Welcome to the Newly Elected Members of your BOC


THE VOTES ARE IN! Effective October 1st, 2019, these newly and reelected Commissioners will join the Board of Commissioners who govern your ACEN:

Newly Elected

Shari Gholson
(Nurse Educator)

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Dr. Shari Gholson, DNP, RN, CNE has 33 years of nursing experience, including 20 years in nursing education. She is a professor of nursing at West Kentucky Community and Technical College and is serving as Dean of the Nursing Division and program coordinator of the Associate Degree Nursing Program since 2006.

Shari earned her Doctorate in Nurse Practice from Northern Kentucky University, Master’s Degree in Nursing from Vanderbilt University (clinical nurse specialist) and a bachelor’s degree in nursing from Murray State University. She also holds the Certified Nurse Educators credential. She has served the college in a number of leadership roles including faculty representative to the WKCTC Board of Directors, chair of the Kentucky Community and Technical College Nursing Curriculum Committee, and has presented at local, state, national, and international conferences/workshops.

Dr. Gholson has served as an ACEN site visitor since 2013, a team chair since 2015, and an Evaluation Review Panel member since 2016. She is a member of several professional associations including Sigma Theta Tau International, American Nurses Association, National League for Nursing, Kentucky Deans and Directors, Kentucky Council of Associate Degree Nursing, and Kentucky Nurses Action Coalition.

Shari considers it an honor walk beside nursing faculty of WKCTC as they chose to teach those that will follow them into the nursing profession and will value the opportunity to do the same with the ACEN organization.


Scott Thigpen
(Nurse Educator)

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Dr. Scott Thigpen, DNP, RN, MSN, CCRN is a Professor of Nursing at South Georgia State College (SGSC) in Douglas, GA. He has led the LPN-RN Bridge program, the ASN program and developed and implemented the RN-BSN program. Dr. Thigpen has served on the SGSC Academic Leadership Team and lead accreditation activities including three successful accreditation site visits for the Southern Association of Colleges and Schools Commission on Colleges (SACSCOC) for the level change from a two-year to four-year college, campus consolidation, and the decennial accreditation as a new institution. He has led SACSCOC substantive changes for the BS in Nursing and the BS in Long-term Healthcare Management.

Dr. Thigpen holds an ASN from South Georgia State College, a BSN and MSN in Adult Health from Valdosta State University and the Doctorate of Nursing Practice from the Medical College of Georgia in Augusta, GA. He is a Certified Critical Care Nurse (CCRN) and a proud member of the American Association of Critical Care Nursing (AACN) where he has served as a speaker at the National Teaching Institute (NTI) for over ten years. He also served as an Endocrine content expert for the AACN Essentials of Critical Care Nursing Orientation Online (ECCO 3.0) which has been utilized by over 1100 nursing facilities in the United States and Canada to orient nurses to progressive care and critical care units. Dr. Thigpen has presented extensively on a variety of nursing and leadership topics throughout the Unites States and internationally in Australia, Canada and Mexico.

In the field of nursing regulation, Dr. Thigpen has served on the Georgia Board of Nursing (2003-2010), as Vice President, Nursing Education Representative, Legal/Discipline Cognizant, and Site Visitor. He represented Georgia as a delegate to the National Council of State Board of Nursing and has been an NCLEX-RN item reviewer.

At the Accreditation Commission for Education in Nursing (ACEN), Dr. Thigpen has attended Nurse Administrator Workshops, Self-Study Forums and Site Visitor Training. He was a member of the ACEN 2017 Standards and Criteria Revision Team and has enjoyed serving the profession as a site visitor and an evaluation review panel member. In his spare time, he enjoys working on the family farm and leading praise and worship at his church.


Lisa A. Young

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Dr. Lisa A. Young DNP, APN, FNP-BC received her Doctor of Nursing Practice from the University of Iowa. Dr. Young received her Bachelors of Nursing, Master’s in Nursing and nurse practitioner training with a focus on community health nursing from Saint Xavier University.

Dr. Young is a board certified family nurse practitioner with over twenty years of experience. Dr. Young is currently the Director of the Wellness/Health Center and an Associate Professor in Nursing at Chicago State University. Her early graduate nursing research on nurse practitioners in nurse managed centers as a cost effective alternative to emergency departments led her to Chicago State University. During her tenure, she conceptualized, implemented, and developed the nurse managed center which serves the campus community. She has clinical oversight and operations of the health center and the Office of Student Health Insurance to ensure students have access to preventative and affordable health care. She has continued to maintain her clinical practice working in the Wellness/Health Center and within the retail industry continuing to serve those without access to affordable health care. Dr. Young served as Interim, Chairperson for the bachelor’s and masters of nursing program and as Interim Assistant Dean for the College of Health Sciences at Chicago State University. Dr. Young’s research interests include nurse managed centers, using assessment to address targeted violence, HIV prevention, health disparities among ethnic minorities. She has an active interest in health policy and nursing political advocacy.

