Lessons from a Review Committee Chair

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July 10, 2023


From July 12th through July 14th, the three NAACLS Review Committees will meet in Montreal, Canada, for their annual summer meeting. During this meeting, the committees will have detailed and thoughtful discussions on accreditation awards  and policy recommendations for the Board of Directors. Over the last fifty years, generous and knowledgeable volunteers have been at the core of NAACLS accreditation. Fewer people work harder and more passionately among those volunteers than Review Committee members. The level of detail in which they review programs and how much time they spend revisiting the standards is hard to describe unless it is seen firsthand. NAACLS contacted former Chairs of the review committees for advice they may give new program directors and volunteers. Below are their responses.    

Sally Pestana (Program Accreditation Review Committee [PARC] Chair: 2015 – 2017) – The ABCs of success as a program director with NAACLS: A – Always take advantage of the NAACLS resources such as the Standards, Standard Compliance Guide, self-study and site visit review checklists, and more! They can be found at NAACLS.org (Editor’s note – alphabet examples continue later in the post).  

Marcia Armstrong  (PARC Chair:  2002- 2005) – As PDs and NAACLS volunteers, it is important to understand that accreditation exists to assure that laboratory and other health-related programs offer quality education to students, as well as to ensure that the graduates are qualified to provide the best health care possible. Because there are differences in community healthcare needs, there is no “one size fits all” means of delivering this education; NAACLS standards are outcomes based and are deliberately non-prescriptive.  

Terry Taff (Review Committee for Accredited Programs [RCAP] Chair: 2008 – 2009) – As a new program director, attend a NAACLS workshop to learn the standards, their interpretations, and means for documentation of compliance. Take advantage of the networking opportunities with the other attendees and speakers.  

Martha Lake (RCAP Chair: 2007 – 2008) – When someone becomes a new program director, it is a steep learning curve. You are not only expected to teach but also manage students and administer the program. My best advice to you is to learn everything you can about your program and how it fits into the institution, whether it be a hospital or university. It is all the little details that, once you know, you can complete a Self Study Doc and  represent your program before and during the site visit. I have seen programs that said they had an advisory committee — but the committee had not met. Oops. If you are moving from one program to another, do not expect them to be the same. If your new program had a stellar accreditation review during the last cycle, do not expect it to be smooth sailing the next time. Every review is different, and every reviewer is different.  

Brenna Ildza (PARC Chair: 2017 – 2020)  – Everyone started in the same place and gained knowledge and wisdom regarding NAACLS policies and practices by observing, participating, and questioning. NAACLS volunteers and staff are welcoming and willing to assist, which creates a positive and productive environment. The work can be challenging but satisfying knowing that it benefits education programs, especially students.  

Wendy Miller (PARC Chair: 2007 – 2010) – Don’t be afraid to ask questions of the NAACLS staff and other NAACLS volunteers. That is how you learn to interpret the standards. If you have new ideas or suggestions, don’t be afraid to speak up. NAACLS is always looking to improve its practices, and your idea might be the spark that is needed to create change.  

Claudia Miller (Clinical Laboratory Sciences Programs Review Committee [CLSPRC] Chair: 2003 – 2005) – New Program Directors: You have accepted a very important position in the development of our profession. Never hesitate to seek assistance if you encounter questions about the administration of your program. Rely on NAACLS sources and other experienced program directors. We all want to grow and strengthen our profession.  

DeAnne Maxwell (RCAP Chair: 2017 -2019) – One of the greatest gifts you can receive is the interaction with the NAACLS staff. They have invaluable experience and will always listen and give you the best advice or know who to reach out to elicit the advice you need.  

Sally Pestana (PARC Chair: 2015 – 2017) – B: Be on the lookout for ways to document everything you do related to program assessment and resulting changes. Document the input from stakeholders such as current students, graduates, program and support faculty, employers, and advisory committee. The more documentation you have, the easier annual reports and self-studies are to complete. Strive for systems you can simply update over time.  

Brenda Barnes (Doctoral Review Committee [DRC] Chair: 2021-2022) – While the self-study report (SSR) can initially seem daunting, consider it as a separate activity. As you complete your first SSR, consider ways to integrate SSR-like activities into your typical workflow. That will (hopefully) make assembling the SSR another regular duty!  

Laura Ahonen (PARC Chair: 2020 – 2022) – Review Standard II now as a new PD. Think about the overall program and your plan for continuous assessment of the quality of the program. Are graduates and employers being surveyed? Are those survey results used in continual quality improvement? Standard II is not something you can create when you write your self-study. Start creating a quality plan now, using Standard II as your guide. You will be thankful that you did!  

Martha Lake (RCAP Chair: 2007 – 2008) – Do a deep dive into your program, looking at it from NAACLS perspective, making a file for every Standard. Then you will know when everything is covered. NAACLS changes the Standards and more frequently changes the things they look for. Ask lots of questions. Contact the discipline lead to make sure that you are correctly interpreting how your school meets each Standard. Probably my best advice in preparing a Self Study is when writing the narratives, be as detailed as possible. Explain your program as if the reader has never seen a program before. Don’t be afraid to call attention to what your program does well – things you are proud of. It will make a difference.  

Candy Hill (RCAP Chair: 2019 – 2021) – As RCAP chair during the COVID years, my advice is to always be willing to “think outside the box.”  We saw more innovative ways of achieving the same goals and staying in compliance with NAACLS Standards during this time, and I hope that we, as Program Directors, continue to do so.  

