ACEN Accreditation Manual GENERAL INFORMATION. A publication of the Accreditation Commission for Education in Nursing. UPDATED: July 31, 2013

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3 ACEN Accreditatin Manual A publicatin f the Accreditatin Cmmissin fr Educatin in Nursing. UPDATED: July 31, 2013 ACEN 3343 Peachtree Rad NE, Suite 850 Atlanta, Gergia Phne: Fax: Website: Cpyright 2013 Accreditatin Cmmissin fr Educatin in Nursing. All Rights Reserved

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5 TABLE OF CONTENTS SECTION 1 - TABLE OF CONTENTS... I INTRODUCTION... 1 MISSION... 1 PURPOSE... 1 GOALS... 1 RECOGNITION... 2 BENEFITS OF ACCREDITATION... 2 PHILOSOPHY OF ACCREDITATION... 3 HISTORY OF NURSING ACCREDITATION... 4 PRODUCTS AND SERVICES... 5 ACEN ORGANIZATIONAL STRUCTURE... 6 THE COMMISSION... 6 OVERALL STRUCTURE OF THE COMMISSION... 6 BOARD OF COMMISSIONERS ACEN BOARD OF COMMISSIONERS... 7 ACEN STAFF... 8 ACCREDITATION STANDARDS AND CRITERIA FOR ACADEMIC QUALITY OF POSTSECONDARY AND HIGHER DEGREE PROGRAMS IN NURSING ACEN DEFINITION OF QUALITY ACEN ACCREDITATION STANDARDS UNDERSTANDING STANDARDS AND CRITERIA IN THE EVALUATION OF NURSING EDUCATION UNITS ACCREDITATION PROCESSES AND PROCEDURES PLANNING FOR ACCREDITATION CANDIDACY PROCESS INITIAL ACCREDITATION CONTINUING ACCREDITATION EVALUATION PROCESS STAFF ASSISTANCE SELF-REVIEW AND SELF-STUDY REPORT THE SITE VISIT Multiple Nursing Prgrams Within a Nursing Educatin Unit Cllabrative and Crdinated Site Visits With Other Agencies Length f Visit Assignment f Site Visit Team Team Chairpersn Respnsibilities f the Team Chairpersn Respnsibilities f the Team Members Respnsibilities f the Nursing Educatin Unit Visit Arrangements Agenda fr the Visit Visiti ng Off-Site Lcatin(s) f the Nursing Prgram THE SITE VISITORS REPORT ACEN Staff Review EVALUATION REVIEW PANEL Nursing Prgram Representative Attendance at the Evaluatin Review Panel Meeting COMMISSION PROGRAM EVALUATORS Eligibility fr Selectin as a Prgram Evaluatr Site Visitr Evaluatin Review Panel Member Appeal Panel Member... 25

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7 ACEN Accreditatin Manual INTRODUCTION MISSION The Accreditatin Cmmissin fr Educatin in Nursing (ACEN) supprts the interests f nursing educatin, nursing practice, and the public by the functins f accreditatin. Accreditatin is a vluntary, self-regulatry prcess by which nn-gvernmental assciatins recgnize educatinal institutins r prgrams that have been fund t meet r exceed standards and criteria fr educatinal quality. Accreditatin als assists in the further imprvement f the institutins r prgrams as related t resurces invested, prcesses fllwed, and results achieved. The mnitring f certificate, diplma, and degree fferings is tied clsely t state examinatin and licensing rules and t the versight f preparatin fr wrk in the prfessin. PURPOSE The purpse f the ACEN is t prvide specialized accreditatin fr prgrams f nursing educatin, bth pstsecndary and higher degree, which ffer either a certificate, a diplma, r a recgnized prfessinal degree (clinical dctrate, master s, baccalaureate, assciate, diplma, and practical). GOALS The gals f the ACEN are t: Prmulgate a cmmn cre f standards and criteria fr the accreditatin f nursing prgrams. Strengthen educatinal quality thrugh assistance t assciated nursing educatin units by evaluatin prcesses, functins, publicatins, and research. Advcate self-regulatin in nursing educatin. Prmte peer review. Fster educatinal equity, access, pprtunity, mbility, and preparatin fr emplyment based upn type f nursing educatin. Serve as gatekeeper t Title IV-HEA prgrams fr which the ACEN is the accrediting agency. (These include sme practical nursing and all hspital diplma prgrams eligible t participate in prgrams administered by the U.S. Department f Educatin r ther federal agencies.) 1

