Preparing for an Accreditation Site Visit

Sharon J. Tanner, EdD, RN
Chief Executive Officer, National League for Nursing Accrediting Commission

This column provides information on accreditation for nursing programs of all types. Readers may submit questions to the National League for Nursing Accrediting Commission. General questions of interest to a wide audience will be addressed in this column while more specific questions or those requiring confidentiality will be answered directly.

QOur master’s nursing program is scheduled for the next site visit in the spring 2013 cycle. What recommendations do you have for me as the nurse administrator as well as the faculty who will be writing the self-study report and preparing documents for the visitors?

AOne of the best ways to prepare for a site visit is to attend one of the NLNAC self-study forums held each spring and fall.  The forums offer nurse administrators and faculty representing programs seeking initial or continuing accreditation the opportunity to review each of the accreditation standards in a criterion by criterion format.  Essential elements of documentation are discussed as well as recommendations for compilation of documents and evidence related to the standards in paper or electronic format.  While hosting your colleagues for an on-site review requires a concerted effort on the part of the faculty, we hope to alleviate some of the stress by providing you with as much information as possible about how to prepare for the visit.  The forum is led by the NLNAC professional staff as well as experienced site visitors who share their personal insights about their own preparation for a visit as well as helpful tips on how to best prepare for the on-site review.

One of the greatest challenges facing nursing programs preparing for an on-site review occurs when “first aid” is needed for the program’s systematic evaluation plan.  What a challenge to repair a neglected plan and place several years of data into a document that has been collecting dust on a shelf!  The much preferred route would be to keep your evaluation plan up-to-date at all times with ongoing, frequent use by the faculty in the manner that the plan is designed and the standard requires.  The true evidence-based approach to quality really works.  I find that nursing programs of all types that have a systematic and comprehensive approach to data collection and analysis with clear and specific documentation of the use of the data by the faculty at regular intervals for program decision-making actually have available, within their plan, most of the information needed to develop the self-study report.  Writing the report is easier when hours are not spent re-creating evaluation plans and documents, particularly faculty meeting minutes, but rather having available documentation that has been kept current between the scheduled accreditation site visits.  An organized data system can save you many hours when the time for the site visit approaches.

As you prepare for the review, you may want to network with nurse administrators and faculty from programs within your state or region that have recently undergone a review.  They may be willing to share information as you prepare for the visit; they may even be willing to share ideas about what worked for them as well as things to avoid.

Please know that you can contact the NLNAC at any time if you have questions about the site visit; our staff will be happy to address your questions about scheduling, fees, and requirements.  In addition, there are multiple resources on the NLNAC Web site at www.nlnac.org under the “Resources for Nursing Programs” link at the side of the page.  We offer guidelines for the preparation of the self-study report as well as a packet for the nurse administrator that includes information about scheduling the visit, program responsibilities, site visitor selection, document preparation, and more.

QAs the nurse administrator, I have found that I am often the only one on campus in the summer finishing the self-study report.  In the past, it has been very difficult for me to get faculty involved in the accreditation process as our history for the program has been for the nurse administrator to be responsible for accreditation. How do I change this pattern and get faculty engaged in the process?

AYour question is a common one as we hear from many nurse administrators who are working during the summer preparing for an upcoming fall visit or over the holidays as they prepare for a spring site visit.  Of course, it is easy for us to respond and say “start your preparation as early as possible.”  However, as former nurse administrators and faculty, we also know that nursing program life gets in the way of the best made plans.

One way to start is by providing your faculty with the knowledge they need to be fully involved in the accreditation process.  I would encourage as many of your faculty members as possible to attend the self-study forum as the preparation of the self-study report should be a team effort with engagement of all faculty members.  Frequently, nurse administrators tell me that it is essential for new faculty members to understand the self-review and peer review processes as early as possible in order to be successful in an educational setting.  We often see new faculty members attending the forum with the support of their administrators and colleagues so they will have essential information about aspects of quality programs available to them early in their careers.

Also, you may want to consider putting key faculty members in charge of the various aspects of the self-study report.  The most common practice used by programs is to divide the accreditation standards among the faculty and direct each group or committee to develop a certain portion of the report.  However, we often hear complaints from faculty members related to their colleagues who do not complete their assigned sections or simply put less than the anticipated effort into the writing phase of the report development.  I frequently see questions on listserves and email about the amount of release time “required” for each faculty member to develop the report.  While some programs are fortunate enough to be able to provide release time or extra compensation for the accreditation process, the majority of accredited programs conduct the comprehensive self-reviews and develop their self-study report as part of the everyday patterns of nursing program activities.

Breaking the patterns of organizational structure is never easy, but I encourage you to consider a new approach with this accreditation review.  Perhaps you can find an “accreditation champion” or leader among your faculty members…have you considered one of your newer faculty members who may not be entrenched in the previous patterns and expectations?  While we often speak about delegation, I find, and you probably do as well, that it is easier to speak about delegation than to actually engage in the process when it comes to something as important as accreditation.  However, the NLNAC speaks often about the accreditation process being faculty-led, and we frequently find that the most successful programs tap their faculty members’ strengths when making change and implementing quality initiatives.

This is a non-final version of an article published in final form in the NURSE EDUCATOR Journal.  September/October 2012 Vol.37, No.5 http://journals.lww.com/nurseeducatoronline/toc/2012/09000