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U.S. Department of Education

Staff Report
to the
Senior Department Official
on
Recognition Compliance Issues

RECOMMENDATION PAGE

1.
Agency:   WASC Accrediting Commission For Community and Junior Colleges (1952/2008)
                  (The dates provided are the date of initial listing as a recognized agency and the date of the agency’s last grant of recognition.)
 
2.
Action Item:   Petition for Continued Recognition
 
3.
Current Scope of Recognition:   The accreditation and preaccreditation ("Candidate for Accreditation") of two-year, associate degree-granting institutions located in California, Hawaii, the United States territories of Guam and American Samoa, the Republic of Palau, the Federated States of Micronesia, the Commonwealth of the Northern Mariana Islands, and the Republic of the Marshall Islands, including the accreditation of such programs offered via distance education at these colleges.
 
4.
Requested Scope of Recognition:   The accreditation and preaccreditation ("Candidate for Accreditation") of community and other colleges with a primarily pre-baccalaureate mission located in California, Hawaii, the United States territories of Guam and American Samoa, the Republic of Palau, the Federated States of Micronesia, the Commonwealth of the Northern Mariana Islands, and the Republic of the Marshall Islands, which offer certificates, associate degrees, and may offer bachelor’s degrees within the institutional scope, and the accreditation of such programs offered via distance education and correspondence education at these colleges. This recognition also extends to the Committee on Substantive Change of the Commission, for decisions on substantive changes.
 
5.
Date of Advisory Committee Meeting:   December, 2013
 
6.
Staff Recommendation:   Continue the agency's recognition and require the agency to come into compliance within 12 months, and submit a compliance report that demonstrates the agency's compliance with all identified issues. Extend the agency's time for coming into compliance for the previous findings of noncompliance in Sections 602.15(a)(3), 602.18(e), and 602.20(a) within the August 13, 2013, CFT Complaint Decision letter, which expires in August 2014. To provide sufficient time for the agency to demonstrate compliance in light of the close timing between the complaint and petition review, Department staff finds good cause to extend the agency’s period for coming into compliance until 12 months of the date of the decision letter on recognition.

Deny the expansion of scope as articulated by the agency. Grant the expansion of scope based on the staff's revisions, if the agency concurs with the modified request, as follows:
The accreditation and preaccreditation ("Candidate for Accreditation") of community and other colleges with a primarily pre-baccalaureate mission located in California, Hawaii, the United States territories of Guam and American Samoa, the Republic of Palau, the Federated States of Micronesia, the Commonwealth of the Northern Mariana Islands, and the Republic of the Marshall Islands, which offer certificates, associate degrees, and the first baccalaureate degree by means of a substantive change review offered by institutions that are already accredited by the agency, and such programs offered via distance education and correspondence education at these colleges. This recognition also extends to the Committee on Substantive Change of the Commission, for decisions on substantive changes, and the Appeals Panel.

 
7.
Issues or Problems:   It does not appear that the agency meets the following sections of the Secretary’s Criteria for Recognition. These issues are summarized below and discussed in detail under the Summary of Findings section.

-- The agency must demonstrate that its standards are sufficient to comprehensively evaluate baccalaureate level degree programs and are comparable to commonly accepted standards for ensuring quality in baccalaureate degree programs. [§602.12(b)]

-- The agency must demonstrate wide acceptance of the agency's standards, policies, procedures, and decisions to grant or deny accreditation by educators. [§602.13]

-- The agency must demonstrate that academic personnel, as generally defined by the accrediting agency and wider higher education community, are represented on its evaluation teams. [§602.15(a)(3)]

-- The agency must demonstrate that it evaluates the appropriateness of the measures of student achievement chosen by its institutions. [§602.16(a)(1)(i)]

-- The agency does not meet the requirements of this section based on its requested scope. It must demonstrate that its standards for accreditation regarding curricula are sufficiently rigorous and comprehensive to ensure that the agency is a reliable authority regarding the quality of the baccalaureate level education provided by the institutions it accredits. The agency needs to incorporate its substantive change protocol requirements for baccalaureate degree programs into the agency’s curricula standards. [§602.16(a)(1)(ii)]

-- The agency does not meet the requirements of this section based on its requested scope. It must demonstrate that its standards for accreditation regarding faculty are sufficiently rigorous and comprehensive to ensure that the agency is a reliable authority regarding the quality of the baccalaureate level education provided by the institutions it accredits. [§602.16(a)(1)(iii)]

-- The agency must demonstrate that it evaluates an institution on its maintenance of clearly specified educational objectives that are consistent with its mission and appropriate in light of the credentials awarded, and is successful in achieving its stated objectives with specific regards to baccalaureate degree programs.