8 ACEN Accreditatin Manual RECOGNITION The Accreditatin Cmmissin fr Educatin in Nursing is recgnized as the accrediting bdy fr all types f nursing educatin by: United States Department f Educatin (USDOE) United States Unifrmed Nursing Services (USUNS) Veterans Health Administratin, Department f Veteran Affairs (VHA) Natinal Cuncil f State Bards f Nursing (NCSBN) State Bards f Nurse Examiners (SBNE) Cuncil fr Higher Educatin Accreditatin (CHEA) Assciatin f Specialized and Prfessinal Accreditrs (ASPA) Pan American Health Organizatin (PAHO) United States Department f Health and Human Services, Bureau f Health Prfessins, Divisin f Nursing (USHHS) Natinal Certificatin Crpratin fr the Obstetric, Gyneclgic and Nenatal Nursing Specialties (NCC) Emplyers Natinal, reginal, and specialized accreditrs that versee federal funding eligibility must be reviewed by the United States Department f Educatin (USDOE) t ensure that the accrediting bdy meets specific standards established by Cngress. The Secretary, f Educatin, U.S. Department f Educatin is charged with review f accrediting bdies and prviding recgnitin t thse accrediting agencies that meet the Secretary f Educatin s criteria. Students in institutins r prgrams accredited by a USDOE-recgnized agency are eligible fr federal financial aid assistance and ther needed resurces. The ACEN als meets the recgnitin standards f the Cuncil fr Higher Educatin Accreditatin (CHEA). CHEA, a nn-gvernmental rganizatin, recgnizes reginal, specialized, and prfessinal accrediting bdies t ensure quality, accuntability, and imprvement in higher educatin. Additinally, the NCC has added ACEN accreditatin as an eligibility requirement fr individuals seeking advanced practice certificatin. BENEFITS OF ACCREDITATION ACEN accreditatin is a vluntary peer review prcess intended t enhance quality imprvement in nursing educatin. Accreditatin: Prvides recgnitin that a nursing educatin prgram has been evaluated and peridically re-evaluated by a qualified, independent grup f respected and cmpetent peers wh have fund it t be meeting apprpriate pstsecndary and higher educatinal purpses in a satisfactry manner. Assures prfessinal develpment pprtunity and validatin fr faculty. Is a gateway t licensure, certificatin, and eligibility fr entitlement prgrams. Identifies areas needing develpment. Fsters nging self-examinatin, re-evaluatin, and fcus n the future. Aids in student recruitment and retentin. 2

9 ACEN Accreditatin Manual Assists emplyers seeking graduates wh are cmpetent nurses. Facilitates career and educatin decisin-making. Prmtes prfessinal and educatinal mbility f prgram graduates. Enables student eligibility fr funding supprt frm federal and state agencies, and fundatins fr thse prgrams that d nt have reginal r natinal accreditatin. Fulfills the eligibility requirement fr applicants seeking advanced certificatin. PHILOSOPHY OF ACCREDITATION The ACEN accreditatin prgram is funded n the belief that specialized accreditatin cntributes t the centrality f nursing fr the public gd and prvides fr the maintenance and enhancement f educatinal quality thrugh cntinuus self-assessment, planning, and imprvement. Accreditatin indicates t the general public and t the educatinal cmmunity that a nursing prgram has clear and apprpriate educatinal bjectives and is wrking t achieve these bjectives. Emphasis is placed upn the ttal nursing prgram and its cmpliance with established standards and criteria in the cntext f its missin/philsphy as well as current and future nursing practice. Accrediting agencies share respnsibility with faculty and clinicians fr the develpment f accreditatin standards, criteria, plicies, and prcedures fr participatin in accreditatin and review f accreditatin prcesses. The ACEN supprts the cntinuatin and strengthening f vluntary specialized accreditatin by peers as a principal means f public accuntability and nging imprvement. Specialized accreditatin sets standards fr prgrams and ensures, thrugh the self-study prcess and accreditatin review, the prmtin f effective educatin and prgram imprvement. Because the nursing educatin unit analysis is clsely related t the gverning rganizatin itself, ACEN activities will, when pssible, be crdinated with ther fficially recgnized reginal and specialized accrediting bdies. Standards and criteria fr accreditatin, materials that dcument cmpliance, plicies, and prcedures are based n principles widely accepted and tested in general and prfessinal educatin. All thse invlved in the prcess must be aware f current develpments in educatin and nursing; the effectiveness f the current standards, criteria, plicies, and prcedures; and the evidence f need fr change. A systematic nging review f all cmpnents f the accreditatin prcess is essential t ensure an up-t-date, reliable, and valid accrediting prcess. 3

