Program Director Manual
What Every Program Director
Needs to Know
Medical Assisting Education Review Board
MAERB
Table of Contents Chapter 1 – General Information
Section Title Page
I. Introduction 4
II. Definitions and Acronyms 5
III. Standards and Guidelines for the Accreditation of Educational Programs in Medical Assisting
9
IV. Educational Competencies for the Medical Assistant (ECMA) 10
V. Important Contacts and Key Links 11
Chapter 2 – Accreditation Process
Section Title Page
VI. Introduction to Accreditation Processes 13
VII. Preparing for Accreditation 15
VIII. Required Personnel 17
XI. Self-Study Preparation 18
X. Site Visit Preparation 19
XI. Hints and Tips for a Successful Visit 21
Chapter 3 – Maintaining Accreditation
Section Title Page
XII. Introduction to Requirements for Maintaining Accreditation 23
XIII. Record Keeping 24
XIV. Outcomes Assessment 25 Appendices
Appendix # Title Page
A. Outcome Thresholds 26
Program Director Manual
Chapter 1
General Information
Medical Assisting Education Review Board
MAERB
Introduction
The Medical Assisting Program Director is often the “glue” that holds the medical assisting program together. Directing a health care program is not an easy job, but it is rewarding, especially when you are the leader of a successful program that is accredited and graduates students who are trained and enter the work force as entry-level medical assistants.
This handbook was created to help program directors and other interested parties understand
accreditation and maintain their programs according to the Standards. The intention of this Handbook is to provide easy reference to questions that all of us as program directors have had from time to time. It is not all inclusive, and the authors of this Handbook hope you will feel free to provide feedback as we strive to improve communication and assistance to those who are on the “front line” in the world of medical assisting.
Throughout the handbook, there are numerous links to other documents, some contained within the handbook Appendices and some on the MAERB website. These links will provide more “in-depth” information regarding the topic being presented. As such, they are key to this document being of the most value to you. Therefore, it is suggested you save this handbook to your computer files or onto a thumb drive and use it electronically to take advantage of the assistance provided.
Definitions and Acronyms
Accreditation a status and a process by which an institution of postsecondary education evaluates its educational activities, in whole or in part, and seeks a status of accreditation, an independent judgment to confirm that it substantially achieves its objectives and is generally equal in quality to comparable institutions or specialized units
Institutional Accreditation peer review process by which the institution periodically evaluates its work and seeks an independent judgment that it achieves substantially its own educational objectives and meets the
established Standards of the body from which it seeks accreditation
Programmatic Accreditation peer review process whereby a specialized program of study within an institution demonstrates that it meets the established
educational Standards and is granted a status of public recognition by a private, non-governmental accrediting agency
Accreditation Standards Standards are statements that describe the minimum requirement
and Guidelines for quality and effectiveness expected of a program or institution and collectively provide a framework for continuous improvement. Guidelines provide interpretive clarification of the Standards via definitions and/or examples
Annual Report Form (ARF) an on-line form, completed and submitted annually by an
accredited medical assisting program to demonstrate meeting the established outcome thresholds for retention, job placement, graduate satisfaction, employer satisfaction and certification
Commission on Accreditation the largest programmatic accreditor in the health sciences field. In of Allied Health Education collaboration with its Committees on Accreditation, CAAHEP
Programs (CAAHEP) reviews and accredits over 2000 educational programs in twenty-three (23) health science occupations.
Committee on Accreditation the body responsible for conducting the peer review and making an
(CoA) accreditation recommendation to CAAHEP
Communities of Interest (CoI) stakeholders in the education and employment of graduates of
CAAHEP accredited medical assisting programs – examples are students, graduates, faculty, sponsor administration, employers, physicians, and the public. All CoIs are to be represented on the program’s Advisory Committee.
Educational Competencies provides Suggested Evaluation Methods for assessing student
for the Medical Assistant success in meeting each of the entry-level competencies as found
(ECMA) in the MAERB Core Curriculum, Appendix B, of the current
Standards
Inactive Status a status of accreditation of no more than two years, granted by CAAHEP, in which the program has no students matriculating in the medical assisting program
Inactive status is generally requested by a program, although MAERB can recommend it if the program has no students for two years as documented in ARF data.
Initial Accreditation the accreditation status awarded the first time a program receives accreditation by CAAHEP when a program has demonstrated substantial compliance with CAAHEP Standards. Initial
accreditation is granted for five years. At the completion of the five years, the program may be recommended for continuing
accreditation or probationary accreditation or the accreditation expires and the program will no longer be considered CAAHEP accredited. A program may request reconsideration of a CoA's decision to allow Initial Accreditation to expire. However, the CoA's decision is final and not appealable to the CAAHEP Board of Directors.
Medical Assisting Education Committee on Accreditation for medical assisting program accredited
Review Board (MAERB) by or seeking accreditation by CAAHEP. MAERB is made up of medical assisting educators, practitioners, educational
administrators, physicians and the public. The role of MAERB is to make accreditation recommendations to CAAHEP.