[§602.17(a)]

-- The agency must provide documentation to demonstrate that it has fully implemented its revised policies to demonstrate that the agency clearly delineates between areas of non-compliance and areas for improvement. The agency must also demonstrate that it provides the institution with a detailed written report that assesses the institution's performance with respect to student achievement. [§602.17(f)]

-- The agency must provide documentation to demonstrate that it provides the institution with a detailed written report that clearly identifies any deficiencies in the institution's compliance with the agency's standards. [§602.18(e)]

-- The agency must provide information and documentation to demonstrate that it requires additional information from an institution when student achievement data, or any other key data or indicators do not meet the agency's standards. [§602.19(b)]

-- The agency must demonstrate that it consistently enforces the time period to return to compliance with the agency's standards. [§602.20(a)]

-- The agency must demonstrate that it takes immediate adverse action if an institution does not bring itself into compliance within the specified period. [§602.20(b)]

-- The agency must provide documentation that it must complete the standards revision process within a reasonable period of time. [§602.21(c)]

-- The agency must provide documentation to demonstrate that it provides written specification of any deficiencies identified at the institution examined. [§602.25(a-e)]

-- The agency must demonstrate that it provides written notice of negative decisions to the Secretary and the other entities required by this section at the same time it notifies the institution of the decision. [§602.26(b)]

EXECUTIVE SUMMARY

 
 

PART I: GENERAL INFORMATION ABOUT THE AGENCY

 
The Accrediting Commission for Community and Junior Colleges, Western Association of Schools and Colleges (ACCJC, commission or agency) is an institutional accreditor. The commission’s institutions are voluntary members that offer two-year educational programs and award associate degrees. They include community colleges, private religious institutions, for-profit and independent nonprofit vocational institutions, and independent junior colleges.

The agency has approximately 130 accredited member institutions. The member institutions are located in California, Hawaii, the United States territories of Guam and American Samoa, the Republic of Palau, the Federated States of Micronesia, the Commonwealth of the Northern Mariana Islands, and the Republic of the Marshall Islands. The majority of the Commission’s member institutions offer at least some courses via distance education delivery modes.

The agency’s recognition enables its institutions to establish eligibility to receive Federal student assistance funding under Title IV of the Higher Education Act of 1965, as amended (Title IV). The agency must meet the Secretary’s separate and independent requirements.
 
 
Recognition History
 
The agency was one of the three original commissions that made up the Western College Association (now the Western Association of Schools and Colleges), which was first recognized by the U.S. Commissioner of Education in 1952. In 1962, the Commissioner of Education recognized the present commission separately. Since that time, the agency has been periodically reviewed and has been granted continued recognition.

The last full review of the agency was conducted in December 2007 at which time the National Advisory Committee on Institutional Quality and Integrity (NACIQI or Committee) recommended and the Secretary concurred that the agency’s recognition be renewed for five years and that it submit an interim report by May 31, 2008, addressing the four issues identified in the staff analysis. Due to the passage of HEOA, the agency's report was on hold until the NACIQI was reconstituted. Due to the lapse in time, the agency was allowed to submit updated information for review as part of the interim report. That interim report and subsequent update was reviewed and accepted at the December 2011 Committee meeting.

In late spring of 2013, the Department received a complaint from the California Federation of Teachers (CFT), as well as other interested parties, about ACCJC. The specific complaint was provided to ACCJC by the CFT at the same time as submitted to the Department. After ACCJC concluded its complaint process, the Department investigated the complaint, to include a request for additional information from ACCJC, and provided its decision in a letter dated August 13, 2013. The letter instructed ACCJC to take immediate steps to correct the areas of non-compliance identified, and to provide its response to those areas within its response to the draft staff analysis of the agency’s petition for recognition. A review of the agency's corrective action and compliance with the cited sections is included within this report.