10 ACEN Accreditatin Manual HISTORY OF NURSING ACCREDITATION 1893 The American Sciety f Superintendents f Training Schls fr Nurses, frerunner f the Natinal League fr Nursing, was funded fr the purpse f establishing and maintaining a universal standard f training fr nurses The Natinal League f Nursing Educatin published Standard f Curriculum fr Schls f Nursing Accrediting activities in nursing educatin were begun by many different rganizatins The Natinal League f Nursing Educatin published A Curriculum Guide fr Schls f Nursing, the last f its type by the rganizatin The Natinal League f Nursing Educatin initiated accreditatin fr prgrams f nursing educatin fr registered nursing The Natinal Nursing Accrediting Service was frmed fr the purpse f unifying accreditatin activities in nursing. It was discntinued in 1952 when accreditatin activities were cnslidated under the Natinal League fr Nursing The U.S. Department f Educatin recgnized the Natinal League fr Nursing (NLN) and included it n the initial list f recgnized accrediting agencies. NLN (later NLNAC) has been cntinually recgnized by the U.S. Department f Educatin since this date The NLN Bard f Directrs established a plicy charging each educatinal cuncil with the respnsibility fr develping its wn accreditatin prgram. The prgram was cnducted thrugh the three NLN membership units: the Cuncil f Baccalaureate and Higher Degree Prgrams; the Cuncil f Diplma and Assciate Degree Prgrams; (the Diplma and Assciate Degree Prgrams separated int tw cuncils in 1965); and the Cuncil f Practical Nursing Prgrams (1966). The accreditatin prgram and services were administered by NLN prfessinal staff Federal funding fr nursing educatin under the Nurse Training Act was cntingent upn the cmpliance f schls f nursing with Title VI f the Civil Rights Act f The Cuncil n Pstsecndary Accreditatin (COPA) recgnized the NLN Accreditatin Prgram Outcme criteria were incrprated int Standards and Criteria fr all accredited prgrams The NLN Bard f Gvernrs apprved the recmmendatin f the NLN Accreditatin Cmmittee t institute cre standards and criteria The NLN Bard f Gvernrs apprved establishment f an independent entity within the rganizatin t be knwn as the Natinal League fr Nursing Accrediting Cmmissin (NLNAC) The NLNAC, nw the Accreditatin Cmmissin fr Educatin in Nursing (ACEN), began peratins with sle authrity and accuntability fr carrying ut the respnsibilities inherent in the accreditatin prcesses. Fifteen (15) Cmmissiners were appinted: nine (9) nurse educatrs, three (3) nursing service representatives, and three (3) public members. The Cmmissiners assumed respnsibilities fr the management, financial decisins, plicy making, and general administratin f the NLNAC. The peer review prcess was strengthened with the frmatin f prgram specific Evaluatin Review Panels. 4

