What does it take for an accrediting agency to earn recognition?

In the United States there are two entities that recognize accrediting agencies – the U.S. Department of Education (USDE) and the Council on Higher Education Accreditation (CHEA). The USDE defines recognition as “…an accrediting agency complies with the criteria for recognition…and that the agency is effective in its application of those criteria.” Additionally, an agency is “…a reliable authority regarding the quality of education or training offered by institutions or programs it accredits…” The ACEN is recognized by both the USDE and CHEA to accredit nursing education programs and schools, both postsecondary and higher degree, which offer either a certificate, diploma, or recognized professional degree (clinical doctorate, master’s, baccalaureate, associate, diploma, and practical nursing) in the United States, its territories, and internationally, including those offered via distance education. The recognition by the USDE also allows the ACEN to act as a Title IV gatekeeper for selected nursing programs.

Recognition is similar to accreditation and involves a multi-layered process to determine whether an accrediting agency is in compliance with requirements set by the USDE or CHEA. For simplicity, the USDE process will be referenced; however, the CHEA process is very similar.

  1. The agency must meet eligibility requirements to serve as an accrediting agency.
    1. If eligible, an agency seeking initial recognition must demonstrate that it has granted accreditation or pre-accreditation:
      1. to one or more institutions if it is requesting recognition as an institutional accrediting agency and to one or more programs if it is requesting recognition as a programmatic accrediting agency
      2. to cover the range of the specific degrees, certificates, institutions, and programs for which it seeks recognition
      3. in the geographic area for which it seeks recognition
    2. If eligible, an agency seeking initial recognition must conduct accrediting activities, including deciding whether to grant or deny accreditation or pre-accreditation, for at least two years prior to seeking recognition.

This is equivalent to a program meeting ACEN eligibility requirements.

  1. The agency must demonstrate that its standards, policies, procedures, and decisions to grant or deny accreditation are widely accepted in the United States by (a) educators and educational institutions; and (b) licensing bodies, practitioners, and employers in the professional or vocational fields for which the educational institutions or programs within the agency’s jurisdiction prepare their students.

The ACEN has held USDE and CHEA recognition for decades and ACEN has been acknowledged as the leading authority for nursing education accreditation for decades; see article in this edition of Bridges. We are very proud that in March 2016 the Secretary of Education renewed ACEN’s recognition. Currently, the ACEN is working on its next reports to the USDE and CHEA. The ACEN will submit its interim report to CHEA in June 2017 and its renewal of recognition application to the USDE in December 2017.

  1. An accrediting agency seeking initial or continued recognition must submit a written application to the Secretary. Each accrediting agency must submit an application for continued recognition at least once every five years, or within a shorter time period specified in the final recognition decision. The application must consist of:
    1. a statement of the agency’s requested scope of recognition
    2. evidence, including documentation, that the agency complies with the criteria for recognition and effectively applies these criteria
    3. evidence of how an agency that includes or seeks to include distance education or correspondence education in its scope of recognition applies its standards in evaluating programs and institutions it accredits that offer distance education or correspondence education

The application is equivalent to a program seeking initial accreditation writing/submitting its self-study report.

The application is equivalent to a program seeking continuing accreditation writing/submitting its Self-Study Report once every eight years or a Follow-up Report within the timeframe specified by the ACEN Board of Commissioners.

  1. After receipt of an agency’s application for initial or continued recognition, Department staff publishes a notice of the agency’s application or report in the Federal Register inviting the public to comment on the agency’s compliance with the criteria for recognition and establishing a deadline for receipt of public comment.

This is equivalent to ACEN’s third-party comment process.

  1. The Department staff analyzes the agency’s application for initial or renewal of recognition to determine whether the agency satisfies the criteria for recognition, taking into account all available relevant information concerning the compliance of the agency with those criteria and in the agency’s effectiveness in applying the criteria.

The analysis of an application for recognition includes (a) observations from site visit(s), on an announced or unannounced basis, to the agency or to a location where agency activities such as training, review and evaluation panel meetings, and decision meetings take place and to one or more of the institutions or programs it accredits or pre-accredits; (b) review of the public comments and other third-party information the Department staff receives by the established deadline, and the agency’s responses to the third-party comments, as appropriate, as well as any other information Department staff assembles for purposes of evaluating the agency; and (c) review of complaints or legal actions involving the agency.

Department staff’s evaluation of an agency may also include a review of information directly related to institutions or programs accredited or pre-accredited by the agency relative to their compliance with the agency’s standards, the effectiveness of the standards, and the agency’s application of those standards.