On-Site Survey Report (SSR) report completed by the survey team that reflects their findings during the site visit
Outcome Assessment instrument that can be used to track student enrollment, retention,
Tracking Tool job placement, graduate and employer surveys, and certification results for assistance in preparing the Annual Report Form. It is available under the Educator tab on the MAERB website.
Outcome Assessment a process for determining if a medical assisting program meets the thresholds established for maintaining accreditation, retention, job placement, graduate satisfaction, employer satisfaction and medical assisting certification
Progress Report responses to the citations and recommendations identified in the CAAHEP letter of accreditation, by the date specified
Self-Study Report (SSR) comprehensive self-examination of a Medical Assisting program seeking accreditation from CAAHEP; includes an Excel Workbook and attachments documenting compliance with each of the
Standards
Sponsoring Institution a post-secondary academic institution accredited by an institutional accrediting agency that is recognized by the U.S. Department of Education and is authorized under applicable law or other acceptable authority to provide a post-secondary program in medical assisting
Surveyor member of the team who reviews the self-study documents and other materials relevant to the site visit and conducts a site visit; educators, educational administrators and practitioners who have successfully completed a training workshop may serve as surveyors.
Other definitions associated with the accreditation process of MAERB can be found in the MAERB Policy Manual, Policy 1.6. To access the Manual, please click here.
Overview of Programmatic Accreditation
Programmatic accreditation is a process that is designed to ensure that students in medical assisting programs receive an education consistent with Standards for entry into practice. Medical assistants who graduate from CAAHEP accredited medical assisting programs are eligible to sit for the AAMA Certification Examination and earn the AAMA credential of Certified Medical Assistant®
(CMA-AAMA). Accreditation is designed to stimulate self-improvement by providing a review of the program based on student outcomes.
The accreditation process involves the program and the Medical Assisting Education Review Board (MAERB), a Committee on Accreditation (CoA) of the Commission on Accreditation of Allied Health Education Programs (CAAHEP), in reviewing the medical assisting programs to determine if the criteria set forth in the Standards and Guidelines for Accreditation of Educational Programs in Medical
Assisting and the relevant CAAHEP and MAERB Policies. If MAERB determines that a program does
meet these criteria, a recommendation for accreditation is forwarded to CAAHEP. CAAHEP is the accreditor and makes the final decision on accreditation status.
Institutions and programs are responsible for providing to the MAERB clear, accurate and complete information regarding the curriculum and personnel in the program. Involvement of key faculty and administrators in the review process is essential to gain full benefit of the process. The Self-Study consists of an Excel Self-Study Report (SSR) and various attachments, each identified in the SSR. The Commission on Accreditation of Allied Health Education Programs (CAAHEP), via MAERB, is responsible for assigning an accreditation team that is well-informed and prepared to determine that the Standards are being consistently applied within the program. In programmatic accreditation, the primary focus is on the curriculum and instruction, including assessment of student learning, and the resulting outcomes of students and graduates. These include, but are not limited to,
retention/graduation, job placement, and credentialing success, as well as employer and graduate satisfaction.
Working together, the institutions, programs, MAERB and CAAHEP are responsible for providing useful evaluation through cooperation and open exchange of issues and concerns in creative variations for accreditation and for promoting efficient use of resources.
Initial accreditation is granted for five (5) years and expires at that time unless CAAHEP grants continuing accreditation to the program. Programs are provided reports by the MAERB on the status of their initial accreditation throughout the five (5) years. If the program is granted continuing
accreditation, the next comprehensive review would be no later than five years after the granting of continuing, ten (10) years after the granting of initial accreditation. Continuing accreditation is granted for a maximum of ten (10) years without a comprehensive review. However, a program could receive an earlier review at the discretion of the MAERB, based on the program's continued compliance with the Standards.
CAAHEP Standards
The Standards and Guidelines for the Accreditation of Educational Programs in Medical Assisting (Standards) were initially adopted in 1969. MAERB is charged with reviewing and suggesting
revisions to CAAHEP at least every five (5) years. This review and revision process includes involving the MAERB’s communities of interest, i.e., educators from CAAHEP accredited medical assisting programs, and sponsoring organizations (AAMA and AMA). The most current, 2008 revision, of the
Standards can be found at the above link.
The Standards identify the minimum requirements a program must meet to become accredited and the graduates prepared to enter the practice of medical assisting. Entry level is defined as eligible to take the certification examination. There are five (5) main Standards with several subtopics:
I. Sponsoring Organization
A. Sponsoring Educational Institution B. Consortium Sponsor
II. Program Goals
A. Program Goals and Outcomes
B. Appropriateness of Goals and Learning Domains C. Minimum Expectations
III. Resources
A. Type and Amount B. Personnel
1. Program Director 2. Faculty
3. Practicum Coordinator C. Curriculum
1. Content and Competencies 2. Practicum
D. Resource Assessment
IV. Student and Graduate Evaluation/Assessment A. Student Evaluation
B. Outcomes Reporting V. Fair Practices
A. Publications and Disclosure
B. Lawful and Non-discriminatory Practices C. Safeguards
D. Student Records E. Substantive Change F. Agreements
Appendix A provides directions for application, maintenance and administration of accreditation. These include administrative requirements for reporting and payment of fees and provide the basis for Administrative Probation if the requirements are not met. The process for requesting inactive status is also found in Appendix A. Additionally, the responsibilities of CAAHEP and MAERB are set forth in Appendix A.
