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The American Association of Colleges of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
There is no conflict of interest or relevant financial interest by the faculty or planners of this activity. The entire webinar and the program evaluation must be completed to earn contact hours. This webinar will be recorded and available until January 14, 2018.
WRITING THE CCNE TEAM REPORT January 14, 2015 Webinar
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Presenters Jennifer Butlin, EdD CCNE Executive Director Lori Schroeder, MA CCNE Director of Accreditation Services
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Expected Outcomes to become familiar with CCNE requirements and expectations for writing the team report to be prepared to write narrative that supports the team’s findings regarding compliance with the Standards and Key Elements to become knowledgeable about the use of “not applicable” to be prepared to respond to questions from CCNE staff, members of the Accreditation Review Committee or the CCNE Board of Commissioners to become familiar with the revised CCNE Procedures 4
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CCNE at a Glance
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CCNE at a GLANCE CCNE currently accredits 1,199 nursing education programs at 650 institutions. Over the next two years, CCNE will conduct 310 on-site evaluations 86 evaluations in Spring 2015 105 evaluations Fall 2015 64 evaluations in Spring 2016 55 evaluations in Fall 2016
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Requirements and Expectations for Writing the Team Report
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REQUIREMENTS AND EXPECTATIONS FOR WRITING THE TEAM REPORT The Team Report includes a brief Introduction that provides an overview of the institution and the program the team’s findings regarding whether each standard is met or not met for each degree and/or certificate program under review the team’s findings regarding whether there is a compliance concern (yes/no/not applicable) for each of the key elements for each degree and/or certificate program under review a brief narrative for each key element that addresses the program’s compliance (yes/no/not applicable) for each degree and/or program under review 8
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REQUIREMENTS AND EXPECTATIONS FOR WRITING THE TEAM REPORT The Introduction (1-1.5 pages) should briefly describe the history of the institution including the types of degrees offered, Carnegie classification and institutional accreditor indicate which degree and certificate programs are under review and whether this is an initial review for accreditation or a review for continuing accreditation by CCNE briefly describe the nursing programs offered by the institution including degrees and tracks verify that the institution provided the opportunity for its communities of interest to provide third-party comments to CCNE 9
REQUIREMENTS AND EXPECTATIONS FOR WRITING THE TEAM REPORT In the Introduction, please do not copy verbatim the information provided on the institution’s website, in the self-study document, or other documents without appropriately attributing the source of that information.
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REQUIREMENTS AND EXPECTATIONS FOR WRITING THE TEAM REPORT Standards and Key Elements indicate if the standard is met or not met for each degree and/or certificate program under review indicate if there is a compliance concern (yes/no) for each key element for each degree and/or certificate program under review indicate if there is a compliance concern (yes/no/not applicable) for Key Elements IV-B, IV-C, and IV-D only, for each degree and/or certificate program under review detailed narrative should be provided for each degree and/or certificate program under review for each key element (when appropriate) detailed narrative should specifically address the elaboration statement for each key element 11
REQUIREMENTS AND EXPECTATIONS FOR WRITING THE TEAM REPORT Post-Graduate APRN Certificate Programs Not all post-graduate APRN certificate programs offer the same tracks as are offered in the master’s and/or DNP programs Accreditation is awarded separately to the post-graduate APRN certificate program A separate discussion in the narrative is necessary for post-graduate APRN certificate programs. For instance the following statements would be sufficient: The post-graduate APRN certificate students (AGNP and FNP) are in the same classes and courses with the MSN students, are meeting the same student learning outcomes and are exposed to the same teaching-learning strategies. For the post-graduate APRN certificate program, student transcripts of prior master’s courses are evaluated through a gap analysis and based on that analysis, a program plan is developed that includes the necessary theory and practicum course requirements and the minimum clinical hours required for eligibility for the national certification exam and 12 advanced practice licensure.