In conjunction with the current review of the agency for its continued recognition, Department staff reviewed the agency’s petition and supporting documentation, and observed an on-site evaluation in October 2013. The Department also received over 100 third-party written comments in connection with the agency’s petition for recognition.

PART II: SUMMARY OF FINDINGS

 
§602.12 Accrediting Experience

(b) A recognized agency seeking an expansion of its scope of recognition must demonstrate that it has granted accreditation or preaccreditation covering the range of the specific degrees, certificates, institutions, and programs for which it seeks the expansion of scope.


(NOTE: Only recognized agencies seeking an expansion of scope need to respond.)


 
The recognition of the ACCJC currently covers the accreditation and preaccreditation of two-year, associate degree-granting institutions within its region using both campus-based instruction and distance education. The agency is requesting an expansion of its current scope to include the preaccreditation and accreditation of institutions offering certificate and baccalaureate degree level programs and all programs via correspondence education. Staff has reviewed the agency's request in the context of the applicable criteria.

This section of the criteria requires the ACCJC to demonstrate that it has granted accreditation covering the range of the specific program levels and delivery modes for which it seeks the expansion of scope. Other aspects are to be considered as they pertain to the agency's experience.

The agency states that it has been approving programs at the baccalaureate level since 2004, and currently has two accredited institutions that offer a baccalaureate level degree program. According to the narrative, the agency states that the review of the baccalaureate level programs occurred jointly with the Accrediting Commission for Senior Colleges and Universities (ACSCU) of the WASC. Specifically, the policy on the joint accreditation process states "ACSCU's purposes for such [candidacy or initial accreditation] reviews include evaluating the institution's readiness to offer the baccalaureate degree", which indicates that the responsibility for the review of baccalaureate degree programs lies solely with the ACSCU and not with the ACCJC. The joint review of the baccalaureate degree level programs does not demonstrate that the ACCJC meets the requirements for the accreditation of baccalaureate level degree programs within the Secretary's Criteria for Recognition nor that it has the required experience itself to review programs at its accredited institutions at that level. In December 2012, the Department notified the ACCJC and ACSCU that the joint accreditation process is not in compliance with the Secretary's Criteria for Recognition (attached).

The agency provided documentation of the initial review of substantive change to add a baccalaureate degree program to an ACCJC-accredited institution. The limited documentation (initial approval letter, substantive change request, and substantive change approval) did not demonstrate that the agency followed its policies and procedures in the joint review of accreditation, nor that the review of the baccalaureate program was comprehensive. And, the policy and procedure covering the joint review of accreditation states "ACSCU staff, in close cooperation with ACCJC staff, will provide primary staff assistance for peer evaluator training, for planning the visit, and for coordinating the reports to the two Commissions" which indicates that the review is conducted primarily by ACSCU, not ACCJC. This information and the limited documentation provided do not demonstrate experience by the ACCJC to review programs at the baccalaureate degree level.

The agency also provided documentation of the review of the renewal of accreditation for that same institution, which was conducted solely by ACCJC. Although the agency provided comprehensive documentation, it does not demonstrate the specific and deliberate review of the baccalaureate degree program, as the agency's policies and procedures do not require a separate review of such a program. In addition, the agency did not provide information or documentation of any additional guidance within the on-site review policies and procedures, nor with regard to the selection and training of evaluators, for baccalaureate level degree programs. The Department noted that the joint accreditation policy and procedures state that the review would be conducted by ACCJC evaluators who have experience at institutions with programs at the baccalaureate degree level in conjunction with experienced ACSCU evaluators; however the agency did not provide any documentation of implementation of that practice.

In addition, the policy and procedures regarding the joint accreditation process were adopted in June 2012, and therefore make it unclear that the current policy and procedures have been consistently applied.

As the agency has stated that its current standards are used in the review of baccalaureate level degree programs, it needs to document how its current standards are sufficient to comprehensively evaluate baccalaureate level degree programs and are comparable to commonly accepted standards for ensuring quality in baccalaureate degree programs. The documentation provided of the initial review for the addition of a baccalaureate degree program was deficient in this area, and the documentation provided of the renewal review of the baccalaureate degree program was not comprehensive. Therefore, the agency has not demonstrated that it has sufficient standards for the review of baccalaureate level degree programs.