Appendix B is the MAERB Core Curriculum. The objectives, cognitive, psychomotor and affective, must be included in a program for accreditation to be granted. It is important to note in the Outcomes Threshold that 100% of the graduates must successfully complete ALL of the psychomotor and affective domain objectives (aka competencies).
Educational Competencies for the Medical Assistant (ECMA)
The Educational Competencies for the Medical Assistant (ECMA) can be used in a variety of ways by
educators, practitioners, physicians and AAMA members. The intended purpose of this document is to provide Suggested Evaluation Methods for meeting each of the entry-level competencies as found in the current Standards. It is not intended that all of the suggested methods of evaluation for each competency included in a curriculum for purposes of accreditation, but this document provides ideas and evaluation methods that can be used to meet the competencies. Documentation of achievement of all competencies found in the psychomotor and affective domains must be evaluated in a manner consistent with the action verb.
The current entry-level competencies are clearly identified in the heading of each page of this document. Listed under each Entry-Level Competency are suggested methods of evaluation which are provided as a curricular guide for educators in developing cognitive objectives, performance objectives, evaluation instruments and teaching materials and methods. The scope and depth to which they are included in a medical assisting program is an individual program decision. This decision should be based on outcome assessment criteria by the communities of interest such as employer requirements of the local area, graduate recommendations, and advisory committee suggestions.
The suggested evaluation methods in the ECMA serve as a guide for medical assisting educators in developing these competencies as dictated by the local community of interest, the educational facility and the needs of students in acquiring entry-level employment.
Important Contacts and Links to Key Websites
Each program is assigned a staff member who serves as the case manager for their program. This individual has readily available all information regarding the programs in their respective case files and should be the first contact with questions regarding your program. The case manager will make an initial introductory contact with new programs as assigned. The Case Managers are:
Jim Hardman [email protected] Jamie Harris [email protected]
Tasha Harris [email protected]
Judy Liptay [email protected]
Irene Lau [email protected]
The Director of Accreditation is responsible for interpretations of the Standards and policies. Case Managers will refer questions to the Director if unsure of the correct response to your questions. The Director is:
Judy Jondahl [email protected]
Department – General Contact
Email [email protected]
Phone 800-228-2262 Fax 312-899-1259 CAAHEP Phone 727-210-2350
American Association of Medical Assistants www.aama-ntl.org
Center for Disease Control and Prevention www.cdc.gov
Commission on Accreditation of Allied Health Education Programs www.caahep.org
Council for Higher Education Accreditation www.chea.org
Health Insurance Portability and Accountability Act www.hhs.gov
Material Safety Data Sheets www.msds.com
Medical Assistants Education Review Board www.maerb.org
Program Director Manual
Chapter 2
Accreditation Process
Medical Assisting Education Review Board
MAERB
Accreditation Requirements and Process
The first requirement for seeking CAAHEP accreditation is for the sponsoring institution of the program to hold postsecondary "institutional accreditation from a USDE recognized agency.” The list of USDE recognized agencies can be found at:
http://ope.ed.gov/accreditation/Search.aspx?6d6f64653d31267264743d392f332f3230303820333a35 343a353320504d
Other requirements for eligibility to seek CAAHEP accreditation for a Medical Assisting Program can be found by clicking the hyperlink and going to page 3.
An Accreditation Packet is available on the MAERB website as well as in this manual. You are
advised to refer to the Accreditation Packet in preparation for an accreditation site visit for either initial or continuing accreditation. Topics covered in the Accreditation Packet include:
Process of Accreditation Key Definitions in Accreditation Steps in Accreditation Process Building a Quality Program
2008 Standards and Guidelines for Medical Assisting Educational Programs
MAERB Core Curriculum for CAAHEP Accredited Medical Assisting Programs Timetable for Self-Study Report and Survey
FAQs
Preparation for the Site Survey MAERB Site Survey Checklist
Tentative Schedule for CAAHEP Site Survey
Required documentation for Core Curriculum and other Standards In summary, the process includes:
1. Submission of the CAAHEP Request for Accreditation Services (RAS) – available on the CAAHEP website, www.caahep.org. Use Option 1 for submission of RAS.
2. Payment of the Accreditation Application Fee – payment made to MAERB at same time the RAS is submitted to CAAHEP.
3. Completion of a Self-Study and submitting it to MAERB four (4) months prior to the scheduled dates for the survey.
4. Payment of base Accreditation Fee – payment made to MAERB at same time SSR is submitted.
5. Program may be contacted for additional information during the review of the SSR by staff, MAERB and survey team
6. Site Visit of 2 ½ days
7. Review of OSSR by staff and MAERB
8. Opportunity for program to respond to factual accuracy of OSSR – No new documentation can be provided with this, only documentation that refutes a citation and that was existing and available to the survey team at the time of the site visit.