11 ACEN Accreditatin Manual 1998 The NLNAC cntinued cllabrative wrk with specialty rganizatins t strengthen applicatin f standards fr advanced practice nursing prgrams. Advanced practice nurses were invited t serve as clinicians n the site visit teams The Secretary f Educatin, U.S. Department f Educatin, renewed NLNAC recgnitin as a natinally recgnized accrediting agency fr nursing educatin The NLNAC received cntinuing recgnitin by the Cuncil fr Higher Educatin Accreditatin (CHEA) The NLNAC was incrprated as a subsidiary f the Natinal League fr Nursing The Secretary f Educatin, U.S. Department f Educatin, renewed NLNAC recgnitin as a natinally recgnized accrediting agency fr nursing educatin The NLNAC received cntinuing recgnitin by the Cuncil fr Higher Educatin Accreditatin (CHEA) The Secretary f Educatin, U.S. Department f Educatin, renewed NLNAC recgnitin as a natinally recgnized accrediting agency fr nursing educatin The name f the Cmmissin was changed t the Accreditatin Cmmissin fr Educatin in Nursing (ACEN). PRODUCTS AND SERVICES Initial accreditatin and cntinuing accreditatin f apprximately 175 nursing prgrams per year Cntinuus mnitring f mre than 1,200 prgrams per year ACEN Accreditatin Manual Clinical Dctrate Prgrams Master s /Pst-Master s Certificate Prgrams Baccalaureate Prgrams Assciate Prgrams Diplma Prgrams Practical Prgrams ACEN Directry f Accredited Nursing Prgrams (electrnic database) Bridges (Quarterly Electrnic Newsletter) Frums/Wrkshps Self-Study Prgram Evaluatr New Nurse Administratr Candidacy Mentring by Prfessinal Staff Reprt t Cnstituents Analysis f ACEN Annual Reprts Analysis f accreditatin cycles ACEN website: 5

12 ACEN Accreditatin Manual ACEN ORGANIZATIONAL STRUCTURE ACEN Bard f Cmmissiners ACEN Chief Executive Officer Prfessinal Staff Administrative Staff Prgram Evaluatrs Supprt Staff LEGEND: Direct THE COMMISSION OVERALL STRUCTURE OF THE COMMISSION The ACEN is gverned by a fifteen-member Bard f Cmmissiners. The Cmmissiners wh are elected by the representatives f ACEN-accredited nursing prgrams. The legal basis fr the fundatin and structure f the Cmmissin is utlined in the Bylaws and the Articles f Incrpratin. The ACEN is incrprated under the laws f the state f New Yrk. BOARD OF COMMISSIONERS Nine (9) Cmmissiners are nurse educatrs representing ACEN-accredited prgrams, three (3) Cmmissiners represent the public, and three (3) Cmmissiners represent nursing service. Cmmissiners are diversified and assure balanced representatin frm acrss identified cnstituencies insfar as pssible. N Gvernr, fficer, r emplyee f the Natinal League fr Nursing r emplyee f the ACEN may serve as a Cmmissiner. The Bard f Cmmissiners sets accreditatin plicy and makes accreditatin, administrative, budget, and plicy decisins. Cmmissiners serve as chairpersns f the prgram-specific Evaluatin Review Panels. Decisin f accreditatin status is made by the Cmmissiners, based n review f prgram materials, the Site Visitrs Reprt, and the recmmendatin f the Evaluatin Review Panel. 6