Dr. Young is a member of several professional organizations which includes Sigma Theta Tau International, American Association of Nurse Practitioners, American Nurses Association, ANA-Illinois, American College Health Association, American Public Health Association, and the Illinois Society of Advanced Practice Nurses. She has contributed professionally as a peer evaluator for the Accrediting Commission for Education in Nursing (ACEN) as one of the initial clinician peer evaluators with over nineteen years of accreditation experience. Dr. Young has served as a national delegate for the United States Agency for International Development (USAID) on a USAID South African Area initiative and educational presentations and US delegate in China.

Dr. Young received her Doctor of Nursing Practice from the University of Iowa, her Bachelors and Master’s in Nursing and nurse practitioner training from Saint Xavier University.


Susan Zlotlow
(Public Member)

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Susan Zlotlow, Ph.D. retired after more than 18 years as the Director of the Office of Program Consultation and Accreditation and an Associate Executive Director of the Education Directorate at the American Psychology Association. She received her undergraduate degree at the University of Rochester and her M.A. and Ph.D. in clinical psychology from the University of Connecticut. She also received an honorary doctoral degree from Palo Alto University. Dr. Zlotlow’s publication and presentation history includes articles on child development and socialization, teaching, and accreditation in psychology.

Dr. Zlotlow taught at Wheaton College (Massachusetts) and has taught undergraduate and graduate classes at the University of Maryland at College Park. She served as a consultant to the public-school system in Albuquerque, New Mexico as well as engaged in clinical practice in Albuquerque, New Mexico and inner-city Baltimore. Prior to working in accreditation, Dr. Zlotlow served as the Assistant Dean in the Graduate School at the University of Maryland, College Park working on internal and external grant funding, including the institutional IRB, research review committees, as well as committees focused on campus resources for graduate students and faculty.

In her more than 18 years in accreditation, Dr. Zlotlow served as the Chair of the External Recognition Issues Committee of the Association of Specialized and Professional Accreditors, a group of programmatic and specialized accreditors that met with members of the Department of Education and Congress on issues related to accreditation. She also represented that group as a negotiator in the 2007 negotiated rulemaking hearings on accreditation issues in the US Higher Education Act. She also served for two terms as a member of the Council on Higher Education Accreditation (CHEA) committee of Specialized/National Accreditation. Dr. Zlotlow served on the Sullivan Commission that reviewed how accreditation standards in health professions impact diversity of those professions. She has received awards for her service from the American Psychological Association, several training councils in psychology, as well as from the Association of Specialized and Professional Accreditors.




Debbie Rahn
(Nurse Educator)

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Dr. Debbie Rahn, EdD, MSN, RN Director of the Reading Hospital School of Health Sciences (RHSHS), is a current member of the ACEN Board of Commissioners and is seeking reelection for a second term of service. While serving on the ACEN Board of Commissioners for the past few years, Dr. Rahn has served on the finance and substantive change committees, as well as serving as an ERP chair and a site visitor. In Dr. Rahn’s current position as Director of the School of Health Sciences, she is responsible for the leadership of multiple diploma and certificate programs including nursing (RN), medical imaging (MI), surgical technology (ST), clinical pastoral education (CPE), Medical Laboratory Science, Diagnostic Medical Sonography, phlebotomy, Emergency Medical Technician (EMT), Advanced EMT, and paramedic programs. Dr. Rahn is a graduate of RHSHS (Nursing Program), Penn State University (BSN), Villanova University (MSN in Nursing Education), and Drexel University (doctorate degree in Educational Leadership and Management with a focus in Higher Education). Dr. Rahn has provided leadership at the school to create dual admission programs for the Nursing, MI, and ST Programs whereby students are dually admitted to a local four year university, receive both a diploma from RHSHS and an associate degree from the university at the time of graduation, and then have the opportunity to seamlessly transition into the university’s BSN (nursing) or Bachelors of Health Sciences (MI, ST) programs. The role as Director of a School of Health Sciences requires that Dr. Rahn work with a variety of program accreditation agencies.

Dr. Rahn has held multiple roles in professional and academic settings including staff nurse, Assistant Head Nurse of an inpatient psychiatric setting, Nurse Manager of an inpatient oncology unit, nursing program faculty, curriculum coordinator, director of a nursing program, and her current role as Director of the School of Health Sciences. She was awarded two grants to increase the use of simulation pedagogy in nursing education. Dr. Rahn has held a variety of leadership roles especially in the areas of ethics, nursing education, and nursing research. Debbie Rahn is a founding member of the Berks Regional Nursing Research Alliance, a grassroots organization representing multiple academic and practice partners, and designed to engage nurses in research and evidence base practice in a geographic area void of a major academic research institution. Dr. Rahn has a long-standing interest in bio-ethics, and currently serves as the vice-chair of the Reading Health System Ethics Committee. One of Dr. Rahn’s research interests is in the role of nursing teamwork related to patient outcomes including nurse-sensitive patient outcomes. She has presented at a variety of local, regional and national conferences, and her research on Transformational Teamwork has been published in the Journal of Nursing Care Quality (JNCQ).