In addition, the agency has not demonstrated that it has the capacity and competence to accredit at baccalaureate degree level. Specifically, the agency has not sufficiently discussed the impact of the expansion of scope on its administrative and fiscal capacity (Section 602.15(a)(1)), nor has it demonstrated that its commissioners and evaluators are qualified and trained on their responsibilities regarding baccalaureate degree programs (Section 602.15(a)(2)).

Finally, the agency states that it wants to expand its scope to include a "limited number" of baccalaureate degree programs. The agency has not defined a "limited number" and the Department requires a definition before final evaluation of the expansion of scope. In addition, the current joint accreditation process limits the number of baccalaureate degrees to one, and any information or documentation submitted within the petition demonstrates the inclusion of only one baccalaureate degree at an institution.

With regards to preaccreditation and accreditation of institutions offering certificate level programs and all programs via correspondence education, the agency did not provide any specific information or documentation to demonstrate that it has the capacity to accredit programs at that specific level or delivery mode.

Analyst Remarks to Response:
In its response to the draft staff analysis, the agency provided information and documentation (in this section and in Section 602.16(b)(c)) to demonstrate that it has the capacity to accredit programs at the certificate level and those programs offered via correspondence education.

In its response with specific regards to baccalaureate programs, the agency stated that the analysis included in the draft staff report differed from the information included in previous correspondence with the Department. The agency states that the "Department in no way challenged whether that [joint review process] was a valid practice for accrediting institutions, but found only that it was not a proper basis for recognition by the Secretary." This statement is correct, but misrepresents the issue. The previously submitted joint review process did not demonstrate that ACCJC had the required experience itself to review programs at its accredited institutions at the baccalaureate level since the evaluation of the baccalaureate program was clearly the responsibility of the other accrediting agency which has the extensive experience and standards in that area. As stated previously, this section of the criteria requires ACCJC to demonstrate that it has granted accreditation covering the range of the specific program levels and delivery modes for which it seeks the expansion of scope.

In addition, the agency stated that the analysis included in the draft staff report "undermines the Department's agreement to a course of action resolving the joint accreditation issue." This statement is incorrect. The previous correspondence from the Department (dated December 19, 2012, and August 13, 2013) provided guidance on the steps toward expanding the scope of ACCJC to include baccalaureate degrees. Those steps include the review of the agency's experience in relation to the requested expansion of scope, as is required for all accrediting agencies requesting such an expansion.

In its response to the draft staff analysis, the agency provided information and documentation concerning the two institutions that have submitted substantive change requests to include baccalaureate degree programs within the grant of accreditation from ACCJC. The information and documentation provided demonstrate that ACCJC followed its substantive change policies and procedures, and that the review of the baccalaureate degrees was comprehensive. Specifically, the agency provided its protocol for review of a baccalaureate degree via the substantive change process, the substantive change proposals for both institutions, and the evaluation team report and accreditation decision made by the Committee on Substantive Change in relation to the addition of a baccalaureate degree at one institution.

The information and documentation (provided in this section and Section 602.15(a)(2)) demonstrates the selection and training of evaluators who have experience at institutions with programs at the baccalaureate degree level and additional guidance within the on-site review policies and procedures. In Section 602.15(a)(2), the agency provided documentation to demonstrate that its commissioners are qualified and trained on their responsibilities regarding baccalaureate degree programs.

In Section 602.15(a)(1), the agency provided additional information and documentation concerning the impact of the expansion of scope on its administrative and fiscal capacity.

