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Self-Study Guidelines For Doctoral & Postdoctoral Programs

A self-study is required for institutions seeking accreditation or re-accreditation by the Commission on Accreditation in Clinical Chemistry (ComACC).  The process of self-evaluation is an effective mechanism through which fellowship programs may identify their strengths and weaknesses. The self-study is a comprehensive assessment of the program that will allow ComACC to ensure the fellowship is meeting the Standards for Accreditation, which can be found at:  http://www.comacc.org/standards/Pages/Default.aspx

The following areas should be addressed in the self-study:

1. Perspective

  • The overall mission, objectives, accomplishments, goals and future plans of the fellowship program should be summarized.

2.  Program Organization

  • Outline of the institutional administrative framework inclusive of where the program fits into the structure.
  • Organizational chart(s) of the fellowship program, the department, and the reporting lines to the parent institution
  • If there is external fellowship training outside of the parent institution, the scope of the training and any associated agreements should be included.

3.  Faculty

  • Program Director:  An introduction to the Program Director, his/her years of experience in this role, certification status, and commitment to the program and the field of Clinical Chemistry.
  • Other Teaching Faculty:  A listing of other teaching faculty, certification if any, title at the institution, role in the program, and approximate percent effort towards the fellowship program.
  • Include a four page (maximum) CV of all faculty listed above as an Appendix to the self-study. Note: For CVs, please use the NIH biosketch format; see: PHS 398/2590 (Rev. 06/09), Biographical Sketch ... - NIH

4.  Institutional Support and Training Facilities

  • Source of salary support, level (NIH guidelines or other), and any additional financial benefits provided to the Fellow, such as book funds or travel funds.
  • A description of the following items:
    • Physical office space provided and where the space resides in relation to Pathology residents or other Fellows within the department, as applicable
    • Learning/teaching resources available such as computers, iPads, library and journal access and access to LIS and/or EMR systems
    • Any additional teaching or learning resources utilized in the fellowship program, such as on-line or specific didactic courses at the parent or other institutions. These may be required, recommended, or available to the Fellow.

5.  Laboratory Facilities and Test Menu

  • A list of the clinical laboratory equipment at the parent institution and any other laboratories where the Fellow trains.  This list should be inclusive for all clinical chemistry instrumentation. If training is provided in other disciplines such as hematology, microbiology, or molecular diagnostics, include a brief description of instrumentation in those areas.
  • A link to any online list of the laboratory test menu for all locations where fellowship training occurs.  If an online link is not available, please provide the list(s) as an Appendix to the self-study.

6.  Curriculum

The clinical and didactic curriculum and instruction of an accredited clinical chemistry training program shall demonstrate an on-going pursuit towards excellence and quality, as well as achievement of pre-determined educational objectives and metrics. The curriculum and instruction shall demonstrate, but not be restricted to, compliance with the minimum requirements defined by the Commission in Appendices I to IV of the Standards and Guidelines.

  • The structure of the program curriculum should be described in sufficient detail such that the reviewer understands how the structure leads to achievement of the program goals and a clear sense of how the Fellow spends his/her time.  Include any formal courses, didactic sessions, seminar series, or conferences that are required or recommended activities. 
  • Specific schedules for all of the above activities should be included when possible and included as an Appendix to the self-study.  The precise breakdown of the trainee's time is ultimately left to the discretion of each program; however, the narrative should outline learning objectives, expectations and goals in sufficient detail for the reviewer to understand how learning progresses throughout the training period. 
  • If training occurs in association with another training program (medical technology, residency, etc.), the extent of integration of the Fellow should be addressed.
  • The clinical on-call process and documentation should be described, including any examples of written or electronic logs and/or or reviews of the trainee's performance.
  • Goals and objectives for an acting directorship, if applicable, should be provided.

7.  Trainee Selection

The recruitment process for fellowship positions and selection of trainees (interviews, etc.) should be described. Include any specific requirements of the application (transcripts, letters, degree or course requirements), and any forms used for evaluating applicants.

8.  Evaluations

  • Trainee evaluation:  The process for evaluating a trainee's progression through the program should be outlined in detail, including any forms used and how the trainee receives this feedback.
  • Program evaluation: The process by which trainees can provide feedback on the structure and content of the program should be outlined in detail. If a formal faculty review/self-assessment of the program occurs, this process and any associated outcomes should be provided.  

9.  Trainees

  • Current trainees:  A list of current trainees and their status in the program should be provided.  Include the full CV for all current trainees in an Appendix.
  • Past trainees: A list of past trainees, certification status, and current positions should be included.

10.  Additional Information and Submission of the Self-Study

Please include any additional information that may be useful to ComACC reviewers to gain a more comprehensive understanding of your program.

Submission of the Self-Study

  • Cover Letter:  A cover letter on institutional letterhead should be included with the formal self-study. The cover letter should address the following items:
    • Permission to release the results of the accreditation process to the National Registry for Clinical Chemistry (NRCC) and the American Board of Clinical Chemistry (ABCC) for the purpose of exam eligibility for the trainee
    • Permission to review evaluation forms of the trainees and the program for the purpose of evaluating the completeness of such evaluations as a component of the program
    • Permission to conduct a one-day on-site visit as applicable
    • Acknowledgement of fees: $1000 for the application and, if applicable, $3500 for the on-site visit to be invoiced after the on-site visit

Signatures

    • Director (and any Co-Director) of the Clinical Chemistry Fellowship
    • Representative of the Division if different from above
    • Representative of the Department (Chair)
    • Representative of the Institution (GME Director, Dean, etc.) if applicable

A template for such a letter is provided below.

Date:
Commission on Accreditation in Clinical Chemistry
c/o Lisa Dunay
ComACC, 900 Seventh Street, NW Suite 400
Washington, DC 20001 U.S.A.

Dear Commissioners:

This letter serves as formal acknowledgement of our self-study for the Clinical Chemistry Fellowship at [institution name], previously submitted electronically as a .pdf file to Ms. Dunay at ldunay@aacc.org for the purpose of accreditation of our program by the Commission on Accreditation in Clinical Chemistry (ComACC).

With this letter, the program provides permission for the following:

  • Permission for ComACC to release the results of the accreditation process to the American Board of Clinical Chemistry (ABCC) and the National Registry for Clinical Chemistry (NRCC) for the purpose of exam eligibility for our trainees
  • Permission for all ComACC Commissioners to review evaluation forms of the trainees and of the program by trainees for the purpose of evaluating the completeness of such evaluations as a component of the program
  • Permission for two ComACC Commissioners to conduct a one-day on-site visit [as applicable]

We understand that there is a self-study application fee of $1,000 and a subsequent fee of $3,500 for the on-site visit (as applicable).

Thank you for consideration of our review.

Signatories (all with date):

  • Director of the program, including current rank at the sponsoring institution
  • Co-director(s) of the program, including current rank at the sponsoring institution
  • Division Chief for Clinical Chemistry/Clinical Pathology (or representative) if different from the above
  • Department Chair/representative if different from the above
  • As applicable: Graduate Medical Education Officer/Representative for the Institution (for those programs that have institution overview/support from that office

Submit by Email: One electronic PDF copy of the completed self-study and the cover letter with signatures and dates to Lisa Dunay at ldunay@aacc.org

Submit check (payable to ComACC) for self-study fee payment to:

Lisa Dunay
AACC
900 Seventh Street, NW Suite 400
Washington, DC 20001 U.S.A.
Tel: 202-835-8705

Accreditation actions and outcome will be communicated to the program director and responsible institutional officials as soon as the Commission has completed its evaluation.

 

Revised October, 2015