November 9-10, 2015
Chicago, Illinois
Revised: 7/8/14
The JRCERT promotes excellence in
education and elevates the quality and
safety of patient care through the
accreditation of educational programs in
radiography, radiation therapy, magnetic
resonance, and medical dosimetry.
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)
4
Leslie F. Winter
CEO
Jay Hicks
Executive Associate
Director
Traci Lang
Assistant Director
Tom Brown
Accreditation Specialist
Jacqueline Kralik Accreditation Specialist
Brian Leonard
Accreditation Specialist
Radiography
613
Radiation
Therapy
74
Magnetic
Resonance
10
Medical
Dosimetry
17
Learning Modules
• What is 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

Application/Self Study Report due within 6 months

Site Visit scheduled within 6 months

Report of Site Visit Team Findings due upon
completion of Exit Summation

Report of Findings due within 3 months

Program response to Report of Findings due within 6-8
weeks
Initial
Continuing
• 3 year maximum
• With or without progress report
•
•
•
•
8 year maximum
5 years with progress report
3 years with progress report
Probation
Program length
Compliance Timeframe
2 year or longer
24 months
1 year
18 months
Failure to demonstrate compliance within the specified
time period will result in Involuntary Withdrawal of
Accreditation.

Learning experience

Benefit to both you and your program

Potential for enhanced respect from peers

Frequent flyer points
Good Communication Skills
Supportive of
the
Accreditation
Process
Clear Analytic Thinking
Diplomacy/ Personable
Detective Skills
Clear Writing Skills
Evaluate
Validate

Assess the program in relation to
STANDARDS & objectives

Review the program’s
mission statement and goals
 resources and activities
 policies and procedures


Standards:

Report of Previous Site
Visit Team Findings &
Other Official
Correspondences

JRCERT Policies and
Procedures

Web Site
JRCERT Professional
Staff
►Radiography
► Radiation Therapy
► MR
► Medical Dosimetry

Application /Self-study
Report
► Review Letter


A great wealth of SV information is
available at this hidden page of our Website

http://www.jrcert.org/site-visitor-hiddeninformation/
Minimum of 2
(State Representative –
NY, NJ, WV, KY, NE,
CA)
Apprentice
participation
Sponsorship
considerations
Conflict of
interest
Geographic
considerations


JRCERT has contracts in Nebraska,
Kentucky, New Jersey, New York, and
West Virginia to share confidential
programmatic information.
Representatives from these states could also
participate in any announced or
unannounced site visits
 Credibility
is extremely important
Review Self-study Report AND review letter
Study STANDARDS
Understand accreditation process & site visitor policies and procedures
Familiarize yourself with your role and assignments
Provide input to the team chair
Contribute to the team’s collective decisions
Review ROF for accuracy and report inaccuracies to the assigned
JRCERT staff
Contact Program Director & plan agenda
Communicate with team members
Assure confidentiality
Perform assessment
Analyze evidence & determine the facts
Assess the program in relation to each objective of each STANDARD
Determine how the program’s efforts affect the effectiveness of the
program
Complete the RSVTF via the AMS
SITE VISIT AGENDA
Chicago City College – South Loop
Radiologic Technology Program
Chicago, Illinois
February 15-16, 2013
SITE VISITORS:
Abe Lincoln, M.Ed., R.T. ( R )
Mickey Mouse, M.S, R.T.(R)(CT)
Team Chair
Team Member
Radiography Program Director
Associate Professor
Bossier Parish Community College
Michigan County College
Bossier City, LA
Silo, MI
Cell Phone: 888-867-5309
Cell Phone: 888-555-4226
2/14/13
3:30 pm
Pick up site visitors at airport
Abe arrives on American Airlines Flight 2960 at 2:45 pm
Mickey arrives on United Airlines Flight 452 at 3:15 pm
2/15/13

