Download - 2008 Standards and Guidelines for the Accreditation of Educational Programs in Medical Assisting
2008 Standards and Guidelines for the Accreditation of Educational
Programs in Medical Assisting
Standard I Sponsorship
04/19/23 2008 Standards 3
I. Sponsorship
A. Sponsoring Educational Institution
must be one of the following:1. a postsecondary academic institution
accredited by an institutional accrediting agency recognized by the US Department of Education or
2. a foreign post-secondary academic institution acceptable to CAAHEP,
– Institution is authorized under applicable law or other acceptable authority to provide a post-secondary program, which awards a minimum of a diploma/certificate at the completion of the program
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I. Sponsorship
B. Consortium Sponsor1. Consists of two or more members for the purpose
of operating an educational program. At least one of the members of the consortium must meet the requirements of a sponsoring educational institution as described in I.A.
2 Responsibilities of each member of the consortium must be clearly documented as a formal affiliation agreement or memorandum of understanding, which include governance and lines of authority.
Sponsorship
Example of a consortium:
Rad Tech students take part of the
courses at the school and part at
the hospital in the Radiology department.
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I. Sponsorship
Multiple Program Options– Programs with multiple options– Program must submit separate self-studies– Surveyor must complete separate (2) on-site
reports.– Call if get to site and unexpectedly find multiple
programs
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I. Sponsorship
C. Responsibilities of Sponsor– must assure that the provisions of these
Standards are met.
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I. Sponsorship – Evidence
Self Study Report – found in dividers A-1 through A-41. Institutional accreditation letter2. Organizational chart3. Narrative of program
On Site Institutional certificate/letter- check for current dates If any questions arise regarding accreditation status, check with
the college administration or call the Accreditation Department at 1-800-228-2262, identify self, state conducting on site survey
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Questions About Sponsorship?
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Standard II Program Goals
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II. Program Goals
A. Program Goals and Outcomes must be– a written statement of the program’s goals and
learning domains
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II. Program Goals
A. Program Goals and Outcomes must be– consistent with and responsive to the demonstrated
needs and expectations of the various communities of interest served by the educational program.
– The communities of interest (COI) that are served by the program must include, but are not limited to,
students, graduates, faculty, sponsor administration, employers, physicians, and the public
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II. Program Goals
A. Program-specific statements of
goals and learning domains – provide the basis for program planning, implementation and
evaluation – Goals must be
based upon the substantiated needs of health care providers, employers, and the educational needs of the student.
compatible with both the mission of the sponsoring institution(s) and the expectations of the communities of interest and nationally accepted standards of roles and functions
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II. Program Goals
B. Appropriateness of Goals and Learning Domains– The program must
regularly assess its goals and learning domains.
– Program personnel must identify and respond to changes in the needs
and/or expectations of its communities of interest.
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II. Program Goals
B. Appropriateness of Goals and Learning Domains– An advisory committee, which is representative of
the communities of interest, must1. be designated and charged with the responsibility
of meeting at LEAST ANNUALLY2. assist program and sponsor personnel in
formulating and periodically revising appropriate goals and learning domains
II. Program Goals
Definition: Communities of Interest are an approach whereby various constituents come together for the purpose of meaningful exchange, and doing so collaboratively across the community of people who share a common interest.
Examples: Public, student
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II. Program Goals
B. Appropriateness of Goals and Learning Domains– An advisory committee, which is representative of
these communities of interest, mustmonitor needs and expectationsensure program responsiveness to change.
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II. Program Goals
C. Minimum Expectations – Must have the following goal defining minimum
expectations:
“To prepare competent entry-level medical assistants in the cognitive (knowledge), psychomotor (skills), and affective (behavior) learning domains.”
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II. Program Goals
C. Minimum Expectations– educational goals beyond entry-level competence
must clearly delineate this intent provide evidence that all students have
achieved the basic competencies prior to entry into the field
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II. Program Goals - Evidence
Self Study Report - Dividers B1 through B-4, E1, 1. College mission statement - catalog
2. Statement of program goals and expected learning outcomes for the 3 domains – catalog, handbook or
syllabi
3. Check advisory committee meeting minutes for meeting at least annually, all communities of interest represented,
and responsiveness to goals and needs of program.
On Site Discuss any concerns with the above findings.
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Program Goals
Questions?
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Standard III Resources
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III. Resources
A. Type and AmountProgram resources must
– be sufficient to ensure the achievement of the program’s goals and outcomes.