With regard to the extent of the expansion request, the agency revised its requested expansion of scope to limit baccalaureate degrees to those within the institution's mission. It is not clear how a determination would be made by an institution or by the agency of whether the offering of multiple baccalaureate degrees would be “within the institution’s mission” or at what point the number of such degrees offered would result in a change in mission. In addition, as noted in Section 602.16(a)(1)(ii), the agency has not demonstrated that its current standards are sufficient to comprehensively evaluate baccalaureate level degree programs and are comparable to commonly accepted standards for ensuring quality in baccalaureate degree programs. The agency has employed the substantive change process for reviewing baccalaureate degrees, which effectively precludes the agency’s review under its standards of a baccalaureate degree-granting institution seeking initial accreditation or of an accredited institution seeking reaffirmation of its accreditation. Considering these factors, Department staff could support a request for an expansion of scope to include the accreditation by means of a substantive change review of the first baccalaureate degree offered by institutions that are already accredited by ACCJC.

In its response, the agency has amended its request an expansion of scope to include a subcommittee of the commission, Committee on Substantive Change, be recognized as a decision-making body. The agency previously submitted documentation to support this request in Section 602.22.
 

§602.13 Acceptance of the agency by others.
The agency must demonstrate that its standards, policies, procedures, and decisions to grant or deny accreditation are widely accepted in the United States by--

(a) Educators and educational institutions; and

(b) Licensing bodies, practitioners, and employers in the professional or vocational fields for which the educational institutions or programs within the agency's jurisdiction prepare their students.
 
The agency has not demonstrated that it has broad acceptance of its standards, policies, procedures, and accrediting decisions from all of the entities required by the Secretary's Criteria for Recognition.

As documentation, the agency provided letters from postsecondary institutions and higher education organizations and associations. However, these letters do not demonstrate broad acceptance of its standards, policies, procedures, and accrediting decisions, as they are letters of gratitude not letters of support. In addition, four faculty senates at California institutions, three California-wide faculty organizations and one national faculty organization provided written comments that indicated their disagreement with the policies and actions of the agency, and that call into question the wide acceptance of the agency's standards, policies, procedures, and decisions to grant or deny accreditation by educators.

Although the letters and comments provided by the agency do not demonstrate wide acceptance, the agency provided information and documentation on the reliance of State agencies on the agency's standards, policies, procedures, and accrediting decisions.

Although the agency also provided the roster for the commission (in Section 602.15(a)(3)), it did not provide any other documentation to demonstrate the wide participation of administrators, educators and employers in accreditation activities. The agency's standards review process does include input from a broad range of internal and external constituents.

The agency accredits diverse degree-granting institutions that prepare graduates for multiple professions. The agency demonstrated that graduation from a regionally-accredited institution is recognized as one way to evaluate credentials, and is widely-accepted among practitioners and employers.

The agency did not provide any information or documentation concerning the wide acceptance of its request of an expansion of scope, to include baccalaureate level degree programs.

Analyst Remarks to Response:
In response to the draft staff analysis, the agency states that it has broad acceptance of its standards, policies, procedures, and accrediting decisions from all of the entities required by the Secretary's Criteria for Recognition.

In support of that assertion, the agency provided numerous letters of support from its member institutions and districts, other recognized accrediting agencies, State associations and organizations, and a national education organization. Department staff notes that the breadth of the types of support and the number of member institutions demonstrated by the letters submitted, and the overall and specific support of the agency's standards, policies, procedures, and accrediting decisions are compelling.

Although the agency indicates that most of the letters of disagreement previously submitted are in regards to the accreditation actions taken concerning one institution, the contents of the letters are not limited to that action and raise additional areas of broad disagreement with the agency's standards, policies, and procedures. In addition, many of the previously-submitted letters of non-support were from educators, whereas only one letter in support submitted by the agency is from an educator. (The agency labeled four letters as from educators, but three of those letters are from a retired, long-term administrator; current chancellor; and current State fiscal advisor; respectively, and cannot be categorized as from "educators".) The agency did not provide documentation in support of its statements (under this section or Section 602.15(a)(3)) that a large number of educators serve on its evaluation teams or participate in workshops. Under Section 602.21(a)(b), the agency did provide some documentation of the involvement of educators in the standards review process. Furthermore, in its response, the agency only commented on two areas of concern included (in the letter from the State Academic Senate and the national association), but did not address the additional areas of concern raised by the other faculty organizations at the institutional, State, and national level except to argue that, as faculty unions, these organizations are supporting the CCSF’s cause. Therefore, the agency has not demonstrated wide acceptance of the agency's standards, policies, procedures, and decisions to grant or deny accreditation by educators.

