JRCNMT Proceedings

Programs Undergoing Review in 2005

South Coast Nuclear Medicine, Santa Barbara, CA

Gateway Community College, North Haven, CT

Hillsborough Community College, Tampa, FL

College of DuPage, Glen Ellyn, IL

Delgado Community College, New Orleans, LA

The Johns Hopkins Hospitals, Baltimore, MD

Springfield Technical Community College, Springfield, MA

St. Vincent’s Hospital & Medical Center, New York, NY

Caldwell Community College & Technical Institute, Hudson, NC

Forsyth Community College, Winston-Salem, NC

Rhode Island Hospital, Providence, RI

Southeast Technical Institute, Sioux Falls, SD

Amarillo College, Amarillo, TX

University of the Incarnate Word, San Antonio, TX

University of Utah Health Sciences Center, Salt Lake City, UT

Naval School of Health Sciences, Portsmouth, VA

West Virginia State College, Institute, WV

Programs Undergoing Review in 2006

Charles R. Drew University of Medicine & Science, Los Angeles, CA

Delaware Technical & Community College, Wilmington, DE

Edward Hines, Jr. VA Hospital, Hines, IL

Triton College, River Grove, IL

Salem State College, Salem, MA

University of Massachusetts Memorial Medical Center/Worcester State College, Worcester, MA

William Beaumont Hospital, Royal Oak, MI

Mayo School of Health Sciences, Rochester, MN

University of Mississippi Medical Center, Jackson, MS

University of Missouri—Columbia, Columbia, MO

St. Louis University, St. Louis, MO

University of Nevada—Las Vegas, Las Vegas, NV

Northport Dept of VA Medical Center, Northport, NY

Ohio State University Medical Center, Columbus, OH

Community College of Allegheny County, Pittsburgh, PA

Wyoming Valley Health Care System, Wilkes-Barre, PA

Midlands Technical College, Columbia, SC

University of Tennessee Medical Center—Knoxville, Knoxville, TN

Baptist College of Health Sciences, Memphis, TN

Galveston College, Galveston, TX

Houston Community College System, Houston, TX

West Virginia University Hospitals, Morgantown, WV

The next meeting of the Joint Review Committee on Educational Programs in Nuclear Medicine Technology is scheduled for October 27–29, 2005.

Telephone Evaluation Reviews— Clinical Affiliates

This policy was developed to reduce expense for addition of affiliates for nuclear technology medicine educational programs that have demonstrated continued compliance with the Essentials and Guidelines.

Programs qualifying for a telephone site review of new clinical affiliates must meet the following criteria:

1. The clinical affiliate application has to be satisfactory: that is, the applicant would qualify for Candidate for Recognition status.

2. There have been no changes in the program director’s position or in that of key staff members.

3. The program must have achieved a 7-year accreditation award.

With these conditions met, the interview will be assigned to an experienced board member.

The office will send a letter to the program director describing the process and requesting that the program director notify each clinical affiliate to advise them of the pending telephone interviews. The reviewer will contact the program director and request the program director establish a selection of time and dates convenient for the clinical affiliate and the students. Students should be provided with a private area for the interview.

In the event that the telephone site review identifies any deficiencies with the Essentials and Guidelines, an on-site evaluation will be conducted.

Extramural Quality Assurance for Clinical Affiliates of JRCNMT Accredited Programs

This policy was developed to provide the sponsoring institution with an alternative mechanism to verify that the clinical education sites students attend are providing the highest quality nuclear medicine in agreement with generally accepted national standards of practice. This policy is intended only for those clinical affiliates that do not participate in a formal extramural quality assurance program such as sponsored by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), the Intersocietal Commmission for the Accreditation of Nuclear Medicine Laboratories (ICANL), or the American College of Radiology (ACR). Such clinical affiliates will be requested to verify that they have the following processes in place. Note: This policy verifies only that required processes are in place, it does not purport to evaluate the results of such policies.

Administrative and Other Protocols: The department or organization has clearly documented patient registration, patient billing and accounting processes that follow CMS and HIPAA regulations. There is also a documented annual process to determine that the operating and capital budget for the host department and staffing and equipment in all areas is adequate.

Human Resources Policies and Procedures: The department has policies and procedures regarding hiring, firing, staffing levels, personnel evaluation, and maintenance of competency. The department and the organization keep up-to-date job descriptions that outline the roles and responsibilities of each individual used in the department and list the minimum qualifications for an individual in that position.

Personnel and Supervision: The qualification, certification, and licensure of personnel are current and at a level commensurate with their job descriptions and there is a process in place to ensure that the documentation of certification and licensure is authentic.

Physical Facilities: The physical facilities are adequate and such that the safety of the staff and patients is maintained at all times. Handicapped access meets all state and federal guidelines

Equipment and Instrumentation: The department has adequate and well-maintained equipment as witnessed by maintenance records and quality control records.

Procedure Manual, Clinical and QC Protocols: The department has full documentation of all its general, clinical and equipment quality control procedures clearly outlining how, when and by whom certain tasks are to be performed. These protocols and procedures need to comply with basic standards outlined in nationally accepted practice guidelines where applicable. The department has protocols outlining image interpretation and reporting procedures.

Radiation Safety and Radioactive Materials Handling Protocols: The department and/or organization has a radiation safety manual with documented procedures on safety and materials handling. These guidelines are in line with NRC or state regulations. Where applicable, all therapy doses are reported and records are maintained and reviewed under the Quality Management Program from the NRC.

Outcome and Quality Assessment: The department maintains a review process for administrative, technical, and clinical outcomes and results to ensure that the highest quality of work product and patient care is produced at all times by all members of the team. The process must involve an assessment of these reviews and an identification process for opportunities for improvement along with an ongoing and documented process for improvement.

The department or organization conducts regular patient and referring physician satisfaction surveys and the results of these surveys are reviewed by administration and acted on when applicable.

For the full policy form contact the JRCNMT office at 406-883-0003 or jrcnmt{at}centurytel.net, or visit www.jrcnmt.org.

All information contained within this document is drawn from the JCAHO’s, ICANL’s and ACR’s latest standards as listed on their web sites.