Procedures for Accreditation of Baccalaureate and Graduate Nursing Education Programs Amended: May 2001 INTRODUCTION The Commission on Collegiate Nursing Education (CCNE) is one of more than 50 educational accrediting agencies that serve the public interest by providing an unbiased assessment of the quality of professional education programs. Conceived by the American Association of Colleges of Nursing (AACN) in 1996, the Commission officially began accrediting operations in 1998. CCNE is an autonomous accrediting arm of the AACN contributing to the improvement of the public's health. CCNE is recognized by the U.S. Secretary of Education to accredit baccalaureate and graduate degree programs in nursing. As a specialized/professional accrediting agency, CCNE is designed to evaluate and make judgments about the quality of baccalaureate and graduate degree programs in nursing that are located in regionally accredited colleges and universities in the United States and its territories. The Commission serves the public interest by assessing and identifying programs that engage in effective educational practices in the preparation of nurses. A determination of accreditation by CCNE is an indication of confidence in the educational institution to offer a program of quality, deserving of public approbation. The procedures described in this publication have been established by CCNE to assist institutions preparing for initial or continued accreditation and to guide the CCNE Board of Commissioners and its committees in the accreditation decision-making process. This publication is designed to be equally useful to applicants seeking initial accreditation and to already-accredited programs undergoing periodic reevaluation. Standards for Accreditation CCNE formulates and adopts accreditation standards, which are described in Standards for Accreditation of Baccalaureate and Graduate Nursing Education Programs. This publication is posted on the CCNE Web site and may be obtained by contacting the CCNE office. Board of Commissioners CCNE is governed by a Board of Commissioners. The Board is the final authority on all policy and accreditation matters affecting CCNE. The Board adopts standards and procedures for the CCNE accreditation process after appropriate opportunity is provided to the community of interest to comment on proposed revisions that are substantive in nature. The Board also has final decision-making authority to grant, deny, reaffirm or withdraw accreditation. The Board is comprised of 13 individuals who broadly represent CCNE's community of interest. The composition of the Board includes three representatives of the faculties of nursing education programs that hold accreditation or preliminary approval by CCNE, three chief nursing administrators (e.g., deans) from nursing education programs that hold accreditation or preliminary approval by CCNE, three representatives from the field of professional nurses, two professional consumers who represent employers of health care professionals, and two public consumers. Accreditation Review Committee The Accreditation Review Committee (ARC) is a standing committee of the Commission. The ARC serves as the primary review body for programs seeking initial or continuing accreditation by CCNE. The composition of the ARC includes at least four members of the CCNE Board and at least four individuals from outside of the Board who broadly represent the interests of baccalaureate and graduate nursing education. All committee members are appointed by the Board chair and are confirmed by the Board. Report Review Committee The Report Review Committee (RRC) is a standing committee of the Commission. The RRC serves as the primary body to review annual reports, continuous improvement progress reports and other reports submitted by programs that hold accreditation or preliminary approval by CCNE. The RRC serves to monitor significant changes in programs between evaluations to ensure continued compliance with established standards and policies. The composition of the RRC includes at least three members of the CCNE Board and at least four individuals from outside of the Board who broadly represent the interests of baccalaureate and graduate nursing education. All committee members are appointed by the chair of the CCNE Board and are confirmed by the Board. The RRC may offer a recommendation to the CCNE Board about the accreditation or preliminary approval status of a program if an annual report, continuous improvement progress report or other report demonstrates serious deficiencies in the educational program to the extent that the program may be in jeopardy. CCNE ACCREDITATION: A VALUE-BASED INITIATIVE CCNE accreditation activities are premised on a statement of principles or values. These values are that the Commission will: Foster trust in the process, in CCNE and in the professional community. Focus on stimulating and supporting continuous quality improvement in nursing education programs and their outcomes. Be inclusive in the implementation of its activities and maintain an openness to the diverse institutional and individual issues and opinions of the interested community. Rely on review and oversight by peers from the community of interest. Maintain integrity through a consistent, fair and honest accreditation process. Value and foster innovation in both the accreditation process and the programs to be accredited. Facilitate and engage in self-assessment. Foster an educational climate that supports program students, graduates and faculty in their pursuit of life-long learning. Maintain a high level of accountability to the publics served by the process, including consumers, students, employers, programs and institutions of higher education. Maintain a process that is both cost-effective and cost-accountable. Encourage programs to develop graduates who are effective professionals and socially responsible citizens. Assure autonomy and due process in its deliberations and decision-making processes. PROCEDURAL OVERVIEW A nursing education program that is located in an institution of higher education accredited by a regional accrediting agency recognized by the U.S. Department of Education may be affiliated with CCNE in either of two ways. One is as a program that holds preliminary approval status by CCNE; the other is as a program that holds accreditation status by CCNE. Both affiliations are voluntary and are initiated by the institution. CCNE evaluates for accreditation purposes baccalaureate and/or graduate nursing education programs offered by an institution's nursing unit. This nursing unit is usually called a college, school, department, or division. During a comprehensive on-site evaluation, CCNE evaluates all degree programs in nursing -- including all program areas and tracks -- offered at the baccalaureate and/or master's levels within the nursing unit. Thus, the unit of accreditation is the baccalaureate and/or master's degree program, not the larger administrative unit. The accreditation process consists of the following five steps: The program conducts a self-study process (self assessment), which generates a document that addresses the extent to which the program is in compliance with the standards for accreditation, as well as addresses the program's strengths and areas for improvement. An evaluation team of peers is appointed by the Commission to visit the program in order to validate the findings of the self study and to assess compliance with the standards for accreditation. Acting as a fact-finding body, the evaluation team prepares a report for the institution and for CCNE. After the institution is provided with an opportunity to respond to