13 ACEN BOARD OF COMMISSIONERS NURSING EDUCATION REPRESENTATIVES ACEN Accreditatin Manual Mary Lu Rusin, EdD, RN, ANEF (Term ) Chair, ACEN Prfessr and Chair, Nursing Department Daemen Cllege Amhurst, New Yrk Nancy Phenix Bittner, PhD, RN, CNS (Term: ) Prfessr Schl f Nursing Science and Health Prfessins Regis Cllege Westn, Massachusetts Susan C. Baltrus, MS, RNBC, CNE (Term ) President, Central Maine Medical Center Cllege f Nursing and Health Prfessins Lewistn, Maine Linda K. Cckrell, MSN, RN (Term ) Prgram Leader, Health and Medical Sciences Central Schl f Practical Nursing Nrflk Technical Ctr., Nrflk Public Schls Nrflk, Virginia Catherine McJannet, MN, RN, CEN (Term ) Vice-Chair, ACEN Directr f Nursing and Health Occupatins Prgrams Suthwestern Cllege San Dieg, Califrnia Ann Bain, EdD, MSN, RN (Term ) Secretary, ACEN Prfessr and Chairpersn Department f Nursing University f Arkansas - Little Rck Little Rck, Arkansas Mary Stec, MSN, RN, CNE (Term ) Curse Crdinatr/Instructr Dixn Schl f Nursing Abingtn Memrial Hspital Willw Grve, Pennsylvania Kimberly K. Cribb, EdD, MSN, RN, CNE (Term ) Directr f MSN Prgram Thmas University Thmasville, Gergia NURSING SERVICE REPRESENTATIVES Christina DiMichele, MSN, RN, NEA-BC (Term ) Nurse Manager The Children's Hspital f Philadelphia Philadelphia, Pennsylvania Peggy Tudr, EdD, MSN, RN, CNE (Term ) Department Chair Assciate Degree Nursing Eastern Kentucky University Richmnd, Kentucky PUBLIC REPRESENTATIVES Gary Carman, PhD, LMSW (Term ) President, Carman Cnsulting Suth Windsr, Cnnecticut Janet Y. Harris, MSN, RN, NEA-BC (Term ) Chief Nursing Officer The University f Mississippi Medical Center Jacksn, Mississippi David E. Ormstedt, JD (Term ) Treasurer, ACEN Attrney/Cnsultant Blmingtn, Indiana 7

14 ACEN Accreditatin Manual Raquel Pasarón, DNP, APRN, FNP-BC (Term ) ARNP/Pediatric Surgery Liaisn Miami Children's Hspital Miami, Flrida Hward S. Smith, EdD (Term ) Educatin Leadership Cnsultant Harris Beach, PLLC Buffal, New Yrk ACEN STAFF 3343 Peachtree Rad NE, Suite 850 Atlanta, Gergia P F Sharn J. Tanner, EdD, RN Chief Executive Officer PROFESSIONAL STAFF SUPPORT STAFF Nell Ard, PhD, RN, CNE, ANEF Assciate Directr Jessica Dermdy Operatins Assistant Abigail Gerding, PhD, RN Assciate Directr Crdia Starling, EdD, RN Assciate Directr ADMINISTRATIVE STAFF Je L. Ortiz, MBA Directr f Finance and Infrmatin Systems Alex Mariquit Directr f Operatins Yvanka Heyburn Executive Assistant 8

15 ACEN Accreditatin Manual Carla Haynes Operatins Specialist Justin Jerme Assistant t the Office f the CEO Katherine Little Accreditatin Specialist Tdd Oesterle Administrative Assistant fr Accreditatin Supprt Jcelyn Pineda Accunting Specialist Rbert Steinbruegge Administrative Assistant t the Prfessinal Staff Zaid Tukan Operatins Analyst Shelia Washingtn Operatins Assistant 9

16 ACEN Accreditatin Manual ACCREDITATION STANDARDS AND CRITERIA FOR ACADEMIC QUALITY OF POSTSECONDARY AND HIGHER DEGREE PROGRAMS IN NURSING ACEN DEFINITION OF QUALITY The cre values f accreditatin emphasize learning, cmmunity, respnsibility, integrity, value, quality, and cntinuus imprvement thrugh reflectin and analysis. They require the nursing prgram t measure itself by exacting standards, hnr high aspiratin and achievement, and expect all persns assciated with the prgram t recgnize their respnsibility t prvide a supprtive and humane envirnment in which peple interact with each ther in a spirit f cperatin, penness, and mutual respect. Accreditatin standards are agreed-upn rules t measure quantity, extent, value, and quality. Criteria are statements that identify the variables that need t be examined in evaluatin f a standard. The ACEN Criteria are presented t peer reviewers as statements that represent an accurate descriptin f an accredited prgram. Peer review is a lng-established and effective cmpnent f prgram evaluatin in educatinal settings. It is used t help determine which prgrams t accredit. Peer reviewers knw the current thinking in the varius prgram types, knw the curriculum rules and cnventins, and are trained t identify prgram cmpliance with Standards and Criteria. Prgram-specific expertise is preserved at the pint f criteria dcumentatin, prgram evaluatin cnducted by peers frm like prgrams at the time f the site visit, during Evaluatin Review Panel deliberatins, and upn appeal. Quality in educatin ensures high levels f pprtunity fr student learning and achievement. Accreditatin is an affirmatin f values central t thinking abut pstsecndary and higher educatin: apprpriate missin, rganizatinal structures, prcesses, and functins; resurces aligned with cre values; cllegiality; and cntinuus self-imprvement. The ACEN accredits all types f nursing educatin prgrams in a variety f pstsecndary and higher educatin settings including vcatinal-technical agencies, hspitals, prprietary schls, prfessinal schls, seminaries, clleges, universities, and ther institutins that ffer diplmas, certificates, and/r academic degrees. 10