9. Review of OSSR and documentation by full MAERB – usually at the winter or summer meeting following the site visit
10. If the recommendation is for an adverse action, program is given an opportunity to request reconsideration – MAERB reviews request before sending a recommendation to CAAHEP 11. Accreditation award letter sent by CAAHEP
12. If a program has citations, the CAAHEP letter will identify them with rationale and documentation required for removal of the citation. The date for submitting the first of a maximum of two (2) progress reports (Policy 2.6) will be included in the CAAHEP letter.
Preparing for Accreditation
1. Attend an Accreditation Workshop
a. Program director should attend an Accreditation Workshop (cost for two people is included in the Application fees)
b. Suggested timing of this is between 12 and 24 months prior to the scheduled on-site visit to take optimal advantage of the information
2. Establish a Self-Study Committee a. Program Director should chair
1) Set deadlines 2) Establish time line
3) Determine who is responsible for changes if needed
4) Keep entire committee informed of activities related to the project b. Committee should include:
1) Advisory committee members 2) Medical assisting faculty 3) Support faculty
4) Academic advisor (Dean) responsible for medical assistant program 5) Support staff (librarian, financial aid, registrar, job placement, etc.) 6) Students
7) Graduates
c. Scheduled follow-up meetings frequently to make certain the project is on track for completion by the due date
3. Take a Critical Look at the Program through:
a. Implementation of Resource Assessment (Form F-5)
b. Implementation of Outcomes Assessment (MAERB graduate and employer surveys, Annual Report, etc.)
c. Placement Reports
d. Retention/Attrition Reports
e. Graduate Exam Results (CMA (AAMA), RMA (AMT), NCMA (NCCT)
f. Program Summative Measures (i.e., Competency Evaluations and Practicum Evaluation of students)
g. Review of results of the assessments
h. Judgments made on how well the program is meeting its goals and learning domains i. Determination of the strengths and weaknesses of the program
j. Determination of any action(s) necessary to bring the program into compliance with the
Standards
4. Establish a Budget for a. Accreditation fees
b. Upgrades of equipment as needed
c. Continuing Education for Program Director and Faculty d. Assessment Fees for the on-site visit
e. Release time for Program Director to prepare report
f. Postage, telephone, costs for materials such as thumb/flash drives g. Secretarial assistance
h. On-site costs (ie, lunches, snacks, travel, etc.) 5. Develop a Time Line
b. Plan time line to meet the date for submission of the Self-Study Report
c. Have all materials in hand at least 4 months prior to the due date for submission d. Provide time for proofreading and making necessary changes prior to submission to
institutional administrators for approval
e. Submit the report to the Accreditation Department when ready
For INITIAL Accreditation
As soon as you decide to apply for accreditation:
1. Start collecting
a. Resource Assessment Data b. attrition/retention data
c. competency evaluation sheets d. content evaluations
e. completed evaluations by the practicum sites
f. MAERB graduate and employer surveys (required); other instruments are acceptable IF questions on the MAERB instrument are included
g. placement data
2. Make sure all materials are dated, tabulated and records kept 3. Document the needs and expectations of the communities of interest
For Continuing Accreditation
1. Use the MAERB survey instruments for graduates and employers (format is optional IF questions on the MAERB instrument are included and rating scale applied)
2. Review other resource assessment tools for completeness and accuracy 3. Update the most recent Resource Assessment Form (Form F-5)
4. Determine if the needs and expectations of the communities of interest have changed; and if anything has changed, document how the program responded
Required Personnel
The Standards include three (3) specific personnel classifications which must be employed by the program. These are:
1. Program Director – Policy 3.3
a. Direct link between the program and MAERB/CAAHEP b. Only one designated program director per program c. Click on hyperlink above to see:
i. full list of responsibilities ii. qualifications
iii. change reporting requirements
d. MAERB currently recognizes four credentials: i. CMA (AAMA) – Certified Medical Assistant ii. RMA (AMT) – Registered Medical Assistant
iii. NCMA – National Certified Medical Assistant - awarded by the National Center for Competency Testing (NCCT); taken and passed after November 30, 2010
iv. CCMA – Certified Clinical Medical Assistant – awarded by the National Health Association (NHA); taken and passed after February 2011
2. Practicum Coordinator – Policy 3.2
a. Primary responsibility for overseeing practicum sites and students in practicum b. May be program director or another individual who meet requirements
c. Program may have more than one d. Click on hyperlink above to see:
i. full list of responsibilities ii. qualifications
iii. change reporting requirements 3. Faculty – Policy 3.6
a. Primary responsibility for providing instruction and assessment of student learning b. Faculty teaching cognitive domain and assessing student achievement of all domains,
cognitive, psychomotor and affective as identified in the MAERB Core Curriculum, Appendix B of the Standards must be approved by MAERB
c. Click on hyperlink above to see: i. full list of responsibilities ii. qualifications
iii. change reporting requirements
Please note that the program director and faculty must have documented instructional preparation in educational theory and techniques. This may include:
1. Formal class work as demonstrated on an official transcript
2. Workshops/seminars as documented by a program content outline and certificate of completion, including the number of hours completed
