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  1. Please review the “Resources” folder in the ACEN Repository for visit information.
  • At the July 2022 meeting the Board of Commissioners approved the following change in the post-visit process. In an effort to improve the process, the Nurse Administrator Response Form (NARF) has been revised to a new “Program Response Form.” This program response is being expanded to allow faculty to respond not only to errors of fact, but also to any items the site visit team identified as needing development or non-compliance; the program will also be able to submit additional information and/or supporting evidence.
  • Additionally, the Evaluation Review Panel (ERP) meeting for Fall 2022 visits will be scheduled first week of April 2023 (this is a change from prior years). The program’s written response and additional evidence will be made available to the ERP and the Board of Commissioners (BOC) for their consideration. It is our hope this process will improve the quality of the recommendations and board decisions. Nurse Administrators for the Fall cycle will also be notified of this change by the ACEN office. However, it will be important for peer evaluators to understand these changes in case there are questions.
  • The scripts in the Resources folder of the repository have been updated to reflect these changes. Please delete any old scripts you may have and review and use the new scripts to ensure accurate communication of this change to the program representatives. The Repository also includes a Preliminary Findings and Recommendation Form, which should be completed by the Team and a copy (electronic or print) provided to the nurse administrator before leaving the visit so they can begin working on their response.
  • Programs are encouraged to being working on non-compliance issues and areas needing development after the site visit so any progress can be included in the program’s response. This should help programs to correct some issues (e.g., ELAs needing rewording; website discrepancies) prior to the ERP meeting.
  • The BOC meeting will also occur in the first week of April 2023, after the ERP meeting. Programs will receive an email regarding the BOC decision 30 days after the BOC meeting (early May). Because of the opportunity for programs to submit a more substantial response, the ERP meeting (like the BOC meeting) will be closed. Nurse administrators and/or peer evaluators should contact the ACEN if they have any questions.
  1. Programs are NO LONGER REQUIRED to mail a hardcopy of the report to each site visitor.
  • Six weeks prior to the visit, the program will upload the report and evidence into the repository. Teams will access all materials from the repository.
  1. Self-Study Report and the ACEN Repository
  • Please do not ask the program to supply information to you before you have read the report or reviewed items in the Repository.
    • We are still receiving complaints from programs reporting they are being asked to provide information before the visit that has already been provided in the report and/or repository.
    • Do not ask the NA to complete portions of the SVR or tables in the SVR. The tables in the SVR are for the site visitors to complete upon verification of the data through appropriate means.
    • Please notice most of the SVR tables also now require that you provide specific details regarding how the information was verified, which is specific to your role as the peer evaluators.
    • An unlocked “Revised or Requested Information” folder will be available six weeks before and during the visit; if additional information is requested or provided, the program should upload it to this folder.
  1. Clinical Representative Meeting
  • The onsite clinical observation has been permanently replaced with a virtual meeting with clinical agency representatives (e.g., Chief Nursing Officer, Director of Education, charge nurses, staff nurses, preceptors, and perhaps program graduates or members of an advisory committee).
  • Site visitors should treat this like any other meeting on the agenda and incorporate the information obtained from the meeting into appropriate sections of the Site Visit Report such as Criteria 2.4, 2.6, 3.8, 4.2, 4.5, 4.6, 4.9, 5.2, 5.3, 6.4.
  1. Exit meeting is OPTIONAL
  • Though most programs do like to have a formal exit meeting, the only required final meeting is with the nurse administrator to review findings and provide the recommendation.
  • The nurse administrator may prefer to only have the private exit meeting with the team, or they can elect to also include on the agenda a formal exit meeting and invite whomever they wish to be present. It is the NA’s meeting, and they decide who is present.
  1. Site Visit Report (SVR) Template
  • Revisions to the template have been made based on feedback and new guidance from the Department of Education; so, you will notice some changes.
  • The tables and prompts have been included to assist you with the completeness of the narrative- Please use them! If you are unclear about what a prompt means, please contact an ACEN Director.
  • When referring to evidence in the repository, use the title of the document (e.g., “College Organization Chart”) and/or a description of the content (e.g., “detailed curriculum map with course and EPSLOs”); do not use references such as “Exhibit 1.5”, “Appendix 4.1b”.
  • Remember, the program’s report itself is not the evidence reviewed, it is the program’s story regarding compliance. It is the interviews, tours, and supporting evidence that peers use to verify, clarify, and/or amplify information when writing the SVR; these are the items that should be referenced in the narrative to support your findings.
  • Data provided by the program in their report (such as program credits and program outcome data), need to be verified by the site visitors; how this information was verified should be described in the SVR narrative.
  • ELAs- We continue to see teams giving Areas Needing Development (AND) for programs that have not consistently met their ELA for EPSLOs, program completion, and/or job placement. Please remember, Standard 6 Outcomes is about quality improvement, and we ask programs to set a realistic and genuine ELA. However, because program faculty are worried about getting an AND or even Non-Compliance for not meeting their own ELAs, some are artificially lowering the ELA so that it is always met. So, teams are encouraged to use their professional judgement when determining whether an AND is needed. Here are some examples for your consideration:
    • A program set a high ELA (60%) for on-time completion; however, they did not meet it for one of the three years of data provided. The team should be looking to see if there was a faculty analysis and actions if appropriate (as it could be anomaly; or, recently, many programs have seen a decrease in completion related to the pandemic). In this case, the team may determine that the program is responding appropriately to the data and using the data for program improvement and the one-time drop does not rise to the level of an AND.
    • A program has a decline in examination pass rate to 70% for 2020 and 75% for 2021 (likely due to the pandemic) but took actions and the rate is now up above the 80% for 2022- this is exactly what we would expect. Therefore, giving an AND may not be appropriate since the program did what is expected and saw the benefit of that based on the trend and now has corrected the issue.
    • A program set an ELA of 70% for job placement and data show they are meeting it consistently in the 90% range. In this case the ELA may be unnecessarily low and an AND could be appropriate to encourage the program to reconsider a more genuine ELA.