Dr. Rahn is a member of multiple professional organizations and has served the profession on state and national committees including Pennsylvania Coalition for the Advancement of Nursing Education (PCANE), Pennsylvania Academic Progression in Nursing (PAPIN), National Education Progression in Nursing Collaborative (NEPIN), Hospital Association of Pennsylvania task force on healthcare workforce, and was the former co-chair for the Pennsylvania Southeast II Regional Action Coalition, addressing recommendations related to nursing education from the Institute of Medicine’s The Future of Nursing: Leading Change, Advancing Health, (IOM, 2011).


Vivian Yates
(Nurse Educator)

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Dr. Vivian Yates, Ph.D., RN has served as the Dean of Nursing at Cuyahoga Community College in Cleveland, Ohio since 2013. She is responsible for the management of a multi-campus nursing program that includes practical and associate degree nursing programs with traditional, LPN to RN, and accelerated tracks. Over 800 students are enrolled in the programs with 42 full-time faculty.

With over 35 years in the nursing profession, Dr. Yates has a background in clinical nursing, academia, nursing administration, and nursing program accreditation. Her clinical background is medical-surgical and psychiatric nursing, serving in both clinical and managerial positions in hospital settings. She has over 25 years of teaching and administrative experience in nursing education; teaching in baccalaureate, associate degree, and practical nursing programs. Her research background includes examining the various facets of cultural diversity in nursing and health care.

Dr. Yates has extensive experience in the area of nursing education accreditation. She served as the Associate Director for Program Accreditation Support for the Accrediting Commission for Education in Nursing (ACEN) in Atlanta, Georgia from 2009 – 2011. She began serving as a site visitor in 1997, and served on several Evaluation Review Panels from 2000 – 2009. She has served as a consultant for nursing programs across the country and has presented at national forums on nursing program accreditation.

Dr. Yates is a member of several national and state nursing organizations including the American Nurses Association, the National League for Nursing, the Ohio Council of Associate Degree Nursing Education Administrators, and the Organization for Associate Degree Nursing. She has served as vice-president and president of her local chapter of the Ohio Nurses Association. She is a member of several nursing advisory boards in northeast Ohio, and serves on the Board of Directors at University Hospitals in Cleveland.

Dr. Yates earned an associate’s degree in nursing at Lorain County Community College, a bachelor’s degree in nursing at the University of Akron, a master’s degree in nursing at Kent State University, and a PhD in education at the University of Akron.


Kathleen Zajic
(Nurse Educator)

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Dr. Kathleen Zajic, EdD, MSN, RN is Professor of Nursing at the College of Saint Mary (CSM) in Omaha, Nebraska. In her 28 years at CSM, Dr. Zajic has served in many administrative and appointed roles including Professor of Nursing, Director of Undergraduate Nursing, Chair of Health Professions, and the Associate Dean of Health Professions. Her career path and roles have been diverse but Dr. Zajic has a passion for nursing education and finds her true home in the classroom and clinical settings. In addition, Dr. Zajic has assumed a variety of appointed and elected roles within the nursing program, division, and college-wide committees; including being elected by her peers to serve as Chair; Faculty Assembly Council.

Dr. Zajic earned her EdD (with an emphasis in Health Professions) from the College of Saint Mary, her MSN (with an emphasis in Community Health Nursing and Nursing Leadership and Management) from the University of Nebraska Medical Center, and her BSN from Creighton University. Dr. Zajic has expertise in curriculum design, program evaluation, leadership, and community health nursing. Dr. Zajic has also served as a consultant within and outside of nursing on curriculum development, design, implementation, program assessment, and an array of public health initiatives.

Dr. Zajic has served as an ACEN site visitor since 2013, ERP chair since 2018, and was a member of the ACEN Standards and Criteria for Transition to Practice Task Force from 2016-2018. Dr. Zajic was elected to the Board of Commissioners in 2016, serving as the Chair of the Substantive Change committee since 2017. Dr. Zajic is a member of several professional organizations including Sigma Theta Tau International, Gamma Pi Chapter, the National League of Nursing, and the National Association of Local Boards of Health. Dr. Zajic provides extensive community service, serving as past chair for the Pottawattamie County Board of Health, Saint Albert School system Wellness Initiative Committee, and the Visiting Nurse Association (VNA) Nurse-Family Advisory Board. When Dr. Zajic is not in the classroom or clinical area she can be found providing health care services to the underserved and vulnerable populations in the Omaha metropolitan area.



By Appointment to the Nominating Committee

Betty Damask-Bembenek
(Nurse Educator)

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Dr. Betty Damask-Bembenek, EdD, MN, RN has 35 years of nursing experience in a variety of nursing healthcare settings and 20 years of experience as a nurse administrator and educator at several universities and community colleges in the western region of the U.S. Nursing has provided me with a diversity of many great experiences and nursing education is one of the most rewarding of all. The diversity of these experiences has enhanced my skill sets to create quality in nursing educational programs through structural empowerment and an inclusive environment for all stakeholders in a variety of settings.