17 ACEN Accreditatin Manual ACEN ACCREDITATION STANDARDS STANDARD 1 Missin and Administrative Capacity The nursing educatin unit s missin reflects the gverning rganizatin s cre values and is cngruent with its strategic gals and bjectives. The gverning rganizatin and prgram have administrative capacity resulting in effective delivery f the nursing prgram and achievement f identified utcmes. STANDARD 6 Outcmes Evaluatin f student learning demnstrates that graduates have achieved identified cmpetencies cnsistent with the institutinal missin and prfessinal standards and that the utcmes f the nursing educatin unit have been achieved. STANDARD 5 Resurces Fiscal, physical, and learning resurces prmte the achievement f the gals and utcmes f the nursing educatin unit. STANDARD 2 Faculty and Staff Qualified faculty and staff prvide leadership and supprt necessary t attain the gals and utcmes f the nursing educatin unit. STANDARD 3 Students Student plicies, develpment, and services supprt the gals and utcmes f the nursing educatin unit. STANDARD 4 Curriculum The curriculum prepares students t achieve the utcmes f the nursing educatin unit, including safe practice in cntemprary health care envirnments. UNDERSTANDING STANDARDS AND CRITERIA IN THE EVALUATION OF NURSING EDUCATION UNITS The singular functin f nursing is the imprvement f the human cnditin. Each certificate, diplma, r degree has an identifiable, discrete set f specific utcmes. Pstsecndary and higher educatin prvide fr the develpment f learners ability t think fr themselves, master analytical prblem-slving, apply scientific knwledge, and make value judgments within the cntext f the specific prgram type. Thus, educatin requires a brad academic rientatin and depth and breadth f intellectual skills translated int cmpetencies s as t fulfill nursing s functins in all types f nursing. Standards are the agreed-upn rules fr the measurement f quantity, extent, value, and quality. Criteria are statements that identify the variables that need t be examined in evaluatin f a standard. 11

18 ACEN Accreditatin Manual Accreditatin Standards and Criteria becme effective n the Cmmissin apprval date. Prgrams scheduled fr review within twelve (12) mnths f revisin f the Standards and Criteria may elect t use the current r the frmer versin f the Standards and Criteria. ACCREDITATION PROCESSES AND PROCEDURES PLANNING FOR ACCREDITATION Nursing educatin units cnsidering accreditatin shuld cntact the ACEN t begin the Candidacy prcess. As part f this prcess, nursing educatin units will be assigned a member f the prfessinal staff as their mentr. The mentring service is prvided t facilitate faculty self-review and planning. The faculty f the prgram and administrative fficers f the gverning rganizatin determine when the prgram is ready t apply fr Candidacy and initial evaluatin. The decisin shuld be based n an in-depth self-study f the prgram in relatin t the ACEN Standards and Criteria. When the ACEN Cmmissin grants accreditatin t a prgram, all students wh graduated during r after the accreditatin cycle* during which the site visit was perfrmed will be recgnized as graduates f an accredited nursing prgram. *Fall Cycle: July 1 t December 31 Spring Cycle: January 1 t June 30 CANDIDACY PROCESS A nursing educatin unit seeking initial accreditatin must apply fr Candidacy. Candidate status is granted after an ACEN prfessinal staff review f a nursing prgram s ptential t achieve ACEN accreditatin. Prgrams must prvide evidence f current State Bard f Nursing apprval and the gverning rganizatin s accreditatin/apprval status (where apprpriate). A prgram seeking accreditatin cmpletes an applicatin fr Candidacy including paying the required fee. Candidate status des nt guarantee that a prgram will achieve initial accreditatin. Prgrams that have achieved Candidate status may indicate the fllwing t ptential students and interested members f the public: Prcedure: This nursing educatin prgram is a candidate fr accreditatin by the Accreditatin Cmmissin fr Educatin in Nursing. Once eligibility fr Candidate status is established in accrdance t ACEN Plicy #3, prgrams will be asked t submit infrmatin * addressing: Faculty academic and experiential qualificatins; The curriculum/prgram plan f study; Resurces t deliver the prgram; 12