7:30 am

8:00 am

8:30 am

9:30 am

10:00 am
11:00 am
12:00 pm
12:30 pm
1:30 pm

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


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3:00 pm
5:00 pm
Pick up Site Visitors at Hotel
Introductory Meeting with Radiography Program
Faculty and Other Administrative Personnel
Campus Tour [Classroom(s), Laboratory, Faculty
Offices, Library, and Student Services]
Meet with Campus Admission’s Director and
Registrar
Meet with Program Personnel
Meet with 1st Year Students
Lunch with Clinical Instructors
Individual Meetings with Clinical Instructors
Tour Clinical Facilities: Northwest Hospital and Craig
T. Johnson Memorial Hospital
Return to Program and Meet with Program Officials
Return to Hotel
Expectations
Evidence
Explain
• Explicit
• Public
• Systematic
collection
• Interpretation
• Matches
expectations
• Use
information
• Document
• Improve
performance
Assessment Plan 2010-2011
Mission: To produce competent, entry-level radiographers.
Goal: Graduates will be clinically competent.
Outcomes:
Measurement
Tool:
Benchmark:
Results: Analysis/ Action Plan:
1. Student will Simulated lab
competency Q6
select
appropriate
technical
factors.
Ave score
2.5
(3 pt scale)
2.75
Benchmark met. For the past 2
years this result has increased:
2008/9-2.5, 2009/10-2.65. This
could be attributed to the increase
in laboratory sections resulting in
a lower faculty to student ratio.
Psychomotor
evaluation Q12
Ave score
2.5
(3 pt scale)
2.45
Benchmark not met. Results for
2008/9-2.65, 2009/10-2.7. There
was a decrease in the average for
the past two(2) years. Initiate an
additional review exercise prior
to the student’s next clinical
assignment. Will continue to
monitor this benchmark
Sustained effort
Monitoring
Evaluate benchmarks
Targets for improvement
Study the problem before trying to solve it!
Evaluate benchmark
Assessment Plan 2010-2011
Mission: To produce competent, entry-level radiographers.
Goal: Graduates will be clinically competent.
Outcomes:
Measurement
Tool:
Benchmark:
Results: Analysis/ Action Plan:
1. Student will Simulated lab
competency Q6
select
appropriate
technical
factors.
Ave score
2.5
(3 pt scale)
2.75
Benchmark met. For the past 2
years this result has increased:
2008/9-2.5, 2009/10-2.65. This
could be attributed to the increase
in laboratory sections resulting in
a lower faculty to student ratio.
Psychomotor
evaluation Q12
Ave score
2.5
(3 pt scale)
2.45
Benchmark not met. Results for
2008/9-2.65, 2009/10-2.7. There
was a decrease in the average for
the past two(2) years. Initiate an
additional review exercise prior
to the student’s next clinical
assignment. Will continue to
monitor this benchmark

On assessment plan

On separate document

Show dates

Should facilitate comparisons
Assessment Plan 2010-2011
Mission: To produce competent, entry-level radiographers.
Goal: Graduates will be clinically competent.
Outcomes:
Measurement
Tool:
Benchmark:
Results: Analysis/ Action Plan:
1. Student will Simulated lab
competency Q6
select
appropriate
technical
factors.
Ave score
2.5
(3 pt scale)
2.75
Benchmark met. For the past 2
years this result has increased:
2008/9-2.5, 2009/10-2.65. This
could be attributed to the increase
in laboratory sections resulting in
a lower faculty to student ratio.
Psychomotor
evaluation Q12
Ave score
2.5
(3 pt scale)
2.45
Benchmark not met. Results for
2008/9-2.65, 2009/10-2.7. There
was a decrease in the average for
the past two(2) years. Initiate an
additional review exercise prior
to the student’s next clinical
assignment. Will continue to
monitor this benchmark
Benchmark: 80

2011 – 82.6

2010 – 83.0

2009 – 84.7

2008 – 87.5

2007 – 90.8


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 policies and
procedures that are in compliance with Nuclear
Regulatory Commission regulations and state laws as
applicable.
39

Interpretation: All students who participate in using
equipment in a energized laboratory or clinical
environment must be monitored for radiation exposure,
including by not limited to simulation procedures or
quality assurance.