The agency states that the speaking requests of agency staff, agency participation in workshops and seminars, and the attendance of institutions at agency-sponsored workshops also demonstrate broad acceptance of its standards, policies, procedures, and accrediting decisions by the entities required by this section.

The agency provided information and documentation concerning the representation of administrators, educators and employers in accreditation activities and evaluation teams in Section 602.15(a)(2). The agency also provided additional information and documentation to demonstrate input from a broad range of internal and external constituents within the standards review process.

With regards to the proposed expansion of scope, the agency states that it has broad acceptance of its standards, policies, procedures, and accrediting decisions for institutions with degrees at the baccalaureate level, and provided letters of support from a member institution, a member district, and the State Chancellor's Office of California. The agency provided additional information and documentation concerning the proposed expansion of scope to include baccalaureate degree-level programs.
 

§602.15 Administrative and fiscal responsibilities
(3) Academic and administrative personnel on its evaluation, policy, and decision-making bodies, if the agency accredits institutions;

 
The agency's bylaws state the commission will include a minimum of five faculty representatives and three administrator representatives. Although the current commission roster states that it meets the composition requirements of the bylaws, the agency has not provided a policy or other guidance as to what would qualify a person to be identified as either primarily an academic, or primarily an administrator, nor did the agency provide any biographical information of the current commissioners to demonstrate that those individuals meet the qualifications for the category noted.

Although the agency provided the bylaws, which include the appeals panel composition requirements, they state that "to the extent practicable" the appeals panel will include academic and administrative representation, but this language does not ensure such representation. The agency also has not provided any documentation that its appeals panel includes both academic and administrative representation.

The Department stated in the August 13, 2013 CFT Complaint Decision Letter (attached) that it is not clear that both academic and administrative personnel are represented on evaluation teams, as there is no specific policy on the composition of evaluation teams and it is not clearly demonstrated by the sample evaluation team rosters provided. Within the petition, the agency provided the suggested standard evaluation assignments based on job title, as well as sample evaluation team rosters, which does not specifically require nor demonstrate adequate representation of both academic and administrative personnel on evaluation teams.

Analyst Remarks to Response:
In response to the draft staff analysis and the August 13, 2013 CFT Complaint Decision Letter, the agency provided additional information and documentation concerning the inclusion of academic and administrative representation on its commission, appeals panel and on-site evaluation teams.

The agency provided its revised evaluation team selection and procedures document, as well as the same document for appeals panels (in Section 602.15(a)(2)), which both include the agency's definition of academic and administrative representatives. The agency's definition of an academic representative is, as follows:
"Academic representatives: include individuals with instructional and/or student services experience who have responsibility for the teaching and student learning support processes. Academics may include faculty, deans, division/ department chairs, directors, provosts, academic and student services vice presidents, and others who have primary responsibility for instruction or instructional support. Faculty are defined by their home institution and may include teaching faculty, counselors, librarians, and individuals with instructionally related responsibilities such as student learning outcomes, distance education, and instructional program or department coordination (such as department chairs elected by their peers for a term)."
(The definitions in both documents are identical except that the one in the evaluation team document also includes the note that a typical team of 10 or 11 will include three academics.)

The agency states that its definition of an academic representative is comparable to the definition of faculty used by the Department's IPEDS system, which is, as follows:
"Persons identified by the institution as such and typically those whose initial assignments are made for the purpose of conducting instruction, research or public service as a principal activity (or activities). They may hold academic rank titles of professor, associate professor, assistant professor, instructor, lecturer or the equivalent of any of those academic ranks. Faculty may also include the chancellor/president, provost, vice provosts, deans, directors or the equivalent, as well as associate deans, assistant deans and executive officers of academic departments (chairpersons, heads or the equivalent) if their principal activity is instruction combined with research and/or public service."

To meet the requirements of this regulation, the Department does not require the use of any one definition for an academic, but does expect that the agency's definition be comparable with the generally accepted policies and practices within the accrediting agency and wider higher education community. Department staff note that the inclusion of student services staff as academic representatives does not meet the generally accepted definition of such representation within the accrediting agency community, nor the spirit of the regulation.

