP Duties • It is important that each member maintain current knowledge of: • The Standards • Current trends in education • The needs of the constituents served by NAACLS • Ideally each RCAP member is an experienced paper reviewer and site visitor volunteer • This expertise is invaluable • Each member should continue to volunteer for these, within their specific discipline area, during their term • A member may be asked to conduct a site visit outside their specific discipline area in special situations

  16. NAACLS Staff • Dianne Cearlock, PhD • Chief Operating Officer • Gwen James-Oriaikhi • Accreditation specialist for CLS/MT and DMS programs • Ed Rotchford • Program coordinator and program services for CLT/MLT, HT, HTL and CG programs

  17. NAACLS Staff • Elizabeth Everson • CIS coordinator (Website and electronic materials) and program services for PathA • Dan Tice • Operations manager and program coordinator for clinical assistant and phlebotomy approval programs • Mark Spence • Program services assistant • Megan Hennessy Eggert • Meetings and publicity coordinator (Meeting arrangements) • Ever Jean Frazier • Accounting assistant (Expense reports)

  18. NAACLS Staff • The staff help keep the RCAP committee on-track and on-schedule • They have a vast amount of knowledge on policies and procedures and how issues have been handled in the past • They provide the continuity for the RCAP committee as members come and go • They may contact individual committee members with questions from program directors or for discussion on issues as they arise

  19. Meeting Protocol • Robert’s Rules of Order are used • The chair creates the meeting agenda and conducts the meeting • Members may add items for discussion to the agenda

  20. Meeting Protocol • Standard agenda items include: • Call to order • Introduction of members, staff and guests • Delegation of quality assurance tracking assignments • Review and approval of the minutes of the previous meeting • Review of programs for accreditation • Initial and continuing by discipline

  21. Meeting Protocol • Standard agenda items include (continued): • Review of programs with progress reports • Review of programs for voluntary withdrawal of accreditation • Special cases • Discussion and informational items • Adjournment

  22. Meeting Protocol • Voting process in the review of programs • Programs that have no concerns remaining are voted in discipline specific groups rather than discussing individually • Discipline specific voting groups • No concerns remain (programs are considered “clean”) • Initial programs by discipline – 5 years recommended award • Continuing programs by discipline – 7 years • Continuing programs by discipline – 5 years

  23. Meeting Protocol • Voting process in the review of programs • Programs with concerns remaining are discussed individually within discipline specific groups • The first reader is responsible for presentation and discussion of the motion • The motion is read followed by the minutes draft • The reader should summarize the concerns of the site visit report, the response and the remaining concerns • The reader partner seconds the motion • Each citation and recommendation for compliance is discussed • The first reader makes any changes, as needed, after discussion • The motion is presented for a vote by the chair

  24. Meeting Protocol • Voting process in the review of programs • A member can request the chair to pull a specific motion from the vote due to: • Error in the final recommendation for award • Errors in interpretation of criteria for standardization of compliance • Errors in use of the RATS and RECS • Omission or resolution of concerns • Other issues • The motion must be pulled, for a detailed discussion, before the group votes on it

  25. Meeting Protocol • Voting Procedures • The chair calls for the vote • All those who agree say “yes” or “aye” • All those who oppose say “no” or “nay” • Any abstentions? • State your name and reason for abstaining • A majority of those present and voting is needed to pass a regular motion • A two-thirds majority is needed to pass motions for withdrawal of or withholding accreditation • A tie vote fails to pass the motion

  26. Meeting Protocol • Voting Procedures • If an RCAP member is an employee of or actively involved in a program being reviewed: • The individual must physically absent from the discussion and vote on the program • An RCAP member should abstain from discussion and voting for a program when one: • Is an academic or clinical affiliate of the sponsoring institution • Is employed in close proximity to the sponsoring institution • Has a personal or professional affiliation with the program or sponsoring institution • Has recently been appointees of, employees of or consultants to the sponsoring institution, or have relatives who are appointees or employees of the sponsoring institution • Is a recent graduate of the program or sponsoring institution

  27. Meeting Protocol • Voting Procedures • Members who performed the paper review or site visit for a program can vote on its motion • New members, whose term begins after the summer meeting, are not eligible to vote at their first summer meeting • The chair votes as a regular member of the committee

  28. Meeting Protocol • Meeting minutes • The vice-chair records the meeting minutes • They are available for review prior to the next scheduled meeting of the committee • Members need to review the minutes and offer corrections and omissions. • The committee must approve the previous meeting minutes as part of the agenda

