By Rochelle Helminski, PARC member

Did you know there is an amazing hidden resource within NAACLS? The discipline lead person!

As a former discipline lead for MLT, I’ve had the pleasure of addressing a wide range of questions over the past six months from fellow program directors, administrators and even students. From clarifying the role of a site program coordinator to navigating the intricacies of certification pass rates, the questions have covered many of the accreditation Standards.

This article is not just a list of questions and answers; it’s a reflection of the dedication and commitment we have to our students, our peers, and the field. By reading through this material, I hope you’ll gain a better understanding of how accreditation Standards provide a framework for your program and the high standards we uphold.

Whether you’re wondering about the qualifications for our adjunct professors or how to report significant changes in class size, you may find that someone else has asked a similar question recently.

Hopefully you learn the discipline lead person is an invaluable resource who can help guide you to find the answers to your questions within the Standards. So, dive in and explore the wealth of information we’ve gathered from past MLT and MLS discipline lead persons

General Program Information

Q: Who signs the letter of intent for the initial application?

Standards I and VI: The letter of intent should be signed by a designated institution official legally authorized to sign contractual agreements on behalf of the institution (DSA), such as a college or hospital administrator. 

Q: What happens if a program does not run a cohort of students for 12 months?

Standards II and VI: If no students are accepted for a 12-month period and no students are currently enrolled, the program may qualify for Inactive Status and must follow the steps regarding Inactive Status. You can find the inactive status process within NAACLS Guide to Accreditation.

Q: How should data be presented in Progress or Interim Reports?

Reports should be concise and focused on key outcomes (certification, placement, graduate/employer feedback). One example per applicable standard is sufficient. Prior data may be referenced if relevant.

Q: What if historical data is lost?

Standard VI: Explain the loss and outline corrective actions. Transparency and a plan for ongoing data collection are more important than completeness.

Q: Is NAACLS prescriptive about program or clinical rotation length?

Standard VIII: No. NAACLS is outcomes-focused. Programs determine their own length and clinical requirements based on competency achievement.

Curriculum and Course Requirements

Q: Can an MLT program waive the requirement for phlebotomy courses? 

MLT Standard VIII: It is up to the program to determine how it meets those competencies and assesses students. 

Q: How should the program report certification rates for students who pass on their second attempt?

Standard II: If a student fails the certification exam but passes on the 2^nd attempt within the first year of graduation, they should be counted as a pass in the outcomes summary chart in the self-study as well as your program’s webpage.

Q: Can high school courses count as prerequisites?

Standard VIII: The Standards do not specify the level of prerequisite coursework, so high school courses can be considered as prerequisites. 

Q: Can MLS programs offer online or flexible learning models?

MLS Standard VIII: Yes. Nontraditional delivery (e.g., online modules, flipped classrooms) is acceptable if all domains – cognitive, psychomotor, affective – are assessed through hands-on or simulated experience.

Q: What are the requirements for MLT-to-MLS bridge programs? 

MLS Standard VIII: Bridge programs must meet all MLS Standards. MLT coursework may not replace MLS-level content or assessments.

Q: Can our MLS program offer categorical certifications like microbiology or hematology? 

MLS Standard VIII: Yes. Categorical certifications (e.g., microbiology, chemistry) may be offered as structured components of an accredited MLS program. NAACLS has recently started accrediting Medical Laboratory Microbiology which ties to the (M) categorical, but this is designed for programs that do not have an MLS program already.

Q: Is online delivery allowed for categoricals? 

Standard VIII: Online is fine — just ensure clinical/applied learning (lab/simulation/clinical) is still part of the experience.

Q: Are there safety or accreditation requirements for student labs? 

Standard I, III, IV: Only if patient results are reported. Otherwise, labs must follow institutional safety policies.

Q: Can we use other hospitals in our system for clinical rotations?

Standard I: Yes, with affiliation agreements or memorandums of understanding, and documentation of each site’s accreditation and clinical liaison.

Reporting and Documentation

Q: How thorough should the narrative be for Standard I? 

Standard I: It is not enough to just indicate that the sponsor meets the Standards; a brief explanation of how the sponsor meets the standards is necessary.

Q: How should significant changes in class size be reported? 

Standard III: Significant changes should be included in the NAACLS Annual Survey of Programs and addressed in the next accreditation cycle. 

Q: How should I attach documents and include a Continuous Quality Improvement (CQI) narrative in the Annual Survey?

