Self-Study Document • Program Information Form • On-Site Resource File
Facilities and Support • Transportation • Agenda • Dining • Fees
This communication gives general guidance about arrangements for the on-site evaluation for accreditation of a baccalaureate and/or graduate degree nursing program by the Commission on Collegiate Nursing Education (CCNE). Also provided are specific guidelines for preparing the self-studydocument and the on-site resource file. The best guidance CCNE can provide is to use your own good judgment when your knowledge of your locale, institution, and community of interest suggests that you make arrangements other than those provided below. Keep in mind the tasks of the evaluators while on site and you can feel confident that your decisions about arrangements will be fully acceptable to the team.
The self-study process is 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 that are in effect at the time of the on-site evaluation. The standards are identified in CCNE’s Standards for Accreditation of Baccalaureate and Graduate Degree Nursing Programs. Since the Standards is itself a living document and is periodically refined, please be clear which issue of the Standards applies to the self-study and the team’s visit. The Standards defines the key elements necessary to demonstrate compliance with each standard. The Standards also includes elaboration at the key element level and information about supporting documentation for each standard.
The self-study document should be organized by standard and by key element within each standard. Each standard should be addressed in terms of the program’s compliance (or lack thereof) with the standard and its key elements. Discussion under each standard should also provide an insightful analysis of the strengths and areas for improvement in relation to each standard. Finally, under each standard, the self-study process should provide a plan of action that addresses the areas the program identified for quality improvement. Programs are encouraged to use the self-study template.
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:
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begins with a brief introduction or overview of the nursing program(s) and the institutional setting in which it/they are located;
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includes a table of contents for both the main document and the appendices;
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includes page numbers;
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separates sections using tab dividers;
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is formatted with 1.5 line spacing and 1-inch margins;
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is copied single sided and uses a font size of 10 or larger for readability; and
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includes tables, where appropriate.
Tables are particularly helpful when presenting faculty qualifications and teaching responsibilities, student enrollment and graduation data, outcomes data, and information showing how the curricula link to the required professional nursing standards and guidelines.
The self-study document should be no longer than 90 pages of text for one or two degree programs and no longer than 100 pages of text for three or more degree programs, excluding any pertinent supplementary information that is provided in an appendix. A URL may be provided for the team to electronically access catalogs and faculty and student handbooks. If the program prefers, hard copies of these supplementary documents may be submitted instead. Other pertinent documents should be referenced in the self-study and made available in the on-site resource file described below. Examples of these documents include 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.
At least 6 weeks prior to the on-site evaluation, the program sends each team member the complete self-study document (including appendices). In addition, the program sends to CCNE offices five paper copies of the self-study document (including appendices), along with an electronic version of the complete document (saved to an electronic storage device, such as a CD or thumb drive).
The Program Information Form
The Program Information Form provides a brief introduction or overview of the nursing program(s) and the institutional setting in which it/they are located. The form must be completed and submitted to each team member and to CCNE offices with the self-study document 6 weeksprior to the on-site evaluation. Send one hard copy of the form to each team member and one copy to CCNE offices. Save the form on the same electronic storage device that contains the complete self-study document. Please do not bind the Program Information Form in the self-study document.
The On-Site Resource File
Before
the CCNE evaluation team arrives on site, the program must compile information in a resource file for on-site review by the team. Please refer to CCNE’s Procedures for Accreditation of Baccalaureate and Graduate Degree Nursing 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 appendix, 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 key element and provides an index of what is available and where it is located. Programs can expect evaluation teams to review at least the following on site:
a) samples of student work;
b) schedule of courses offered (with instructors identified) over the previous 3 years;
c) faculty vitae and teaching assignments;
d) course syllabi;
e) personnel manuals (if not included as part of the self-study document);
f) survey responses and data summaries;
g) course evaluation responses and data summaries;
h) minutes of major committees that document compliance with standards and key elements;
i) the nursing unit budget for the current and previous 2 fiscal years;
j) evidence that the program afforded its constituents the opportunity to send third-party comments to CCNE in advance of the review; and
k) a record of formal student complaints and grievances, if any, for the past 3 years.
Include a summary of faculty accomplishments and publications for quick reference.
Consistent with expectations of the U.S. 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, Web sites) must accurately describe the program’s offerings, outcomes, accreditation/approval status, academic calendar, recruitment and admission policies, transfer of credit policies, grading policies, degree completion requirements, tuition, and fees. The program also will need to provide evidence in its resource file that it has tracked graduation rates, NCLEX-RN® pass rates, certification examination pass rates, and employment rates for graduates, as appropriate, for the past 3 years.
CCNE evaluators will arrive the day before the on-site evaluation. Please 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 staff or team members will advise you. It is important to convey to each team member emergency (not office) contact information for a designated program representative in the unlikely event that travel plans are changed due to unforeseeable circumstances (e.g., weather, illness).
