Insights on Accreditation – May/June 2012

Ensuring NLNAC’s Accountability in the Accreditation Process

Sharon J. Tanner, EdD, RN
Chief Executive Officer, National League for Nursing Accrediting Commission

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This column provides information on accreditation for nursing programs of all types. Readers may submit questions to the National League for Nursing Accrediting Commission. General questions of interest to a wide audience will be addressed in this column while more specific questions or those requiring confidentiality will be answered directly.

[dropcap]Q[/dropcap]The faculty and I recently heard you speak about the report that NLNAC was doing for the U.S. Department of Education.  Why does NLNAC engage in the recognition process with the Department?  Does it matter to the nursing program whether or not the accrediting agency is recognized by the Department of Education?

[dropcap]A[/dropcap]NLNAC values its recognition by both the United States Department of Education (USDOE) and the Council for Higher Education Accreditation (CHEA). NLNAC’s mission is somewhat unique in that not only do we offer accreditation to all six types of nursing programs, but we also serve as the Title IV Gatekeeper for approximately 100 of our accredited nursing programs.  The majority of nursing programs are within regionally-accredited colleges or universities, and, in those cases, the institutional accrediting agency serves as the Title IV Gatekeeper.  However, because NLNAC serves programs that are within accredited medical facilities or are hospital-associated programs as well as those within technical institutions, we have the responsibility of serving as gatekeeper for the federal financial funds for their students.  So, NLNAC must meet not only the federal regulations for all accrediting agencies recognized by the USDOE but also the regulations related to federal financial aid programs.

The USDOE Regulations that govern accrediting agencies are available on the Department’s website at  I am often contacted by graduate nursing students, particularly those in a nursing education track/option, about the process of accreditation and program review.  Frequently, students who contact me have been tasked with exploring the accreditation process and learning more about the regulations that guide the work of accreditation in ensuring quality programming for all types of nursing students.

As part of the recognition review process, NLNAC is required to submit a petition that addresses each of the regulations in the same manner that nursing programs address their compliance with each of the NLNAC Accreditation Standards and Criteria when a program is completing a Self-Study Report in preparation for the periodic onsite reviews.  The petition document includes a narrative summary of our own compliance with the regulations accompanied by supporting evidence that the regulations are met through our accreditation review activities such as site visits, focused visits, annual reporting, and monitoring of substantive changes.
One of the most important regulations for accrediting agencies is contained in 602.14 which states that the Secretary (of the Department of Education) recognizes only those agencies that can clearly demonstrate that they are separate and independent of the associated membership or trade association.  Recognized accrediting agencies must function independently of any other agency or organization in terms of all administrative and fiscal responsibilities and functions, particularly those related to accreditation.

A second area that is closely examined for compliance is the Standards by which the agency conducts review of programs (in our case – nursing programs of all six types) for assurance of quality for the students and the public served.  NLNAC is required to describe the review process for the Accreditation Standards as well as how the Standards are implemented and applied in a fair and consistent manner.  Documentation to verify that the Standards guide the process of review includes Self-Study Reports, Site Visitors’ Reports, Focused Visit Reports, Evaluation Review Panel Summaries, and decision letters from the NLNAC Board of Commissioners.

At this point, it is probably clear that the petition is not quite the same as a Self-Study Report submitted by a nursing program.  Instead of a limit of 200 pages that is given to the programs, the petition for review is thousands of pages with many examples of documents from program reviews of the six different types of nursing programs that we accredit.  Each portion of the regulation requires related evidence that NLNAC has carried out the prescribed procedures and has the policies in place to support the nursing programs’ efforts to meet the Standards as written.  At all times, the focus is on protection of the students in terms of receiving the highest quality instruction and related experiences to ensure safe and competent practice in the many healthcare settings in which graduates are employed.

Nurse administrators often ask why a substantive change report is required when the faculty decide to change the curriculum, add a program option/track, implement a new delivery method, etc.  The USDOE Regulations guide the work of the NLNAC and other accrediting agencies.  The policies such as the one related to substantive change are directly linked to the USDOE Regulations and the requirements for monitoring curriculum, enrollment changes, locations, change of ownership, etc.  In addition, there is specific mention of the ongoing monitoring required of all accredited programs.  This is accomplished through the use of the NLNAC Annual Reports, which all programs are required to submit each fall.  The NLNAC professional staff carefully review the information submitted to ensure that follow-up is done with any unreported substantive changes or identified trends in terms of student learning outcomes or program outcomes.

Nursing is often heralded as the exemplar in assessment of student learning on many campuses.  As part of the ongoing emphasis on quality programs, the focus on student learning outcomes and program outcomes is driven by both the USDOE emphasis on outcomes and NLNAC’s own mission of promoting quality improvement for all programs.  Within the USDOE Regulations, you will note that there is a specific mention of the program outcomes that are identified in Standard 6 Outcomes.

Previously, we discussed the review of the Accreditation Standards and the challenging but exciting work of the many volunteers who step forward to evaluate the effectiveness of the Standards and to draft any necessary revisions of the measures used to determine whether or not a nursing program achieves accreditation.  During this process, the USDOE Regulations are included in the documents that the Subcommittee volunteers are provided.  The importance of adherence to the regulations is quite clear.  Just as with any nursing program, the NLNAC must clearly demonstrate ongoing compliance with the National Recognition Criteria of the Department.  However, unlike nursing programs, the maximum length of time that an agency can be recognized is five (5) years, so the review process is continuous in terms of maintaining compliance.

In addition to submission of a petition, at least one analyst from the USDOE attends the meetings of the NLNAC to personally observe the accreditation decision-making process.  This is to ensure that the Standards are guiding the decisions and that no conflicts of interest are allowed to interfere with the objective review of each program.  Following the onsite observation of the decision-making meetings, the NLNAC is required to appear before National Advisory Committee on Institutional Quality and Integrity (NACIQI) to address any questions about the petition or the NLNAC accreditation process.

The administrators, faculty, and students within NLNAC-accredited programs can be assured that we are always focused on compliance with the requirements of both USDOE and CHEA.  Being recognized by these organizations ensures our constituents that accreditation by NLNAC has meaning and value to each student and graduate as well as to the numerous communities of interest that are served by each program.

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This is a non-final version of an article published in final form in the NURSE EDUCATOR Journal. May/June 2012 Vol.37, No.3 ht