Dr. Bembenek has been Director of Nursing Education at Colorado Mountain College since 2009, and serves as the Dean for the School of Nursing, Health Science and Public Safety. At Metro State University, she was part of the faculty for the BSN program. Dr. Bembenek served as nurse administrator and faculty member at Weber State University and Division Chair of Nursing and Health Sciences at Salt Lake Community College. Areas of teaching and clinical practice have included nursing administration, education, emergency and trauma services, medical/surgical, obstetrics, critical care and rural nursing.

Dr. Bembenek has actively participated as a program evaluator and evaluation review panel member for the Associate Degree Programs and the combined AD & BSN panels for the Accreditation Commission for Education in Nursing (ACEN) for several years. Serving on the Board of Commissioners for associate degree programs would be an honor and privilege to support continuous improvement for nursing education.

Education Background:

  • Doctoral of Education: Ed.D. in Organizational Leadership, Northcentral University, Prescott, Arizona
  • Master of Nursing: Management, University of Phoenix, College of Nursing, Salt Lake City, Utah
  • Bachelor of Science in Nursing, Marian College, Fond Du Lac, Wisconsin
  • Associate of Science in Nursing, North Central Technical College, Wausau, Wisconsin


Each Commissioner will serve a three-year term from October 1, 2019 through September 30, 2022. The exception is Shari Gholson, who will serve from October 1, 2019 through September 30, 2021. The two-year term has the same expectations as the three-year; it is meant as a one-time occurrence to expand the number of nurse educators on the board to a total of 11. The 17 Board of Commissioner represent the following roles: 11 nursing education representatives, 3 nursing service representatives, and 3 public representatives. This diversification ensures the ACEN Board of Commissioners are able to give balanced representation from across identified constituencies insofar as possible.

The Board of Commissioners is a governing board and has the authority of a governing board, which is (1) ensuring the financial resources of the ACEN such as setting the fee schedule, budget, and reviewing the audit; (2) setting policy such as the policies found in the Accreditation Manual and the Standards and Criteria; and (3) most importantly, having the sole authority to determine the accreditation status of nursing programs. Members of the Board of Commissioners also serve as Chairpersons at Evaluation Review Panels, guiding the panelists through discussions and asking for status recommendations. We are very excited to congratulate our new and returning members of the Board of Commissioners!

Clarify, Verify, Amplify


By Donna Meyer, MSN, RN, ANEF, FAADN  |  CEO  |  Organization for Associate Degree Nursing; And Cynthia Maskey, PhD, RN, CNE  |  Treasurer  |  Organization for Associate Degree Nursing
Bridges, Volume XIII – Issue 2, June 2019

As a nursing program prepares for an ACEN site visit, it is important to keep two things in mind. One, nursing program accreditation is an important subject for nurse educators in recognizing the importance of continuous quality improvement; two, be clear in the explanations of the information and let your light shine! Nurses are hard-working, organized, dynamic, and humble. Nurse educators and administrators, which comprise the Organization for Associate Degree Nursing’s (OADN’s) membership, achieve great things but too often do not take credit for their efforts and accomplishments. The peer evaluators will arrive in the ACEN mindset that their task is to CLARIFY, VERIFY, & AMPLIFY the information that your program has provided for them. Careful thought should be given as to how to assist in this task.

Full faculty involvement is imperative throughout the accreditation process. Faculty should be involved early in writing the Self-Study Report and, very importantly, helping to gather the evidence that supports what is written. Faculty and administrators should work together to review the documents for clarity. Documents should be viewed through the lens of an outside peer evaluator. This can be difficult when one is working within the program day-in and day-out, but an attempt should be made to make sure that information is comprehensive and, again, clear. Sometimes what makes perfect sense to someone working within a curriculum might take a little bit of explanation to someone unfamiliar.

Remember that the preparation for the site visit is the time to point out what makes the nursing program special, exceptional, and successful! Each program has unique challenges and achievements within their communities. Those should be noted and amplified. The site visit is the time to recognize areas where the program may need to do better, but also to celebrate those ongoing accomplishments and the needs met in the community.

OADN formed a partnership with the ACEN because we believe that “accreditation not only serves the public as a measure of quality for healthcare employers and academic partners of associate degree programs, but also is an assurance of quality educational standards applied to faculty, staff and students.” OADN believes in the quality of associate degree programs. The site visit is truly an opportunity to demonstrate all that your programs have to offer. Through individual program accreditation, we also take an important step in collectively recognizing the excellent nursing education delivered by associate degree nursing programs across our nation.

