Preparing for Accreditation Sue E. Bingham, RN, PhD, CNE Nancy O. DeBasio, PhD, RN, FAAN Kathy Hankel RN, MS Kathy B. Hill, JD, MSN, RN Frances D. Monahan PhD, RN, ANEF
PANEL OBJECTIVES Preparing for Accreditation Differentiate between the process of gaining candidacy or new applicant status and becoming accredited Describe the process for preparing for an accreditation visit. Discuss the role of outcomes and data needed to measure program and student learning outcomes 2
APPROVAL vs. ACCREDITATION Processes for being granted approval to apply for accreditation Approval ACEN: Candidacy Presentation addresses selected Standards and Criteria up to 200 pgs for 1 program, 300 pages for multiple programs CNEA: Pre-Accreditation Candidacy Application worksheet available as a guide Executive Summary addresses five Standards 10 pgs for 1-2 programs; 15 pgs for 3-4 programs CCNE: New Applicant Review Process (accepted status) letter of request signed by CEO, CAO, and Chief Nurse Administrator CCNE Program Information Form 5 pages or less; summary of program s ability to meet accreditation standards vacen/ccne provides 2 year window for accreditation; CNEA provides 3 year window 3
APPROVAL vs. ACCREDITATION Processes for accreditation initial or re-accreditation Accreditation ACEN/CNEA Self Study Report (SSR); CCNE Self Study Document (SSD) Site Visit/On-Site Evaluation (Team Leader; 2-3+ site visitors/evaluators) Site Visit Team Report: written by visiting evaluation team; validates information contained in SSR/SSD (verify, clarify, and amplify) After Site Visit data from SSR/SSD and site visit reviewed by: ACEN Evaluation Review Panel (ERP); CCNE Accreditation Review Committee (ARC): CNEA Initial Program Application Sub-committee (IPASC) Final decision made regarding accreditation status and duration: ACEN Board of Commissioners; CCNE Board of Commissioners: CNEA Board of Commissioners Decision rendered approximately 6 months after site visit 4
PREPARING FOR SITE VISIT/On-site Evaluation Begin planning and preparing 1-2 years ahead of site visit Schedule site visit a minimum of 12 months in advance ACEN/CCNE site visits held in fall/spring semesters; CNEA year round Attend workshop and/or listen to webinars on preparation of SSR/SSD and site visit Submit draft agenda and SSR/SSD 6-8 weeks prior to site visit (CCNE online) Maintain page limit on SSR/SSD ACEN: 200 pgs including appendices 1 program (except for SEP and Faculty Profile Table); 300 pgs for multiple programs CNEA: 100 for 1 program; 150 for 2 programs; contact CNEA for more than 2 programs CCNE: 90 pg limit 1-2 programs, 100 pg limit greater than 3 programs excluding appendices Use Appendices for content best addressed outside of SSR narrative Solicit third party public comments as specified by accrediting body before site visit 5
PREPARING FOR THE SITE VISIT/On-site evaluation Home away from home for Team Leader and site visitors Arrange for comfortable hotel accommodations Close to school (school does not pay for hotel) Transportation between the hotel and the institution Provide team with names/addresses of area restaurants Restaurant at hotel offering breakfast/dinner is helpful Light refreshments for late night snacks Arrange for lunch on Day 1 and 2 (ask team about allergies or other food concerns) Ensure visit to clinical site is scheduled when students will be in clinical Consider scheduling a Mock Site Visit 6
WRITE A SOLID SELF STUDY (SSR/SSD) Remember from clinical practice If it wasn t documented, it wasn t done Solid Self-Study Standards and Criteria/Quality Indicators/Key Elements: address in a clear, thorough, and complete manner Well written, carefully proofed, externally reviewed Tables used in place of narrative when possible Judicious use of examples that validate statements made in SSR/SSD Address Levels of Achievement/Outcomes expected vs. actual Collect and analyze data and DOCUMENT (LINK minutes with date) Make evidence-based decisions and DOCUMENT (LINK minutes with date) Develop Action Plans for unmet LOA/Outcome.. AND DOCUMENT (LINK minutes with date) 7
ADEQUATELY ADDRESSING ELAs/OUTCOMES It s all about expected levels of achievement (ELAs) / outcomes!!! Department of Education minimum requirement: Program Outcomes (ACEN/CCNE/CNEA) Completion rate: 70% Licensure/certification rate: 80% Employment rate: 70% Other Outcomes Student Learning Outcomes Faculty Outcomes (teaching, scholarship, service, practice, other) Program-selected Outcomes (student/alumni achievement; student/alumni/employer satisfaction data) 8
PREPARING THE AGENDA Every moment counts!!! Site visit team leader and nursing program administrator prepare the agenda (may want to ask team leader for an agenda template) Schedule constituent meetings in 30-60 minute blocks Reserve time on the agenda for breaks for the team Identify times for review of materials in the resource room (2-3 hrs/ team member/day) Allow time in the schedule for transport to clinical sites, classroom observations, other campuses Schedule meeting time with nursing unit administrator at the end of the first two days Reserve the last day for the evaluators to finalize their report Set a time for the exit interview with the nursing program administrator; an additional time may be set for other constituents 9
PREPARING THE RESOURCE ROOM Accommodate needs of visiting team Provide: quiet, private area in which to work (room should be able to be locked) enough space for 3-4 site visitors/evaluators to be able to work and spread out office supplies (pens, pencils, paper clips, tablets, stapler, etc.) name tag for each site visitor documents organized so they are easy to find (hanging files, colored folders/tabs) e-documents should be well organized and easily navigated passwords needed to access online resources/ learning management system/courses at least one computer; printer, paper, and shredder Provide: light refreshments (water, coffee, and healthy snacks) food options that accommodate dietary restrictions 10
DURING THE VISIT Remember to breathe, breathe, breathe On the first day of the visit: orient the team to the Resource Room show location of necessary documentation and how to access it have IT person readily available Assign a staff member who will be the go to person for the Resource Room Knowledgeable about the materials in the Resource Room Obtain needed documents and get questions answered Designate staff/faculty to accompany site visitors to scheduled meeting Deliver and pick-up 11
ONLINE RESOURCES Where to go with questions - see References Accreditation Commission for Education in Nursing (ACEN) http://www.acenursing.org/resources-for-nursing-programs/ 12
RESOURCES Accreditation Commission for Education in Nursing (2017) Retrieved from http://www.acenursing.org/resources-for-nursing-programs/ Commission on Collegiate Nursing Education (2017) Retrieved from http://www.aacnnursing.org/ccne Commission for Nursing Education (2017) Retrieved from http://www.nln.org/accreditation-services/the-nln-commission-for-nursing-educationaccreditation-%28cnea%29 13
14