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III. Resources
A. Type and Amount
Program resources must include, but are not limited to
Faculty Supplies and equipment
Support staff
Facilities Clerical staff Finances
Instructional materials
Curriculum Computer resources
Practicum Sites Faculty cont ed Offices
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III. Resources - Evidence
Self Study Report - Dividers D-4 through D-7 and Form F1, F 5-8 Check list of resources that include equipment, supplies,
instructional reference materials, finances (budget), facilities, and continuing education for staff and faculty.
Review budget for adequate monies to maintain program
On Site Tour Facilities Check classrooms, labs, offices, equipment, supplies, computers,
printers, instructional reference materials, and any other resources made available to students and faculty.
Interview faculty to verify resources meet their needs Interview students to verify supplies/equipment are in working order
and adequate numbers
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Resources - Physical
Questions?
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III. Resources
B. PersonnelThe sponsor must
– Appoint sufficient faculty and staff with the
Necessary qualifications to perform functions identified in documented job descriptions and to
To achieve program’s stated goals and outcomes
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III. Resources
B.1. Program Director a. Responsibilities
Must:– Be responsible for the effectiveness of the
program including outcomes, organization, administration, continuous review, planning and development
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III. Resources
B.1. Program Directorb. Qualifications - Must have
minimum of an associate degree instruction in educational theory and techniques credential in medical assisting by a nationally
accredited credentialing organization accredited by the National Commission for Certifying Agencies (NCCA) Unless a full-time medical assisting faculty member is so credentialed
a minimum of 3 years experience in healthcare, including a minimum of 40 hours of experience in an ambulatory health care setting performing or observing administrative and clinical procedures of medical assisting
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III. Resources
Persons approved as program directors under previous Standards will continue to be approved in that position.
If a person leaves his/her current position and takes
another position with another program the person would not be approved in the new position. It is not transferable.
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III. Resources - Evidence
Self Study Report - Divider C1 and Form F61. Job Descriptions for program director2. CV for program director – Resume
On Site Interview PD to verify responsibilities on job description are what is
expected of PD Verify college transcript and credential certificate Verify 3 years of healthcare work experience Verify 40 hours of ambulatory experience Verify transcripts/certificates in ed theory and techniques
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III. Resources
Program Director Qualification Guideline:Instruction in educational theory and techniques may include
college courses,
seminars, workshops, or
in-service on topics such as
learning theory
instructional design
test construction
teaching methodology or assessment techniques
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Instruction in Educational Theory and Techniques continued
What it does not include… How to take attendance How to complete department paperwork How to refer students for counseling How to use college equipment such as
copiers, faxes, printers, AV, etc. How to post grades How to use power point
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III. Resources
B.2. Faculty and/or Instructional Staff
a. Responsibilities must
– utilize instructional plans, – direct and assess student progress in achieving
theory and performance requirements of the program.
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III. Resources
B.2. Faculty and/or Instructional Staff
b. Qualifications must be
– knowledgeable in course content as evidenced by education and/or experience
– effective in directing and evaluating student learning and laboratory performance,
– prepared in educational theory and techniques.
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III. Resources - Evidence
Self Study Report - Divider C2 and Form F81. Faculty job description2. CV for faculty
On Site Interview faculty to verify education and/or experience relates to
courses taught and faculty meet qualifications and responsibilities listed on job description
Verify that faculty use an instructional plan and evaluate and assess student learning
Verify all faculty are prepared in educational theory and techniques
Verify CMA, RMA, NCMA, and CCMA credential for full-time faculty member if contributing to qualifications of PD
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III. Resources
B.3. Practicum Coordinatora. ResponsibilitiesThe practicum coordinator must
Select and approve sitesProvide orientation for site supervisorsProvide oversight of the experience including on-site assessment of student experiences and the quality of the
learning opportunities at least once during each assigned hours that students are assigned to the site.
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III. Resources
B.3. Practicum Coordinator
b. Qualifications
The coordinator must be
knowledgeable in program curriculum as evidenced by education or experience and
effective in evaluating student learning and performance
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Guideline
The responsibilities of the Practicum Coordinator may be fulfilled by the Program Director, faculty member(s), or other qualified designee.
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III. Resources- Evidence
Self Study Report – Dividers C3 and Form F7
1. Practicum Coordinator job description
2. Practicum Coordinator’s CV
On Site Review supervisor and student evaluations of externship Interview practicum students and recent graduates to determine
effectiveness of student learning and performance by practicum coordinator
Interview facility supervisors to verify on site assessment of students and supervisor orientation conducted by practicum coordinator
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Resources – Evidence
On site Continued
Verify coordinator selects sites Verify supervisor orientation Verify practicum coordinator has made at
least one on-site visit to facility Verify affiliation agreements for each site Verify student practicum objectives are met
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Resources - Personnel
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III. Resources
C. Curriculum
The curriculum must – ensure the achievement of program
goals and learning domains.