The agency's definition states that academic representatives may include deans, department chairs, or other related administrative roles as long as those individuals have a "primary responsibility for instruction or instructional support." This differs from the IPEDS definition, to which the agency stated its definition was comparable, in that individuals with administrative titles can only be included as faculty if "their principal activity is instruction combined with research and/or public service." A position responsibility differs significantly from an activity.

Noting the agency's definition, the use of the term academic for individuals whose primary responsibilities are administrative and who are not directly engaged in a significant manner in postsecondary teaching and/or research misrepresents the experience expected for an individual in this role. Department staff also note that the inclusion of individuals whose principal activities are administrative limits the number of individuals whose primary activity is classroom instruction as academic representatives and may affect the evaluation team's ability to adequately review an institution in the related areas of the agency's standards.

Department staff observed an on-site evaluation in October 2013, and noted that the agency listed five team members as academics, out of a team of 10. Through individual interviews and reviews of biographical information provided to the institution, Department staff noted that two members of the team were faculty in the classroom, one was an interim academic dean with no teaching responsibilities for the past few years, one was an academic dean that had not taught in over 10 years, and one was a vice chancellor for student affairs who had never taught. (Department staff noted that the team assistant was also listed as an academic, but generally the team assistant is not considered a member of the evaluation team by the agency. For this review, the team assistant had to fill-in for an absent team member, but the role he was filling was administrative, which he was able to do as an academic dean.)

The agency provided its statistics concerning the academic, administrative and other representatives on evaluation teams in 2012, which indicates adequate representation of both academic and administrative personnel on evaluation teams. However, the agency did not provide any documentation to support those statistics, and documentation submitted and previously reviewed does not support those statistics.

With regard to the commission composition, the agency provided the biographical forms for all commissioners (in Section 602.15(a)(2)) which demonstrates that the current commission includes a minimum of five academic representatives who are faculty and three administrator representatives who are two-year college administrators, with at least one representing an independent institution, as required by the agency's bylaws.

Regarding its appeals panel, the agency provided its revised bylaws to ensure both academic and administrative representation when convened. The agency provided its current appeals panel pool with the representative notation (in Section 602.15(a)(2)), and biographical information (in Section 602.23(a)), to demonstrate that those individuals meet the agency's definition.

Within its request for an expansion of scope, the agency provided its revised bylaws to ensure both academic and administrative representation on its Committee on Substantive Change and documentation of such representation (in Section 602.22(a)(1)).
 

§602.16 Accreditation and preaccreditation standards
(a) The agency must demonstrate that it has standards for accreditation, and preaccreditation, if offered, that are sufficiently rigorous to ensure that the agency is a reliable authority regarding the quality of the education or training provided by the institutions or programs it accredits. The agency meets this requirement if -
(1) The agency's accreditation standards effectively address the quality of the institution or program in the following areas:
(i) Success with respect to student achievement in relation to the institution's mission, which may include different standards for different institutions or programs, as established by the institution, including, as appropriate, consideration of course completion, State licensing examination, and job placement rates.

 
The agency provides its expectations regarding student achievement in relation to the institution's mission, which are contained within the agency's Standard I, and Standard II.A.

Standard I states that an institution must have a strong commitment to a mission that emphasizes achievement of student learning, and must use analyses of quantitative and qualitative data in an ongoing and systematic cycle of evaluation, integrated planning, implementation, and re-evaluation to verify and improve the effectiveness by which the mission is accomplished. Subsection B further requires an institution to demonstrate its effectiveness by providing 1) evidence of the achievement of student learning outcomes and 2) evidence of institution and program performance. And, the institution must use ongoing and systematic evaluation and planning to refine its key processes and improve student learning.

Standard II.A states that an institution must systematically assess instructional programs to assure currency, improve teaching and learning strategies, and achieve stated student learning outcomes. Sub-section 1 further requires that an institution must identify student learning outcomes for courses, programs, certificates, and degrees; assess student achievement of those outcomes; and use assessment results to make improvements. And, the institution must engage in ongoing, systematic evaluation and integrated planning to assure currency and measure achievement of its stated student learning outcomes for courses, certificates, programs including general and vocational education, and degrees.

