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!