Five Tried and True Tips for a Successful Site Visit


By Susan Thornock, EdD, RN  |  Chair, Annie Taylor Dee School of Nursing  |  Weber State University
Bridges, Volume XIII – Issue 2, June 2019

Recent discussion with other healthcare programs in our Dumke College of Health Professions on the Weber State University Campus, in Ogden, UT led to comments laced with humor and expressions of sympathy when the topic of nursing accreditation was mentioned. Accreditation for our Annie Taylor Dee School of Nursing has become legendary at our mid-sized university.

Over the past 10 years, our Annie Taylor Dee School of Nursing has hosted peer evaluators several times—three were site visits and the others were focused visits for a new program, added location, or change of curriculum. We are beginning a Doctor of Nursing Practice program in Fall 2019 and will then be sure to have another visit within the next year or two. With each visit we learn something new, something to be applied to our continuing growth and progression in nursing education. Considering all that could be shared, and there are many tidbits, there are five main areas of focus that I would consider key to a successful visit.

Primary to everything else is to arm yourself, your faculty, and your campus administration with as much knowledge as possible. The ACEN makes this abundantly easy with a comprehensive website and open access to experts. There is always someone at the end of the telephone or readily available through email to respond to any questions. There is no question too stupid to ask, and you are always made to feel like you are brilliant and your questions are valid. Never hesitate to take advantage of this support. Becoming very familiar with the website and how to navigate through the information is crucial. This should always be the first source as almost all questions can be answered at this site.

Of equal importance is to create a team of faculty, make sure you include all faculty, and add students to that team. From my perspective as a chair, I consider this the biggest catapult to a successful site visit. Our site visit 10 years ago was one person trying to provide everything necessary for 40 faculty and several hundred students. The failure of that visit was due to the process, not the individual. Our most recent site visit had 60 staff and faculty armed with knowledge and with the expectation to be fully involved. The outcome of that visit was a successful visit, happy and engaged faculty, and a place on Maslow’s Hierarchy that could be nearing self-actualization.

The third suggestion to a successful outcome is to create your own experts. The best way to do this is to make sure all faculty are encouraged to become peer evaluators. Faculty that have been involved in a site visit as a peer evaluator are absolutely necessary in the refining process before the peer evaluators arrive, while they are there, and in the follow-up after everyone has gone home. Try not to disregard practical experience when it comes to accreditation. You can be assured that the ACEN will help with this endeavor and will welcome and train your faculty willing to become peer evaluators.

Fourth is finding your balance—what needs to be displayed or presented as opposed to what you want to present. There is some wisdom in understanding the difference in what the ACEN peer evaluators will want to see and what you might want to show them. An over-abundance of information, or information that is disorganized, will only confuse and frustrate your peer evaluators. A word of caution: if you are confused, they are too. A practice run with your faculty experts is always a good idea.

Last, it really does not matter how confident you feel, how well-prepared you think you are (or are not), your environment will be disrupted when your peer evaluators arrive. I am one to believe disruption does, in many instances, lead to good things. In my opinion, disruption is a cousin to the chaos theory, and with the right care, proper attention, and a good deal of teamwork, the outcome can help advance our desire to provide the best nursing education possible. That is after all, one of the objectives and a most desired outcome of the ACEN. Good luck with your next site visit!

The Site Visit


By Suzette Farmer, PhD, RN  |  Director  |  ACEN
Bridges, Volume XIII – Issue 2, June 2019

Now that the program has written its Self-Study Report (SSR), collected and organized its supporting documentation, and planned the visit agenda with the team chair, it’s time for the visit to occur. The site visit is a critical and necessary step in the peer review process. The goal of the onsite peer evaluators is to determine the extent to which the program is in compliance with the ACEN Accreditation Standards and Criteria. The peer evaluators will read the program’s Self-Study Report prior to the visit and, once onsite, they will verify, clarify, and amplify the program’s compliance with the Standards and Criteria. The peer evaluators will write a report, called the Site Visit Report (SVR), in which they will document their findings about the program’s compliance and they will make their accreditation recommendation regarding the program’s accreditation status. The team will also identify any areas of non-compliance and/or areas needing development for each Criterion. The purpose of this brief article is to provide an overview of what the program faculty and administrators can expect when the peer evaluators are onsite.

As confirmed with the site visit team chair, the team will arrive at the nearest airport and the program will provide or arrange for transportation of the peer evaluators to the hotel where they will stay during the visit. The program is responsible for providing or arranging all transportation for the team throughout the visit, including daily transportation from the hotel to campus and vice-versa, transportation to clinical sites, and transportation to the airport at the end of the visit. Remember that peer evaluators will have luggage when they arrive and depart, and most will carry bags with their laptops on a daily basis; make sure there is adequate room for people and paraphernalia when transporting the site visit team!

