ACEN – Around the World

ACEN – AROUND THE WORLD

By Nell Ard, PhD, RN, CNE, ANEF | Director | ACEN
Bridges, Volume XIII – Issue 3, August 2019

Were you aware that the ACEN has nursing programs accredited around the world? The ACEN has a long history of accrediting nursing programs in the United States – since 1938. The ACEN also accredits nursing programs in United States territories, including: Puerto Rico, the Virgin Islands, and Guam. The first program in Puerto Rico accredited with the ACEN was in 1963; currently, there are over 20 accredited nursing programs in Puerto Rico with other programs pursing the accreditation process. The University of the Virgin Islands was initially accredited in Fall 1987, while the University of Guam was initially accredited in Fall 1996.

The ACEN has been recognized as an accrediting agency by both the United States Department of Education (USDE) since 1952 and the Council for Higher Education Accreditation (CHEA) since 2001. With the CHEA recognition, the ACEN has the opportunity to accredit nursing programs internationally, since the ACEN is the only nursing accrediting agency recognized by CHEA. It is the CHEA recognition that allows the ACEN to accredit international nursing programs.

The first international nursing program was accredited by the ACEN in 2000; however, it was not until 2010 that the ACEN initially developed and released a position statement regarding the accreditation of international nursing programs. Since then, the ACEN continues to seek to broaden the impact of accreditation by encompassing programs across the globe; this resulted in a revised position statement in August 2018.

Currently, there are six international nursing programs accredited, four programs with a Candidate Status, and four programs actively pursuing the Candidacy process. The countries with currently accredited nursing programs include Scotland, Saudi Arabia, the Sultanate of Oman, Turkey, and Jordan; countries having programs with a Candidate status include Jordan, Kuwait, and Columbia.

The ACEN Standards and Criteria are broad enough to enable all programs to demonstrate compliance in a variety of ways. Just as the domestic programs may differ in how they demonstrate compliance with the Standards and Criteria, the ACEN recognizes that some international programs may demonstrate Criteria achievement differently based upon nursing education in that country/region and as with some domestic programs, some of the Criteria may not be applicable.

International programs seeking and maintaining ACEN accreditation utilize the same Standards and Criteria; they follow the same peer-review process as the programs in the U.S. and its territories. International programs are also expected to adhere to all ACEN policies, including, but not limited to: reporting substantive changes, publishing program outcomes data to constituents, and submitting annual reports to the ACEN.

The ACEN provides the international nursing programs access to the same resources as domestic programs as well as access to resources specific to international programs. Additionally, the ACEN has also developed an Accreditation Manual Supplement for International Programs. The supplement provides the international programs with information regarding the candidacy process specific to international programs as well as international site visits. This supplement addresses the potential need for interpreter/translator services during accreditation visits, cultural sensitivity, and security needs during onsite visits.

The Candidacy process for an international program varies slightly with the process for domestic programs; these variations are to provide additional support and to promote success with the accreditation process. The International Candidacy Eligibility Application Form requires the program to provide additional information regarding the potential for the program to be successful with the accreditation process, including, but not limited to: information about the administration, faculty, curriculum, and finances.

Similar to domestic programs, when an international program is deemed eligible to pursue the international candidacy process, the program is assigned a professional staff member to be a mentor during the Candidacy process. The mentor works with the program during the candidacy period and assists the program faculty through the submission of the Candidacy Presentation; this presentation includes the same selected Standards and Criteria to be considered for Candidacy as the review for domestic programs. However, a variation in the international Candidacy Presentation process is the inclusion of an onsite Consulting Visit. The purpose of the onsite Consulting Visit is to verify that the program faculty and institutional administration understand the ACEN accreditation process and Standards and Criteria. Additionally, the consulting visit will verify that the program has the resources for a successful initial accreditation visit as well as maintaining accreditation once achieved. During the Consulting Visit, the professional staff members review all of the Standards and Criteria and provide the program with specific, detailed feedback to support the program in the accreditation process.

The benefits to international nursing programs to pursue the accreditation process with the ACEN include, but are not limited to:

  • Increasing the global reach of the program,
  • Helping students meet the U.S. undergraduate- and graduate-level nursing program admission requirements,
  • Facilitating the transfer of credits,
  • Providing recognition that the nursing program has been evaluated, and periodically reevaluated, by a qualified independent group of peers, and
  • Demonstrates the extent to which the program meets appropriate educational purposes and standards of educational quality specific to nursing education.