19 ACEN Accreditatin Manual The systematic plan f evaluatin; and Catalg (where apprpriate). All materials submitted are reviewed by the ACEN prfessinal staff. Applicants are ntified if apprved fr Candidate status. A prgram that has achieved Candidate status must cmplete the accreditatin prcess within tw (2) years. * Additinal infrmatin related t the preparatin f the Candidacy presentatin is available nline at INITIAL ACCREDITATION A gverning rganizatin that ffers a prgram nt previusly accredited by the Cmmissin initiates the prcess thrugh its chief executive fficer. The chief executive fficer f the gverning rganizatin fr the nursing educatin unit must authrize the ACEN t cnduct the accreditatin prcess by submitting the fficial authrizatin frm sent frm the Cmmissin. All prgrams seeking initial accreditatin must first apply and be apprved as a Candidate fr accreditatin. A nursing prgram may discntinue the initial accreditatin prcess up t twelve (12) weeks prir t the date f the site visit. Changes within twelve (12) weeks f the scheduled site visit will result in the prgram being respnsible fr all expenses incurred fr the site visit. CONTINUING ACCREDITATION Planning fr cntinued accreditatin is an nging prcess. A prgram must be visited and re-evaluated at specified intervals t ensure cntinuing cmpliance with the Accreditatin Standards and Criteria. The ACEN staff ntifies the prgram f a pending visit apprximately ne (1) year in advance. Dates fr the site visit are scheduled in cnsultatin with the nurse administratr, as the prgram must be in full peratin during the visit. Official authrizatin t cnduct the ACEN accreditatin prcess is secured frm the chief executive fficer f the gverning rganizatin and the nurse administratr fr the nursing educatin unit. The prgram will receive an authrizatin frm frm the ACEN apprximately ne (1) year befre the visit is t take place. If the nurse administratr f an ACEN-accredited prgram chses t cancel the accreditatin prcess, ntificatin f cancellatin must be submitted in writing by the nurse administratr and the chief executive fficer f the gverning rganizatin t the ACEN CEO. The Bard f Cmmissiners will then take frmal actin and remve the prgram frm the fficial listings f ACEN-accredited prgrams. Any changes made within twelve (12) weeks f a scheduled site visit will result in the prgram being respnsible fr all expenses incurred. If a prgram is ntified abut its need t cmply with a Cmmissin actin and des nt respnd, the prgram will be remved frm the fficial listings f ACEN-accredited prgrams by the Cmmissin at its next scheduled meeting. 13