3. In-service, as documented by a content outline and proof of successful completion, including number of hours completed
4. Topics related to learning theory, curriculum design, test construction, teaching methodology, or assessment techniques
Self-Study Preparation and Submission
Completing the Self-Study (SSR)
1. All Green shaded boxes must be answered
2. Yellow shaded boxes may be answered if applicable 3. Blue shaded boxes contain drop down lists to be answered
4. Ivory shaded boxes indicate a drop down answer has been selected
5. Red shaded boxes indicate a drop down box is not consistent with the Standard 6. Orange shaded boxes contain information from other cells that are locked
Submitting the SSR
1. Transfer all documents to MAERB electronically per instructions
2. Documents required in the Appendices that are available in Word, Excel, or Adobe Acrobat must be sent as electronic attachments electronically as directed. Identify each with the name of the Appendix (divider) specified on the SSR
3. Until further notice, send on 4 thumb drives to the Accreditation Department at: MAERB
20 N. Wacker Drive, Suite 1575 Chicago, IL 60606
Site Visit Preparation
Once the SSR has been submitted, it’s time to prepare for the visit:
1. Compile and organize documentation for the comprehensive review (on-site survey)
2. Arrange for payment of remaining accreditation fees (Due when Self-study Report is submitted). 3. Accept the Survey Team
a. The accreditation Department contacts the PD with the names of the
b. team assignment and provides brief background information of the members c. Respond as soon as possible so team members can be confirmed
4. Compile and organize documentation using the file labels available on the MAERB website for organizing the curriculum files with the documentation listed below:
Note: Electronic record keeping is strongly supported by MAERB. The electronic files set up in the same manner as hard copy files.
a. For the Cognitive (content) Domain
Grading policy
Grading scale
Pass score
Official roster of students within the program most recently assessed in each of the cognitive domain areas
Copy of blank exams for each of the objectives in the cognitive domain (highlight the questions which cover the objective in the designated folder)
Gradebook or transcripts covering all students in the covered cohorts, documenting satisfactory completion of each objective
b. For the Psychomotor and Affective Domains (Taught)
Grading policy documenting inclusion of all requirements for successful completion of all psychomotor and affective domains (competencies)
Official roster of the students in the most recently assessed cohort for each of the psychomotor and affective domain areas
Copy of a blank skills assessment tool or a blank work product (ie, day sheet) if
applicable, used to assess student competence on each objective (competency) in each of the psychomotor and affective domains
c. For Psychomotor and Affective Domain (Achievement)
Completed Master Competency Form (provided on MAERB web page) AND statement
in syllabus with regards to passing competencies taught in course (Example:
100% of competencies must be passed in order to pass the course)
OR
Transcripts/gradebooks with grades for competencies outlined AND statement in syllabus with regards to passing competencies taught in course (see above)
OR
Complete individual evaluation of competencies AND statement in syllabus with regards to passing competencies taught in course (see above)
d. Other Documentation to have available
Outcomes Data
RAW DATA for outcomes for the most current 5-year window (consistent with the most current Annual Report). Include:
o Graduate surveys o Employer surveys o Placement data
o Exam statistics for CMA (AAMA), RMA (AMT), NCMA (NCCT)
Personnel files documenting qualifications
Textbooks currently being used
Catalog
Student Handbook
Recruitment/advertising documents
Hints and Tips for a Successful Site Visit
1. The documentation for assessment of the objectives should be highlighted, with the appropriate areas in different colors. The color-coding for the objectives should be obvious to the surveyors. 2. If evaluation tools documents achievement of more than one curriculum area, additional copies of
the tools must be made and placed with the appropriate domain documentation.
3. Electronic files for Cognitive/Psychomotor/Affective Domain documentation are encouraged a. Identify files with Domain and Objective number
b. Include copies of blank evaluation tools and/or expected work product
c. If grading system is electronic, surveyors will need to have access to your files/system 4. Program will be required to maintain a file of raw data for outcomes for the most current 5 year
window (consistent with most current Annual Report). This includes: a. Graduate Surveys
b. Employer Surveys c. Placement data d. Exam statistics
i. CMA (AAMA) ii. RMA (AMT) iii. NCMA (NCCT) iv. CCMA (NHA)
5. The Accreditation Department will supply the MAERB Site Survey Checklist a. Check off each item on the list as prepared and ready
b. Be sure that all materials are in the folders for the Standards in boxes or computer files – each domain should have a folder for each area with the significant information highlighted
6. Select the persons who will participate in the on-site visit and arrange accommodations (room on campus) for the opening and exit interviews
7. Prepare a list of names, titles and positions of all individuals that the survey team will interview, including lists of students if at all possible
8. Arrange interviews with administration, faculty, medical advisor, students, support staff, advisory committee members, and graduates (in conjunction with the Team Coordinator)
9. Arrange for lunch(es) in cooperation with the Team Coordinator. 10. Finalize the On-Site Survey Agenda with the Team Coordinator.