The site visit team will meet face-to-face for the first time at the airport or after they arrive at the hotel. During this initial meeting, the team will review their assignments and the program information they have reviewed to date. Typically, a peer evaluator will be assigned two Standards for which they are assigned primary accountability for evaluation during the visit and for describing the program’s compliance with the assigned Standards in the SVR. Based on each individual’s review of the SSR prior to the visit and their assigned areas of responsibility, the team will discuss their preliminary findings and areas for clarification, and they will review the planned agenda during their initial face-to-face meeting. Not all site team members will be involved in all scheduled meetings and observations during the visit. The team chair will review the agenda with the nurse administrator at the start of the visit and adjustments to the agenda may be requested in order to ensure each team member has the opportunity to comprehensively evaluate their assigned Standards.

For most site visits, peer evaluators will be onsite for two full days and part of a third day. Under the leadership of the team chair and based on the site visit agenda and their assigned areas of responsibility, the peer evaluators begin the work of verifying the program’s compliance with the Standards and Criteria as soon as they arrive onsite on the first full day of the visit. Site visits are fast-paced and often intense for both the program and the peer evaluator! The nurse administrator, program faculty, students, institutional administrators and support staff, and identified stakeholders (e.g., clinical agency representatives) should expect to be asked many questions. Peer evaluators ask questions to ascertain and verify the accuracy of what they read in the SSR and to ensure they clearly understand: the roles, responsibilities, and expectations of the nurse administrator and faculty; the curricular design, organization, and delivery, including practice learning for all program types; student support services and policies; compliance with the Higher Education Reauthorization Act, Title IV; sufficiency of fiscal, physical, and learning resources for students and faculty; and program evaluation/improvement processes based on student learning outcomes and program outcomes. In addition to asking questions, peer evaluators will review supporting documentation (e.g., meeting minutes) provided by the program to evaluate the program’s compliance with the Standards and Criteria. Peer evaluators may also request additional supporting documentation if questions arise during interviews or document review processes. It is possible these requests could be for items already provided in the evidence room, which the team may need assistance locating.

The nurse administrator and program faculty can anticipate answering a multitude of questions, and they should anticipate that many of the same or similar questions will be asked throughout the visit as the peer evaluators check and double check information. The nurse administrator should anticipate being asked to secure additional documentation and to explain the institutional and program policies and processes. The team chair is expected to keep the nurse administrator informed about any identified concerns in order to allow the program time to provide additional documentation and/or information to clarify and address any questions or concerns the team identifies during the visit.

You may have heard the ACEN mantra that the purpose of the site visit is to verify, clarify, and amplify…but not terrify! While any evaluation process can be intimidating and stressful, the ACEN and your peer evaluators are committed to evaluation processes that are fair, consistent, and collegial. Ultimately, nurse administrators and program faculty who have completed an honest and comprehensive evaluation of their program’s compliance with the Standards and Criteria will not be surprised by the findings and recommendations from their peers. Once your peers have shared their preliminary findings and recommendation for accreditation at the exit meeting on the last day of the visit, they will depart for the airport and the nurse administrator and program faculty should celebrate the completion of this step in the peer review process!

Preparing for a Site Visit


By Katrina Woody  |  Process Development and Content Editor  |  ACEN
Bridges, Volume XIII – Issue 2, June 2019

Preparing for a site visit takes teamwork and time and, if preparation was not started in advance, the process may seem daunting to some. A mantra at the ACEN is to verify, clarify, and amplify, not terrify! Below is are some thoughts for helping you and your colleagues take a deep breath as your team begins the accreditation journey, whether it’s your first time or your fifth.

Some Thoughts on Preparing the Self-Study, Focused Visit, and Follow-Up Reports:

The typical accreditation time-frame is eight years for continuing programs and five years for initial programs. Advanced planning is needed to produce the site visit report and prepare for the actual site visit. For instance, Standard 6 Outcomes requires ongoing assessment of outcomes at continuous, regular intervals and Criteria 6.2, 6.3, and 6.4 requires three years of data for programs seeking continuing accreditation. Therefore, the nursing faculty must be continuously collecting and analyzing job placement, program completion, and pass rate data, which means the assessment of these outcomes will always be ready for a site visit regardless of when the visit is scheduled. For Criterion 6.1, the faculty must identify an analysis cycle for the end-of-program student learning outcomes that will occur at regular, ongoing intervals (e.g., every year to no more than five years). In support of the analysis cycle, collection of assessment data for each end-of-program student learning outcome should be made at regular intervals to ensure sufficient data is available. For example, the first two end-of-program SLOs are reviewed in the first year of the analysis cycle, then the next two are evaluated in the second year, and the process continues until all the end-of-program student learning outcomes undergo the entire assessment process.

Every institution uses different planning timeframes and the budgeting process at your institution may begin 12 to 24 months before your site visit. Make sure the funds needed for your site visit are included in the budget. Advanced planning ensures expenses incurred are not overlooked. For example, site visit costs are more than accreditation fees; there’s also the onsite cost of peer evaluators, and, depending on choices made on writing your report, the cost of faculty and staff overtime, editors, or other factors need to be considered.

