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!


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!