Application for Minor Clinical Affiliate

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Application for Minor Clinical Affiliate

  1. 1. Please photocopy for multi-affiliates APPLICATION FOR ADDITION OF MINOR CLINICAL AFFILIATE Please return original and two (2) copies to: Jan M. Winn, M.Ed., RT(N), CNMT Executive Director Joint Review Committee on Educational Programs in Nuclear Medicine Technology 2000 W. Danforth Road Suite 130, #203 Edmond OK 73003 Telephone: (405) 285-0546 Fax: (405) 285-0579 jrcnmt@coxinet.net www.jrcnmt.org
  2. 2. APPLICATION FOR ADDITION OF MINOR CLINICAL AFFILIATE DATE SUBMITTED SPONSORING INSTITUTION ADDRESS CITY STATE ZIP CODE TOTAL APPROVED PROGRAM STUDENT CAPACITY REQUESTED PROGRAM CLINICAL STUDENT CAPACITY _____________________________________________________________________________________ AFFILIATE APPLICANT ADDRESS CITY STATE ZIP CODE TELEPHONE FAX DEPT ACCREDITED BY DATE *REQUESTED AFFILIATE STUDENT CAPACITY MAXIMUM STUDENT CAPACITY * Identify the requested student capacity per agreement with the clinical education center. DISTANCE (MILES) TO SPONSOR SHARED AFFILIATE** **Identify any other educational program that utilizes this clinical affiliate. AFFILIATE MEDICAL DIRECTOR AFFILIATE CLINICAL SUPERVISOR CHIEF EXECUTIVE OFFICER PERSON TO WHOM ALL CORRESPONDENCE SHOULD BE SENT NAME TITLE MAILING ADDRESS CITY STATE ZIP CODE TELEPHONE FAX EMAIL
  3. 3. INSTRUCTIONS FOR COMPLETION OF THE APPLICATION FOR MINOR CLINICAL AFFILIATE Essentials I.B.2. and I.B.3 The clinical component of an educational program shall provide an environment for supervised competency-based clinical education and experience and offer a sufficient and well-balanced variety of nuclear medicine procedures, examinations and equipment. A minor affiliate is a participating institution that provides clinical education experiences not essential to fulfill but that enhances the curriculum requirements of the Essentials and Guidelines for an Accredited Educational Program for the Nuclear Medicine Technologist. A student would be assigned to a minor affiliate for not more than ten business days. The application for each minor affiliate must include: 1. Identification of affiliate (please complete the cover page). 2. Description of the role of the requested minor clinical affiliate in the overall organization of the nuclear medicine technology program. How does the addition of the minor clinical affiliate enhance the program? 3. Copy of the accreditation document of the clinical affiliate or completed External Quality Assurance form (Form CL-G). 4. Statement of educational objectives defining the purpose of the assignment. 5. Curricula vita for the clinical supervisor and medical director at the clinical affiliate. (Please see attached Form A). 6. Formal affiliation agreement documenting the responsibilities of the sponsoring institution and the clinical affiliate. INSTRUCTIONS FOR ASSEMBLING THE FINAL DOCUMENT 1. The application and all forms must be typewritten. Only signatures should be handwritten. 2. The application should be placed in a flat, report cover style binder. 3. The cover of the report should clearly identify the name of the sponsoring institution, the name(s) of the requested minor clinical affiliate(s), date submitted, and an indication as to whether it is the original or a copy. The complete submittal must consist of an original and two copies. An example follows: NAME OF SPONSORING INSTITUTION REQUESTED MINOR CLINICAL AFFILIATE(S) (include city and state for each affiliate) DATE SUBMITTED ORIGINAL (OR COPY # OF 2) There is a one-time fee of $500 for processing the application (s) when submitted separately. There are no annual fees and an on-site evaluation will not be conducted. An invoice for the application fee will be sent upon request. Revised 04/04, 05/05, 01/07
  4. 4. FORM A CURRICULUM VITAE NAME INSTITUTION TITLE How many years with this program EDUCATION: (List highest degree first) Certification* Institution Major Years Attended Degree (Cert., AA, BA) Board Nuclear Medicine Education (Institution): Years Attended Degree (Cert., AA, BA) *Attach documentation of your certification or board examination Employment History in Nuclear Medicine (list most recent position first, include length of time in position) Professional organizations and Society(ies) membership: Professional Development Activities Relevant to Nuclear Medicine Narrative description of responsibilities in NMT education program* *Identify % of time spent in the nuclear medicine department and in the nuclear medicine program. Note: Do not send a comprehensive curriculum vitae. Use this form.
