AACN - CCNE - Advice

General Advice for Programs Hosting
an On-Site Evaluation by CCNE

This communication is intended to relay suggestions to programs preparing to host an on-site evaluation by the Commission on Collegiate Nursing Education (CCNE). Specific guidelines for preparing the self-study document and the on-site resource file are provided. While this document also provides general guidance about arrangements for the CCNE on-site evaluation team, it is only that. There will be instances where common sense will tell you that an option other than what is recommended here is best. You know your locale, institution and people best; if you keep in mind the tasks of the evaluators while on site, you should be able to make decisions about arrangements that will be fully acceptable to the team. In other words, the best guidance is to use your own good judgment.

The self-study process should be viewed as an opportunity for the nursing unit to engage in critical self-evaluation leading to self-improvement. This process of self-analysis should result in the preparation of a self-study document that addresses the accreditation standards as described in CCNE's Standards for Accreditation of Baccalaureate and Graduate Nursing Education Programs. This document defines the key elements necessary to demonstrate compliance with each standard and also suggests documentation that may be used to demonstrate compliance.

It is suggested that the program organize the self-study document by standard, and, within each standard, by key element. Each standard should be addressed in terms of the program's compliance (or lack thereof) with the standard and its key elements, and should also include an analytical discussion that provides an insightful analysis of the strengths and areas for improvement in relation to that standard. Finally, under each standard, there should be a plan of action that addresses the areas for improvement that have been identified by the program as a result of the self-study process.

No specific format for the self-study document is mandated by CCNE, but certain elements provide for a clearer understanding of the information contained in it. The document should be organized to facilitate an assessment by the evaluation team and other reviewers about the program's compliance with each standard. It is particularly helpful to the reviewers if the document begins with a brief introduction of the nursing program and the institutional setting in which it is located. The Program Information Form, which CCNE provides for completion by program officials, should be submitted with the self-study document.

It is also helpful if pages in the document are numbered sequentially, and if sections are organized by standard and separated by tab dividers. It is recommended that programs format the document using 1.5 line spacing and one-inch margins. It is further recommended that programs copy the main document single sided and use a font size of 10 or larger. The use of tables is encouraged, where appropriate; tables tend to be helpful in presenting faculty and student data and curricular requirements, in particular. Finally, a table of contents for the main document, as well as for the appendices, serves as a helpful reference to reviewers of the document.

Except in unusual instances, a program should limit the self-study document to 75 pages, plus well selected exhibits in a volume of appendices. Catalogs and other informational materials should be included, as appropriate. Supplementary documents such as faculty curricula vitae; university reports; committee meeting minutes; examples of student work; copies of student, alumni or other constituent survey instruments; and data summaries of survey responses should be referenced in the document, as appropriate, and made available in the on-site resource file described below.

Before the CCNE evaluation team arrives on site, the program must compile information in a resource file (also commonly referred to as the "resource room") for on-site inspection by the team. Please refer to CCNE's Procedures for Accreditation of Baccalaureate and Graduate Nursing Education Programs for information regarding what should be included. In general, the resource file should include any materials referenced in the self-study document that were not included in the appendices, and any other information that provides evidence of compliance with the accreditation standards and their key elements. It is helpful when the program organizes the resource file by standard and provides an index of what is available.

Consistent with expectations of the US Department of Education, documentation describing the methods of advertising used by the program must be made available to the evaluation team. Promotional materials or recruitment literature used by the program (including catalogs, bulletins, publications or combination of publications) must accurately describe the program's academic calendar, admission policies, grading policies, degree completion requirements, tuition, and fees. The program also will need to provide evidence in its resource file that it tracks degree completion rates of its students, as well as rates of job placement or other measures of success of its recent graduates. Pass rates on the NCLEX-RN for first-time takers and pass rates on certification examinations also should be provided, as appropriate.

Since CCNE evaluators will arrive the day before the on-site evaluation, you should reserve a single hotel room for each team member, showing arrival on the day prior to the visit and departure on the last day of the visit. If any travel plans differ from this schedule, CCNE team members will advise you of such.

The team expects comfortable but not lavish accommodations. Much more important is that the facilities be conducive to the work the team needs to do. If at all possible, arrange for a nearby hotel with an on-site restaurant, room service, a business center, and 24-hour switchboard service.

Individual hotel rooms should have a desk or table with good lighting. Team members generally have several hours of reading and writing to do in the evenings, so this is very important.

The team members meet in executive session in the evenings, so at least one hotel room (preferably the team leader's) should be able to accommodate the full team with a table large enough to seat the team and with enough workspace for laptop computers and documents. If hotel rooms cannot accommodate the team, a small conference or meeting room should be arranged in the hotel.

