CCNE Accreditation

Submitting a Substantive Change Notification

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Institutions with CCNE accredited nursing programs are required to notify CCNE of any substantive changes affecting the nursing programs. Substantive change notifications must be emailed as a PDF document to ccnesubchange@aacn.nche.edu. The policy regarding substantive change notifications can be found in the CCNE Accreditation Procedures for Accreditation of Baccalaureate & Graduate Degree Nursing Programs, and is as follows:

Irrespective of required annual reports, continuous improvement progress 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, ownership, or significant reduction in resources of the institution or program;
  • change in status with state board of nursing or other accrediting or approval entity, including cases in which the program is placed on warning or probationary status by any regulatory body;
  • change in degree offerings, program options, and track offerings (including the development, suspension or closing of a track);
  • the addition of a new nursing degree (e.g., a master’s degree), when another nursing degree (e.g., a baccalaureate degree) 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 activities; and
  • significant change in the student achievement (see below).

Consistent with the U.S. Secretary of Education’s Procedures and Criteria for Recognition of Accrediting Agencies, CCNE has identified student achievement thresholds for nursing programs within its scope. The CCNE accreditation standards require that nursing programs provide data related to student achievement (Standard IV). If any of the following conditions exist with respect to student achievement, the program must submit a substantive change report--including a written explanation and action plan--to CCNE:

  • degree completion rates for the baccalaureate, master’s, or DNP program are less than 80% in the expected time period, as defined by the program;

  • annual NCLEX-RN® pass rates for all test takers (first time and repeat) over a 3-year period are less than 80% (CCNE recognizes that many state regulatory agencies establish minimum licensure thresholds, and that these vary by state);

  • job placement/employment rates for the baccalaureate or master’s program within 12 months following degree completion are less than 80%; and

  • certification pass rates for all test takers (first time and repeat) for any specialty area over a 3-year period are less than 80% (CCNE recognizes that many state regulatory agencies do not require national certification. However, a program still must report pass rate data to CCNE even when not required by the state.)

The substantive change report 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.

The substantive change report is submitted by the chief nurse administrator and must document the nature and scope of the substantive change. The report also must document how, if at all, the change affects the program's compliance with the accreditation standards. The substantive change report should not exceed 5 pages, unless otherwise negotiated with CCNE staff.

The substantive change report is reviewed by the CCNE Executive Committee, which comprises the officers of the Board. Upon review of the report, the committee may act to approve the change or may request additional information. If warranted, the report is forwarded to the CCNE Board for review and action. The Board’s review of a substantive change report may result in additional reporting requirements, a focused or comprehensive on-site evaluation, or an adverse action.

Continued accreditation of the program is contingent upon the chief nurse administrator's 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.

Please contact Crystal Pool, CCNE Assistant Director, at cpool@aacn.nche.edu or (202) 887-6791, ext. 245, if you have any questions regarding substantive changes.