Submitting a Substantive Change Notification
The policy regarding substantive change notifications can be found on pages 20-21 in the CCNE Procedures for Accreditation of Baccalaureate and Graduate Nursing Programs, and is as follows:
Irrespective of required annual reports, continuous improvement progress reports, compliance reports, or other reports, the program is required to notify CCNE of any substantive change affecting the nursing program. Substantive changes include, but are not limited to:
- change in established mission or goals of the program;
- change in legal status, control, or ownership of the institution or program, including acquisition of another institution or program;
- a significant reduction in resources of the institution or program;
- change in status with a state board of nursing or other regulatory agency, including cases in which the institution or program is placed on warning, probationary, or show cause status;
- change in status with an institutional accrediting agency or nursing accrediting agency, including cases in which the institution or program is placed on warning, probationary, or show cause status;
- change in (including development, suspension, or closure of) program offerings or options, including both degree and post-graduate APRN certificate programs and tracks within those programs (see the section on Withdrawal of Accreditation: Closed Programs for information on the timing of reporting the closing of a program);
- the addition of a new nursing program (e.g., a master’s degree program, a DNP program, or a post-graduate APRN certificate program), when another nursing program (e.g., a baccalaureate degree program) is accredited by CCNE;
- the addition of courses that represent a significant change in method or location of delivery from those offered when CCNE last evaluated the program;
- change of the chief nurse administrator;
- significant change in faculty composition and size;
- significant change in student enrollment;
- significant change in teaching affiliations;
- major curricular revisions; and
- change in student achievement such that completion rates, pass rates, and/or employment rates fall below CCNE’s expectations.
Consistent with the U.S. Secretary of Education’s procedures and criteria for the recognition of accrediting agencies, CCNE has identified student achievement expectations for nursing programs within its scope. Refer to the Standards for Accreditation of Baccalaureate and Graduate Nursing Programs and the Guidelines for Assessment of Student Achievement, available on the CCNE website, for CCNE’s expectations relative to completion rates, pass rates, and employment rates.
The substantive change notification must be submitted to CCNE no earlier than 90 days prior to implementation or occurrence of the change, but no later than 90 days after implementation or occurrence of the change. See the section on Withdrawal of Accreditation: Closed Programs for information on the timing of reporting the closing of a degree offering.
The substantive change notification is submitted by the chief nurse administrator and must document the nature and scope of the substantive change. The notification also must document how, if at all, the change affects the program's compliance with the accreditation standards. The substantive change notification should not exceed 5 pages, unless otherwise negotiated with CCNE staff.
The substantive change notification is reviewed by the CCNE Substantive Change Advisory Group (SCAG), and then by the CCNE Executive Committee. Upon review of the notification, the Executive Committee may act to approve the change or may request additional information. If warranted, the notification is forwarded to the CCNE Board for review and action. The Board’s review of a substantive change notification may result in additional reporting requirements, a focused or comprehensive on-site evaluation, issuance of a show cause directive, or an adverse action.
Continued accreditation of the program is contingent upon the chief nurse administrator apprising CCNE of substantive changes in a timely manner. The chief nurse administrator is encouraged to contact CCNE staff if there is a question about whether a particular change constitutes a substantive change.
Substantive change notifications must be emailed as a PDF document to firstname.lastname@example.org.
Please contact Benjamin Murray, Director of Accreditation Services, at email@example.com or (202) 887-6791, ext. 275, if you have any questions regarding substantive changes.