Having ACEN-accredited nursing programs around the world provides the ACEN to partner with those programs in ensuring quality nursing education is available globally. While there are many similarities in nursing education globally, having the opportunity to network with nurse educators and programs from around the world, the ACEN-accredited international programs provide depth and diversity to the ACEN and its constituents. The ACEN is the leading authority for nursing education accreditation in the United States, its territories, and around the world!

Mingle with Marcy, August 2019

MINGLE WITH MARCY

Your CEO Answers Frequently Asked Questions

By Dr. Marcy Stoll, EdD, MSN | CEO | ACEN
Bridges, Volume XIII – Issue 3, August 2019

Is a program pursuing candidacy and initial accreditation with the ACEN required to submit substantive changes?

A nursing program seeking initial accreditation must apply for Candidacy. The ACEN encourages all nursing programs to be accredited for graduates to have the maximum educational and career benefits of their education. Contrary to rumors, a nursing program does not have to have graduates or outcomes data before being accredited by the ACEN. All existing nursing programs should seek initial accreditation as soon as possible and all new nursing programs should seek initial accreditation so the first cohort of graduating students graduate from an accredited nursing program.

Programs pursuing Candidacy and initial accreditation with the ACEN must notify the ACEN of changes that occur in the program during the entire Candidacy process as both eligibility for Candidacy and Candidate status are based upon the information provided in the Candidacy Eligibility Application or the Candidacy Presentation. Changes that occur can affect the program’s eligibility to pursue the process and/or achieve initial accreditation with the ACEN. Therefore, programs must notify the ACEN of changes, which include, but are not limited to: changes in nurse administrator, change in status with the state regulatory agency or the accrediting body of the governing organization, changes in curriculum/options, potential addition of a new location, or implementation of distance education. Contact ACEN professional staff for guidance related to any change and the potential need to report a change. The ACEN must be notified of all changes no less than four months prior to the change, or as soon as possible for any unexpected changes. The notification should be in writing and should address the selected Criteria from the Candidacy Presentation related to the change (e.g., all of the Standard 4 Curriculum Criteria for a change in the curriculum and/or new option). Failure to notify the ACEN of changes may delay or jeopardize a nursing program from being approved for Candidacy, hosting an initial accreditation visit, or being granted initial accreditation by the Board of Commissioners.

Learn more about Candidacy here.

How often are programs reviewed by the ACEN after being granted initial accreditation?

Initial accreditation is the first peer review process for a candidate nursing program seeking accreditation with the ACEN. Once a nursing program is granted initial accreditation, continuing accreditation is the cyclical peer review process for an accredited nursing program to maintain accreditation with the ACEN.

The first continuing accreditation peer review process occurs five years after initial accreditation is granted, and then the continuing accreditation peer review process occurs every eight years thereafter.

There are two reasons why a continuing accreditation peer review process would occur sooner than between the customary cyclical review process.

    1. The nursing program made or will make a significant change in the nursing program. This is known as “substantive change” and the change is so significant that the ACEN Board of Commissioners authorizes a focused visit. The Focused Visit Report provides information related to the program’s compliance with a selected number of ACEN Standards and Criteria. The Standards and Criteria to be reviewed are based on the reason for the focused visit, such as the addition of a new off-campus instructional site (e.g., where the didactic component of the nursing courses are taught) or implementation of distance education. Note, the addition of a clinical site is not a significant change in the nursing program, thus not a substantive change. See the ACEN Glossary for helpful definitions.The Focused Visit Report differs from the Substantive Change Prospectus. While the Substantive Change Prospectus outlines a proposed substantive change or describes a substantive change that occurred (e.g., decline in program outcomes), the purpose of the Focused Visit Report is to demonstrate a nursing program’s continuing compliance with the Accreditation Standards approximately six months after implementation of the substantive change.

      Learn more about a focused visit here.

 

  1. The second reason there may be a visit between accreditation cycles is related to follow-up. If a program is found in non-compliance with one or more Accreditation Standards and placed on conditions, warning, or good cause by the Board of Commissioners, then a follow-up report is required.Learn more about a follow-up visit here.

