CCNE Accreditation

Submitting a Substantive Change Notification

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Institutions with CCNE accredited post-baccalaureate nurse residency programs are required to notify CCNE of any substantive changes affecting the residency program.  Substantive change notifications must be emailed to Benjamin Murray, CCNE Associate Director, as a PDF document to bmurray@aacn.nche.edu. The policy regarding substantive change notifications can be found in the CCNE Procedures for Accreditation of Post-Baccalaureate Nurse Residency Programs (2009), and is as follows:

Irrespective of required continuous improvement progress reports or other reports, the program is required to notify CCNE of any substantive change affecting the residency program. Substantive changes include, but are not limited to:

•    major change in the parent institution, including a change in its accreditation status;

•    change in criteria for enrollment in the nurse residency program;

•    major curricular revisions;

•    change in program length;

•    change of the chief nursing office or residency coordinator;

•    significant change in program faculty;

•    significant change in resident enrollment; and

•    significant change in the partnership between the parent institution and the academic institution.

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 nursing officer 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 RAC [Residency Accreditation Committee]. 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 nursing officer's apprising CCNE of substantive changes in a timely manner. The chief nursing officer is encouraged to contact CCNE staff if there is a question about whether a particular change constitutes a substantive change.