  29. Meeting Protocol • Quality Assurance of the RCAP process • The QA process ensures each program is reviewed objectively and treated equally • Some members are assigned to monitor an individual or set of Standards during the meeting • A form is provided to document each time the assigned Standard is cited as marginal or non-compliance • Note the motion number, type of citation and reason(s) for the citation

  30. Meeting Protocol • Quality Assurance • The assigned member needs to monitor the citation and insure each is applied consistently across all programs cited • The QA form is returned to the chair after completion of the meeting for inclusion in the RCAP Chair’s report to the BOD QA committee

  31. Meeting Etiquette • The summer meeting is traditionally face to face. • Individuals microphones are used to due to large size of the committee and room • Turn on the microphone and raise a hand to be recognized by the chair before speaking • Only 4 microphones can be active at any one time • The chair has master control of all microphones • After speaking, turn off the microphone

  32. Meeting Etiquette • At the summer meeting: • Keep comments brief, concise and to the point • Keep side conversations to a minimum to avoid disruption of the meeting • Avoid interrupting others • Ask questions for clarification • Return from breaks and lunch on time

  33. Meeting Etiquette • The winter meeting is done via teleconference • NAACLS provides the central phone system • There are no visual clues available as with the face to face meeting • One lacks the ability to read an individual's facial cues or body language over the phone • A speaker phone provides the convenience of being “hands-free” • Plan on being present for the entire 2 day scheduled meeting • Remember each day can be up to an 8 hour session that requires your full attention the entire time

  34. Meeting Etiquette • At the teleconference meeting: • Be aware of background noises such as other telephones, conversations, keyboard tapping • A quiet environment is ideal to allow for one’s full concentration and limited disruptions to others • Use the mute button appropriately • Identify one’s self before speaking • Speak directly into the phone • Keep comments brief, concise and to the point • Avoid interruption of others • Ask for clarification as needed

  35. Meeting Etiquette • At the teleconference meeting: • Notify the chair if one must exit and reenter the meeting while in session • Absences need to be documented in the meeting minutes as they occur • Mid-morning, lunch and mid-afternoon breaks are scheduled • One may log off the phone during these breaks but must reenter the meeting prior to its commencement • Return on time from breaks and lunch

  36. Confidentiality • The committee reviews details of NAACLS accredited programs across the country • The information must remain confidential and cannot be used for personal gain • Each year, a RCAP member must review, complete and sign the confidentiality policy statement for NAACLS

  37. Conflict of Interest • One’s professional and personal interests cannot conflict with the obligations of NAACLS or RCAP • Each year, a RCAP member must review, complete and sign the conflict of interest form for NAACLS • Example of conflict of interest • Concurrent board member or officer for one of the following sponsoring, participating or affiliated organizations for NAACLS • ASCP, AGT, ASCLS, NSH, AAPA

  38. Absences • It critical that each RCAP member prepare for, attend and actively participate in each meeting • Unavoidable absences must be communicated to the chair as soon as possible • Absence from two consecutive meetings is cause for permanent removal from the committee

  39. Change is Member Status • A significant change in a professional position requires immediate notification of the RCAP chair and NAACLS CEO • An example of a significant change • The RCAP member is no longer associated with a clinical laboratory science program • The BOD determines if the individual may continue their RCAP membership

  40. RCAP Vacancies • Vacancies due to departure of a RCAP member, before completion of a term, are filled by appointment by the BOD • The individual appointed must meet the requirements of the position being filled • The appointment is valid for the remainder of the of the four year term being filled

  41. Learning Assessment A RCAP member wants to pull a motion for discussion at the winter meeting. It must be done: • Prior to completion of the meeting agenda by the chair • After the committee votes on this specific motion • Just prior to voting on it by the committee • After voting on all motions is completed

  42. Learning Assessment To be a RCAP member, one is traditionally: • Elected by the NAACLS BOD • Elected by the RCAP members • Selected by the NAACLS staff • Selected by the NAACLS BOD President

  43. Learning Assessment A RCAP member can vote on a motion if one: • Is employed by sponsoring institution • Performed the site visit • Is the program director • Is an instructor at a clinical affiliate of the program

  44. Learning Assessment Citation of Standards are tracked during the meeting to insure: • The competency of the RCAP members • The BOD is informed of all Standards not being met • New members comprehend interpretation of the Standards • Programs are reviewed objectively and treated equally

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