the team's accreditation report, the team's report, along with the self-study document and any other information the institution wishes to provide following the on-site evaluation, is reviewed by the ARC. The CCNE Board, taking into consideration the ARC recommendation about accreditation, decides whether to grant, deny, reaffirm or withdraw accreditation of the program. If accreditation is denied or withdrawn, the institution is accorded opportunities to seek review of the decision. The Commission periodically reviews accredited programs between on-site evaluations in order to monitor continued compliance with CCNE standards, as well as progress in improving the quality of the educational program. This five-step process is reinitiated every 10 years or sooner, depending on the success of the program in demonstrating continued compliance and improvements in the quality of the educational program. PRELIMINARY APPROVAL Preliminary approval is a temporary status that was awarded to selected nursing education programs that were reviewed by CCNE and met, at least, the following general requirements: The nursing education program is viable and appears, based upon the review of submitted materials, to be conducted in a manner that will enable eventual compliance with CCNE accreditation standards. The institution has a history of seeking and ensuring continuing accreditation and program recognition by appropriate accrediting and regulatory agencies. The institution has ensured the continuing viability of the nursing education program by being responsive to the concerns of accrediting and regulatory agencies. Preliminary approval is not a prerequisite to accreditation, nor is it a status of accreditation by CCNE. Programs that hold preliminary approval status are expected to make progress toward accreditation by CCNE; however, preliminary approval does not automatically assure eventual accreditation. If a program that holds preliminary approval status is granted accreditation by CCNE, then the accreditation status replaces the preliminary approval status for that program. CCNE must remove a program from preliminary approval status if the program a) fails to host an on-site evaluation for accreditation during or before the designated review period; b) is denied accreditation by CCNE based on the findings of an on-site evaluation; c) withdraws voluntarily from the preliminary approval process; d) fails to submit to CCNE periodic reports or other evidence documenting continued compliance with the general requirements for preliminary approval; and/or e) after due notice, fails to pay its fees to CCNE. If a program that has been removed from preliminary approval status wishes at a later date to pursue accreditation by CCNE, the program must reapply to CCNE as a new applicant for accreditation. Programs that hold preliminary approval status and are seeking accreditation by CCNE, and programs that are accredited by CCNE and are seeking continued accreditation by CCNE, are eligible for a maximum accreditation term of 10 years. Programs that do not hold preliminary approval status and desire to seek accreditation by CCNE must apply to CCNE as a new applicant for accreditation. New applicants for accreditation are eligible for a maximum accreditation term of five years. INITIAL ACCREDITATION Institutions that seek initial accreditation by CCNE of a baccalaureate and/or graduate program in nursing education, and institutions that have had accreditation withdrawn by CCNE and desire to regain accreditation, must first submit an application for accreditation. New Applicants A program that does not hold preliminary approval or accreditation by CCNE begins the accreditation review process by requesting applicant status. The written application must include: A request signed by the chief executive officer of the institution in which the program is located, inviting CCNE to initiate the accreditation process. The request should be co-signed by the chief administrative officer of the institutional unit in which the program is located and by the chief nursing administrator. Evidence that the institution in which the program is located is accredited by a regional accrediting agency that is recognized by the U.S. Secretary of Education. Payment of the fee for new applicants as indicated in CCNE's fee schedule. A completed CCNE Program Information Form. A catalog, bulletin or other publication for the institution and the program. Documentation that briefly summarizes the ability of the program to meet the established accreditation standards. The program should be able to present this information in five pages or less. This documentation must include the following: a. a description of the educational setting; b. a stated mission, with supporting goals and/or objectives, related to the institutional mission; and c. a description of the curriculum and the resources available to support the program. A program requesting applicant status must send its written application to the CCNE office. The application is reviewed by CCNE staff, and, if needed, by the co-chairs of the ARC in order to determine completeness of the application and readiness of the program to initiate the accreditation review process. A request for applicant status will be accepted at any time, but applicants should understand that once a program is accepted as an applicant, the program must proceed toward accreditation. Specifically, an applicant must submit an acceptable self-study document and host an on-site evaluation by CCNE within two years of the date of acceptance as an applicant; failure to do so will result in termination of applicant status. At any time during applicant status, a program may withdraw its application, on written notice to CCNE, and no further review activities will be conducted. New Programs Programs that hold preliminary approval or accreditation by CCNE and seek accreditation of a new program are required to submit to CCNE a letter of intent to request an accreditation review. The fee for adding a new program is indicated in CCNE's fee schedule. INITIATING THE REEVALUATION PROCESS In order for accreditation to be reaffirmed, CCNE conducts a reevaluation of the program on a periodic basis. Approximately 12-18 months prior to the time the on-site evaluation is to be scheduled, CCNE staff advises the chief nursing administrator that arrangements should be made for reevaluation. The program should at that time determine whether it wishes to pursue continuing accreditation. A letter of intent from the chief nursing administrator should be sent to CCNE, requesting reevaluation and proposing possible dates for the on-site evaluation. When the request is received, the date for the on-site evaluation and team appointments are determined by CCNE staff in consultation with the chief nursing administrator. THE ACCREDITATION REVIEW PROCESS Self Study In seeking initial or continuing accreditation, the program is required to conduct a self study related to program quality and program effectiveness. The process of self-analysis should result in the preparation of an analytical document that addresses all accreditation standards. The self-study document must include data and other information about the program and must demonstrate that this information is analyzed and used in program improvement efforts. In the self-study document, the program should identify its strengths and areas for improvement, as well as its plans to address continuous improvement. The self-study document should be no longer than 75 pages of general text, excluding any pertinent supplementary information. CCNE staff is available to provide advice to the program about