The ACEN requires you to submit a substantive change report for any year when your programʼs overall annual licensure/certification examination pass rate (for all locations, program options, etc. combined) does not meet the benchmark established in Criterion 5.3 (2023 Standards and Criteria).

NOTE: For graduate programs (clinical doctorate and master’s/post-masters) offering multiple certifications, the aggregate pass rate for all certification examinations is used to determine if a substantive change is required.

Criterion 5.3 states:
The program’s most recent annual pass rate OR the mean pass rate for three most recent years must meet at least one of the following based on the total number of test-takers:

• 80% or greater for all first-time test-takers; or
  80% or greater for all first-time test-takers and repeaters; or
  at or above the national/territorial mean based on the nursing program type.

Template for Reporting: Licensure/Certification Examination Pass Rate(.docx)

When to Report

If the program’s first-time licensure/examination pass rate does not meet the benchmark established in Criterion 5.3 (2023 Standards and Criteria), a substantive change is required. Changes involving unmet benchmarks for licensure/certification examination pass rates follow Procedure 4 for review and may be accepted by the ACEN Staff without requiring Board approval.

NOTE: If your program is currently being monitored for non-compliance with Criterion 5.3 (2023 Standards and Criteria) (i.e., conditions, warning, or good cause accreditation status), a substantive change report is not required.

*All programs with APRN options are also expected to adhere to the current National Task Force Guidelines for Evaluation of Nurse Practitioner Programs as well as other requirements of the specialty organizations as they apply to the current ACEN Standards and Criteria.

The ACEN requires you to submit a substantive change report for your programʼs annual program completion rate if the following conditions are applicable:

• Condition 1 Your programʼs overall (all locations, program options, etc.) annual completion rate falls 25% or more below your programʼs established expected level of achievement (ELA) for two (2) consecutive years

OR

• Condition 2 Your programʼs overall (all locations, program options, etc.) annual completion rate falls 40% or more below your programʼs established ELA for a single year

The minimum threshold for reporting is determined by finding the difference in percentages (NOT points) between the established your programʼs ELA for completion and your programʼs actual completion rate.

NOTE: If your program is currently being monitored for non-compliance with Criterion  5.2 (2023 Standards and Criteria) (i.e., conditions, warning, or good cause accreditation status), a substantive change report is not required.

Template for Reporting: Program Completion Rate (.docx)

Determining if a Program Completion Report is Required

To determine if a report is required, calculate the minimal completion rate threshold for your program based on your established ELA.

Condition 1: 25% or More Below for Two (2) Consecutive Years

Calculate 25% of your programʼs ELA by multiplying your programʼs ELA for program completion by 0.75.

EXAMPLE:
ELA: 75%
25% of ELA: 75 x 0.75 = 56.25%

In this example, 56.25% represents the threshold for reporting program completion rates that are 25% below the ELA for two (2) consecutive years.

When to Report

• If your programʼs completion rate is 25% or more below the program’s ELA for two (2) consecutive years, a substantive change report is required.
• If your programʼs completion rate is less than 25% below the program’s ELA, a substantive change report is not required.
• If your program’s completion rate is 25-39% below the ELA for a single year, a substantive change is not required. If the program’s completion rate falls 25% or more below the ELA for a second year, a report is required.

Condition 2: 40% or More Below for a Single Year

Calculate 40% of your programʼs ELA by multiplying your programʼs ELA for program completion by 0.60.

EXAMPLE:
ELA: 75%
40% of ELA: 75 x 0.60 = 45%

In this example, 45% represents the threshold for reporting program completion rates that are 40% or more below the ELA for any single year.

When to Report

• If your programʼs completion rate is below the 40% threshold for any single year, a substantive change report is required.

The ACEN requires you to submit a substantive change report for your programʼs annual program job placement rate if the following conditions are applicable:

• Condition 1 Your programʼs annual job placement rate falls 25% or more below your programʼs established expected level of achievement (ELA) for two (2) consecutive years

OR

• Condition 2 Your programʼs job placement rate falls 40% or more below your programʼs established ELA for a single year

The minimum threshold for reporting is determined by finding the difference in percentages (NOT points) between the programʼs established ELA for job placement and your programʼs actual job placement rate.

NOTE: If your program is currently being monitored for non-compliance with Criterion 5.4 (2023 Standards and Criteria) (i.e., conditions, warning, or good cause accreditation status), a substantive change report is not required.

Template for Reporting: Job Placement Rate (.docx)

Determining if a Job Placement Rate Report is Required

To determine if a report is required, calculate the minimal job placement rate threshold for your program based on your established ELA.

Condition 1: 25% or More Below for Two (2) Consecutive Years

Calculate 25% of your programʼs ELA by multiplying your programʼs ELA for job placement by 0.75.

EXAMPLE:
ELA: 95%
25% of ELA: 95 x 0.75 = 71.25%

In this example, 71.25% represents the threshold for reporting job placement rates that are 25% below the ELA for two (2) consecutive years.

When to Report

• If your programʼs job placement rate is 25% or more below the program’s ELA for two (2) consecutive years, a substantive change report is required.
• If your programʼs job placement rate is less than 25% below the program’s ELA, a substantive change report is not required.
• If your program’s job placement rate is 25-39% below the ELA for a single year, a substantive change is not required. If the program’s job placement rate falls 25% or greater below the ELA for a second year, a report is required.

Condition 2: 40% or More Below for a Single Year

Calculate 40% of your programʼs ELA for job placement by multiplying your programʼs ELA for program completion by 0.60.

EXAMPLE:
ELA: 95%
40% of ELA: 95 x 0.60 = 57%

In this example, 57% represents the threshold for reporting job placement rates that are 40% or more below the expected level of achievement for any single year.

When to Report

• If your programʼs job placement rate is below the 40% threshold for any single year, a substantive change report is required.