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, and a business center with printers. Each room needs to be furnished with a desk or table with good lighting. It is very helpful for the hotel room to have Internet access as team members may need to access the institution’s Web site or other information. Team members generally have several hours of reading and writing to do in the evenings, so this is very important. Please reserve nonsmoking rooms only, unless a team member requests otherwise. CCNE recognizes that the availability of hotels, particularly in rural areas, is limited; and appreciates the program’s efforts to select accommodations that will best meet the needs of the team.
Team members will pay for their hotel accommodations and will be reimbursed by CCNE. Please make sure that the hotel is aware of this, particularly since the rooms are booked with an institutional credit card or account.
The team members meet in executive session in the evenings, so at least one hotel room (preferably the team leader’s room) should be able to accommodate the full team with a table large enough to seat all team members, and with enough workspace and electrical outlets for laptop computers and documents. If hotel rooms cannot accommodate the entire 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 (the “resource room”). 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 team use where members can leave their belongings, 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. The resource room should be dedicated to the team’s use for the duration of the visit. The program is responsible for securing the room, as appropriate, due to the confidential nature of the documents stored there.
Please be sure that appropriate personnel are available during the on-site evaluation to assist the team and to escort them to and from appointments.
CCNE appreciates program efforts to support team access to technology during the on-site evaluation. Expect that team members will bring laptop computers to the visit; those who don’t have access to a laptop may ask to borrow one from the institution, if one is available. Such requests should be made in advance through the team leader. You also should anticipate that team members using computers will need to have access to a printer during the visit, preferably in the resource room.
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 near the institution, team members may be willing to walk to and from their destinations. If the hotel is not within a short 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 regarding who will meet the team, at what time, and where. Keep in mind that, due to departure schedules, team members may need to bring their luggage on site on the final day of the visit.
The program is responsible for preparing an agenda for the on-site evaluation no later than 2 months before the visit. Once the proposed agenda has been developed, it should be shared with the team leader. The team leader may have questions about and/or may request changes to the agenda. The program should distribute the final agenda to the team and to CCNE staff 6 weeks before the visit, at the same time the complete self-study document and the Program Information Form are submitted.
If the program has elected to host a joint visit by CCNE and another regulatory or approval entity, please notify both the CCNE staff and the team of this arrangement at least 2 months before the visit.
On the first day of the visit, please have name tags available for the members of the evaluation team to wear during the visit. This will help identify who these individuals are for your constituents, especially during meetings with the team.
Assume that members of 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 chief nurse administrator may only attend sessions with the team that are specifically designated for program officials. Faculty may not attend sessions that are designed for students or alumni (even if a current faculty member is enrolled as a student or is an alumnus).
For most visits, these meetings will be conducted in person (face-to-face). However, CCNE recognizes that, for nontraditional programs and/or those with substantial distance learning offerings, technology may be used to bring together a remote constituent group and the team (e.g., audio or Web conferencing). The team will need to have the opportunity to meet with students who are enrolled in the distance education program, if any. The manner in which this meeting is facilitated (face-to-face or via technology) is at the discretion of the program. The program needs to ensure that sessions with the team are not recorded and that only members of the designated constituent group are able to participate in the meeting. In addition, it is important that the program arranges for the team to meet with students who are representative of the degrees and tracks under review for accreditation. The program should provide to the team a list of the participants’ names with titles, if appropriate, who attend each meeting.
The program should anticipate that the team will want a tour of the program’s physical facilities while on site. The team (or members thereof) also will need to observe students engaged in classroom and clinical activities. If there are no opportunities for the team to observe students in class during the visit, the program needs to make special arrangements to provide the team access to these activities in advance of the visit (e.g., a video or opportunity to observe an online class). To access classes remotely, the program is responsible for providing the team with certain information prior to the site visit, including access codes, passwords, specific instructions, and technology support by a staff member at the institution, as appropriate.
Please be sure to reserve time on the agenda to give team members occasional breaks (a couple of 15-minute breaks each day should suffice). Your constituents usually will be meeting with the team in one-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 and their requests for information. Additionally, if you need to transport the team between campuses, clinical sites, or teaching sites, you should schedule time for this in the agenda.
It is important to reserve some time on the agenda -- preferably toward the end of the day before the team returns to the hotel -- for the team to review the materials contained in the on-site resource file. This time in the resource room requires concentration on the part of the team with minimum disruptions. It is also helpful to schedule a meeting with a program administrator at the end of each of the first 2 days of the visit to discuss any questions of the team or requests for additional materials.
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.
The last day of the visit agenda should be reserved for executive sessions of the team and the exit interview. During that time the team will conclude its review of the on-site resource file, seek any clarification needed from program representatives or constituents, conclude its preparation of the draft accreditation report, and prepare for the exit interview. It is at the chief nurse administrator’s discretion whom to invite to the exit interview. Please discuss with the team leader whether lunch for the team should be provided on the last day of the visit.
Consultation with the team leader is strongly recommended during the development of the visit agenda. CCNE staff members also are available to assist the program as the agenda is prepared.
Fees
Click
here for information about fees related
to the on-site evaluation.
July 2009
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