Mastering the Journey to Continuous Compliance

The accreditation process of a nursing program requires self-assessment, peer evaluation, and identifying areas of improvement. In 2008, the Commission on Collegiate Nursing Education (CCNE) began offering a 10-year accreditation with a Continuous Improvement Progress Report (CIPR) at the fifth year. This article focuses on an in-depth analysis of a system in which the school of nursing utilized an ad hoc committee to complete the CIPR. Reports generated by the ad hoc committee concluded that need for improvement was warranted related to policy review. An action plan for continuous compliance generated implementation of policy software and the creation of an academic support specialist position. An ad hoc committee completed the CIPR rather than paying faculty overload hours; policy was an exemplar. Faculty development, team performance, and accountability resulted in a plan for continual compliance that can be adopted in other nursing schools to meet CCNE accreditation.


Introduction
Those employed in nursing education will easily recognize the sense of anxiety that accompanies the preparation of a self-study or site visit for accreditation. The knowledge of the time commitment required and the importance of positive outcomes for a nursing program can result in sleepless nights and long days for those involved in preparing for accreditation. The accreditation process requires significant self-assessment and peer evaluation; this process results in ensuring the quality of a nursing program and identifying areas of improvement. In addition, the program evaluation data need to be collected on a regular basis (Lewallen, 2015). An ongoing course of action assists faculty and administration with engagement and enhances the environment for quality improvement over time (Ellis & Halstead, 2012). Promotion of faculty engagement and knowledge of components of the accreditation process such as curricular review is paramount to the necessity of the continuous process and the ownership by the faculty (Dearmon, Lawson, & Hall, 2011). The purpose of this article is to describe the challenge of and practical approaches to the Commission on Collegiate Nursing Education (CCNE) accreditation and/or Continuous Improvement Progress Report (CIPR) processes. From this description, other universities, schools of nursing, or departments can utilize the approaches in their accreditation practices.
Beginning in 2008, the CCNE offered a 10-year accreditation with a CIPR due at the 5-year mark. Our school of nursing (SON) received a 10-year accreditation in 2009, with an interim report due in December 2014. While much preparation, energy, and time are usually placed on the process and writing of the self-study, the "interim reporting that is required in between the comprehensive site visit may be less understood" (Ellis & Halstead, 2012, p. 18). And in similar fashion to many nursing programs, thoughts of accreditation were placed on the "back burner" while dealing with changes in our SON. The process of preparing and writing the CIPR provides an opportunity for program evaluation in determining the most successful activities that will expedite the "ongoing continuous quality improvement (CQI)" necessary to support the CCNE standards (Ellis & Halstead, 2012, p. 18). The CCNE standards were revised in 2013 and became effective on January 1, 2014 (American Association of Colleges of Nursing, 2015). In response to the newly revised standards, it was determined based on program growth that an aggressive approach to adoption needed to be the plan of action. The practical aspects of accomplishing this plan of action are limited in the literature (Lewallen, 2015).
Since 2009, our program has demonstrated significant growth, including modification from a four-to a five-semester program. In addition, enrollment has now essentially doubled with admissions of about 60 students each fall and spring semesters. The number of faculty has increased by nine, most of whom have never been involved in a CIPR self-study. It was decided to make the self-study an ongoing process. As a result of this decision, it was determined there was a need to revise the program effectiveness plan (PEP) to demonstrate continuous evaluation. As the CIPR report needed to be written utilizing newly published standards, an Accreditation and Policy/Procedure Ad Hoc Committee was established to complete this task.

Background
Over the past 30 years, the SON has maintained accreditation status with positive outcomes. The school has grown in the number of students and admission cycles as well as course and graduate offerings. The SON found that what worked in the past for the accreditation process needed to be altered based on the changes in the size and strategic plan of the SON and the university. Current practices needed to change from an informal review to a more formal review.
Historically, the SON had relied heavily on two writers for preparation of the CIPR. It was typical for one senior faculty member to be given workload release to assist the dean in this process. The traditional preparation for the report included an exhaustive retrospective review and audit of policies, procedures, committee minutes, and outcomes data from several prior annual reports. This method was often tedious as it often uncovered (a) policies that were in need of review/revision, (b) data that had to be extrapolated from various sources and data owners, (c) outcomes data that had lack of clear definition, and (d) less than optimal nonelectronic record-keeping systems that had proven difficult to navigate. Where in the past, universities and schools depended on one or two administrators to write accreditation reports, the trend is now more appropriate to use dedicated faculty and/or faculty committees, staff, and administrative positions for the functions of program evaluation and accreditation (Romanelli, 2013). Because of these hurdles and evolving trends, and with the new CCNE standards focus on continual compliance, the ad hoc committee was formed to identify new methods and systems to modify the CIPR process using a team approach and putting in place new systems for the future that would support continual compliance. In addition, this committee was also responsible for program evaluation and oversight for policy and procedure formation and dissemination. The purpose for a program evaluation committee allows ease of accreditation visit reports such as the CIPR, focuses on readiness for changes in the program and/or curriculum, sustains consistency in curricular issues, and continues currency in nursing and educational trends (Gard, Flannigan, & Cluskey, 2004). A program evaluation committee has been described as being responsible for (a) development, implementation, and revision of the program evaluation plan; (b) recommending data collection instruments and procedures relating to program evaluation; (c) data collection and analysis; and (d) reporting findings to the department chair and program committee to facilitate program improvement. (Davis, Grinnell, & Niemer, 2013, pp. 672-673)