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III. Resources
Instruction must bean appropriate sequence of classroom, laboratory and clinical
activities, based on clearly written course syllabi that include
– course description– course objectives – methods of evaluation– topic outline and– competencies required for graduation which must be
provided prior to implementation of each segment of the curriculum
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III. Resources
C. Curriculum1. Content and CompetenciesThe program must demonstrate that
the content and competencies included in the program’s curriculum meet or exceed
those stated in the latest edition of the MAERB Core Curriculum (Appendix B)
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III. Resources
– Program length (Guideline)Ensures student achievement of
the MAERB Core Curriculum
– Program sequence (Guideline)Defined as logical progression of learning (content before practice, skill set before externship)
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III. Resources – Curriculum Evidence
Self Study Report – Dividers C4, Form F2, F3, F4, F4a
1. Review course syllabi for description, objectives, methods of evaluation including pass score, topic outline, and competencies to be achieved in the course.
On Site
Program director will supply an official roster for the most recently graduated cohort.
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Curriculum Evidence Continued
Cognitive Domain To verify the program teaches all of the objectives,
review blank exams that cover each of the objectives in the 11 cognitive areas. Each exam must have the questions highlighted that pertains to each objective.
To verify the graduates have achieved the cognitive objectives, check transcripts or grade books for a final grade of the most recently graduated cohort in all the courses where the objectives are taught.
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Resources – Curriculum - Evidence
On Site Continued1. To verify the competencies in the psychomotor and affective
domains have been taught, check the blank assessment tool (check off sheet or work product) for each of the assigned competencies in each of the 11 domains. The accreditation department will provide a list of the ones to check.
2. To verify the graduates have achieved the competencies, review a master sheet (individual or class) for the most recently graduated cohort showing the grade for each competency. If the competencies are a component of the final grade in the course, a transcript is another option.
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Resources - Curriculum
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C.2. Practicum must besupervised, unpaid experienceat least 160 contact hours in an ambulatory health care settingperforming psychomotor and affective
competencies and be completed prior to graduation.
III. Resources
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III. Resources
C.2. Practicum (continued)
supervision of students at the practicum site must be provided by an individual who has knowledge of the medical assisting profession
III. Resources
C.2 Practicum (continued)
Students will be evaluated on the Practicum experience by the preceptor and the instructor on the objectives and competencies required to pass the program. Students must pass 100% of skills and competencies in order to graduate from the program.
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III. Resources
C.2. Practicum (Guidelines)– Program should ensure that the externship
experience and instruction of students are Meaningful Parallel in content and concept with material presented
in lecture and laboratory sessions.– Sites should be selected
To afford each student a variety of experiences
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III. Resources - Evidence
Self Study Report – Dividers D1-2, and C7Review affiliation agreements for content of supervision and non paid experience.
On Site– Review time logs – Review student evaluations of experience– Review supervisor evaluations– Review supervisor evaluations of practicum experience– Interview with supervisors – Interview with current students or recent graduates who are
completing or completed practicum
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Practicum
Questions
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III. Resources
D. Resource Assessment– The program must at least annually assess the appropriateness
and effectiveness of the resources described in these standards.
– The results of resource assessment must be the basis for ongoing planning and appropriate change.
– An action plan must be developed when deficiencies are identified in the program resources.
– Implementation of the action plan must be documented and results measured by ongoing resource assessment.
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Guideline
The format for resource assessments should be: Purpose statement Measurement systems Dates of measurement Results Analyses Action Plans Follow-up
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III. Resources - Evidence
Self Study Report – Dividers D1-51. Resource assessment grid2. Assessment toolsOn Site Review latest resource assessment grid Review completed assessment tools for
student evaluations of faculty and coursesstudent evaluations of college resourcesstudent evaluations of practicum experiencesupervisors evaluation of practicum students
Interview students to verify assessment of resources, evaluation of faculty, and evaluation of courses.
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Resource Assessment
Questions?
Standard IV Student and Graduate
Evaluation/Assessment
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IV. Student and Graduate Evaluation/Assessment
A. Student Evaluation; 1. Frequency and Purpose
Evaluation of students must – be conducted on a recurrent basis and
with sufficient frequency to– provide both the students and program faculty with valid and
timely indications of the students’ progress toward and achievement of the competencies and learning domains stated in the curriculum.