 

Schedule of Fees

The ACEN continuously looks for ways to reduce costs in order to maintain a fair and reasonable fee structure. In fact, the fee schedule for nursing programs located in the U.S. and U.S. territories has remained the same for four consecutive years, and the fee schedule for international nursing program was significantly reduced in 2019.

Candidacy is the process the ACEN uses for nursing programs seeking initial accreditation regardless of geographic location. However, the Candidacy process differs for international nursing programs. Information regarding the process for international nursing program is available here.

Candidacy is an affordable process where fees are billed in portions depending on what part of the process a nursing program is in.

  • The fee schedule for nursing programs located in the U.S. and U.S. territories is available here.
  • The fee schedule for international nursing programs is available here.
  • An Illustration of Cost with Timeline was created to clarify the costs associated with candidacy and initial accreditation.

From Candidacy to Accreditation

FROM CANDIDACY TO ACCREDITATION:
Austin Community College’s Journey as the First in Texas to Offer an RN-to-BSN Program

By Nina Almasy, DNP, RN, CNE | Department Chair, Professional Nursing | Austin Community College; And Patricia Recek, MSN, RN | Dean of Health Sciences | Austin Community College
Bridges, Volume XIII – Issue 3, August 2019

In the summer of 2017, the professional nursing department at Austin Community College (ACC) embarked on the journey to develop and implement the RN-to-BSN program by August 2018. In alignment with the college mission, the program aimed to meet the local needs of preparing the nursing workforce at the baccalaureate level by offering an affordable and accessible program in the region.

The journey could be described as a two-step process with an intricate timeline, resembling the famous Texas Two-Step dance. The two major steps of this journey included (a) obtaining all necessary approvals from various regulatory entities and (b) obtaining accreditation. The program had to obtain approval of several regulatory entities, including the college’s Board of Trustees, The Board of Nursing, and the governing organization’s regulatory entities: the Texas Higher Education Coordinating Board and the Commission on Colleges of the Southern Association of Colleges and Schools.

It was essential that at each step, the timeline for each entity’s needed approval was carefully considered. For example, for submission of the ACEN Candidacy Eligibility Application, ACC needed to include documentation that the program proposal was sent both to the state’s Board of Nursing and the governing organization’s regulatory entities, which are the Texas Higher Education Coordinating Board and the Commission on Colleges of the Southern Association of Colleges and Schools.

Achievement of these two essential steps required ongoing intricate partnership among various stakeholders and entities within and outside the college—and most importantly, keen attention to the timelines to successfully complete both steps.

Early in the program development stages, in order to better understand the local need, the department created the RN-to-BSN Advisory Committee, which is comprised of key area healthcare nurse leaders and nursing schools. In addition, several needs-assessment surveys and focus groups were conducted.

Program and curriculum development was guided by a review of the literature and best practices, as well as consideration of professional guidelines and baccalaureate essentials and competencies. The faculty worked diligently to ensure that the assessment and evaluation methodology for end-of-program student learning outcomes was carefully considered, as they developed the curriculum.

Obtaining nursing education accreditation that was effective for the first graduates of the program was one of the most important steps. We at ACC were committed to ensuring that our BSN graduates were eligible to apply to graduate schools, should they choose to do so. ACC’s associate degree program has been accredited by ACEN for several years, and the relationship with the ACEN had been a positive and collaborative one that allowed us to move forward to candidacy. ACC reached out to then ACEN and Dr. Nell Ard in August 2018 to determine if this aggressive timeline was achievable. Dr. Ard was so responsive from the very beginning, providing essential information to ensure we were progressing correctly.

The journey from ACEN candidacy to accreditation could be described as a collaborative, collegial process. Once the candidacy process began and the program applied for initial accreditation, an ACEN professional staff member, Dr. Ard, was assigned as a mentor and resource. The department chair of the program sought the expertise and supportive guidance offered by the mentor. This mentorship support was key in ensuring that the program not only met candidacy requirements, but also ensured that the program met the ACEN Standards and Criteria. Additionally, the ACEN website offered invaluable information and resources that were useful to the faculty and administrators throughout the entire accreditation process. It is safe to say that no stone was left unturned on the ACEN website!

