Joint Accreditation Criteria Review: JAC3

The first grouping of JA criteria is headed Mission and Overall Program Improvement. They focus on the continuing education (CE) program as a whole.

JAC3 states: 

The provider identifies, plans and implements the needed or desired changes in the overall program (e.g., planners, teachers, infrastructure, methods, resources, facilities, interventions) that are required to improve its ability to meet the CE mission.

If you’ve been following this series, I hope you’re starting to see how each criterion in this section builds on the last. In JAC1, we wrote a mission statement. In JAC2, we developed and implemented a plan for evaluating whether our program is meeting that mission statement. Now we need to do something with the information gleaned from that program analysis.

JAC3 is all about program improvement. Perhaps you found something in your program analysis that is preventing you from meeting the goals outlined in your mission statement. Or perhaps there are other factors that could improve your program.

Would a new learning management system (LMS) improve the experience your learners have? Are you looking to expand the activities you offer to include standardized patients? Is your building in need of repairs that are making it inaccessible to all of the learners you hope to serve?

While you should start with your program analysis and develop plans to address any concerns you found in that process, JAC3 is more expansive than what might be identified in your steps to achieve JAC2. The sky’s the limit, with one big caveat.

If you reread the criterion, there are three pieces. You need to identify a needed or desired change. Let’s take that last example I gave – the building isn’t accessible. What are we going to do about it? That’s step two. Let’s say that it needs a ramp. And maybe our classes are on the second floor, and the building is so old that it doesn’t have an elevator. So to make the building accessible, we need a way for people with limited mobility to get into the building and we need a way for them to get to the classroom. So we have a plan – we need to build a ramp and install an elevator.

Here’s the rub. Now we need to implement that plan. It’s possible a handy CE office could go outside and build a ramp, but that staff is going to need some help in order to install an elevator.

Perhaps this isn’t the best improvement to highlight in our self study since we may not be able to implement this plan no matter how important we find it to be. Or perhaps we need to tackle it a different way. If we can find an accessible place to hold our activities, we could do that.

One thing to keep in mind is that implementation doesn’t mean the process is complete. You could be in the process of sourcing LMS vendors, the first step in the implementation process. Or, with my above example, you could have approval that the elevator is scheduled to be installed in 18 months and the ramp is under construction.

The key is that you need to show that you’ve identified a desired or needed change, made a plan to make that change, and that the plan is in progress. Most programs have an ongoing process of improvement, be those changes big or small. As long as you can describe how those changes will improve your program, you’re meeting JAC3.

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Joint Accreditation Criteria Review: JAC2

The first grouping of JA criteria is headed Mission and Overall Program Improvement. They focus on the continuing education (CE) program as a whole.

JAC2 states: 

The provider gathers data or information and conducts a program-based analysis on the degree to which its CE mission—as it relates to changes in skills/strategy, or performance of the healthcare team, and/or patient outcomes—has been met through the conduct of CE activities/educational interventions.

You’ve met JAC1, meaning you have a mission statement that talks about educating the healthcare team. Now you need to determine whether or not you’re meeting that mission, and that is the focus of this criterion.

The place to start is with that mission statement. What are the outcomes that you describe in it? Is your mission to educate the team and improve their skills and/or strategies? Are you trying to improve the performance of the healthcare team? Or are you intending to improve patient outcomes? It could also be a combination of the three. Your mission statement is unique to your CE program, so how you evaluate it will be unique to you.

The key is that you do need to have a regular process of reviewing all of the activities that you’ve put on and assessing the impact that they have had on whatever you’ve described in your mission statement. And then it’s up to you to determine if your results show that you are meeting that mission or not.

What exactly you do with that determination is for the next criterion (JAC3). JAC2 is about your program analysis process. What information do you gather? How do you collect it? How frequently? This all depends on what your mission statement says.

I like to start by breaking my mission statement apart. What are the specific goals? Which can be measured? How can I measure them? What is the threshold at which we can consider that goal to be achieved?

Having answered those questions, I’m able to describe the process of conducting a program-based analysis. And once that process is described, it’s much easier to put it into practice. And that is what JAC2 is looking for.

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