  5. 5. FORM CL-G Extramural Quality Assurance for Clinical Affiliates of JRCNMT Accredited Programs1 Purpose: To provide the sponsoring institution with an alternative mechanism to verify that clinical education sites students attend are providing the highest quality Nuclear Medicine in agreement with generally accepted national standards of practice. Administrative and Other Protocols The department and/or organization has clearly documented patient registration, patient billing and accounting processes that follow the CMS and HIPAA regulation. There is also a documented annual process to determine the operating and capital budget for the host department and staffing and equipment in all areas is adequate. Patient registration process Yes No Capital and operating budget process Yes No Process of determining resources needs Yes No 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 employed in the department and also lists the minimum qualifications for an individual in that position. Job descriptions Yes No Human Resources manual Yes No Personnel and Supervision: The qualification, certification and licensure of personnel are current and at a level commensurate with their job descriptions and that there is a process in place to ensure the documentation of certification and licensure is authentic. Certification and licensure Medical Director Yes No Technical Director Yes No Medical staff Yes No Nuclear medicine technologists Yes No Direct patient care personnel Yes No Physician and nuclear medicine technologist trainees Yes No Physical Facilities: The physical facilities are adequate and such that the safety of the staff and patients is maintained at all times. Also, that handicapped access meets all state and federal guidelines Annual Health and Safety checks Yes No Disaster, Infection Control and Fire procedures Yes No 1 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.
  6. 6. Equipment and Instrumentation The department has adequate and well maintained equipment as witnessed by maintenance records and quality control records. Maintenance records Yes No Annual Health and Safety checks Yes No Quality Control Records Yes No 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. Procedure manual Yes No 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. Radiation Safety Manual Yes No MSDS Sheets Yes No Quality Management Program (where applicable) Yes No State/NRC inspection Reports Yes No 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, an identification process for opportunities for improvement along with an ongoing and documented process for improvement. The department and/or organization conducts regular patient and referring physician satisfaction surveys and the results of these surveys are reviewed by administration and acted upon, when applicable. Total Quality Improvement Plan Yes No Outcome and accuracy reporting Yes No By my signature I hereby affirm that the information submitted on this form is accurate. Affiliate Clinical Supervisor (print) Chief Executive Officer/Designee (print) Signature Signature Date Date Adopted 04/22/05 / Rev. 11/12/06
  7. 7. SELF-STUDY MINOR CLINICAL AFFILIATE - CHECKLIST Name of Affiliate: If the minor clinical affiliate application is part of the comprehensive self-study report, please identify the location of requested documentation by providing the Volume, Tab and/or Page number of the item in your final document. If the application is submitted separately, complete a checklist for each affiliate. Reproduce this document as needed. This form must be included with the application. PROGRAM USE REVIEW COMMITTEE USE ONLY DOCUMENTATION Satis. Unsatis. Completed Check List Data Form (Cover Page) Location: Location: IDENTITY OF AFFILIATE Role and responsibilities of the minor clinical affiliate. Description of responsibilities. Location: Institutional accreditation document or External Quality Assurance form. Location: OBJECTIVE Statement of educational objectives defining the courses provided for the nuclear medicine technology student. Location: CV & CERTIFICATIONS Minor clinical affiliate supervisor and medical director. Affiliate Clinical Supervisor – Completed Form A. Location: Affiliate Medical Director – Completed Form A. Location: FORMAL AFFILIATION AGREEMENT Documenting the responsibilities of the sponsoring institution and the academic affiliate Location: Comments:

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