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!

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

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.

ATLANTA, Dec. 5, 2017 – The board members of the Accreditation Commission for Education in Nursing (ACEN) and the Organization for Associate Degree Nursing (OADN) made the announcement today that the two organizations have entered into a partnership. The goal of this partnership is to increase the benefits and the efficacy of the support network for associate degree nursing (ADN) programs and their students. While both the ACEN and OADN will continue to operate completely independently and will not gain any ownership interests, rights, or financial stakes in the companion organization, the constituents of each organization will see many benefits immediately:

Members of OADN will have direct access to assistance, advice, continuing education, and current best practices related to accreditation. Through the partnership there will be an increase in opportunities to learn and engage in the accreditation process for all associate degree programs reaching the important achievement of initial and/or continuing accreditation.

Faculty members associated with the ACEN’s accredited programs and OADN’s members can increase their skill development, teambuilding, and leadership through separate and joint programming offered by the ACEN and OADN, and will be able to more readily connect and network with the community of ADN program faculty throughout the United States.

Both the ACEN and OADN will be able to improve their outreach efforts to support ADN programs, and will be able to enhance and supplement their current professional development offerings, benefitting both the ACEN’s accredited programs and OADN’s members.

The partnership will facilitate ACEN accredited programs and OADN members access to timely and important information about academic progression, which will further advance the success of graduates from ADN programs.

Dr. Marsal P. Stoll, Chief Executive Officer for the ACEN, sees this partnership as another way for the organization to concretely carry out its mission. Says Dr. Stoll, “The ACEN has accredited associate degree programs since the inception of our agency in the 1950’s and the majority of ACEN-accredited programs are associate degree programs; currently 721 associate degree programs hold ACEN accreditation. This partnership with OADN is another way for the ACEN to fulfill its commitment of being a supportive partner for nursing education programs.”

ACEN is the largest accreditor of ADN programs and the only accrediting agency for ADN programs recognized by the U.S. Department of Education. OADN strongly supports accreditation as evidenced by a 2017 revised position paper [1] stating that “accreditation remains a constant, nationally recognized marker of educational quality and program outcome achievement.” OADN’s Chief Executive Officer Donna Meyer stated, “ADN programs are crucial to meeting the nursing workforce needs of our country. These programs are of the highest caliber and accreditation only reinforces this status. Additionally, non-accredited programs may be restricted from obtaining clinical placement sites, face decreased ability to obtain federal grant dollars, and impede the graduate’s ability to move forward in their education. The OADN Board of Directors believes strongly that working in partnership with ACEN we can increase the number of accredited ADN Programs.”

In support of accreditation and academic progression, OADN is one of the national organizations taking the lead in the new initiative on academic progression, the National Education Progression in Nursing (NEPIN) collaborative, partially funded by the Robert Wood Johnson Foundation. To learn more about the ACEN, programmatic accreditation and the benefits thereof, please visit http://www.acenursing.org/. For more information about OADN, the only national organization dedicated to associate degree nursing, please visit https://oadn.org/.

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[1] “Accreditation Position Statement,” OADN, https://www.oadn.org/images/pdf/resources-initiatives/170802_OADN_Accreditation_PositionStatement_final.pdf