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:

1.Document the makeup of the RCAP members and their roles and duties

2.Determine how one becomes a RCAP member3.Identify the NAACLS staff and their roles4.Comprehend the meeting process

Learning OutcomesUpon completion of this unit of instruction and review of additional resources, the learner shall be able to:

5.Describe the voting process and how a motion is pulled for discussion

6.Recognize instances when a RCAP member should be absent or abstain from discussions of and voting for a motion

7.Identify the role of quality assurance in the RCAP process

Learning Outcomes

Upon completion of this unit of instruction and review of additional resources, the learner shall be able to:

8.Recognize meeting etiquette 9.Recognize the necessity for confidentiality and

avoiding conflict of interests while an RCAP member10. Determine the outcome of multiple absences or

significant change in professional status of a RCAP member

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

RCAP Role

• Forwards accreditation recommendations to the Board of Directors (BOD)

• Develops and implements operational policies and procedures for accreditation

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

RCAP Membership

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

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

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Learning Assessment

A RCAP member wants to pull a motion for discussion at the winter meeting. It must be done:

a. Prior to completion of the meeting agenda by the chair

b.After the committee votes on this specific motion

c. Just prior to voting on it by the committeed.After voting on all motions is completed

Learning Assessment

To be a RCAP member, one is traditionally:a. Elected by the NAACLS BODb.Elected by the RCAP membersc. Selected by the NAACLS staffd.Selected by the NAACLS BOD President

Learning Assessment

A RCAP member can vote on a motion if one:a. Is employed by sponsoring institutionb.Performed the site visitc. Is the program directord.Is an instructor at a clinical affiliate of the

program

Learning Assessment

Citation of Standards are tracked during the meeting to insure:

a. The competency of the RCAP membersb.The BOD is informed of all Standards not

being metc. New members comprehend interpretation of

the Standardsd.Programs are reviewed objectively and

treated equally