  1. If, at any point in its evaluation of an agency seeking initial recognition, Department staff determines that the agency fails to demonstrate compliance with the basic eligibility requirements, the staff (a) returns the agency’s application and provides the agency with an explanation of the deficiencies that caused staff to take that action and (b) recommends that the agency withdraw its application and reapply when the agency can demonstrate compliance.
  1. Except with respect to an application that has been returned or is withdrawn, when Department staff completes its evaluation of the agency, the staff:
    1. prepares a written draft analysis of the agency;
    2. sends the draft analysis, including any identified areas of non-compliance and a proposed recognition recommendation, and all supporting documentation, including all third-party comments the Department received by the established deadline, to the agency;
    3. invites the agency to provide a written response to the draft analysis and proposed recognition recommendation and third-party comments, specifying a deadline that provides at least 30 days for the agency’s response; and
    4. reviews the response to the draft analysis the agency submits, if any, and prepares the written final analysis.

The final analysis includes a recognition recommendation to the senior Department official, as the Department staff deems appropriate, including, but not limited to, a recommendation to approve, deny, limit, suspend, or terminate recognition, require the submission of a compliance report and continue recognition pending a final decision on compliance, approve or deny a request for expansion of scope, or revise or affirm the scope of the agency.

Provides to the agency, no later than seven days before the Advisory Committee meeting, the final staff analysis and any other available information provided to the Advisory Committee.

This is equal to ACEN’s site visit, site visit report, and nurse administrator response form processes. The Advisory Committee is equal to ACEN’s Evaluation Review Panel. The senior department official is equal to the ACEN Board of Commissioners.

  1. Before the Advisory Committee meeting, Department staff provides the Advisory Committee with the following information:
    1. the agency’s initial recognition application or renewal of recognition application and supporting documentation;
    2. the final Department staff analysis and any supporting documentation;
    3. the agency’s response to the draft analysis if requested by the Advisory Committee;
    4. any written third-party comments the Department received about the agency as well as any agency response to third-party comments; and
    5. any other information Department staff relied upon in developing its analysis.
  1. At least 30 days before the Advisory Committee meeting, the Department publishes a notice of the meeting in the Federal Register inviting interested parties, including those who submitted third-party comments concerning the agency’s compliance with the criteria for recognition, to make oral presentations before the Advisory Committee.
  1. The Advisory Committee considers the materials provided in a public meeting and invites Department staff, the agency, and other interested parties to make oral presentations during the meeting. A transcript is made of all Advisory Committee meetings.
  1. The written motion adopted by the Advisory Committee regarding each agency’s recognition will be made available during the Advisory Committee meeting. The Department will provide each agency, upon request, with a copy of the motion on recognition at the meeting. Each agency that was reviewed will be sent an electronic copy of the motion relative to that agency as soon as practicable after the meeting.
  1. After each meeting of the Advisory Committee at which a review of agencies occurs, the Advisory Committee forwards to the senior Department official its recommendation with respect to each agency, which may include, but is not limited to, a recommendation to approve, deny, limit, suspend, or terminate recognition, to grant or deny a request for expansion of scope, to revise or affirm the scope of the agency, or to require the agency to submit a compliance report and to continue recognition pending a final decision on compliance.

Steps eight through twelve are similar to ACEN’s Evaluation Review Panel process.

  1. Within ten days following the Advisory Committee meeting, the agency and Department staff may submit written comments to the senior Department official on the Advisory Committee’s recommendation. The agency must simultaneously submit a copy of its written comments, if any, to Department staff. Department staff must simultaneously submit a copy of its written comments, if any, to the agency.
  1. The senior Department official makes a decision regarding recognition of an agency based on the record compiled.

This is equivalent to ACEN Board of Commissioners making an accreditation decision regarding a program.

What happens if an agency isn’t recognized?

The USDE has due process to appeal an adverse action if an agency decides to appeal its decision. If appealed and the Department’s decision is upheld then the agency is not recognized and any institution/program that was seeking the agency’s accreditation or any institution/program that held the agency’s accreditation would not be accredited. The agency may pursue recognition again, if it chooses to.

ACEN has due process for appealing the denial of initial or continuing accreditation if the program decides to appeal the Board of Commissioners’ decision. If the appeal of the Board’s decision to deny initial or continuing accreditation is upheld, then current and future students would not be graduates of an accredited program. For a program that held ACEN accreditation, ONLY graduates during the period of time that the program held accreditation would be graduates of an accredited program. Programs may pursue accreditation with the ACEN again, if they so choose.