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REQUIREMENTS AND EXPECTATIONS FOR WRITING THE TEAM REPORT Determination of “Met” or “Not Met” The team makes a determination regarding whether a standard is met or not met for each degree and/or certificate program under review. The determination is at the discretion of the team, and is not based on a specific number of compliance concerns at the key element level.
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REQUIREMENTS AND EXPECTATIONS FOR WRITING THE TEAM REPORT Use of Compliance Concern “No” This designation should be used when the team is able to confirm through a review of evidence (e.g., materials found in the resource room, interview, self-study document) that the program is in substantial compliance with the key element. It should be evident to the reader of the team report that the program is in compliance with the key element based on a clearly written succinct response that supports the team’s finding.
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REQUIREMENTS AND EXPECTATIONS FOR WRITING THE TEAM REPORT Use of Compliance Concern “Yes” This designation should only be used when the team is unable to find evidence that supports a program’s compliance or when the evidence produced (e.g., low pass rates) suggests that there are compliance concerns with the key element. If the team concludes that there is a compliance concern, the reader of the report should be able to answer the following question “The team found a compliance concern for this key element because….” The evidence does not have to be present in the self-study document. It may be provided in the resource room, gleaned from interviews, etc. There should not be a finding of a compliance concern if the evidence of compliance is provided on 15 site.
REQUIREMENTS AND EXPECTATIONS FOR WRITING THE TEAM REPORT Use of Compliance Concern “Not Applicable” This designation should only be used for Key Elements IV-B, IV-C and IV-D, if appropriate. Key Element IV-B (program completion) is only not applicable if there have been no graduates and/or completers. This determination is to be made by DEGREE not by TRACK. For instance, if an institution offers a baccalaureate program with pre- and post-licensure programs and the pre-licensure program has graduates and the post-graduate program does not have graduates, this key element is still applicable. 16
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REQUIREMENTS AND EXPECTATIONS FOR WRITING THE TEAM REPORT Use of Compliance Concern “Not Applicable” Key Element IV-C (pass rates) is only not applicable if no graduates or completers have taken licensure or certification exams. This determination is made by TRACK and by CAMPUS/SITE within each degree and/or certificate program. For instance, if the institution offers a master’s program with family nurse practitioner and nurse educator tracks, and the program prepares students for those exams, pass rate data must be provided for each track. Additionally, if each track is offered at more than one campus/site, the data need to be provided by track at each campus/site. This key element is applicable, if data are available for at least one of the tracks offered at any campus/site. 17
REQUIREMENTS AND EXPECTATIONS FOR WRITING THE TEAM REPORT Use of Compliance Concern “Not Applicable” Key Element IV-D (employment rates) is only not applicable if there have been no graduates or completers. This determination is to be made by DEGREE not by TRACK. For instance, if an institution offers a baccalaureate program with pre- and post-licensure programs and the pre-licensure program has graduates and the post-licensure program does not have graduates, this key element is still applicable.