Standard IV: The Annual Survey of Programs is administered to all NAACLS programs each fall. In accordance with Standard VI, the survey is required for programs to self-report annually. It does not require a narrative, and you are unable to attach any documents to the Annual Survey. However, should your Annual Survey contain any concerns during the review process, NAACLS may request that the program present an Action Plan within six months detailing the program’s plan to manage the concern. In addition, programs that submit outcomes which do not meet NAACLS’ benchmarks will also be required to submit an Action Plan. When you submit an Action Plan, at that time you would submit a narrative and attach any documentation in support of that narrative.

An aggregate report from the surveys is published each summer after pulling together self-reported data from programs.

Faculty and Staff

Q: Is certification required for MLT adjunct professors? 

MLT Standard VII: Certification is not a requirement, but it is an example of how faculty may be deemed qualified. 

Q: What qualifies as teaching experience for a program director? 

Standard VII: Teaching experience can come from laboratory experience instructing students or teaching experience via an educational institution, or a combination totaling three years. 

Program Operations

Q: Are there any issues with running two types of programs, one hybrid and one distance? 

Standards I and IV: It is important that the program clearly defines the different types of experiences students may have. 

Q: What is the policy for a program director vacancy? 

Standard VII: Refer to the policy in the Guide to Accreditation and Program Official Approval Form. 

Q: How do I report a change in college president?

You may either email Julie Braglia to request the Change in Administration form or find it on the NAACLS Website on the Documents page.

Student and Program Records

Q: How long should we keep records like clinical evaluations or attendance? 

Standard IV: Transcripts must be permanent. Other records (e.g., evaluations) should be kept for at least three years prior to reaccreditation.

Q: Do I need to accept experiential learning credits? 

Standard IV, VIII: No. Programs may accept it at their discretion, but a written policy is recommended.

Q: Does the program have to redact names in reports? 

Standard II: It is good practice to redact names for privacy purposes. 

Q: Can we pay students while they are in the program?

Standard V: Yes, you may pay students, but they may not be substituted for laboratory/personnel to perform direct patient and/or reportable work. Additionally, student employment at that site must non-compulsory and outside of assigned clinical/applied learning or academic hours. 

Master’s vs. Bachelor’s Programs

Q: We’re launching a master’s-level MLS program. Do we need separate accreditation? 

MLS Standard VIII: No. NAACLS accredits the MLS pathway regardless of degree level.  While the Standards for a master’s level are the same as a bachelor’s level program, NAACLS depends on established universities processes to ensure the over all education is at a master’s level.

Outcome Measures & Placement Rates

Q: A student graduated but didn’t pursue work or further education – how do I count them in placement stats?

Standard II: Only include graduates who seek employment or further education. Those who opt out should not count against the rate.

Q: Should I use graduation or degree conferral dates when tracking certification exam timing?

Standard II: Use the official graduation date, not the degree conferral date.

Sponsorship & Budget Questions

Q: I’m unclear about who the sponsor is in a large health system. How should this be handled? 

Standard I: The sponsoring institution is the main instructional site that employs the program director, who must be approved by NAACLS. The sponsoring institution hosts the site visit and can grant graduates a degree or certificate. Additional sites require affiliation or partnership documentation to ensure all components of the Standards are met.

Q: My administration won’t let me access our program budget. Is that a problem? 

Standard VII: NAACLS Standards require evidence of the program director’s participation in budget preparation and resource planning.

Miscellaneous

Q: Can simulated experiences on campus substitute for clinical experience? 

Standard IV: This is generally acceptable as long as the program addresses all required areas for clinical/applied learning outlined in the Standards. 

Q: How do I respond to a comment on a Site Visit Report that was not listed on the summary page? 

If it was not listed on the Summary Page, I recommend contacting the NAACLS Office. Programs are not responsible for addressing items if they are not included within the Summary Page.

Final Tips

– Transparency is key. Accreditation bodies prefer an honest narrative over missing or confusing data.

– Document everything. If it’s not written down, it didn’t happen.

– Use NAACLS resources. The Standards Compliance Guide and Guide to Accreditation are your best friends.

Program directors and faculty are encouraged to take full advantage of the NAACLS Discipline Lead Person (DLP) as a resource. The DLP is available to provide clarification on Standards, offer practical guidance, and assist with questions related to accreditation, curriculum development, clinical sites, and program operations. Early engagement with the DLP can help programs navigate complex issues more confidently and ensure alignment with accreditation expectations. Reaching out with questions—whether simple or complex—is welcomed!