Formation/Development of Ad Hoc Committee
While the past accreditations were maintained by one to two key faculty/administrators, the current process needed to actively involve input from an ad hoc committee and from individual faculty and staff to ensure a strategic move toward continuous compliance. In addition to the key focus on CIPR completion, the newly formed ad hoc committee quickly determined that it must also encompass oversight of policy and procedure management. The Accreditation and Policy/ Procedure committee was sanctioned as an ad hoc committee of the Faculty Organization (FO) and was charged to oversee and guide each committee regarding structure and function in relationship to the PEP.
The new Accreditation and Policy/Procedure Ad hoc Committee began 1 year and one semester prior to the CIPR deadline. In addition, the ad hoc committee met weekly to biweekly for the first few months after it was established. The ad hoc committee was comprised of four full-time faculty members and a staff support person. The initial goal to conduct a needs analysis proved difficult as there was little past analysis. The first task undertaken was to ensure equal education to all team members in the CIPR process. This preparation was completed by group attendance at an online webinar. The ad hoc committee also reviewed the 2013 CCNE Accreditation Standards (CCNE, 2013b) and used the Crosswalk (CCNE, 2013a) to review the changes/differences between 2013 and former 2009 standards. This review of standards provided all team members with the historical nature of standards and compliance.
The ad hoc committee then conducted an evaluation of the completion status for all plan items of the Evaluation of Program Plan (which became the Program Evaluation Plan) from the last survey report. Members reviewed each item planned for in the prior report to determine whether all action plans were completed, modified, or still in process. Next, the analysis focused on a complete policy and procedure review for the faculty and student handbooks. It was determined that during this phase of analysis that a set structure would be utilized to specifically identify (a) date of last review, (b) any items within the policy or procedure that needed revision, (c) which standing committee of the FO should be assigned and be responsible for content for the particular document, (d) who the actual document owner (by name) would be, and (e) recommendations regarding policy structure, content, or overlap between policies (which could be a source of error). At the conclusion of these two analysis methods, a report was provided to the FO Committee outlining status of each prior action plan and global state of the policies/procedures for both manuals.
Finally, an analysis of all outcome measures (student, faculty, and external) was conducted. This review uncovered many areas for improvement in relation to data definitions, data ownership responsibilities, data storage methods, and accuracy. As a result, it was determined that it would be key to establish strict data definitions in outcome measures and to optimally design a new data warehousing system approach.

Outcomes of the Review of the Ad Hoc Committee
The ad hoc committee concluded that there was significant need for improvement regarding the currency and review of policies along with lack of a precise mechanism for policy/ procedure generation. Further work from this point centered on development of a precise mechanism/algorithm by which policies moved from writing to committee review/approval, to actual implementation within electronic documents, to the website links. As expected, several policies had been revised and/or approved that had not gone along the general accepted mechanism. In response to these findings, as well as data precision and storage flaws, the ad hoc committee concluded that modifications were indicated to move from a reactive model to a proactive, systematic compliance model.

Action Plan for Continuous Compliance Model
A search for policy/procedure software products was initiated by the ad hoc committee. Committee members were unable to locate a product designed specifically for nursing schools. Discussion ensued regarding different software systems within health care. The ad hoc committee reviewed these systems to explore their functionality and then requested a demonstration of one of the products, PolicyTech™ (Navex Global, 2015). This system uses Microsoft Word for document development, which was easily recognizable to team members. In addition, this system offered batch document upload of our nearly 100 policies.
Other key features of this program included the ability to set annual review dates to ensure timely compliance with reviews/revisions. The electronic notification system of the policy management system allows for email alerts to be sent to the policy owners at increasingly frequent intervals when policies are set for review and alert other faculty members to participate in revisions. When a policy is submitted for approval as revised, an electronic notification is sent to whomever administration has chosen as final approver. Once a policy is approved, notification is sent (with a quick access link to the policy) to all faculty and/or staff who have been preset as readers.
When the readers open their email notifications and click on the links, they can read the policy and add comments, which are sent back to the owner of the policy closing the compliance feedback loop.
Administratively, the policy management system offers some additional features helpful for document version control, allowing for archival of documents with clear electronic documentation of dates of policy review, revision, and archival. It is then clear when changes were made, and easy analysis is possible to audit past committee actions regarding changes due to regulation or standard implementation. The system also offers a report feature that allows the user to retrieve reports to determine faculty and staff compliance with reading current annual reviews of policies and can also be modified to be used as evidence of annual required training if it is loaded as a specific policy document within the system. This policy management system can be used in this same manner for student compliance; however, the cost increases based on the number of users who are allowed on the system at one time.
Based on the assessment and recommendation of the ad hoc committee, the policy management system was reviewed by our Chief Information Officer and team and compared with other vendors of similar products. Implementation of the system required initial meetings across departments for the development of departmental-specific policy flow streams. These meetings were necessary to ensure the mapping of policy owners to writers, reviewers, approvers, and readers was clear. Names of faculty, staff, and students, as well as email mapping were required, which was undertaken by Information Services. That process took significant time, although less than manual entry by each department. Each department also had to establish the role of a Document Control Administrator, whose role would have primary oversight at the department level and be able to reset document owners if people or positions changed. The establishment of this role became one function, assimilated by a new job position that was created based on committee input for ensuring compliance, the Academic Support Specialist.