the self-study process. A completed CCNE Program Information Form should be submitted with the self-study document. No format for the self-study document is mandated by CCNE. As a general guide, the self-study document should be organized to facilitate an assessment of each accreditation standard by the evaluation team. Guidelines for preparing the self-study document are posted on the CCNE Web site and may be obtained by contacting the CCNE office. At least six weeks prior to the scheduled on-site evaluation, the program must distribute copies of the self-study document and supplements as follows: one copy to each member of the evaluation team and five copies to the CCNE office. Self-study documents submitted to the CCNE office are available for public review by appointment only but will not be distributed by CCNE. Third-Party Comments The Commission provides the opportunity for program constituents to submit, in writing, comments concerning an educational program's qualifications for accreditation status. Approximately three months before the scheduled on-site evaluation, the program must notify its major constituents that an accreditation review is scheduled; this notification should indicate that written third-party comments will be received by CCNE until 30 days before the scheduled visit. The form of such notice is at the discretion of the program, but it should include the name and mailing address of CCNE. The fact that constituents were informed of this opportunity will be verified by the evaluation team during the on-site evaluation process. Only signed comments will be accepted by CCNE. CCNE shares third-party comments with members of the evaluation team prior to the visit, but at no time during the review process are these comments shared with the program. During its review of the program, the evaluation team considers third-party comments, if any, that relate to the accreditation standards. Planning for the On-Site Evaluation While planning for reaccreditation is an ongoing activity in any institution, the specific logistics for the actual on-site evaluation should be arranged several months prior to the on-site evaluation. The chief nursing administrator should propose a draft agenda for the evaluation no later than eight weeks prior to the review and should share it with the team leader. The team leader and the chief nursing administrator should discuss the plans for the on-site evaluation, review the agenda and finalize arrangements for the team. A brochure providing guidance for the accreditation review may be obtained by contacting the CCNE office. Comprehensive On-Site Evaluation The comprehensive on-site evaluation is conducted to assess the program's compliance with CCNE standards. The evaluation typically occurs over a three-day period. The chief nursing administrator will be consulted regarding dates and arrangements for the evaluation. The evaluation team assigned to review the program gathers data and information that are used by the ARC and CCNE Board to assess whether the educational program is in compliance with the standards for accreditation. The Commission may elect to conduct subsequent on-site evaluations before granting initial accreditation. In general, a new program should have enrolled students in at least one year of the program before hosting an on-site evaluation. The procedures for conducting evaluations to determine initial accreditation are the same as those used in the reevaluation of accredited programs. A comprehensive on-site evaluation is conducted to accomplish the following three objectives: to validate the findings and conclusions of the self-study document; to collect information to be used by the ARC and CCNE Board to assess compliance with CCNE accreditation standards; to gain insight into the plans of program officials and faculty to engage in continued self-improvement for the educational program. The evaluation team appointed to conduct the on-site evaluation gathers information that supplements and validates information provided in the self-study document. The team forms judgments about the institution and educational program based upon observations and impressions as well as upon information presented in the self-study document. These judgments appear in a written report prepared by the team, which is described later in this publication. The team leader, on behalf of the team, provides a summary of its findings verbally to program representatives during the exit interview -- the final session of the on-site evaluation. Evaluation Team and Observers Team members are selected for the particular perspective they can contribute to the evaluation team. Team members make important contributions, individually as experts and collectively as a team of peer evaluators. The composition of a comprehensive evaluation team includes trained CCNE evaluators appointed in accordance with the type and specialty orientation of the program. All evaluation teams must consist of one or more educators and one or more practicing nurses. The educator who serves on the evaluation team has depth of knowledge in one or more areas of nursing expertise and is familiar with nursing education and program development. He or she is responsible for helping the team to understand the special nature of nursing education and the importance of preparing safe and effective nurses. Educators assist the team in evaluating curricula, faculty qualifications, internal governance, student services, student and faculty outcomes, and research. The practicing nurse who serves on the evaluation team regularly engages, as his or her primary professional role, in the provision of nursing care to individuals, families, groups or communities. The practicing nurse is responsible for assessing the application of program activities to the community and the nursing profession and for assessing the success of the program in preparing nurses for safe and effective nursing practice. The practicing nurse has knowledge about nursing in general and depth of knowledge in at least one area of nursing practice. The size of the evaluation team is determined in accordance with the type and specialty orientation of the program. Normally the size of the team will not exceed four members. In general, three team members, including the team leader, are appointed to evaluate a baccalaureate program or a master's program; four team members, including the team leader, are appointed to evaluate both a baccalaureate and a master's program. CCNE staff assigns team leaders and team members to serve on the evaluation teams from the list of on-site evaluators. In order to preclude conflicts of interest, the chief nursing administrator is provided with the opportunity to reject, for cause, any member of the proposed evaluation team. Conflicts of interest are addressed in a subsequent section of this publication. With the consent of CCNE and the team leader, the chief nursing administrator may invite individuals from interested agencies to observe the evaluation at no expense to CCNE. Observers may be included in all evaluation activities but generally are not permitted to attend executive sessions of the team. CCNE may invite individuals to observe the evaluation, as well, but this would be at no expense to the program under review. On-Site Resource File Before the CCNE evaluation team arrives on site, the program should compile information in a resource file for on-site inspection by the team. 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 or combination of publications) must accurately describe the program's academic calendar, admission policies, grading policies, degree completion requirements, tuition and fees. The program should provide evidence 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. Financial resources available to support the program also should be documented. 