20 ACEN Accreditatin Manual EVALUATION PROCESS The ACEN accreditatin prcess includes the fllwing: Candidacy (fr prgrams seeking initial accreditatin) Prgram preparatin f the Self-Study Reprt Team site visit fr prgram evaluatin by prgram specific site visitrs Site Visitrs Reprt Staff review Evaluatin Review Panel with prgram-specific expertise Staff review and referral t the Cmmissin Cmmissin accreditatin decisin Appeal panel (when apprpriate) The ACEN prcess fr the evaluatin f nursing educatin prgrams is a cmprehensive fur-step prcess with the prgram self-review and Self-Study Reprt as the first step. The secnd step is the site visit cnducted by peer evaluatrs resulting in the Site Visitrs Reprt. In the third step, a peer Evaluatin Review Panel examines the reprts written by and abut the prgram (Self-Study Reprt and Site Visitrs Reprt). The final step is a review f the prcess and the decisin n accreditatin status by the ACEN Bard f Cmmissiners. STAFF ASSISTANCE The ACEN prfessinal staff is available t assist a prgram preparing fr an accreditatin visit. Self-Study Frums are ffered annually t prvide infrmatin abut the accreditatin prcesses and details regarding the preparatin f the Self-Study Reprt. All prgrams seeking initial accreditatin are expected t attend a Frum; hwever, the Frums are available t anyne planning an accreditatin review. Dates and lcatins are psted n the ACEN website (www.acenursing.rg). Prgrams applying fr initial accreditatin will be assigned an ACEN prfessinal staff member as a mentr nce they have begun the Candidacy prcess. SELF-REVIEW AND SELF-STUDY REPORT Any prgram applying fr accreditatin must prepare a Self-Study Reprt t demnstrate the extent t which the prgram meets the ACEN Accreditatin Standards and Criteria. The prcess f self-study represents the cmbined effrt f the gverning rganizatin administratrs, nursing educatin unit administratrs, faculty, staff, students, and ther individuals cncerned with the nursing prgram. All thse assciated with the prgram shuld participate in the self-study prcess. Brad participatin leads t an understanding f the ttal prgram. 14

21 ACEN Accreditatin Manual The Self-Study Reprt is the primary dcument used by the site visit team, the Evaluatin Review Panels, and the Bard f Cmmissiners t understand the nursing prgram. The reprt must be based n the ACEN Accreditatin Standards and Criteria in effect at the time f the review and the mst recent editin f the ACEN Accreditatin Manual. Accreditatin Standards and Criteria becme effective n the Cmmissin apprval date. Prgrams scheduled fr review within twelve (12) mnths f revisin f the Standards and Criteria may elect t use the current r the frmer versin f the Standards and Criteria. Faculty and administratrs are respnsible fr presenting evidence that clearly indicates hw the Standards and Criteria are being met. Members f the site visit team will use the Self-Study Reprt in preparatin fr their visit t the prgram. Guidelines fr the Preparatin f the Self-Study Reprt are available nline at THE SITE VISIT The purpse f the accreditatin visit is t evaluate the nursing educatin unit by clarifying, verifying, and amplifying prgram materials as presented in the Self-Study Reprt. Based n these data, the site visit team will make a recmmendatin relative t the accreditatin status f the prgram(s). The visit is an essential part f the accreditatin prcess. It gives the schl an pprtunity t demnstrate and highlight infrmatin presented in the Self-Study Reprt and prvides fr interactin amng all cncerned: administratrs, faculty, students, staff, and site visitrs. In additin, the nsite visit allws site visitrs an pprtunity t see the nursing prgram first-hand. The site visitrs verify cngruence between the Self-Study Reprt and the actual practices f the prgram s that the members f the Evaluatin Review Panel and Cmmissiners have a clear and cmplete understanding f the prgram. Multiple Nursing Prgrams Within a Nursing Educatin Unit The ACEN encurages nursing educatin units ffering mre than ne type f prgram (i.e., clinical dctrate, master s, baccalaureate, assciate, diplma, and practical) t request that all prgrams be reviewed fr accreditatin at the same time. The nursing educatin unit will prepare ne (1) Self-Study Reprt. The ACEN prfessinal staff will wrk with the nurse administratr t establish ne (1) visit team whse recmmendatins fr each prgram s accreditatin status will be reviewed by the apprpriate Evaluatin Review Panel. Cllabrative and Crdinated Site Visits With Other Agencies The ACEN welcmes the pprtunity t cperate with ther accreditatin and apprvalgranting agencies. The gal is t increase efficiency and decrease faculty wrklad while maximizing utcmes. Tw (2) ptins are available: the Crdinated and the Cllabrative Visit. 15

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