The type of report will determine who needs to be involved. Experience suggests using a self-study steering committee and subcommittees approach is effective and efficient. Consider dividing writing the narrative and gathering evidence by Standard and setting clear timelines for each step, including editing and proofreading. Consider each nursing faculty members’ strengths and make assignments accordingly. For example, some nursing faculty members love data and assessment, therefore, Standard 6 Outcomes would be the perfect assignment, whereas, Standard 2 Faculty and Staff would be the perfect assignment for someone detail- and policy/procedure-oriented. Experience also suggests, the more complex the report, the more stakeholders that need to be involved. Consider involving your students, graduates, and other colleagues such as advisory committee representatives and clinical agency representatives to assist in writing your report. Also, ask your colleagues in the financial aid office, the business office, the library, and in student services to help write some sections of your report. For example, colleagues in the financial aid office can assist with Standard 3 Students, specifically in Criterion 3.6; business office colleagues can assist with Standard 5 Resources, specifically Criterion 5.1; and colleagues in student services can assist with Standard 3 Students, specifically Criterion 3.4.

Your report is the opportunity to tell the story about your program’s compliance with the ACEN Accreditation Standards and Criteria. It also serves as a critical point of reference for your peer evaluators, and as such, your report must be accurate, clear, and well-planned.

Some Thoughts on Pre-Visit Communications with the ACEN:

Two years before your program is scheduled for its site visit, the nurse administrator will receive a formal reminder from the ACEN. This emailed document serves as the catalyst for the accreditation review process. It serves as a reminder regarding factors such as, if not already started, your report needs to be drafted, fees considered, important dates that students are off-campus (e.g., Spring/Fall Break, holidays, school closures, etc.) reported, and the Information Form for Accreditation Site Visit must be submitted to the ACEN no later than the date provided in the reminder letter.

The information form is required as it confirms that your program is requesting a site visit in the assigned cycle. The information form also provides important demographic information to the ACEN, such as how many students are enrolled, percentage of distance education used, number of program locations, and other information used to determine the number of peer evaluators needed, matching peer evaluators’ experiences with your program, and which dates are appropriate for the site visit.

For programs seeking initial accreditation, your official letter from the ACEN confirming Candidacy status serves as your reminder to submit your information form. This form is due one year prior to the cycle in which you wish to have your initial visit. Just keep in mind, Candidacy expires after two years of being approved for Candidacy!

Your nursing program impacts the surrounding community, so don’t forget the required public meeting. A public meeting is a meeting during the site visit that is hosted by the nursing program for community members to share their thoughts regarding the program and the graduates who serve the community. Announcements for the public meeting must be made available six weeks in advance of the site visit. If members of the public are unable to attend the public meeting, they may submit a written third-party comment to the ACEN CEO prior to the site visit.

Some Thoughts on Helpful Resources:

The ACEN wants your program to be the best it can be and to succeed in achieving accreditation. A multitude of opportunities are provided for your accreditation journey. The ACEN offers the Self-Study Forum, offered a few times a year in different locations for your convenience. The Forum is an opportunity to dive into the current Standards and Criteria, earn continuing education units, and learn from real-life examples, guidance, and information about the Standards and how to accurately represent your program in your report.

Another great learning opportunity provided is the Program Administrator Workshop, which is geared toward inexperienced program administrators (e.g., nurse administrator, coordinators, faculty with release time for administrative duties, etc.) to help transition into their role and understand information related to ACEN accreditation policies and processes. Information provided here helps acclimate new program administrators to the ACEN and your new work family.

Added in 2018, was the ACEN Annual ConferenceIOh ok to your repertoire of helpful resources. The Conference is a new and exciting way to jump into accreditation at any time! Additionally, if you’re in the process of preparing for a site visit, our exclusive Knowledge Café, which is offered at the Conference, is a great resource. This café allows you access to exemplary Self-Study Reports, Follow-Up Reports, Focused Visit Reports, and more. Additionally, the Conference’s Human Library is available to “checkout a professional;” this includes the opportunity to talk with an ACEN professional staff member or a member of the ACEN Board of Commissioners for greater insight into the accreditation process.

Other resources available include the ACEN website; Advisory Review, which is a one-time opportunity for a program to receive feedback from an ACEN professional staff member regarding a draft of accreditation documents like the Self-Study Report and others; Observer opportunities; a Nurse Administrator Checklist; a pre-site visit conference call for initial programs; and a growing library of webinars to help you prepare!


Yes, preparing for an accreditation site visit takes time and teamwork. However, by taking advantage of the ACEN as your supportive partner, your site visit can be less stressful!

Mingle with Marcy, June 2019


Your CEO Answers Frequently Asked Questions

By Dr. Marcy Stoll, EdD, MSN  |  CEO  |  ACEN
Bridges, Volume XIII – Issue 2, June 2019

How does the ACEN decide which peer evaluators visit which programs?