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. If not included in the self-study document or appendices, the program should be prepared to make the following materials/documentation available for review by the team on site: list of names, titles, and educational credentials of each faculty member and administrative officer associated with the program faculty curricula vitae a list of faculty accomplishments (e.g., publications, presentations and awards) for the past three years student achievement data to include licensure pass rates, certification pass rates, graduation rates, job placement rates and other measures of student success, as deemed appropriate by the program examples of student work schedule of courses offered (with instructor identified) over the last three years course syllabi copies of the professional nursing standards/guidelines used by the program criteria for selecting and evaluating preceptors student handbooks faculty handbooks and personnel manuals evidence of ongoing, systematic program evaluation survey responses and data summaries course evaluation responses and data summaries a record of written student complaints and grievances, if any, for the past three years program budget (revenues by source and expenditures by type) for the current and previous two fiscal years current affiliation agreements with other facilities and institutions at which student instruction occurs major institutional and nursing unit reports and records for the past three years, such as minutes of faculty meetings, strategic planning documents and annual reports progress reports submitted to and accreditation reports received from other applicable accrediting/recognizing agencies since the last comprehensive evaluation official correspondence about accreditation received from other applicable accrediting/recognizing agencies since the last comprehensive evaluation summary data regarding faculty teaching loads summary data regarding the number and size of classes collective bargaining agreement, if applicable program advertising directed at prospective students evidence that constituents were informed of the opportunity to provide third-party comments to CCNE in advance of the on-site evaluation one complete copy of the self-study document other materials as necessary to be determined by the team leader Preparation of the Report The team's report represents the findings of the team based upon its study of institutional documents, and other materials provided by the program, along with information garnered during confidential interviews with program constituents. All statements, findings and recommendations included in the report are made in good faith with a view toward enhancing the quality of the educational program. The report reflects only that information obtained as part of the educational evaluation process conducted in accordance with CCNE procedures. In general, the team's report is an assessment of the program's compliance with the CCNE accreditation standards. Evaluation teams are expected to make written determination about whether each program under review complies with each accreditation standard. Evaluation teams use the following terminology in the reports to describe compliance with each standard: "This standard is met for the baccalaureate/master's program" and "This standard is not met for the baccalaureate/master's program." These terms are defined as follows: This standard is met for the baccalaureate/master's program. The program complies with the standard and its key elements. This standard is not met for the baccalaureate/master's program. The program fails to meet the standard and its key elements or performs so poorly in regard to the standard and its key elements that the efforts of the program are found to be unacceptable. It is expected that the team's assessment of whether each program complies with each standard will begin with one of the above statements. It is possible for one program to meet a standard and for the other program not to meet that standard. Following will be a narrative description of the program's compliance (or lack thereof) that supports the team's judgment. The team's report must address the program's compliance with each key element. The team leader coordinates the development of the report and ensures that a draft report has been written before leaving the site. The team does not formulate an accreditation recommendation about the program but does make a determination about whether each program has met or not met each standard. The team's report is edited by the team leader and is sent in hard copy and on diskette to the CCNE office within two weeks following the visit. CCNE staff then reviews the team's report and sends a final copy of it to the chief nursing administrator. Institutional Response The chief nursing administrator is provided no less than two weeks to respond to the report of the evaluation team. The response may: offer corrections of errors as they relate to names, positions, data, and other documentable facts; and/or offer comments that agree or disagree with the opinions and conclusions stated in the report, including any documentation demonstrating progress toward compliance with the standards. The chief nursing administrator's written response to the report, if any, is appended to the team's report. The team's report with the written response to it is sent to the ARC and, subsequently, to the CCNE Board. Since the written response to the report is considered along with the team's report at the ARC and Board meetings, it generally is not necessary for the chief nursing administrator to attend those meetings. THE ACCREDITATION DECISION-MAKING PROCESS Review by the Accreditation Review Committee The ARC is provided copies of the team's report, self-study document, and response to the team's report that was submitted by the chief nursing administrator. The ARC may consider additional facts or other information not available to the team at the time of the visit as part of the review of the report. The extent to which the additional information will affect the recommendation of the ARC is a matter of judgment within its discretion. If the chief nursing administrator elects to meet with the ARC, he/she may provide a verbal statement to the ARC regarding the findings identified in the team's report. The ARC reserves the right to limit the time of the verbal presentation. The team leader may be contacted by the ARC to provide a verbal summary of findings, to provide clarification to the team's report, and/or to answer any questions of the ARC. The team leader also may be asked to elaborate further on the team's findings as stated in the report. The team leader also may be invited to meet with the ARC in person if circumstances are warranted as determined by the ARC. The ARC reviews all materials carefully and formulates a recommendation regarding a proposed action to be taken by the CCNE Board. The proposed accreditation action includes: accreditation status and period of accreditation; identification of any areas where the program is not in compliance with CCNE standards; and a schedule for progress or special reports to be submitted and for the conduct of subsequent comprehensive or focused evaluations, if needed. Action by the Board of Commissioners At a meeting of the CCNE Board that occurs following the meeting of the ARC, the Board considers the proposed accreditation action recommended by the ARC. The chair of the ARC provides a