Adopted by the Joint Review Committee on Education in Radiologic Technology:
04/15 (effective 04/15)
40


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.
41

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)
42


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.
43

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)
44
Sponsorship
• Consortium
• Cooperative
Agreement
Substantive
Changes
• Policy 11.400





Protect Student Privacy
Verification of students participation, completion &
receiving credit
Disclose cost



Resources
Advisement
Faculty





Traditional vs Distance
Classrooms
Laboratories

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

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
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Well-Structured
Appropriately Sequenced
Team must observe a portion of at least one course
Available to Distance Students
Advisement

Travel arrangements







lowest coach airfare
personal auto
rental car
stay over
Coordinate travel schedules: Team chair & program
officials
Arrive early evening before site visit
Departure should allow time for thorough
presentation of exit summation
Clarify any concerns regarding your
role as a team member
Familiarize yourself with program
effectiveness concept
Review agenda & determine
potential questions for interview
Provide:
The program must provide/ make available
materials verifying achievement of desired
outcome.
Describe:
A brief description that demonstrates steps
taken to implement a procedure or achieve
an outcome.
Prior
• Review the
program selfstudy & other
materials
supplied by the
program.
• Areas to follow
up
During
• Outline specific
questions that
can be asked of
each respondent
type.
Ending
• Summarize a
program’s
strengths &
concerns.

California radiographers and therapists’
licenses are to be posted in the department.


Spot check the names posted with the names
provided on the database listing for that particular
facility
Inquire if Radiologists/Oncologists are still
supervising students
1. Read Confidentiality Statement
2. Explain purpose
3. Review agenda

Program’s mission/goals

Curriculum

Clinical plan

Visit clinical sites

Tour campus facilities

Interviews

Establish the reason for the interview


Establish rapport



individual vs. group
assure confidentiality & autonomy
listen attentively
Structure the interview



start with broad questions
fully explore each topic before moving to the next
use open-ended, non-leading questions

Evaluate responses & explore further as
necessary:



to assure full and accurate information
to assure your understanding
when answers are not consistent

Respond neutrally to all responses

Know when to move on

Positive

Upbeat




Enthusiastic

Confident
Welcome break from
your routine
Skeptical



Tense
Defensive
Anxious
Intrusive/Disruptive

How can we help you/the
school?

What would you like us to
include in the report that
would be helpful to you?



Blank check to request the
JRCERT’s support resolving
other than accreditation issues.

Blank check to request the
JRCERT’s support resolving
other than accreditation issues.
In my school we do it
differently.

Big Problem.
This appears to be an excellent
program.

No Problem.

This is a beautiful program.


This is a model for other
schools.

No Problem.

Your reputation is well known.

No Problem.

In my school, we do it the same
way.

No Problem.
No Problem.
Confidentiality
& exit
statements
Objectives
assessment
Accreditation
cycle
Strengths
Suggestions

Thank your host.

Take your time.

Read confidentiality statement.

List the strengths of the program.

Go through each of the

Be specific.

Be complete.

Maintain professional demeanor.

Do not ask the program director to help you
write the report.

Maintain control.

It’s not over until it’s over.

Know the accreditation process.

Know when to stop talking.
1. Try to email/mail any additional information to
office within 7 days (Policy = 4 weeks)
2. Expense voucher
3. Evaluation of other team members
* Will be emailed to you after RSVTF is received in
office.

The Site visitor has no further contact with
program

Each site visitor receives copy of ROF letter

report any inaccuracies/misinterpretations to JRCERT

The visit team is a TEAM.

The team chair is the spokesperson and in charge
of the visit assuring evaluation is:




Focused on outcomes
Comprehensive and thorough
Fair
The team is entrusted with the highest form of
professional confidence.

It is important to display a receptive attitude to the
program’s philosophy, mission, and goals.

Time management during the visit is critical.

The JRCERT staff is available for assistance if
problems or concerns arise before, during, or after
the visit.
Be on time
Maintain
objectivity.
Be a
contributing
team member.
Do your
homework.
Focus on
STANDARDS
& program’s
effectiveness.
Maintain
confidentiality.
Do not be
drawn into
irrelevant
discussions
Avoid measuring
program by your
program’s
practice
Concentrate
on accuracy
and fairness
Be
conscientious
of costs



Be sure you have signed attendance sheet
Please, complete evaluations
Please turn in your name badges
for supporting excellence in education and
quality patient care through programmatic
accreditation.
76