ACEN Accreditation Manual – Policy 32


ACEN Accreditation Manual – Section II Policies

Observer On Site Visit Team

A nursing program beginning its initial or continuing accreditation review process may designate one person who is to be allowed to accompany a site visit team to observe and learn from site visit team activities and from the review process experience of persons at the host nursing program.

  1. A site visit team may have only one observer and that observer may not have any conflict of interest as defined by ACEN Policy #1 Code of Conduct and Conflict of Interest.
  2. All host nursing programs must agree to have an observer accompany the site visit team.
  3. The ACEN cannot guarantee that all requests can be honored due to the variability in the number of scheduled site visits.
  4. Requests to have an observer accompany the site visit team will be filled on a first-come, first-served basis; nursing programs that agree to host an observer will receive priority.
  5. All requests must be submitted to the ACEN staff member assigned to manage the observer process.



  1. All observers are under the same obligation as site visit team members regarding the maintenance of confidentiality of the governing organization/nursing program information, materials, and committee discussions and proceedings. See ACEN Policy #1 Code of Conduct and Conflict of Interest.
  2. Every effort will be made to ensure that the observer receives from the nursing program, in advance of the visit, the same information and materials that site visit team members receive from the nursing program.
  3. Every effort will be made to ensure that the observer is included in all ACEN pre-site visit conferences.
  4. The observer is expected to make his/her own travel arrangements and to inform the host nursing program and site visit team chair regarding those arrangements. It is customary for the host nursing program to arrange to meet committee members at the pre-arranged airport, train station, or bus station, and transport site visit team members to the place of lodging. It will normally be possible to include observers in these arrangements.
  5. Reservations for hotel rooms are customarily made by the host nursing program. The ACEN staff, in communicating with the host nursing program about the observer, will request that the host nursing program make a reservation for the observer as well. If the observer elects to make other arrangements for housing, the ACEN and the host nursing program must be informed of that fact. It is recommended that the observer stay at the same place of lodging as the site visit team so as to facilitate prompt attendance at all committee meetings, make most effective use of local travel arrangements, and maximize interaction with the site visit team members.
  6. Neither the ACEN nor the host nursing program is responsible for any expenses (e.g., travel, lodging, meal, etc.) incurred by the observer in connection with observing the site visit team process. All expenses must be borne by the observer and/or the observer’s governing organization/nursing program.
  7. The observer is expected to arrive in time for the organizational meeting on the first day of the site visit and remain for the duration of the visit as well as be punctual for all committee activities scheduled by the site visit team chair.
  8. Observers should not be assigned any responsibility for data gathering, evaluation, or writing of the Site Visit Report. The extent of verbal participation by the observer in executive sessions of the site visit team is at the discretion of the site visit team chair.
  9. Site visit team members have a full agenda and limited time in which to carry out their responsibilities. It is anticipated that there will be numerous opportunities for the observer to interact with site visit team members as they fulfill their responsibilities; however, the observer must be flexible.
  10. If the observer arranges to accompany a site visit team member on an interview, the observer should behave in a discreet manner so as not to interfere in any way with the site visit team member’s ability to meet his/her responsibilities as a peer evaluator.


Policy #32 History
Developed October 2016

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