written and oral report of the ARC's recommendation. The Board may accept the recommendation or it may choose to take an alternative action that it believes is appropriate. ACCREDITATION CATEGORIES Accreditation Accreditation is the recognition status accorded by the CCNE Board to a baccalaureate or graduate nursing education program that is in compliance with CCNE standards. Accreditation is an indication of CCNE confidence in the overall integrity of the program, the demonstrated success of the program officials to engage in continuous self-improvement, and the ability and wherewithal of the educational program to continue to be a successful enterprise for the foreseeable future. Initial accreditation may be granted for a time period extending for up to five years. Accreditation may be reaffirmed for a time period extending for up to 10 years based upon demonstrated substantial compliance with the standards for accreditation and the continuing advancement of the program. An on-site reevaluation serves as the basis for determining reaffirmation of accreditation. Accreditation Denied Accreditation is denied by the CCNE Board when a baccalaureate or graduate nursing education program seeking initial accreditation fails to demonstrate its ability to meet the accreditation standards. When the Board considers an action to deny accreditation, factors that have a significant impact on the effectiveness of the program are identified as the basis for the action. The sponsoring institution has an ethical obligation to inform students in the program and applicants to the program of this adverse action. The CCNE Board also issues a public statement concerning final actions to deny accreditation. Before an action of the Board to deny accreditation is made public, the institution must be afforded the opportunity to seek and fully exhaust the procedural reconsideration and appeal processes. Following implementation of the procedural reconsideration and appeal processes, if the action to deny accreditation is sustained by the Board, the effective date of the denial of accreditation will be the date the Board sustained the action. Accreditation Withdrawn Accreditation is withdrawn by the CCNE Board when a baccalaureate or graduate nursing education program pursuing reaccreditation fails to demonstrate its ability to meet the accreditation standards or when it fails to submit reports or payment of fees as requested by CCNE. When the Board considers an action to withdraw accreditation because of noncompliance with CCNE standards, factors that have a significant impact on the effectiveness of the educational program are identified as the basis for the action. The sponsoring institution has an ethical obligation to inform students in the program and applicants to the program of this adverse action. The CCNE Board also issues a public statement concerning final actions to withdraw accreditation. Before an action of the Board to withdraw accreditation is made public, the institution must be afforded the opportunity to seek and fully exhaust the procedural reconsideration and appeal processes. Following implementation of the procedural reconsideration and appeal processes, if the action to withdraw accreditation is sustained by the Board, the effective date of the withdrawal of accreditation will be the date the Board sustained the action. Termination of Accreditation: Closed Programs Accreditation does not extend to nonexistent educational programs. The CCNE Board will withdraw accreditation of any baccalaureate or graduate nursing education program that is closed or otherwise terminated voluntarily. Accreditation will be withdrawn effective at the time of closure of the program. This policy applies to new programs as well as existing programs. Actions to withdraw accreditation of closed programs are not subject to further review under the procedural reconsideration and appeal processes. Upon learning of the closing of a program, CCNE staff will notify the U. S. Secretary of Education, regional accrediting agency, other applicable accrediting agencies, and the public of said action. Voluntary Withdrawal from Accreditation The pursuit of initial accreditation and the pursuit of reaccreditation are considered to be voluntary processes. An institution that seeks initial accreditation or reaccreditation of its baccalaureate or graduate nursing education program is permitted to withdraw from these processes at any time. Upon receiving notification from an institution of its intent to withdraw from the accreditation process, the Commission will notify the U. S. Secretary of Education, regional accrediting agency, other applicable accrediting agencies, and the public of said action. Adverse Actions Adverse actions include decisions of the CCNE Board to deny or withdraw accreditation. Adverse actions are subject to review within the procedural reconsideration and appeal processes. Procedural reconsideration and appeal processes may be initiated by the sponsoring institution at the invitation of the CCNE Board under the obligations specified in this document. ACCREDITATION PERIOD An accreditation term is the period during which the accreditation status remains valid. Accreditation status is stated as valid through a specific date and is subject to the provisions of monitoring program performance described in this document. Accreditation automatically lapses at the conclusion of the term unless certain conditions have been met. For a review for continued accreditation by CCNE, the program must have submitted an acceptable self-study document and hosted an on-site evaluation prior to the termination date. If these conditions have been met, the accreditation status will continue until the first meeting of the CCNE Board at which the decision about continued accreditation can be made. If a program fails to permit reevaluation after proper notice, the accreditation status is subject to withdrawal at the time the term lapses. The effective date and termination of an accreditation term are important because accreditation status sometimes establishes eligibility of a program for participation in certain federal programs and/or establishes the qualifications of graduates to pursue certain career opportunities. The Commission's procedures are structured, as much as possible, to protect the interests of students who enter an accredited program with the expectation that they will graduate from such. Programs must be aware of decisions that may put students at risk and must represent those possibilities accurately. For clarification: For programs that are granted or reaffirmed accreditation by CCNE, accreditation is effective on the date of the decision by the CCNE Board. Accreditation continues in effect until the first CCNE Board meeting at which a decision can be made, providing the conditions for accreditation described in this document have been met. Accreditation status lapses on the date specified if the program fails to host a timely reevaluation after proper notice. Accreditation status lapses on the date of dissolution or disestablishment of a program by its parent institution. In granting a term of accreditation the CCNE Board shows its confidence in the competency and effectiveness of the educational program and in its continuing ability to comply with CCNE standards. At the discretion of the CCNE Board, reaccreditation and accreditation of a program that holds preliminary approval may extend for up to a maximum period of 10 years based upon the results of a comprehensive on-site evaluation. At the discretion of the CCNE Board, initial accreditation may extend up to a maximum period of five years based upon the results