11. Provide a room on campus with privacy for surveyors to work throughout the visit
12. Be sure the required documentation is in the room and organized for easy review, including the color-coding of the domains and the objectives within each domain
13. Check to see the need for a computer and/or printer for survey team use a. Computer should be able to accept flash/thumb drives
b. Internet access to be able to access raw data
c. Printer will need to print the on-site survey report for use by survey team at the exit interview d. Shredder
Program Director Manual
Chapter 3
Maintaining Accreditation
Medical Assisting Education Review Board
MAERB
Maintaining Accreditation
Institutions and programs are responsible for:
1. Providing to the MAERB clear, accurate and complete information regarding the curriculum and objectives
2. Meeting established outcome thresholds 3. Notifying the MAERB of personnel changes:
a. program director b. practicum coordinator c. faculty
4. Notification of changes in the chief executive officer and dean or equivalent can be made via email or on-line and must include:
a. name b. credentials c. title
d. contact information i. street address ii. email address iii. telephone number(s) iv. fax number
Program director, practicum coordinator and faculty changes must be made in accordance with the associated policy.
5. Paying all MAERB and CAAHEP fees when due. A late fee penalty will be assessed by MAERB if fees due to them are not received after two notices.
MAERB is implementing new on-line reporting of some program changes. Detailed instructions on this will be provided for existing program directors, both in written format and via webinars. New program directors will also be provided training in use of the on-line reporting.
Other Program changes that must be reported in accordance with MAERB policy include: 1. Curriculum Changes
2. Sponsoring Organization Changes
a. Change in Ownership
b. Change of Chief Executive Officer
c. Change of Dean (individual to whom program director reports) d. Any adverse decisions affecting institutional accreditation e. Transfer of Sponsorship
Record Keeping
Student records must be maintained for accreditation purposes. If you are preparing for your initial program accreditation or gearing up for a continuing accreditation visit, one of the most important things you can do is follow the Policies and Procedures for CAAHEP accredited Medical Assisting programs developed by the Medical Assisting Education Review Board (MAERB) in regard to student record retention. While a program may continue to maintain 100% of the dated, graded, signed assessment tools for the most recently assessed cohort as evidence of student achievement of each psychomotor and affective domain objective, a new option is provided in Policy 2.7. There is also an article in the Spring 2010 MAERB Report discussing record retention.
Programs will be required to maintain a file of raw data (Policy 2.7) for all outcomes for the five (5) year window reported on the most recent ARF. These files are to include:
1. Graduate Surveys 2. Employer Surveys 3. Job Placement Data 4. Retention Data
The Outcome Assessment Tracking Tool, available on the website, provides a method to maintain a summary of the data. This tool is an Excel document in which you can establish five tabs, one for each cohort or year in the current five (5) year window and track the individual students in the appropriate year of entry into the program for each outcome.
For MAERB tracking purposes, you may establish a “trigger date” for when the individual becomes a medical assisting student. This date must be no later than when the student enters the first course in which they are assessed on the psychomotor and/or affective domain objectives (competencies) found in the MAERB Core Curriculum. An article regarding establishment of the “trigger date” can be found in the Fall 2011 MAERB Report.
Outcomes Assessment
Annual Report Form (ARF)
Submission of an Annual Report Form is required of all CAAHEP accredited medical assisting programs. This is a tool used to report outcomes assessment on the outcomes identified in the
Standards: retention, job placement, graduate and employer satisfaction, and medical assisting
certification. The data is reported for a five year window or from the first year accredited, if your program is in the initial accreditation status. Each year, the program is expected to update the four previous years’ data and add the data for the fifth year. The ARFs are for four calendar years prior to the year in which it is being completed plus the current year, i.e., in Fall 2013/Spring 2014, the ARF will cover 2009-2013. Determination of when a program’s ARF is due is based on the number of admission cycles per year the program has and when the program is due for a comprehensive review (self-study and site visit).
Prior to the ARFs going live on the website, each program director is notified of the User ID and Password required for completing his/her program(s) ARF. Other individuals in the institution with responsibility for oversight of the medical assisting program receive a User ID and Password which allows Read Only access to the ARF. Detailed instructions are available on the website when the program director signs in to complete this task.
MAERB has established thresholds for each of the outcomes which must be achieved for a program to remain in good standing. The thresholds are identified and defined in the Outcome Threshold Grid. Each fall or spring programs are required to complete and submit on-line the ARF for their
program(s). MAERB reviews all of the ARFs according to Policy 1.16, looking at the most current three (3) reporting years and the five (5) year aggregate for all outcomes except certification. Certification will enter complete five years’ data with the 2014 ARF submission and become part of the total outcomes assessment. An outcome assessment tracking tool is available on the MAERB website, Educator Page, to assist in maintaining the data for completing the ARF.