The candidacy process involved ongoing review of the curriculum and the systematic plan for evaluation by a team of faculty and college leadership. Upon granting candidacy status, the ACEN also provided two comprehensive, independent reviews of the Candidacy presentation conducted by the ACEN professional staff. The faculty carefully examined the two reviews and staff input, then made necessary adjustments and revisions to the systematic plan for evaluation to ensure that the program is not only high quality, but also on track to meeting all ACEN Standards and Criteria for initial accreditation.

ACC was granted candidacy in June 2018, had the site visit in February 2019, and is awaiting action from the commission in September 2019, the final step in our accreditation journey.

When and How to Start the Candidacy Process

WHEN AND HOW TO START THE CANDIDACY PROCESS

By Greg Donaldson | Report Processing and Quality Assurance | ACEN
Bridges, Volume XIII – Issue 3, August 2019

When to Start the Candidacy Process (Eligibility)

Accreditation Candidacy with the ACEN cannot be discussed without first discussing what it means to become eligible for Candidacy. The distinction between eligibility and official Candidacy is of paramount importance. In fact, one of the most common questions presented to ACEN professional staff members is, “What is the difference between eligibility and Candidacy?”

Eligibility simply means that a governing organization/institution and a nursing program meet the ACEN required prerequisites and has been approved to submit a Candidacy Presentation to the ACEN. A program eligible for Candidacy is not automatically a Candidate for ACEN accreditation. It is only after the review and approval of a Candidacy Presentation that a nursing program becomes an official ACEN Candidate, and the program is listed as such on the ACEN website. More information regarding the Candidacy eligibility process can be found in Policy #3 Eligibility for Initial and Continuing Accreditation.

Assuming that a program has been deemed eligible for Candidacy, another common question is “When should I submit my program’s Candidacy Presentation?” The short answer to this question is that a Candidacy Presentation must be submitted within one year of the date of eligibility. Please note, however, that programs applying for accreditation will be assigned an ACEN professional staff member to mentor the program leaders and faculty members after eligibility is confirmed. Though a Candidacy Presentation can be submitted at any point after eligibility is confirmed, the ACEN strongly advises programs to submit Candidacy Presentations only after conferring with the assigned professional staff mentor. Throughout the entire Candidacy process, the ACEN professional staff mentor is the best available resource for any nursing program.

How to Start the Candidacy Process (Submitting a Candidacy Presentation)

A nursing program seeking Candidacy will receive a letter verifying its eligibility. From the date of this letter, the program has 30 days in which to submit its eligibility fee payment and one year in which to submit the Candidacy Presentation. A governing organization that offers a program not accredited by the ACEN initiates the Candidacy process through its chief executive officer and nurse administrator. The chief executive officer of the governing organization for the nursing program/nursing education unit as well as the nurse administrator must authorize the ACEN to conduct the accreditation process by submitting the Official Authorization for Candidacy Process Form, which is sent to the program with the letter confirming eligibility. When the signed Authorization is received, ACEN professional staff members can officially begin reviewing the Candidacy Presentation.

Essentially, a Candidacy Presentation is a condensed version of a Self-Study Report. A Candidacy Presentation does not include all of the ACEN Standards, and those Standards included (Standards 2, 4, 5, and 6) are limited to certain criteria within these Standards. The written Candidacy Presentation should be developed by the program leaders and faculty members and submitted electronically by emailing the document to Dr. Nell Ard. Please use the following link to find more information regarding how to compose a Candidacy Presentation: http://www.acenursing.net/resources/Guidelines_CandidacyPresentation_Sep2017.pdf

All materials submitted are reviewed by the ACEN professional staff. Applicants receive written notification whether the program is approved for Candidacy, deferred, or disapproved. Approval for Candidacy is granted when the nursing program demonstrates it is currently compliant with the requirements of the Candidacy Presentation as well as the Candidacy process, or demonstrates the ability to be compliant during the Candidacy period. Additional information about Candidacy can be found in Policy #34 in the ACEN Accreditation Manual.

Questions along the way

Each nursing program is unique, so it is natural that program leaders and faculty members need to ask questions specific to their program. The ACEN cannot put enough emphasis on the importance of reaching out to the professional staff mentor.