of an on-site evaluation. The Board may elect to deviate from the 10-year accreditation period when a program has undergone a substantial change, when major deterioration in the program has occurred, when the sponsoring institution requests an earlier evaluation, and when a formal complaint against an accredited program requires on-site evaluation of the issues surrounding the complaint. The Board reserves the right to conduct an evaluation of the program whenever circumstances require such review. This evaluation may have an impact on a previously-granted accreditation period, resulting in a reduced accreditation term. It is the Commission's policy not to grant extensions of accreditation terms. However, a program that is accredited by CCNE may request a postponement of its regularly scheduled review but only for extraordinary reasons. A request for postponement by an accredited program must be made in writing at least 12 months prior to the expiration of the accreditation term. Any exceptions must be approved by the CCNE Board and require action by the Board to extend the current accreditation term by a specified period of time. NOTIFICATION TO THE INSTITUTION CCNE notifies institutions of the accreditation action pertaining to the nursing education program in writing only. The CCNE staff advises the institution of the action within 30 days of the date on which the Board completes its accreditation deliberations. CCNE sends the accreditation action letter to the chief nursing administrator at the institution. A copy of the accreditation action letter, as well as the final accreditation report and the program's response to it, is sent to the institution's chief executive officer. The institution is encouraged to make the report readily available for review by faculty, students, administrative personnel and other program constituents. Accreditation decisions of the Board, including a notice of concerns and/or areas in which the program is not in compliance with CCNE standards, are transmitted in writing to the sponsoring institution's chief executive officer and to the chief nursing administrator. For adverse actions, the written communication to the affected institution contains the following information: the specific reasons for taking the adverse action; the date the action becomes effective; an invitation to the institution to initiate procedural reconsideration and appeal processes and the date by which such a request must be received by CCNE; and a reminder to the institution regarding its obligation to inform students in the nursing education program and applicants to the program about the adverse action if no request for procedural reconsideration or appeal is made. Notification of adverse accreditation actions is confidential, except as required under the section, "Disclosure," and is transmitted by certified mail. MONITORING PROGRAM PERFORMANCE Annual Reports The chief nursing administrator of a program that holds accreditation or preliminary approval by CCNE is required each year to submit a report to CCNE, providing statistical data and other information about the sponsoring institution, program, faculty, and students. The information submitted in the annual report is utilized to update CCNE records to help determine whether the program continues to comply with the accreditation standards. Annual reports are reviewed by CCNE staff, and, if particular concerns or problems are identified, the reports are reviewed further by the RRC. Data supplied annually to AACN may be used by CCNE to fulfill its annual reporting requirements. Continuous Improvement Progress Reports The purpose of the continuous improvement progress report is to demonstrate ongoing improvement and to help programs to assess their plans and progress. The chief nursing administrator of the accredited program is required to submit one continuous improvement progress report, unless additional progress reports are specifically requested by the Board. The continuous improvement progress report is submitted in year five of a 10-year accreditation period, in year three of a five-year accreditation period, or at the mid-point of any other designated accreditation period. The continuous improvement progress report provides information on the progress of the sponsoring institution in correcting areas of concern that have been specified previously to the institution related to the CCNE standards. It also provides an opportunity for the program to report on efforts to address areas of continuous quality improvement, including a detailed description of any new strengths, concerns, and/or objectives identified for the program since the last on-site evaluation, and the institution's efforts toward improving the program as based upon ongoing self study. The report contains documentation and statistical data about any changes in the educational program and changes in the institution as a whole that may affect the nursing education program, such as, but not limited to the following: policy revisions identified in catalogs, handbooks, and other such publications; new or revised planning documents; significant increase or decrease in resources available to the program; and additions or deletions to teaching affiliations. The continuous improvement progress report should not exceed 15 pages, unless otherwise negotiated with CCNE staff. Continuous improvement progress reports are reviewed by the RRC. At the request of the RRC, the chief nursing administrator may be asked to meet with the RRC to discuss information included in the continuous improvement progress report. Other Reports The CCNE Board may on occasion request that the chief nursing administrator submit special reports on matters of particular interest. These reports enable the review of matters that are considered to be of significant and urgent importance in the educational preparation of baccalaureate and graduate prepared nurses and that may affect the continuing accreditation of the program. A special report is required of a program when there are concerns about its compliance with an accreditation standard at the time the accreditation decision is made. The request for a special report will specify the area(s) of concern/deficiency and the date of expected submission. The Board must require that the program satisfactorily address the area(s) of concern/deficiency and demonstrate compliance with the accreditation standard within two years, a period which may be extended only for good cause. If a program fails to do so within the specified period, the Board must take adverse action with regard to the program's accreditation status. It is the responsibility of the program to submit the special report to CCNE offices on a timely basis. The special report should not exceed 15 pages, unless otherwise negotiated with CCNE staff. The report will be reviewed by the RRC, which will make a recommendation to the Board. The report will also be reviewed by the Board, which will act either to accept the special report or not to accept the special report. Special reports are accepted if the Board concludes, based on evidence provided in the special report, that the program has demonstrated compliance with the standard(s) in question. If the program has not fully resolved the cited concerns/deficiencies, the Board must act not to accept the special report and must a) take adverse action with regard to the program's accreditation status; or b) extend the time period by which the program must resolve the cited concerns/deficiencies. In order for the Board to grant an extension of the time period for achieving compliance, the program, as part of its special report, must show cause for