DR. NAACLS – SITE VISITOR SELECTIONS

Dear Dr. NAACLS,

I am the program director of a NAACLS accredited program, and my program is scheduled to have a site visit next spring.  In an effort to make this visit go as smoothly as possible, I would like to lend a hand in selecting the individuals that visit my program.  I am looking to have visitors that work in the same types of conditions and settings that I do, as I think it will be easier for the visitors to understand the intricacies of the program.  Would this be okay?

Sincerely,

Dr. Efficient

Dear Dr. Efficient,

While I certainly appreciate your willingness to help, NAACLS believes that the best outcome is to have the NAACLS staff select the site visitors for site visits.  Even if there are good intentions, there is a chance for a potential conflict of interest if the program director were to be involved in picking the individuals that are supposed to be objectively reviewing the program.

Additionally, the Council for Higher Education Accreditation (CHEA) – the agency that recognizes NAACLS – maintains robust requirements of its recognized accrediting bodies for conflict of interest policies to be established and followed. In short, NAACLS MUST follow its own established policies and procedures for site visitor selection.

That said, NAACLS does consider many factors when selecting volunteers to conduct site visits – and employment experiences are included!  In fact, NAACLS defines the full qualifications in its published Volunteer Manual, available on the NAACLS Website:

• Current or experienced program director, faculty member, clinical laboratory professional, physician or dean with knowledge of the clinical laboratory sciences.
• Current or prior association with a NAACLS accredited program.
• Currently licensed and/or credentialed and in good standing with the licensing/accrediting body, as appropriate.
• Familiarity with NAACLS’ Standards.
• Familiarity with current practices in:
  • Clinical laboratory procedures.
  • Staffing, space, equipment, budgeting for clinical services and educational purposes.
  • Health professions education.
• Familiarity with the purposes of accreditation and the protocol for conducting a site visit and reporting the outcome.
• Ability to conduct interviews and perform observational functions with discretion.
• Capacity for making objective assessments based upon established criteria.
• Ability to respect and maintain confidentiality of privileged information.
• Experience as a site visit team member is necessary to qualify as team coordinator. Satisfactory completion of NAACLS’ Accreditation Process Workshop or Site Visitor Training Workshop is helpful, but not mandatory to qualify as a team member.

NAACLS also has other factors that are used in site visitor selection.  The proximity of a volunteer to a program’s location is always considered, as NAACLS avoids sending a volunteer to visit a program within his or her own state borders whenever possible.  Volunteers should also not visit a program which they have either attended in the past, or have worked for in the past.

A last factor that plays into site visitor selection is volunteer availability.  The larger the volunteer pool, the more available selections that NAACLS’ staff can take into account when putting together the site visit schedule.  NAACLS takes a very active role in seeing that those willing to volunteer have an opportunity to do so, and that includes building the pool of volunteers that qualify as a “Team Coordinator”.

However, even taking all of this into account, program directors still do have a say in the site visit team selection by their ability to not approve of one or more proposed team members.  For example, if a program director senses a possible conflict of interest, s/he can deny the visitor and request that another one be proposed.  The program should know, though, that any denial of site visitors could cause a possible delay in when the site visit takes place.

Sincerely,

Dr. NAACLS