Understanding the ACEN Accreditation Cycle Timeline

Timeline to Candidacy

THE TIMELINE TO CANDIDACY: HOW LONG DOES IT TAKE?

By Matt Middlebrooks | Candidacy and Content Editor | ACEN
Bridges, Volume XIII – Issue 3, August 2019

At ACEN, we are often asked, “How long will it take for my program to become accredited if I apply today?” The answer, as to many of life’s great questions, is: “it depends.”

Ultimately, much of the Candidacy timeline’s length is determined by the program leaders and nursing faculty rather than by the ACEN. It takes some time to complete the Candidacy Eligibility Application, and potentially a significant amount of time to complete the Candidacy Presentation which is a condensed version of the Self-Study Report covering selected Standards and Criteria. This article provides the program information about components of the process and the time that each takes to assist the program in developing a timeline for achieving Candidacy and initial accreditation.

Once the Candidacy Eligibility Application has been submitted, it takes the ACEN an average of a week to review the application and respond in writing via email. At this point, assuming the program was deemed eligible, the program leaders and nursing faculty can begin working on the Candidacy Presentation. As this is an in-depth document that requires time to prepare (see our guidelines for more detail), the time it takes will vary from program to program. We highly advise that you first work with your assigned professional staff mentor for the Candidacy process before submitting your Presentation. Your professional staff mentor, one of the ACEN professional staff, will assist you in clarifying questions related to the Candidacy Presentation and the required components, which can assist you in “telling the program’s story” and providing every possible advantage in the process. The maximum amount of time to submit the Candidacy Presentation is one year, as eligibility expires one year after it is granted.

Once program leaders and nursing faculty submit the Candidacy Presentation, it’s time for the next step of ACEN review. The ACEN professional staff, who are professional nurse educators, complete a comprehensive review of the Presentation and generate extensive feedback for the benefit of the program leaders and nursing faculty in achieving compliance with the ACEN Standards and Criteria; this process can take up to six weeks to complete. If the professional staff identify that the program is currently compliant with the requirements of the Candidacy Presentation as well as the Candidacy process, or demonstrates the ability to become compliant during the Candidacy period, then the ACEN will designate your program as a Candidate for accreditation.

If the professional staff’s review identifies non-compliance or cannot determine whether the program is able to achieve compliance by the time of the site visit, fear not! Rather than outright deny Candidacy, the ACEN can defer a Candidacy decision in such cases. This extends the eligibility period for up to a year, allowing program leaders and nursing faculty to resubmit the Candidacy Presentation after working with the assigned professional staff mentor to remedy areas needing improvement that were identified in the first review.

Whether it takes one year or two to achieve Candidacy, the next step is scheduling the initial accreditation site visit. The Candidacy period lasts for two years, so program leaders and nursing faculty may elect to host the initial site visit in an available accreditation cycle during the Candidacy period. Application deadlines are always March 1 for a Fall accreditation visit or July 1 for a Spring accreditation visit. The program must have achieved Candidate status prior to requesting an initial accreditation visit. Program leaders and nursing faculty will also need to write the complete Self-Study Report in preparation for an initial accreditation site visit.

Once the visit has taken place, the Self-Study Report and accompanying Site Visit Report will be reviewed by the Evaluation Review Panel, which convenes in January for a Fall cycle and June for a Spring cycle. The final step of the peer review process is a review by the ACEN Board of Commissioners, which meets in March for the Fall cycle and September for the Spring cycle. The program will be notified within 30 calendar days of the Board’s decision.

All told, if everything takes the maximum amount of time possible, the Candidacy process can last as long as four years from the time a Candidacy Eligibility Application is submitted to hosting the initial visit with the additional six months for the final decision. Programs can also complete the overall process from application to site visit in as little as nine months. Even for longer cases, though, there is good news: due to recent revisions to ACEN Policy #34, the effective date of initial accreditation is the date on which the Candidacy period leading to the initial accreditation decision began!

As always, feel free to contact your staff at the ACEN office for more information or to ask any questions you might have. We’re always glad to help, and are looking forward to working with you and your colleagues on your journey to Candidacy and ACEN accreditation.

Clarify, Verify, Amplify

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

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

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

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!

Conclusion:

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

MINGLE WITH MARCY

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.