A site visit is conducted by peer evaluators from the same type of nursing program as the nursing program being visited (e.g., associate, master’s, diploma, practical), and to the extent possible matching institutional characteristics such as public, private, for-profit, not-for-profit, Carnegie classification, size, and setting (rural/suburban/urban).

Typically, there are (a) three peer evaluators on an initial accreditation site visit and the routine cyclical continuing accreditation site visit and (b) less than three peer evaluators on a follow-up site visit and focused site visit. Regardless of the type of site visit, the number of peer evaluators may increase for any site visit based on the intricacies of the nursing program being visited. Intricacies considered are:

a. Domestic vs. International site visit;
b. Number of nursing programs (one program or multiple programs) being reviewed during the site visit;
c. Number of faculty and students;
d. Geographic distance between main campus and all off-campus instructional sites, if applicable; and
e. Distance education, if applicable.

The location of a peer evaluator and the location of the site visit are considered in selecting peer evaluators to keep travel costs as low as possible. Additionally, the experience of team members and the team chair is considered. Almost everyday, someone becomes a new peer evaluator or a new team chair upon completing the ACEN online peer evaluator training program or the team chair training program. In efforts to best prepare these new peer evaluators and new team chairs, site visit teams are composed of experienced members and only one newly trained member.

Conflicts of interest are also considered in selecting peer evaluators per ACEN Policy #1 Code of Conduct and Conflict of Interest. In all circumstances, peer evaluators must avoid actual conflicts of interest and also the appearance of conflicts of interest.

How are concerns addressed during the site visit?

The purpose of the site visit is for peer evaluators to determine the extent to which the nursing program meets the Standards and Criteria being reviewed by clarifying, verifying, and amplifying the narrative and evidence presented in the program’s report. Based on findings, your peer evaluators visiting the nursing program will make an accreditation recommendation.

Six weeks before the site visit, your peer evaluators on the site visit team began their review upon receipt of the program’s report. Typically, peer evaluators develop a list of “tell me more” questions as they study the program’s report. Often during these six seeks, your peer evaluators may request information not included in the program’s report from the nurse administrator of the program that may answer their “tell me more” questions.

During the site visit, your peer evaluators will meet with many stakeholders such as students, nursing faculty, nurse administrator, administrators, general education faculty, non-nursing colleagues, communities of interest, and members of the public. In these meetings, your peers will ask verifying, clarifying, and amplifying questions related to the attendees’ expertise and knowledge of the nursing program. For example, the president will likely be asked questions related to Criteria 1.1, 1.2, and 5.1; financial aid coworkers understand the information addressed in Criterion 3.6; and student services colleagues can answer questions related to Criterion 3.4.

During any site visit, your peer evaluators will tour physical facilities and talk with stakeholders during the tour. For example, your peer evaluators will tour the library to verify the print and electronic resources described in the Self-Study Report are available to the nursing students and nursing faculty members. Another example is, your peers will ask library staff questions about how the nursing faculty have input into the selection of resources.

During any site visit, your peer evaluators will continue their review of the evidence provided before the site visit as well as evidence provided during the site visit. Be prepared to provide evidence not prepared in advance of the site visit. For example, during a meeting someone may mention a document that was not already provided to your peer evaluators.

Throughout the site visit, the Team Chair and the nurse administrator will talk often. Typically, the Team Chair will meet, at minimum, with the nurse administrator at the end of each day to share a progress report. The purpose of these meetings to help facilitate communication between your peer evaluators and your primary program representative – the nurse administrator.

Your peer evaluators will repeat their questioning, touring, and reviewing process throughout the visit. This provides multiple opportunities for (a) program representatives to verify, clarify, and amplify information about the program and (b) your peer evaluators to understand the nursing program as much as possible to develop their independent analysis and make as accurate as possible a professional judgment on the nursing program’s compliance with the Standards and Criteria being reviewed.

On the last day of the visit at the Exit Meeting, your peer evaluators will share their findings, which may or may not include Strengths, Areas Needing Development, and Areas of Non-compliance. Your peer evaluators will also share their accreditation recommendation.

Per the ACEN Glossary:

  • Area Needing Development – Peer evaluators determined based on their professional judgment that evidence demonstrates the nursing program is in compliance with an Accreditation Standard; however, evidence also demonstrates that an opportunity for improvement is available to enhance the quality of the nursing program.
  • Non-compliance – Peer evaluators determined based on their professional judgment that evidence demonstrates the nursing program is not in compliance with an Accreditation Standard.
  • Strength – Peer evaluators determined based on their professional judgment that evidence demonstrates something extraordinary, significantly exceeding common practice in the nursing program

The peer review process will continue through remaining two steps – Evaluation Review Panel and ACEN Board of Commissioners. Your Board of Commissioners has the sole authority to determine the accreditation status of nursing programs. If your Board of Commissioners determines a Standard is non-compliant then the noncompliance is handled through the Follow-Up Report process. Most commonly your Board of Commissioners will set the Follow-Up Report to be due 12 months, 18 months, or 24 months after their decision.