Academic Support Specialist
While continual compliance is the responsibility of every faculty member, it became clear through the exhaustive review of SON reports and documents while compiling the CIPR, that centralization of data management was imperative for success. Data had been traditionally kept for committee chairs and reviewed in minutes and sometimes annual reports; however, data were often difficult to consistently locate. Inconsistencies in data definitions for outcome measures can easily occur as changes in committee membership or chairmanship naturally occur. This type of inconsistency could lead to wrong conclusions about performance and perhaps lack of appropriate resource allocation in quality action plans. Therefore, the conclusion of the ad hoc committee determined that each committee governing specific outcomes data needed to clearly define outcomes. Once outcomes were established, it was essential that all data be mapped and warehoused via one designated entity. The responsibility of the data keeper would be quality of data, timeliness of data reporting, and serving as the sole source for historical outcomes performance. Because this was central to embracing continuous compliance, the position of Academic Program Specialist was developed and approved. The staff person selected for this role now works as an active member of the ad hoc committee, and all outcomes data are easily accessed via one office.

Lessons Learned
Over the time frame of 1 year, the ad hoc committee learned many valuable lessons which are provided here for others who may be embarking on similar journeys to achieve continual compliance. Key suggestions are provided to describe best practice for implementation of a policy management system, and additional valuable findings are noted as a result of this journey, including improvement in faculty standards knowledge, cost-effectiveness, and data warehousing.

Implementation of a Policy Management System
While the decision to recommend a specific policy management software was achieved relatively quickly, implementation at the school level was slowed greatly because the university also chose to adopt the system for overall use. This increased the overall planning time due to the inclusion of different colleges/schools, information technology, and administration versus just the time that would have been required to do departmental-level training.

Improved Standards Knowledge
The process of the development of the CIPR greatly enhanced future preparation and readiness for self-study. Ad hoc committee members became familiar with the new CCNE standards through webinar, conference, and review of crosswalks. The ad hoc committee also wanted the faculty to become familiar with the new standards and encouraged them to become immersed in the review of the new standards as well as the process of self-study review through the standing committees and the FO. The team approach to review new CCNE standards by different assigned committee structures created a sense of accountability and better understanding of the new standards through a thorough policy and procedure review in relation to standards. Nursing faculty members need to broaden their understanding of the accreditation standards by which their schools of nursing are evaluated (Sharts-Hopko, 2015).

Cost-Effectiveness With Benefits
The ad hoc committee served as a cost-effective method to oversee the total faculty preparation of the CIPR report. Preparation for the CIPR and/or the self-study can be accomplished through enlisting the services of full-time faculty to work within their workload or in overload. Some schools may enlist the service of faculty emeritus or nursing consultants to assist in the compilation of these significant reports. It is common for many colleges to enlist the services of faculty in overload or pull out of workload to accomplish similar tasks. Some colleges additionally hire editors. As the workload of the group was balanced among team members and across FO-specific committees, the report was generated accurately and over many months, easing the workload without any significant additional costs.

Data Warehousing
It is important to note that the most difficult tasks in CIPR completion are data retrieval, storage, and presentation, both historically and concurrently throughout the report preparation period. Through this process of preparing the CIPR, we learned the priority need for standardization of metric definitions as well as central repository. Performance information must be housed with one system, and one data manager is required to ensure continuous compliance. By the development of the role of Academic Support Specialist, the SON is now assured that all faculty members know what data are submitted at what intervals, as well as have an ongoing centralized location for accessing data for various purposes, including grant preparation processes, media releases, and accreditation needs.

Conclusions and Outlook
In conclusion, the CIPR process proved to be cost-effective, while promoting faculty development in team performance improvement and CCNE standards knowledge. This in-depth analysis of our system in relation to meeting the new CCNE continuous compliance standards helped our SON look beyond the here and now and do highly productive strategic planning for ensuring ongoing standards readiness. Using an ad hoc committee, as well as reporting structure back to the faculty's governance body, heightened committee importance and accountability. Delegation to additional targeted and assigned subcommittees to ensure ownership of committee-specific policy and procedure management as well as data analysis proved to be essential in overall faculty ownership and participation in the CIPR. As a result, a large portion of faculty are more knowledgeable and engaged in continual compliance as an ongoing journey. Centralization of data management was essential to ensure data accuracy and to position ourselves in a new reality where integral performance data are easily available for data analytics. Based on our journey in mastering continual compliance, the process could be easily adopted in nursing schools to best position themselves for CCNE readiness and accreditation.