Program Director Manual
Appendix A
Outcome Thresholds
Medical Assisting Education Review Board
MAERB
Outcome Assessment Thresholds
CAAHEP Accredited Medical Assisting Educational Programs
The Medical Assisting Education Review Board (MAERB) has established the following thresholds for outcome assessment in medical assisting programs accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP). These outcomes are mandated as part of the 2008
Standards and Guidelines for the Accreditation of Educational Programs in Medical Assisting, Section
IV.B. They are monitored annually through the MAERB Annual Report.
Outcome Threshold Example
Programmatic Retention/Attrition Rate
<60%
If 100 students enter the program during the 5-year period, the attrition can be no more than 40. Positive Job Placement
(includes work in medical assisting or a related field, continuing in school or being in
the military) >60%
If a program had 100 graduates in the 5-year period, at least 60 would need to have a position in medical assisting or a related field, be continuing their education and/or be in the military. Graduate Satisfaction Success Rate
(Survey – CRB Instrument)
>80%
If 30 graduates return surveys during the 5-year period, at least 24 of these would need to give a satisfactory rating on the program. Graduate Survey Participation Rate
>30%
If the program had 100 graduates in the 5-year period, at least 30 would need to return the survey. Employer Satisfaction Success Rate
(Survey – MAERB Instrument)
>80%
If a program received 20 employer satisfaction surveys in the 5-year period, at least 16 would need to report satisfaction with the graduates of the program. Employer Survey Participation Rate
>30%
If 40 employer surveys were sent to employers within the 5-year period, at least 12 would need to be returned.
National Credentialing Success Rate (CMA (AAMA), RMA (AMT) NCMA (NCCT) – after November 2010
CCMA (NHA) – after February 2011
>70%
If a program has 100 graduates within the 5-year reporting period, at least 70 of those 100 would need to become credentialed as a CMA (AAMA) or RMA (AMT).
Programmatic Summative Measures Threshold Example Psychomotor and Affective Domain
Objectives Success Rate
100%
If a program had 100 graduates in the ARF reporting year, all 100 graduates would need to have successfully completed all of the psychomotor and affective domain objectives, meeting the cut
(passing) score established by the program as a minimum standard to be met.
Psychomotor and Affective Domain Objectives Participation Rate
100%
If a program had 100 graduates in the ARF reporting year, a program would need to have an evaluation completed for each of the 100 graduates on all psychomotor and affective domain objectives. Practicum Evaluation of Students Success
Rate
Cognitive Psychomotor Affective
100%
If the program had 100 graduates in the ARF reporting year, all 100 graduates would need to have successfully completed cognitive, psychomotor, and affective skills performed during the practicum. Practicum Evaluation of Students
Participation Rate
100%
If a program had 100 graduates in the ARF reporting year, an
practicum evaluation would need to be completed for each of the 100 graduates.
If a program fails to meet one or more of the thresholds for the 5 years or the most current reporting year, the MAERB initiates a dialogue to assist the program in its determination of the reason(s) for the
noncompliance. The program will also be directed to develop and implement of an effective action plan to achieve compliance. MAERB will monitor progress of the action plan in achieving compliance with the established threshold.
Examples of the types of dialogue between the program and the MAERB include, but are not limited to the following:
A list of questions prepared by the MAERB that the program would answer to communicate its analysis and action plan for improving the outcome(s), as part of the ARF
Development of an action plan as part of ARF A progress report
A focused on-site survey
A comprehensive review (i.e., a full self-study report and on-site survey)
A program failing to meet a single threshold for 3 consecutive years or to meet multiple thresholds within the time frame specified by MAERB will be subject to an adverse recommendation being sent to
CAAHEP.
The MAERB is committed to assisting programs in their efforts to achieve and maintain the outcomes assessment thresholds.
Program Director Manual
Appendix B
Sample Syllabus
Medical Assisting Education Review Board
MAERB
SAMPLE SYLLABUS
ANYTIME COMMUNITY COLLEGEALLIED HEALTH INSTRUCTION SYLLABUS
COURSE NO.: ALH 130
COURSE NAME: Electrocardiography for the Healthcare Provider CREDIT HOURS: LECTURE HOURS: 0 LAB HOURS: 2
CLASS TIMES: ______________________________________________________________ INSTRUCTOR: PHONE NO.: OFFICE NO.: OFFICE HOURS: E-MAIL: ___________________________________________________________________________ PREREQUISITES
DEV 075 and DEV 085; BIO 107 REQUIRED
Text: ECGs Made Easy, 3rd Ed., by Aehlert. COURSE DESCRIPTION
Principles of electrocardiography including equipment operation, recording and troubleshooting will be covered. In addition, students will independently review and learn various electrocardiography
rhythms and arrhythmias.
COURSE OUTCOMES AND OBJECTIVES
1. Components and functions of EKG equipment
Identify the major components and their functions of single and multiple lead EKG equipment.
2. Record a 12-lead EKG tracing.
Perform and record a 12-lead EKG tracing on patients. 3. Functions of cardiovascular system.
Describe the structure and general functions of the cardiovascular system. 4. Physiological basis of an EKG tracing.
Describe the physiological basis of an EKG tracing and correlate it to the events in a cardiac cycle.