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IV. Student and Graduate Evaluation/Assessment
Guideline:
“Validity” means the evaluation methods chosen are consistent with the
learning and performance objectives.
Methods of assessment are carefully designed and constructed to measure stated learning and performance objectives at the
appropriate level of difficulty.
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IV. Student and Graduate Evaluation/Assessment
Guidelines cont’d
Methods used to evaluate skills and behaviors are – consistent with stated externship performance
expectations and – designed to assess competency attainment.
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IV. Student and Graduate Evaluation/Assessment
A. Student Evaluation
2. Documentation– Records of student evaluations must be
maintained in sufficient detail to document learning progress and achievements.
See program retention of student records in operational policy 2.7
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IV. Student and Graduate Evaluation/Assessment- Evidence
Self Study Report – Dividers C-41. Check syllabi for grading policy, grading scale, and
pass score2. Check syllabi for frequency of testsOn Site
Interview – students to verify frequency of testing/check-offs– faculty to verify frequency of testing/check-offs– program director and faculty to verify maintenance
of student evaluations
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IV. Student and Graduate Evaluation/Assessment
B.1. Outcomes Assessment– The program must
periodically assess its effectiveness in achieving its stated goals and learning domains.
– The results of this evaluation must be reflected in the review and timely revision of the
program.
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IV. Student and Graduate Evaluation/Assessment
B. 1. Outcomes Assessment (continued)– Outcomes assessments include, but are not limited to;
Performance on national credentialing examinations Programmatic retention/attrition Graduate satisfaction Employer satisfaction Job placement Programmatic summative measures (i.e. competency achievement and
externship evaluation of students)
The program must meet outcomes assessment thresholds. (Only continuing accreditation programs are required to complete the annual report form, ARF, where the thresholds are found.)
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IV. Student and Graduate Evaluation/Assessment
B.2. Outcomes Reporting– The program must periodically submit
its goals(s), learning domains, evaluation systems (including type, cut score, validity,
and reliability), outcomes, its analysis of the outcomes and an appropriate action plan based on the analysis.
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IV.B. Student and Graduate Evaluation/Assessment
B.2. Outcomes Reporting
Programs not meeting the established thresholds must– begin a dialogue with the Medical Assisting
Education Review Board (MAERB) to develop an appropriate plan of action to respond to the identified shortcomings
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IV. Student and Graduate Evaluation/Assessment - Evidence
Self Study Report – Dividers D1-31. Review outcome tools
On Site
Verify Performance on national credentialing examinations Programmatic retention/attrition Graduate satisfaction Employer satisfaction Job placement
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Assessment
Questions?
Standard V Fair Practices
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V. Fair Practices
A. Publications and Disclosures
1. Announcements, catalogs,
publications, and advertising
must accurately reflect the
program offered.
Note: Do not cite here if program does not have the required CAAHEP accreditation statement.
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V. Fair Practices
A. Publications and Disclosures2. At least the following must be made known
to all applicants and students:– the sponsor’s institutional and programmatic accreditation
status Cite here– the name, address, phone number and web site of the
accrediting agencies;– admissions policies and practices including technical
standards (when used);– policies on advanced placement– transfer of credits
V. Fair Practices
Advanced placement
If the school does not grant credit for advanced placement, there must be a statement in the catalog, handbook, and/or syllabus to this effect.
Example: The School accepts and uses the scores from the ACT National, the ACT Residual, the SAT National, and the School’s math and English placement tests to determine placement into math and English courses. Students who do not have ACT or SAT scores may have to take the School’s placement test.
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V. Fair Practices
A.2. Continued
credits for experiential learning number of credits required for completion of the program tuition/fees and other costs required to complete the
program policies and processes for withdrawal and for refunds of
tuition/fees.
V. Fair Practices
Definition of Experiential Learning: Learning required through work, military service, professional training, hobbies, recreation, and other meaningful activities. These experiences are evaluated for their equivalency to specific courses and their ability to satisfy institutional and degree requirements. Example: A person has worked as a secretary in an office for 20 years. She wants to return to school to get a degree in Office Administration. She has typed for all these years and is an expert with Word and other computer applications. She wants to get credit for a Computer Skills course and a Microsoft Word Applications course based on her experience. She will petition the school for credit for these two courses by submitting a portfolio documenting her knowledge, not her work experience. Schools cannot give credit for work experience … they give credit for what you know.