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EXPECTATIONS FOR WRITING THE TEAM REPORT
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Developing and Editing the Team Report Narrative
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DEVELOPING AND EDITING THE TEAM REPORT NARRATIVE The team report narrative should specifically relate to the key element and the elaboration statement support the team’s finding regarding compliance at the key element level for each degree and/or certificate program under review clearly describe the evidence provided and where it was found, particularly if it was not found in the self-study document (e.g., a review of minutes, interviews, bylaws, catalogs, etc.) clearly describe the reason for the compliance concern, if one is noted by the team be edited for voice, style, spelling, grammar, etc., prior to submitting it to CCNE 21
DEVELOPING AND EDITING THE TEAM REPORT NARRATIVE The team report narrative should not be ambiguous or contradictory repeat information provided elsewhere in the report if it is not specific to the key element that is being addressed
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DEVELOPING KEY ELEMENT NARRATIVE PRESENT ADDITIONAL RELEVANT BACKGROUND CLEARLY DESCRIBING THE INITIAL POINTS
ADDRESS THE KEY ELEMENT AND ELABORATION STATEMENT BY PRESENTING THE MOST RELEVANT POINTS FIRST
REINFORCE THE MAIN MESSAGE WITH DETAILS AND EXAMPLES FINAL POLISH TO ENSURE COMPLETENESS AND READABILITY Look over your work and avoid excessive length
WRITE CLEARLY AND CONCISELY EMPHASIZE THE TEAM’S INVOLVEMENT
Use primarily the active rather than the passive voice
In meetings with faculty, they confirmed that ... (ok) In meetings, the faculty confirmed that ... (better)
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The Relationship Between Key Elements
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THE RELATIONSHIP BETWEEN KEY ELEMENTS The standards and key elements relate to one another. It may help to remember that Standard I addresses mission and governance Standard II addresses institutional commitment and resources Standard III addresses curriculum and teaching-learning practices Standard IV addresses assessment and achievement of program outcomes
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THE RELATIONSHIP BETWEEN KEY ELEMENTS For instance, Key Elements I-C, II-F and IV-F are all related to faculty expectations and outcomes. Key Element I-C is related to the identification of expected nursing faculty outcomes and the congruence of these outcomes to those identified by the parent institution Key Element II-F is seeking confirmation of the institution and program’s support of the expected faculty outcomes identified in I-C Key Element IV-F is related to how identified faculty outcomes are collected and measured, individually and in the aggregate, and how the actual aggregate data are analyzed and compared to the expected outcomes 26
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THE RELATIONSHIP BETWEEN KEY ELEMENTS
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Standard IV
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KEY ELEMENT IV-A A systematic process is used to determine program effectiveness.
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KEY ELEMENT IV-A (CONT.) Elaboration: The program uses a systematic process to obtain relevant data to determine program effectiveness. The process: is written, ongoing, and exists to determine achievement of program outcomes; is comprehensive (i.e., includes completion, licensure, certification, and employment rates, as required by the U.S. Department of Education; and other program outcomes); identifies which quantitative and/or qualitative data are collected to assess achievement of the program outcomes; includes timelines for collection, review of expected and actual outcomes, and analysis; and is periodically reviewed and revised as appropriate.
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KEY ELEMENTS IV-B, IV-C AND IV-D refer to the specific expectations (rates) that have been set by CCNE as noted in each elaboration data are provided for the entire degree/certificate program under review (for Key Elements IV-B and IV-D) data are provided for each campus/site and track under review for licensure pass rates (for Key Element IV-C) data are provided for each certification exam for which the program prepares graduates (for Key Element IV-C)
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KEY ELEMENT IV-B Program completion rates demonstrate program effectiveness.
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KEY ELEMENT IV-B (CONT.) Elaboration: The program demonstrates achievement of required program outcomes regarding completion. For each degree program (baccalaureate, master’s, and DNP) and post-graduate APRN certificate program: The completion rate for each of the three most recent calendar years is provided. The program specifies the entry point and defines the time period to completion. The program describes the formula it uses to calculate the completion rate.
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KEY ELEMENT IV-B (CONT.) The completion rate for the most recent calendar year is 70% or higher. However, if the completion rate for the most recent calendar year is less than 70%, (1) the completion rate is 70% or higher when the annual completion rates for the three most recent calendar years are averaged or (2) the completion rate is 70% or higher when excluding students who have identified factors such as family obligations, relocation, financial barriers, and decisions to change major or to transfer to another institution of higher education. A program with a completion rate less than 70% for the most recent calendar year provides a written explanation/analysis with documentation for the variance. This key element is not applicable to a new degree or certificate program that does not yet have individuals who have completed the program. 34
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KEY ELEMENT IV-B (CONT.) For CCNE purposes, “completion rate” means: a) those who have completed the post-graduate APRN certificate program (if under review); and b) those who have graduated from the nursing degree program under review. When calculating the rate, programs should not include individuals who have completed coursework but who have not yet been awarded the certificate or graduated from the program.
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KEY ELEMENT IV-C Licensure and certification pass rates demonstrate program effectiveness.