not fully resolving the previously stipulated deficiencies. The Board will award an extension of the time period for achieving compliance only if the program has made substantial progress toward compliance and the quality of the program is not in jeopardy. The Board determines the appropriateness of an extension of time for achieving compliance on a case by case basis. If a program does not submit a requested special report, the Board will take adverse action with regard to the program's accreditation status. When an accreditation term is awarded for a period less than the maximum possible, the Board may, at its discretion, require a special report and specify that an extension of the term is possible, pending a future determination by the Board that the cited concerns/deficiencies have been resolved satisfactorily. If, upon review of the special report, the Board concludes that the program has satisfactorily resolved the cited concerns/deficiencies, a new decision must be made at that time, regarding the extension of the accreditation term. Focused On-Site Evaluation The CCNE Board may require focused evaluations to review specific issues between comprehensive evaluations. The purposes of focused evaluations are: To follow up on unresolved matters from the most recent comprehensive on-site evaluation. To evaluate new concerns or issues that come to light during the review of annual reports, continuous improvement progress reports, or other reports. To assess substantive changes in the program. Continued accreditation may be contingent upon the results of a focused evaluation. Teams for the focused evaluation are appointed and configured in accordance with the scope and special purpose associated with each visit. Focused evaluations are usually conducted over a one-day period. The schedule for the focused evaluation includes opportunities for the team to meet with the appropriate personnel and review programmatic materials relative to the special purpose of the visit. The rights, privileges and responsibilities of institutions during a focused evaluation are the same as those accorded an institution for a comprehensive evaluation. The team's report based on a focused evaluation is considered by the CCNE Board. Substantive Changes Irrespective of required annual reports, progress reports, or other reports, the chief nursing administrator is required to notify CCNE of any substantive change affecting the nursing education program. Substantive changes include, but are not limited to: change in legal status, control, ownership, or resources of the institution; change in status with state board of nursing or other accrediting or approval agency; significant change in faculty composition and size; significant change in teaching affiliations; significant change in student enrollment or student achievement; major curricular revisions; and change in degree offerings, specialty track offerings, or program options. The substantive change report must document how, if at all, the change affects the program's compliance with the accreditation standards. The substantive change report should not exceed five pages, unless otherwise negotiated with CCNE staff. A report submitted by the chief nursing administrator on the nature and scope of the substantive change is reviewed by CCNE staff. If warranted, the report is reviewed by the CCNE Board. Continued accreditation of the program is contingent upon the chief nursing administrator's apprising CCNE of substantive changes. The chief nursing administrator is advised to contact CCNE staff to determine whether a particular change constitutes a substantive change for the purpose of submitting a report to CCNE. REVIEW OF ADVERSE ACTIONS If an adverse action is taken by CCNE, the sponsoring institution is provided with an opportunity to request procedural reconsideration of the adverse action and may appeal the decision to a hearing committee. A request to initiate the processes for procedural reconsideration or appeal must articulate the reasons for the request and will not be accepted solely on the basis of dissatisfaction with the adverse decision, nor will it be accepted on the basis of modifications made subsequent to the determination of the adverse action. The sponsoring institution receives formal written notification of the adverse action following the meeting of the CCNE Board. The basis for the adverse action and the institution's right to request procedural reconsideration and appeal are clearly stated in the notification letter. When the CCNE Board considers an adverse action, the action shall not become final, nor shall it be published, until the sponsoring institution affected thereby has been afforded an opportunity to request procedural reconsideration and file a written appeal. If the institution does not initiate the procedural reconsideration or appeal processes, the institution's rights to due process from CCNE are considered to be exhausted. During the due process period, the new applicant, preliminary approval or accreditation status of the educational program shall revert to the status prior to the adverse action. Following implementation of the procedural reconsideration and appeal processes, if the CCNE Board sustains the adverse action, the effective date of the action will be the date on which the action is sustained. If the CCNE Board reverses the adverse action and, thus, acts to accredit the program, the effective date of the accreditation action will be the date on which the previous action was taken by the Board. Procedural Reconsideration Procedural reconsideration is the process that allows the sponsoring institution the opportunity to request that the CCNE Board review its decision for the purpose of determining whether CCNE procedures described in this publication were followed by an evaluation team, the ARC, the RRC or the CCNE Board. Because procedural reconsideration is designed for the review of errors in the application of CCNE procedures, matters of disagreement related to issues of substance are not reviewed within the procedural reconsideration process. Such matters, however, may be identified as the basis for an appeal. A request for procedural reconsideration must be submitted within 21 working days following receipt of the notification letter. If such a request is not submitted and postmarked within this 21-day period, all rights to procedural reconsideration will be considered to be waived by the institution. The written request must be submitted to the CCNE office by certified mail, return receipt requested. The request for procedural reconsideration must identify the procedure(s) in question and describe in detail the institution's claim that the procedure(s) was not followed, including any documentary evidence to support the claim. Following review by CCNE staff, the request for procedural reconsideration is considered by the Executive Committee of the Board by conference call or actual meeting. Based on a recommendation of the Executive Committee, a decision may be made by the CCNE Board, either by conference call or actual meeting to: a) sustain the previous action, b) rescind the previous action and refer the matter for additional review by the ARC or RRC, or c) defer action and seek an invitation from the institution to conduct a new on-site evaluation. If a new evaluation is conducted, the institution will be responsible for the cost of the evaluation. The institution's chief executive officer and the chief nursing administrator are notified of the action taken by the CCNE Board with respect to the procedural reconsideration no later than 30 days following the conference call or meeting held to review