5. Rate and rhythm disturbances of an EKG.
Please Note: Yellow Highlighted areas are required fields for the syllabus.
Interpret basic rate and rhythm disturbances from an EKG tracing.
ENTRY LEVEL COMPETENCIES FOR MEDICAL ASSISTANT
Taken from the 2008 Standards and Guidelines for the Medical Assisting Educational Programs This course includes the following competencies:
Foundations for Clinical Practice: I. Anatomy & Physiology: I.P.5. Perform electrocardiography
I.P.6 Perform patient screening using established protocols I.P.11. Perform quality control
I.P.16. Screen test results
I.A.1. Apply critical thinking skills in performing patient assessment and care I.A.2. Use language/verbal skills that enable patient’s understanding
ATTENDANCE
Attendance at each class is necessary because important information not found in the text will be discussed. If a class absence occurs, it is the responsibility of the student to contact the instructor or a fellow student to obtain the missed material and assignments.
Non-attendance and tardiness are considered to be non-professional and will not be tolerated. Two points will be deducted from the Participation Grade for each absence, regardless of reason given for the absence. Any student who misses two or more classes may be subject to administrative dismissal from the program upon review of each individual case. All cases of absenteeism are subject to
administrative review by the faculty.
ALH 130 – Electrocardiography for the Healthcare Provider COURSE OUTLINE
XX/XX/XX DAY 1 Overview of course and expectations Review of A & P (Chapter 1)
Basic Electrophysiology (Chapter 2) Sinus Mechanisms (Chapter 3) XX/XX/XX DAY 2 NO CLASS: CAMPUS CLOSED XX/XX/XX DAY 3 QUIZ #1
Review Sinus Rhythms Atrial Rhythms (Chapter 4) XX/XX/XX DAY 4 QUIZ #2
Review Atrial Rhythms Premature Beats
Junctional Rhythms (Chapter 5) XX/XX/XX DAY 5 TEST, Chapters 1 through 4 XX/XX/XX DAY 6 QUIZ #3
Review Junctional Rhythms/ Premature Beats Ventricular Rhythms (Chapter 6)
AV Blocks (Chapter 7)
XX/XX/XX DAY 7 QUIZ #4 (Ventricular Rhythms) ECG Hook Up and Practice XX/XX/XX DAY 8 QUIZ #5 (AV Blocks)
Review all Cardiac Rhythms Practice ECG’s
XX/XX/XX DAY 9 FINAL EXAM, Chapters 1 through 7 Practice ECG’s
XX/XX/XX DAY 10 Lab Check offs ASSIGNMENTS
Reading assignments are included in the course outline. Failure of the student to prepare for the class may result in poor comprehension of material presented in the classroom and lab. Therefore, students are expected to complete each reading assignment prior to the next class day. There are NO MAKE-UP QUIZZES. Students who are absent will receive a zero, however the lowest quiz score will be dropped before the final grade is calculated.
The student will receive a competency module stipulating the steps for completion of the EKGs. The competency must be practiced with a student partner and signed by that partner before a student will be permitted to perform a return demonstration for the instructor.
METHOD OF EVALUATION
Quizzes (20 points each) 100 pts.
Laboratory Check-off Evaluation 92
Test and Final Examination 200
Participation & attendance-- 100 (10 points for each class)
TOTAL 492 pts.
The grading scale for ALH 130 is:
441 – 492 pts 90 – 100% = A 391 – 440 pts 80 – 89% = B 342 – 390 pts 70 – 79% = C 293 – 341 pts 60 – 69% = D Below 293 points or 60% = F
70% is an estimated figure which is considered a minimum level of achievement. Any student who receives a final score below 70% WILL NOT PASS the course. For Respiratory Care students, failure to receive a grade of ‘C’ or better will necessitate withdrawal from the program until this course can be repeated and passed successfully. For Medical Assistant Technology students in order for he/she to pass the class must receive an average of 70% or above in the given course AND obtain an
average score or above on all competency evaluations within the given course. CAAHEP accreditation requires 100% of all MAS graduates pass 100% of all competencies.
GRADING FINAL LABORATORY CHECK-OFF
1. Each critical requirement of the procedure has a value of 16 points. Critical requirements are identified by (**) two asterisks.
2. Each essential requirement of the procedure has a value of 6 points. Essential requirements are identified by (*) one asterisk.
3. Important steps of the procedure have a value of 2 points. Important steps are identified with no asterisks.
4. A minimum of 80% must be attained on the return demonstration in order to pass the procedure.
5. In the event that the student does not meet the minimum score requirement of 80%, the student will receive a “Zero” for the procedure and will be required to repeat the procedure within one week, and must achieve a minimum of 80% points to pass the repeat demonstration. A penalty of 10 points will automatically be deducted from the return demonstration after each one week period. The student will not be permitted to repeat any given procedure more than twice i.e., a total of three attempts. The grade achieved on the third attempt will be recorded.
6. The student would be prepared for relating knowledge about the skill that would pertain to the procedure being performed at the time of the return demonstration. 7. A student exhibiting unprofessional conduct during laboratory practice or testing will
