Mingle with Marcy, June 2019


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.