the recommendation of the Executive Committee. If the previous action is sustained, the sponsoring institution is provided with an opportunity to appeal the decision to a hearing committee. Written Appeal Following completion of the procedural reconsideration process or in lieu of the procedural reconsideration process, the sponsoring institution may appeal the decision to a hearing committee. The institution is free to pursue either a substantive or procedural claim as part of the appeal process. The CCNE Board may dismiss an appeal that does not articulate the reasons for the appeal. The sponsoring institution's written appeal must be received in the CCNE office within 21 working days following receipt of the most recent letter from CCNE notifying the institution of the adverse action or the outcome of procedural reconsideration. Payment of the appeals fee must accompany the written appeal. The written appeal must include the facts and reasons that are the basis of the institution's appeal. The written appeal must be submitted to the CCNE office by certified mail, return receipt requested. Hearing Committee The committee assigned to hear the appeal is appointed by the CCNE Board chair and is subject to the approval of the sponsoring institution. The hearing committee functions as an independent review body for the purpose of reviewing materials and hearing verbal presentations from representatives of the program and representatives of CCNE relative to the adverse action. The size and composition of the committee must take into consideration the nature of the appeal, and the content and scope of activities of the educational program under consideration. Membership of the hearing committee may not include any member of the CCNE Board or other ARC or RRC member or on-site evaluator who was involved in the review of the program leading to the adverse decision. The committee consists of three to five members. The CCNE Board chair designates one member of the committee to act as chair of the hearing. A list of names of potential members of the hearing committee is identified by CCNE staff and forwarded to the chief nursing administrator within 21 working days of receipt of the request for appeal. The appellant is provided reasonable opportunity (not to exceed 10 working days) to reject individuals from the list. From those names on the list who are not rejected, the CCNE Board chair appoints the members of the committee. The chief nursing administrator is informed of the individuals appointed. The final composition of the hearing committee is confirmed within 15 working days of the chief nursing administrator's response to the list of names. Appeal Hearing: Time and Location The appeal hearing takes place no later than 60 days and no sooner than 30 days following confirmation of appointment of the committee. A date and time for the appeal hearing are determined by CCNE staff in consultation with the chief nursing administrator and the committee chair. The site of the hearing is determined by CCNE staff. In selecting the site, staff must ensure that the confidentiality of the process can be maintained. Written Materials and Documents At the time of the program's written appeal, the chief nursing administrator submits information that supports the basis for the appeal. Supplementary information following confirmation of the appointment of the committee may be considered by the committee if it is received no later than two weeks prior to the hearing. The committee may request that additional materials and documents be submitted after this deadline or after the hearing. Rights of Participants At the hearing, the appellant is afforded full opportunity to present documented facts and arguments orally and/or in writing. The appellant institution, at its own expense, may bring faculty and administrative representatives and legal counsel. Because the nature of the hearing is investigative rather than adversarial, the participation of legal counsel is limited to providing advice to the appellant. Provision for cross-examination is not available. CCNE, at its own expense, may have members or representatives, consultants, and legal counsel in attendance at the hearing. At least one CCNE staff member is present at the hearing and acts as a technical advisor to the hearing committee. As part of the hearing, the committee may, without the institutional representatives present, meet with or conduct telephone conference calls with representatives of the CCNE Board, the ARC, the RRC or the on-site evaluation team, interviewing those individuals who were directly involved in the adverse action. The hearing is conducted in executive session and may be recorded only by CCNE. Purpose of the Hearing The purpose of the hearing is not to reevaluate anew the educational program but rather to determine whether established standards and procedures were applied properly as related to the adverse decision, and that the decision was supported by substantial evidence. The hearing committee is empowered to review substantive matters based upon information that was reasonably available to the evaluation team, the ARC, the RRC or the CCNE Board. The committee also is empowered to determine whether CCNE procedures were appropriately followed. The committee does not consider new information provided by the institution relative to compliance with CCNE standards and procedures. General Rules for the Hearing The chair of the hearing committee presides over the hearing and his/her decisions pertaining to rules of order and procedures are final and not open to debate. All remarks are considered to be on the record and are part of an executive session. Issues regarding personalities, which may be subject to slander and libel laws, are explicitly prohibited. Specific allegations regarding individual performance also are prohibited unless actual documented evidence can be provided to substantiate these allegations. Issues that were not included in the original request for the appeal may not be considered. Oral Presentation At the time of the hearing, representatives of the appellant institution are provided with an opportunity to present oral remarks. The committee determines specific time limitations prior to the hearing in an effort to confine the hearing to a reasonable period of time. In the interest of reducing the expenses of the appellant, the institution may videotape or audiotape the oral remarks of representatives who speak on behalf of the appellant. Prerecorded remarks that will be part of the oral presentation of the institution are subject to the time limitations identified by the committee. If the appellant institution elects to prerecord oral remarks of its representatives, the authenticity of the prerecorded tapes must be certified. A list of all individuals, including legal counsel, who provide oral remarks (in person or prerecorded) on behalf of the appellant must be submitted to the committee at least two weeks prior to the hearing. No representatives of the institution who are not specifically identified prior to the deadline may participate in the hearing, with the exception of substitutes for participants who become ill or otherwise incapacitated. Summary of Findings The hearing committee deliberates in executive session following the presentation of oral remarks. The committee develops recommendations, formulates plans for a written summary of findings, and determines significant areas of concern. The committee chair coordinates the development of the written summary of findings. Included in the confidential summary of findings is the committee's recommendation. The summary of findings is forwarded to the CCNE B