Accreditation Preparation

1. Accreditation Preparation Patty Knecht PhD (c) RN ANEF Mary Moss EdD MSN RN CNE Kay Tupala MSN RN

2. Presentation Outcomes • Identify key processes for effective ongoing accreditation approval, including faculty and community engagement. • Discuss common challenges to complying with accreditation standards and criteria • Identify strategies to improve the ongoing collection, analysis, and utilization of course outcome and program outcome data.  ATI Educational Summit April 2014

3. 10 Key Processes • Know the Standards & Criteria – Regardless of Accreditor • Have a Program Evaluation Plan or a Process • Start Early – Continual Focus • Put Some Thought into Organization • Involve Your Faculty • Involve Students, Graduates, and Employers (Stakeholders) • Curriculum Considerations • Self Study Report • Use All Resources – ACEN or CCNE website, ATI • Understand Program Outcomes and Student Outcomes ATI Educational Summit April 2014

4. What Should You Understand about Accreditation? ATI Educational Summit April 2014

5. 1. Know the Standards & Criteria • Answer all parts of the criterion • Provide enough evidence to prove you meet that criterion • Try to predict what site visitors might ask for related to each criterion • Make up a list of potential questions related to each criteria • Consider having a colleague do a mock site visit • Pay attention to the list of items needed to provide proof that you meet this criterion ATI Educational Summit April 2014

6. 2. Program Evaluation Plan or Process • The plan for program improvement must be continuous • Even though you must have 3-5 years of data - make it continuous • Examples: • Communities of interest • Graduate and employer surveys • Parent organization ATI Educational Summit April 2014

7. 3. Start Early! • The preparations take longer than you think • Consider making a timeline • Work back from the date of the site visit • Initial vs. continuing accreditation ATI Educational Summit April 2014

8. 4. Organization • Evidence or proof of meeting the criterion • Hard copy documents – A Document Room • Electronic documents - Links in the SSR (need to be saved where the link will work without a password) • A password protected website CLICK ATI Educational Summit April 2014

9. 5. Faculty and Staff Variables • It is essential that the faculty take ownership and actively participate in the process. Faculty need to know and understand what is expected of the program. • Are they actively participating and collecting data? Find a way to build time into schedules. • Do faculty participate in the decision making? Do they own the decisions made within the group? Do they live with the decisions? • How many of the faculty were present at the last site visit? • The percentage of adjunct faculty is increasing. Is there a role for adjuncts? ATI Educational Summit April 2014

10. 6. Stakeholders Graduates College or Parent Organization Students Employers ATI Educational Summit April 2014

11. 7. Curriculum Considerations • Is it regularly reviewed? • Do foundational principles link through the entire program? Are terms and concepts consistent throughout all areas: Mission/Vision/Philosophy/Framework/ Purpose/Program Outcomes/Course Competencies? Are they aligned? • Can you show how individual activities in a unit builds to a course and then build to the SLOs? • Is curriculum current, utilizing evidenced based standards such as QSEN, IOM, JC, Baccalaureate Essentials or Core Measures? ATI Educational Summit April 2014

12. 8. Self Study Report • Purpose of the SSR – present your program in the best light. • Prove how you meet each criterion • Be very specific – don't just repeat the criterion • Use information for the program improvement plan to support the criterion ATI Educational Summit April 2014

13. 9. Use All of Your Resources • Definitely check out the ACEN or CCNE website • Call the main ACEN or CCNE office – ask if you have questions. They might review your materials • Ask your colleagues for their input • Attend professional development sessions on accreditation • Consider a mock site visit or have someone review your Program Plan ATI Educational Summit April 2014

14. 10. Know the Difference • Program Outcomes – measure the effectiveness of the program. Is the program meeting its goals and outcomes • Usually looking at cohort groups • Usually includes measures based on decisions about the program as a whole – NCLEX, completion rates, job placement rates • Student Outcomes - measure individual student learning. Can you prove that the student has learned something? • Usually looking at individual students • Measure your learning outcomes – whatever you decide they are. FIRST DECIDE, THEN MEASURE. ATI Educational Summit April 2014

15. Can you use ATI to help prepare? Example-Results of Employer Surveys • Need better clinical judgment and priority setting • Do we want to make decisions based on one data source? Could you track in ATI? • Choose the areas • Track each cohort for a few quarters or semesters, and then make some decisions. Two data sources are a strong reason to change ATI Educational Summit April 2014

16. ATI Educational Summit April 2014

17. Common Challenges in Compliance with Standards and Criteria Utilization of Data is a Key Element

18. Data Circle Collection, assessment, analysis, implementation, and evaluation Location Aggregate Type Completion date

19. To Avoid Common Challenges … Create a Clear, Succinct, Documented Process with Delineated Staff Roles

20. Management of the Program Review ProcessKey Roles

21. Data Collected and Utilized to Inform Program Decision Making • Aggregate Data - Compiled over several years, inclusive of all cohorts. However, also collected and analyzed by: • Location • Program type • Completion date • Findings are utilized to support: program key discussions; assessment of expected level of achievements; suggested actions (strategies) implemented; ongoing evaluation; and suggested revisions

22. How Much Data is Needed? • Initial Accreditation • Data collected, trended, and utilized for decision making from program inception • Continuing Accreditation • Data collected, trended, and utilized for decision making since last accreditation approval (last three years)