Marcia Armstrong (PARC Chair: 2002 – 2005) – When writing or reviewing a self-study, the writer or reviewer must be able to clearly and accurately describe how the individual program meets each Standard. NAACLS guides are a wonderful source of information for all, as these guides are developed by review committees composed of experienced educators and are evaluated regularly to clarify what is required in a self-study. Also, the NAACLS review committee discipline leads are available to clarify standards online or by phone. Don’t guess – ask! Writing a self-study is the best way to self-evaluate your own program. Reviewing a self-study is an excellent tool to review one’s program, as well as the one being reviewed. We all benefit in this process. And, on a practical note, the self-study and review must be grammatically correct, so please check grammar and spelling before submitting a self-study or review.  

DeAnne Maxwell (RCAP Chair: 2017 – 2019) – On a personal note, always trust yourself. You know your faculty and your program the most…but don’t become complacent. Have open eyes and ears to what will work better. Never insist that your way is the only way. Being open-minded will allow you to explore all the possibilities ahead of you. Always continue to evaluate your program to make the lives of your faculty and students more meaningful. You have started on one of the best educational endeavors you could have ever hoped for. Love every second until you don’t. Then you make sure someone else is ready to steer your ship. Good luck.  

Sally Pestana (Program Accreditation Review Committee [PARC] Chair: 2015 – 2017) – C: Consider volunteering as a NAACLS self-study reviewer or site visitor. The best way to gain a deep understanding of NAACLS accreditation standards and other NAACLS requirements is to assess other programs for those standards and requirements. Just like the best educator understands what she/he teaches, the best program director thoroughly understands the accreditation requirements. Not only will you become more knowledgeable about the standards and other NAACLS requirements, but you will also work with peers who are passionate about the quality accreditation adds to laboratory science programs.  

DeAnne Maxwell (RCAP Chair: 2017 -2019) – Being involved with NAACLS gives you an opportunity to be on the forefront of CLS education. Performing self-study reviews and site visits give you the opportunity to view best practices from all over the country in all different modes of delivery and educational structures. When you are a new PD, the site visitors you have may be able to provide you with a career long ear and advice as you navigate your program. Being involved with RCAP also gives you the opportunity to effect change in how laboratory science education evolves.  

Martha Lake (RCAP Chair: 2007 – 2008) – Advice for Volunteers for NAACLS. 1. Meet the deadlines for report submission. 2. Read every word of the Self Study. Self Study reviewers should read it more than once, going back and forth between the SS and the report form. 3. If you are part of a review team, make contact early and compare notes. 4. Do not ever put in your personal opinions. Stick to the Standards in your evaluation.  

DeAnne Maxwell (RCAP Chair: 2017 -2019) – After your first site visit—volunteer—it’s an opportunity to share ideas and build a network of PDs. Volunteers: There are several roles you can take as a volunteer. In the beginning, you can become a site visitor. You will be paired with an experienced person. As your experience develops, you can serve as a lead site visitor, mentor, Self Study reviewer, or member of the Review Committee. To be a volunteer is rewarding and ensures the continuation of quality programs for our profession.  

Suzanne Campbell (PARC Chair 2011) – As a previous chair of PARC, I believe a handful of things were beneficial to me: 1. I had been a program director for a few years and had completed a re-accreditation cycle. While PARC did not require a site visit at that time, having completed all aspects of a re-accreditation provided a solid foundation of knowledge and experience. 2. To be an effective review committee member and chair, you must be familiar with all of the guiding documents that NAACLS uses, e.g. self-study template, self-study review document, site visit review document, and the standard compliance guide.  

DeAnne Maxwell (RCAP Chair: 2017 -2019) – Working with NAACLS staff and volunteers has been one of the most collaborative, rewarding, and uplifting joys of my 40-plus years in laboratory science education.  

Suzanne Campbell (PARC Chair 2011) – 3. Do your homework and do it well! This may be an unspoken expectation but it really does assist the committee member and greatly enhances the progress of the committee itself. Having everyone prepared and ready to work with identified meeting outcomes makes for a more efficient and proficient committee. 4. Be open to others thoughts and opinions. NAACLS has always allowed “programs to determine how to meet approval/accreditation Standards,” so while the process needs to be outlined and minimum guidelines established, being open to more than one correct way to achieve the end goals is beneficial. 5. Be a good communicator!  

Martha Lake (RCAP Chair: 2007 – 2008) – 5. If you are a new site visitor — good for you, you will find that you will learn something good to take home. 6. As a site visitor, contact your teammate early. If you are the lead, then contact the program director early. The PD will be nervous and will welcome your email or call. 7. Read the self-study – all of it. Do not rely on the SS report as the only basis of your review. I have found numerous times when items were covered in the SS that the document reviewer missed or the other way around. 8. Have each member of the SV team complete the report form about a month before the visit and compare notes. Then the team leader should contact the PD to give them a “heads-up” on what they need to supply either before or during the visit. If there are missing items or information, ask for it before the visit. It will make the site visit go much more smoothly. 9. Smile during the visit, this is not adversarial but a gathering of colleagues with a common goal — to create great educational programs. And, thank you all for your service!  

NAACLS would like to express the deepest gratitude to anyone who has served on a NAACLS review committee. Your time and expertise have directly contributed to the high quality of NAACLS Accredited programs. We appreciate you and all NAACLS volunteers. Thank you!


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