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KEY ELEMENT IV-C (CONT.) Elaboration: The pre-licensure program demonstrates achievement of required program outcomes regarding licensure. The NCLEX-RN® pass rate for each campus/site and track is provided for each of the three most recent calendar years. The NCLEX-RN® pass rate for each campus/site and track is 80% or higher for first-time takers for the most recent calendar year. However, if the NCLEX-RN® pass rate for any campus/site and track is less than 80% for first-time takers for the most recent calendar year, (1) the pass rate for that campus/site or track is 80% or higher for all takers (first-time and repeat) for the most recent calendar year, (2) the pass rate for that campus/site or track is 80% or higher for first-time takers when the annual pass rates for the three most recent calendar years are averaged, or (3) the pass rate for that campus/site or track is 80% or higher for all takers (first-time and repeat) when the annual pass rates for the three most recent calendar years are averaged. 37
KEY ELEMENT IV-C (CONT.) A campus/site or track with an NCLEX-RN® pass rate of less than 80% for first-time takers for the most recent calendar year provides a written explanation/analysis with documentation for the variance and a plan to meet the 80% NCLEX-RN® pass rate for first-time takers. The explanation may include trend data, information about numbers of test takers, data relative to specific campuses/sites or tracks, and data on repeat takers. The graduate program demonstrates achievement of required program outcomes regarding certification. Certification results are obtained and reported in the aggregate for those graduates taking each examination, even when national certification is not required to practice in a particular state.
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KEY ELEMENT IV-C (CONT.) Data are provided regarding the number of graduates and the number of graduates taking each certification examination. The certification pass rate for each examination for which the program prepares graduates is provided for each of the three most recent calendar years. The certification pass rate for each examination is 80% or higher for first-time takers for the most recent calendar year. However, if the pass rate for any certification examination is less than 80% for first-time takers for the most recent calendar year, (1) the pass rate for that certification examination is 80% or higher for all takers (first-time and repeat) for the most recent calendar year, (2) the pass rate for that certification examination is 80% or higher for first-time takers when the annual pass rates for the three most recent calendar years are averaged, or (3) the pass rate for that certification examination is 80% or higher for all takers (first-time and repeat) when the annual pass rates for 39 the three most recent calendar years are averaged.
KEY ELEMENT IV-C (CONT.) A program with a pass rate of less than 80% for any certification examination for the most recent calendar year provides a written explanation/analysis with documentation for the variance and a plan to meet the 80% certification pass rate for first-time takers. The explanation may include trend data, information about numbers of test takers, and data on repeat takers. This key element is not applicable to a new degree or certificate program that does not yet have individuals who have taken licensure or certification examinations.
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KEY ELEMENT IV-D Employment rates demonstrate program effectiveness.
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KEY ELEMENT IV-D (CONT.) Elaboration: The program demonstrates achievement of required outcomes regarding employment rates. The employment rate is collected separately for each degree program (baccalaureate, master’s, and DNP) and post-graduate APRN certificate program. Data are collected within 12 months of program completion. For example, employment data may be collected at the time of program completion or at any time within 12 months of program completion. The employment rate is 70% or higher. However, if the employment rate is less than 70%, the employment rate is 70% or higher when excluding graduates who have elected not to be employed.
Any program with an employment rate less than 70% provides a written explanation/analysis with documentation for the variance. This key element is not applicable to a new degree or certificate program that does not yet have individuals who have completed the 42 program.
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GUIDELINES FOR ASSESSMENT OF STUDENT ACHIEVEMENT For examples of completion, licensure, certification and employment rates that meet or do not meet CCNE’s expectations, refer to the Guidelines for Assessment of Student Achievement.
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KEY ELEMENT IV-E Program outcomes demonstrate program effectiveness.