    In other words, if the faculty are using their data and the SPE process appropriately when the ELA is not met, this is what we expect them to do. Just because some conforming language exists, it is the team’s decision as to whether or not an AND is needed for the particular program reviewed.

  1. Verification of qualifications (nurse administrator, faculty, and staff)
  • Job descriptions should be reviewed for the NA, program coordinators, faculty, and all staff so qualifications can be summarized in the SVR tables.
  • If these items were not provided, the Team Chair should request them to be uploaded to the “Revised or Requested Information” folder in the Repository so that the team can confirm requirements.
  • The team should then verify that all individuals in these positions meet the job requirements.
  1. Programs should now have transitioned to on-time program completion.
  • However, teams should not expect there to be three years of on-time data. Some programs may have recently transitioned an only have one year of on-time data.
  • If the program has not transitioned, the team should discuss an Areas Needing Development. Please note: programs may continue to collect/report additional data points such as 150% or ultimate completion rates in addition to on-time, which can be discussed in the SVR narrative to provide additional context regarding student success.
  1. Beginning May 3, 2023, every air traveler 18 years of age and older will need a REAL ID-compliant driver’s license, state-issued enhanced driver’s license, or another acceptable form of ID to fly within the United States. Details here:


Additionally for Team Chairs:

  • Please contact the nurse administrator as soon as reasonable after receiving the site visit confirmation to begin planning and alleviate anxiety for the program. Many teams have had late confirmations due to volunteer shortages and the nurse administrators have been getting anxious.
  • Please request and review of the draft agenda from the nurse administrator to ensure it includes all required agenda items for the visit type, and appropriate breaks and travel times between meetings.
  • Please discuss the plan for review of faculty and student files with the nurse administrator as part of the visit planning (paper or electronic onsite or electronic in repository) which may impact the agenda; guidelines are available on the ACEN website:
  • Finally, please remind the Nurse Administrator and faculty that the new 2023 ACEN Standards and Criteria are now available and that all programs must transition to the new Standards by January 1, 2024.

For any questions, please contact one of the ACEN directors:

Suzette Farmer
Office: (404) 975-3090
Cell: (404) 803-7706
[email protected]

Nell Ard
Office: (404) 975-5004
Cell: (404) 803-7329
[email protected]

Keri Nunn-Ellison
Office: (404) 975-5008
Cell: (404) 805-0985
[email protected]