23. Is this How You Feel When Asked…Did You Utilize Data to Make All Program Decisions?

24. Never Enough Time…

25. Utilize Each Member of the Team for their Expertise

26. WorkloadNurse Administrator/Faculty • Nurse administrators in small programs often have a teaching assignment • Assure the nurse administrator has enough time to do the programmatic work • Survey of faculty and support staff • Discussion with the nurse administrator & supervisor

27. New Administrators New Faculty • New program administrators • Orientation/Mentoring requirement • Prioritizing accreditation • Project management • Delegation • New faculty • Orientation to the accreditation process • Ensure this is part of orientation plan for new faculty

28. Support Staff’s RoleOrganization of Data for Faculty and Staff Sample Email: “Attached is all the info you will need to review for SEP Standard 2. If you notice anything is missing from attachments please email me and I will get the info to you.” In addition, I have also attached the most recent site visitors report and a copy of the 12-13 SEP for reference.

29. Sample of an Email Attachment

30. Faculty

31. Faculty Involvement in College Committees/Governance • Nursing faculty are so…..busy • Strategically plan how to assure faculty are represented and participating on college committees • Involve the faculty in problem solving participation, specific to their own areas of interest • Committee examples include: college budget planning, governance, human resources, curriculum, strategic planning, etc.

32. Faculty/Staff Credentials • Know the faculty/staff credential requirements of your program • State Board of Nursing vs Accrediting Body • Full time and part time faculty differences • Maintain accurate credential documentation in the HR department • Suggest a mock site visit, check ALL faculty credentials • Degree (i.e. Completion date or expected date of completion) • Expertise (Align with area of teaching and maintenance) • Scholarship

33. Faculty/StaffOther Factors to Consider • Number and utilization • Orientation and mentoring • Evaluation (Is it systematic?) • Use of preceptors • Distance education implications

34. Faculty and Staff Consider the following scenario: You are applying for initial accreditation. The program has doubled student enrollment in the last two years. Three new part time positions were approved and appointed in response to the increased enrollment. What data can you utilize as evidence of how you have made strategic program decisions in an attempt to meet this standard’s expected level of achievement? What other data should you consider collecting to further inform program decision making?

35. Student FTE’s

36. FacultySample Data Chart

37. FacultySample Data Chart

38. Sample Faculty Profile Table

39. Students

40. Student Involvement in Program and College Committees • Nursing students are so busy! • Encourage students to participate in Student Senate and other committees available to them at your college • Assure students have input into program decisions • Ideas for student representation • Listening sessions with Program Director • Semester reps attending faculty meetings • Input via specific emails • Follow up on their feedback

41. Student Outcomes • Specific to your program • Write in measurable terms • Evaluate with varied tools • Examples include: Student assessments, including tests, papers, presentations, portfolios, student surveys

42. Resources • Growth in program Growth in resources • Program budget should reflect this • Do you have enough classrooms/lab space/clinical sites? • Need data to prove this • What’s your full time to part time faculty ratio? • Show evidence that program growth did not adversely impact program quality

43. CurriculumEvaluation • Maintain a process for evaluating curriculum • Larger schools – nursing curriculum committee • Smaller schools – all faculty involved in this process • How do you assure “current standards of practice” are integrated in the curriculum? • Track critical integration • QSEN • National Patient Safety Goals • Healthy People 2020 • Evidence-based practice integration • State Nurse Practice Act

44. CurriculumOther Factors to Consider • Alignment/congruency (SLO/course/program outcomes) • Faculty Input • Cultural and ethnically diverse • Evaluation methodologies (Student, course, and program) • Length • Practice learning environments

45. Curriculum Consider the following scenario: Student program surveys indicate that 50%, 64%, and 68% (2011, 2012 & 2013) of the students believe the practice learning environments do not support the achievement of SLOs. What data can you utilize as evidence of how the program has made strategic program decisions in an attempt to meet this standard’s expected level of achievement? What other data should you consider collecting to inform program decision making?

46. Programmatic Changes • MUST KNOW and follow: • Accrediting body requirements and timelines regarding approval/implementation of changes • State Board of Nursing requirements and timelines regarding approval/implementation of changes • Be patient, plan ahead, change can’t occur overnight • If in doubt, consult!

47. Process to Determine Program Effectiveness • Both CCNE and ACEN require a systematic process to determine program effectiveness • Challenge: having faculty champions to develop, maintain the plan, enter and track data, and evaluate decisions made based on data

48. Meeting Program Outcomes NCLEX Pass Rates • NCLEX pass rates • ACEN – 3 year average, at or above national average • CCNE – 80% average pass rate annually • Maintain your pass rate data by cohort (if data available by student) • Document discussion/plans for improving NCLEX pass rates if not in compliance • Show trends in pass rates with programmatic changes

49. Program Outcomes/Effectiveness Consider the following scenario: Three year graduate and program satisfaction survey rates of return from 2011 – 2013 are 12%, 14% and 17% respectively? (All areas are rated satisfactory or above) What data can you utilize as evidence of how the program has made strategic program decisions in an attempt to meet this standard’s expected level of achievement? What other data should you consider collecting to further inform program decision making?

50. Program Outcomes • Licensure (NCLEX) Exam (First time test takers) • Program Completion • Graduate Program Satisfaction • Employer Program Satisfaction • Job Placement Rates