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KEY ELEMENT IV-E (CONT.) Elaboration: The program demonstrates achievement of outcomes other than those related to completion rates (Key Element IV-B), licensure and certification pass rates (Key Element IV-C), and employment rates (Key Element IV-D); and those related to faculty (Key Element IV-F). Program outcomes are defined by the program and incorporate expected levels of achievement. Program outcomes are appropriate and relevant to the degree and certificate programs offered and may include (but are not limited to) student learning outcomes; student and alumni achievement; and student, alumni, and employer satisfaction data. Analysis of the data demonstrates that, in the aggregate, the program is achieving its outcomes. Any program with outcomes lower than expected provides a written explanation/analysis for the variance.
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KEY ELEMENT IV-F Faculty outcomes, individually and in the aggregate, demonstrate program effectiveness.
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KEY ELEMENT IV-F (CONT.) Elaboration: The program demonstrates achievement of expected faculty outcomes. Expected faculty outcomes: are identified for the faculty as a group; incorporate expected levels of achievement; reflect expectations of faculty in their roles and evaluation of faculty performance; are consistent with and contribute to achievement of the program’s mission and goals; and are congruent with institution and program expectations. Actual faculty outcomes are presented in the aggregate for the faculty as a group, analyzed, and compared to expected outcomes. 47
KEY ELEMENT IV-G The program defines and reviews formal complaints according to established policies.
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KEY ELEMENT IV-G (CONT.) Elaboration: The program defines what constitutes a formal complaint and maintains a record of formal complaints received. The program’s definition of formal complaints includes, at a minimum, student complaints. The program’s definition of formal complaints and the procedures for filing a complaint are communicated to relevant constituencies.
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KEY ELEMENT IV-H Data analysis is used to foster ongoing program improvement.
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KEY ELEMENT IV-H (CONT.) Elaboration: The program uses outcome data for improvement. Data regarding completion, licensure, certification, and employment rates; other program outcomes; and formal complaints are used as indicated to foster program improvement. Data regarding actual outcomes are compared to expected outcomes. Discrepancies between actual and expected outcomes inform areas for improvement. Changes to the program to foster improvement and achievement of program outcomes are deliberate, ongoing, and analyzed for effectiveness. Faculty are engaged in the program improvement process.
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Finalizing the Team Report
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FINALIZING THE TEAM REPORT When developing the Team Report, the team should refer to the Guidelines for Writing the Team Report (available in the CCNE Online Community). After the team has completed writing the team report it: is uploaded into the CCNE Online Community by the team leader read and edited by two CCNE staff provided to the chief nurse administrator with an invitation to submit a written response
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FINALIZING THE TEAM REPORT During the editing process, staff review the report for: voice, style, spelling, grammar, etc. completeness of narrative by key element appropriateness of narrative by key element clarity of narrative by key element
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FINALIZING THE TEAM REPORT During the editing process, staff may: edit for voice, style, spelling, grammar, consistency, flow, clarity, etc. move narrative between key elements delete narrative that is not related to the standards or key elements contact the team leader to: edit the report further for length confirm the team’s finding (compliance concern yes/no/not applicable) gather additional information seek clarification
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Update to CCNE Procedures (Amended November 2014)
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UPDATE TO CCNE PROCEDURES (NOVEMBER 2014) Highlights: new language throughout for the accreditation of post-graduate APRN certificate program compliance report now a separate requirement from continuous improvement progress report (CIPR) when compliance concerns third-party comments process has been revised substantive change notification section rewritten for consistency with revised standards new applicant programs now required to submit substantive change notification, if needed, prior to Board action the definition of the practicing nurse representative who serves on the team has been revised http://www.aacn.nche.edu/ccne-accreditation/Procedures.pdf
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Questions
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Contacting CCNE Staff Lori Schroeder, Director of Accreditation Services
[email protected] Please join us in wishing Libby Cooperman well in her retirement and join us in welcoming Executive Assistant, Mr. Stéphane Charreau. Please feel free to contact Mr. Charreau at Mr. Stéphane Charreau x256 or
[email protected]. ONE DUPONT CIRCLE NW SUITE 530 WASHINGTON DC 20036-1120 WWW.AACN.NCHE.EDU/ CCNE-ACCREDITATION
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