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V. Fair Practices
The required language for publicizing the CAAHEP status of accreditation for a medical assisting program can be found on the MAERB web site.
Cite V.A.2. if the program does not state the CAAHEP accreditation statement accurately or does not publish the statement at all.
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V. Fair Practices
A. Publications and Disclosure
3. At least the following must be made
known to all students: academic calendar student grievance procedure criteria for successful completion of each segment of
the curriculum policy and processes by which students may perform clinical work
while enrolled in the program and students must be supervised and not receive compensation for
practicum
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V. Fair Practices
A. 4. Sponsor must maintain and provide upon request current and consistent information about student/graduate achievement that includes the results of one or more of the outcomes assessments required in these Standards.
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Guideline
The sponsor should develop a suitable means of communicating to the communities of interest the achievement of students and graduates.
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V. Fair Practices - Publications and Disclosure - Evidence
Self-Study Report – Dividers E 3-7Check catalog and/or handbook for Institutional and programmatic accreditation Admissions Advanced placement and experiential learning Transfer of credits Academic calendar Withdrawal and refunds Tuition and fees Practicum supervision and no pay Grievance (student) Graduation requirements and requirements for each segment of program Clinical work
Check catalog for CAAHEP accreditation statement
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Fair Practices - Publications and Disclosure - Evidence
On site
Verify any item that was not made available in the self study report.
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V. Fair Practices
B. Lawful and Non-discriminatory Practices– All activities associated with the program, including
student and faculty recruitment, student admission, and faculty employment practices, must be
non-discriminatory in accord with federal and state statutes, rules and
regulations.
– There must be a faculty grievance procedure made known to all paid faculty.
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V. Fair Practices
C. SafeguardsThe health and safety of patients,
students, and faculty associated
with the educational activities of
the students must be adequately
safeguarded. – All activities required in the program must be
educational and– students must not be substituted for staff.
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Guideline
Safeguards may include OSHA and CDC guidelines, and any state, local or institutional guidelines/policies related to health and safety
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V. Fair Practices - Non-discriminatory practices and safeguards - Evidence
Self Study ReportCheck catalog or handbook for lawful and non-discriminatory
practices for Student admission and recruitment Faculty recruitment and employment Faculty grievance Health and safety issues
On SiteInspect laboratory facilities for Safety equipment and biohazard signs and waste disposal MSDS sheets and quality control logInterview students for adhering to laboratory safety precautions
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V. Fair Practices
D. Student Records– Satisfactory records must be maintained for
student admission, advisement, counseling, and evaluation.
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V. Fair Practices
D. Student Records– Grades and credits for courses must be recorded
on the student transcript and permanently maintained by the sponsor in a safe and accessible location.
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V. Fair Practices – Student Records -Evidence
On site– Inspect student records and transcripts for accuracy and for
storage in a safe and accessible location
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V. Fair Practices
E. Substantive Change– The sponsor must report substantive
change(s) as described in Appendix A to CAAHEP/MAERB in a timely manner.
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V. Fair Practices
E. Substantive Change– Additional substantive changes to be reported to
MAERB within the time limits prescribed include: 1. Changes in the institution’s legal status
or form of control2. Change/addition/deletion of courses that represent a
significant departure in content;
3. Change in method of curriculum delivery;
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V. Fair Practices
E. Substantive Change cont’d
4. Change of the degree or credential awarded;
5. Change of clock hours to credit hours or vice versa; and
6. Substantial increase/decrease in clock or credit hours for successful completion of the program.
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V. Fair Practices – Substantive Change - Evidence
On-site 1. Report any deviations from Self-study Report (SSR)
that are found on-site
2. Check general information tab on On-site Survey Report (OSSR) to verify all information is correct. Make changes if applicable and type in your name and date
04/19/23 2008 Standards 96
V. Fair Practices
F. Agreements
There must be a formal affiliation agreement or memorandum of understanding between the sponsor and all other entities that participate in the education of the students describing the relationship, role, and responsibilities between the sponsor and that entity.
04/19/23 2008 Standards 97
V. Fair Practices
F. Agreements– Affiliation agreements must include a statement
that students must be supervised and must not receive compensation.
04/19/23 2008 Standards 98
V. Fair Practices
Self Study Report – Divider E 7Check for statement of supervision, non pay, and roles/responsibilities of parties
On Site Check copies of affiliation agreements with all current
externship sites
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2008 STANDARDS AND GUIDELINES
Questions?
