Volume 95 - Spring 2007	Download

Affiliation Agreements Current Challenges for Program Directors by Karen Madsen Myers, MA, MT(ASCP)SC, CLS(NCA) Chair, Programs Approval Review Committee (PARC)

      Recent trends regarding affiliation agreements between educational programs and clinical sites offer challenges for programs in the clinical laboratory sciences. Programs are now constrained in ways that can make meeting the requirements of accreditation and approval standards related to affiliation agreements difficult. Clinical facilities may require that their own standardized agreements be used in lieu of the program's agreement. When programs use the agreements from their own facility, they may be limited by language covering a number of health professions within a college or university. System-wide clinical umbrella agreements provide programs with both a challenge and support. The challenge comes from standardized formats found in system-wide agreements which are difficult to alter; support is in maintaining only one agreement for multiple sites where previously many agreements were required.

      The NAACLS Program Standards have evolved in review committees and within the professions as guide posts that underlay an accredited or approved educational experience that assures the consistency of the educational process and the safety of the enrolled student leading to outcomes that are compatible with successful professional practice. In the current climate the locus of control over the content of agreements has changed.

      Negotiating agreements becomes just one more challenge for program officials who are already dealing with sites that don't always have time to train students at the times programs need them. Programs have long dealt with assuring the consistency of experiences between and within laboratories, and assuring adequate rotation sites for students especially in complex areas such as blood banking and microbiology. Dianne Cearlock, PhD, Chief Executive Officer of NAACLS, asks, "What are programs to do when they badly need clinical affiliates to meet their students' clinical needs but the affiliates want to control the content of the affiliation agreement?" This is particularly critical in locations where there is a low density of clinical sites or in geographic locales where there is competition among programs for sites.

      Clinical sites are dealing with liability issues related to HIPPA and JCAHO requirements. Students who enter a clinical site must go through background checks and training related to confidentiality and safety. Language regarding these requirements is beginning to appear in affiliation agreements while some items required by the NAACLS Standards are missing and must be negotiated by program officials often over a protracted period of time. Perhaps it is time for us to begin a conversation that revisits the required content of clinical affiliation agreements in the clinical laboratory sciences.

      Dr. Dianne Cearlock is open to such a conversation, "While these trends have triggered changes in the purposes (liability instead of meeting accreditation standards), content and processes of developing affiliation agreements, accrediting agencies have not made much adaptation for these changes. We require the same content in agreements as before while the program directors have much less input and control. Program directors are frequently between a rock and a hard place. They must have clinical placements to meet student needs, and they must have affiliation agreements that meet accreditation standards, but they do not have as much control over the content of the agreements."

Issues From the Field
      Interviews with several program officials and review committee members provided a clearer picture of the challenges programs encounter as they strive to maintain and add clinical site affiliations. These challenges can be divided into content issues and process issues.

      Because many sites are requiring a "one size fits all" standardized agreement and because many agreements are focused on nursing, agreements do not always contain all the specifics required by the NAACLS Standards. Venus Ward, PhD, of the University of Kansas Medical Center, has recently run into content issues as she attempted to add new clinical sites. She found that some agreements contained restrictions and requirements that did not apply to clinical laboratory science students including providing on-site preceptors and liability insurance to cover equipment breakage by students. She also states that some agreements lack a termination clause and do not address issues of student health and safety. K. Nisi Zell, EdD, of Coastal Georgia Community College, a NAACLS programs review committee member, confirms that clinical agreements are often missing statements regarding student safety.

      Sandra DiFalco, MS, MT(ASCP), of The Colorado for Medical Laboratory Science, coordinates agreements with multiple sites. She adds that many sites have differing up front requirements for students entering a clinical rotation. This makes standardizing agreements from the program's side challenging and negotiating changes in agreements is time consuming for both program officials and the legal departments that review agreements.

      Sometimes it is difficult to negotiate any change. Several programs provided input regarding the national "set in stone" format utilized by VA Medical Centers and the challenges they encountered bringing wording in line with NAACLS Standards. Many programs work around standardized language by writing addendums to the agreement or memorandums of understanding that are signed by program representatives and appropriate clinical contacts at the local facility.

      Katherine Griener, MS, MT(ASCP), of Marist College shared her story regarding VA clinical affiliations. The standardized agreement with her local VA facility did not include the language required by the NAACLS Standards. She had one of two choices: either to drop the clinical affiliate or negotiate the agreement changes by the due date for her response to program review. The VA site was an integral component of her program's clinical education; she chose the later course. Negotiation of the local agreement required discussion at the national level where she was referred to multiple VA officials. Long before the local office signed off on the changes, the deadline for her response came and went, and she was forced to submit documentation to NAACLS minus the updated VA agreement required changes. She received a five-year rather than a seven-year accreditation on the basis of the missing language in the VA agreement. Dr. Cearlock brings up another issue regarding affiliation addendums and memorandums of understanding when she questions the use of such addendums by asking if they are legally binding. She points to the practice of memorandums and addendums often being signed by program directors and laboratory directors while affiliation agreements are typically signed by CEOs and Provosts.

      Sandra DiFalco raises a process challenge. Rotation contacts who negotiate affiliation agreement content with programs are often individuals who are not familiar with laboratories and the clinical laboratory sciences. Venus Ward adds that at sites where a sufficient number of students are provided with clinical assignments that the hospital education department oversees the signing of agreements rather than the laboratory manager. Education departments are usually run by people with nursing credentials. The needs of nursing students differ from the needs of laboratory science students and coming to an understanding of the difference and reflecting this in agreements can take a good deal of negotiation and time. With system wide standardized agreements, the legal department that performs reviews and signs off on agreements can be located at a site quite distant from the local affiliate. Transport and negotiation of agreements at a distance takes even more time in such instances.

Closing Thoughts
      The profession is already dealing with a national shortage of laboratory personnel. Programs in the clinical laboratory sciences are our major source of new practitioners. While we certainly are not asking to lessen the charge given to program faculty that they assure the quality and consistency of educational experiences for students and assure students' safety within those experiences, perhaps the time has come to begin discussing the issues raised in this article and to look for ways to reasonably accommodate the constraints placed on programs as they relate to affiliation agreements. Without accommodation programs may be unable to meet the requirements set forth in the Standards. More programs may find themselves in the position in which Katherine Greiner found herself. Making a choice between dropping a clinical site or keeping the site and receiving a citation during program review is a weighty decision and probably not one many program directors would wish to make.

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