A room should be available for use by the team while on campus. A table in that room should be large enough to accommodate the full team. While interviews of various constituent groups can take place in locations best suited for the sessions, it is often effective to have a central room designated for evaluation team use where members can leave their belongings, can conduct some interview sessions, can review documentation in the resource file or other materials requested by the team, and can conduct occasional executive sessions to monitor the progress of the work.

Please be sure that appropriate personnel are available during the on-site evaluation to assist the team and to escort them to appointments.

CCNE appreciates program efforts to support team access to technology during the on-site evaluation. Some team members may bring with them a laptop computer for use on site; others who don't have access to laptop computers may ask to borrow one from the institution, if one is available. You also should anticipate that team members using computers will need to have access to a printer during the evaluation process. Providing a printer in the team's work room is particularly helpful.

Team members are responsible for making their own travel arrangements and most often will arrive by air. Because of differing arrival times and sometimes undependable flight schedules, team members do not expect to be picked up at the airport. It is thoughtful, however, to give them instructions about the best means to get to the hotel. Information about price differentials, such as those between an airport bus and a taxicab, is also helpful. Unless faced with time constraints, most team members will select the least costly form of transportation. Certainly, if the hotel provides complimentary van service to and from the airport, let the team members know how to access that service.

If the hotel is conveniently located to the institution, team members may be willing to walk to and from their destinations. If the hotel is not within walking distance to the institution, you should make arrangements to transport the team between the hotel and the institution. Be sure the team leader knows the specific arrangements about who will meet the team, at what time and where. Keep in mind that team members' departure times may be scheduled so that they may need to bring their luggage on site on the final day of the visit.

You should prepare an agenda for the on-site evaluation no later than eight weeks before the visit. Once the proposed agenda has been developed, you should share it with the team leader. You should expect that the team leader will contact you to discuss the agenda and/or to request revisions to the agenda. You should distribute the final agenda to the team and to CCNE staff no later than one month before the visit.

You should expect that the team will want to meet separately with a variety of constituents, including students, faculty, alumni, community representatives (e.g., employers of graduates and/or agency representatives), program administrators and institution officials.

The team (or members thereof) will need to observe students engaged in classroom and clinical activities. You should also anticipate that team members will want a tour of the physical facilities.

Please be sure to reserve time on the agenda to give evaluators occasional breaks (a couple of 15-minute breaks each day should suffice). Your constituents usually will be meeting with the team in one to two-hour blocks of time; the team, however, will be engaged in an intense and constant dialogue from early morning to late in the day. Team members appreciate your sensitivity to these concerns. Additionally, if you will need to transport team members between campuses, clinical sites or teaching sites, you should schedule time for this in the agenda.

You should reserve some time on the agenda -- preferably toward the end of the day but before the team returns to the hotel -- for the team to review the materials contained in the on-site resource file.

The team's agenda on the last day of the visit should be reserved for executive sessions of the team. During that time the team will conclude its review of the on-site resource file, seek any clarification needed from program representatives, conclude its preparation of the draft accreditation report, and prepare for the exit interview with program representatives.

Consultation with CCNE staff and/or the team leader is available during the development of the agenda.

Dining

Do not plan on entertaining the team in the evening. Because the team is on campus to make judgments about your program, this is an inappropriate time for the team and program constituents to socialize. In addition, team members have considerable work to do in the evening, and entertaining would significantly infringe upon their time.

Typically team members will not be familiar with the immediate locale, so they appreciate recommendations for good places to eat. It is appreciated when you have several suggestions to offer, including a range of options in terms of types of food, price, and atmosphere.

The availability on site of hot and cold drinks, including some caffeine-free and low-calorie choices, is generally appreciated in the morning and mid-afternoon.

Programs often find it useful to schedule the team for lunch with a group so that informal interaction can take place. This usually works well if sufficient time is included on the schedule to transport the group to and from the luncheon site, and if the group is small enough to permit a meaningful discussion. Meals with very large groups tend to be pleasant but not as helpful in terms of eliciting information.

The team does not expect receptions or parties. It is occasionally acceptable to have such an event, but only if it fulfills a special need of the program and is not a substitute for a structured interview session with a particular constituent group. As a general rule, a reception where people gather in casual conversation among themselves and team members is not a good format for the team to gather information in an organized way. Any social event, other than a working lunch, should be cleared with CCNE staff before being included on the team's agenda.

Lunch on the last day of the visit should be a working lunch, but limited to the team members in executive session. The team will be working diligently at this point, coming to its conclusions and preparing for the exit interview. Please arrange to have lunch brought into the room where the team is working; sandwiches, salads or other light fare is usually well received.

Fees