The agency's evaluation process requires an institution to submit its student achievement information and documentation with its self-study. The agency's Manual for Institutional Self Evaluation provides guidance to institutions on what types of student achievement data should be included and how to review such data longitudinally and in a disaggregated form to inform the evaluation and planning processes. Within the manual, the agency also provides a presentation template, to be used to present student achievement data and a list of questions to answer in the review of such data.

In a section titled "Evidence of Compliance with other Areas Related to Federal Requirements" of the manual, the agency states the following:
"The institution must establish standards of success with respect to student achievement in relation to the institution's mission. It will set expectations for course and program completion, student persistence from term to term, degree and certificate completion, State licensing exam scores, job placement, and transfer rates. The institution must demonstrate it gathers data on institution-set standards, analyzes results on student achievement, and makes appropriate changes/improvements to increase student performance, educational quality, and institutional effectiveness. Evaluation teams will identify these institution-set standards, determine their reasonableness, review the data and analyze the college's performance, describe the institution's overall performance, and determine whether the institution is meeting its standards."

The self-study is available in advance and on-site for verification by the evaluation team. That information and documentation is then examined and evaluated by the evaluators to assess the institution's compliance with the agency's achievement standards. The agency's Guide to Evaluating Institutions provides evaluators with the guidance on how to evaluate self-studies to determine compliance with its standards with respect to student achievement.

The agency provided example self-studies, which included course success rates, transfer rates, and retention rates – both combined and disaggregated by demographics, and which incorporate recommended tables for data reporting. One of the examples includes an institution-established goal and the institution measured its success against it. However, both examples provided are for institutions which offer vocational programs, but only one included discussion of, and neither included any assessment of, job placement rates and only one included a statement on State licensing examination pass rates (but no assessment).

In addition, the evaluation reports provided in this section do not demonstrate that the evaluation teams made a judgment about the appropriateness of the measures of student achievement chosen by the institution nor rigor of the goals established by the institution. Both examples provided do not indicate that the institutions have comprehensive student achievement assessment mechanisms in place, and therefore makes it appear that the agency's current measure of success with regard to student achievement is an institution's engagement in the process of reviewing its outcomes data. Department staff noted that one evaluation report (provided in Section 602.17(f)) includes a citation for failure to provide data on student learning at the course, program, and institutional level, and to develop measures of student achievement chosen by the institution.

Analyst Remarks to Response:
In response to the draft staff analysis, the agency provided additional information concerning its review of institutions with regard to its student achievement standards. Specifically, the agency states that it directed renewed focus in this area in fall 2012 due to concerns that the commission had regarding the inconsistent information provided in evaluation team reports regarding the identification of the measures used by an institution to assess student achievement and the assessment of the appropriateness of those institutionally-established standards, as well as the job placement rates and State licensing examination pass rates in vocational programs. The agency stated that it provided additional training and guidance to evaluation teams and institutions concerning the expected review regarding the agency's student achievement standards; however the agency did not provide documentation of any training or guidance in this area.

The agency provided additional documentation of self-studies and evaluation team reports. Although the self-studies and evaluation team reports include a review of job placement rates and State licensing examination pass rates, they do not include assessment of that data. The evaluation reports also include a review of institutionally-established measures of student achievement, but do not include an assessment by the evaluation team of such measures. Therefore, the agency has not demonstrated that it makes a judgment about the appropriateness of the measures of student achievement chosen by an institution.
 

(a)(1)(ii) Curricula.
 
The agency provides its expectations regarding curricula in agency's Eligibility Requirement #8 and Standard II.A.

Eligibility Requirement #8 states that an institution must have its principal degree programs congruent with its mission, based on recognized higher education field(s) of study, of sufficient content and length, conducted at levels of quality and rigor appropriate to the degrees offered, and culminate in identified student outcomes. The institution must have at least one two-year degree program.

Standard II.A states that the institution offers quality instructional programs in recognized and emerging fields of study that culminate in identified student outcomes leading to degrees, certificates, employment, or transfer to other higher education institutions or programs consistent with its mission. Sub-section 2 further requires that an institution assures the quality and improvement of all instructional courses and programs offered regardless of delivery mode (traditional or distance) or level (certificate, associate's degree, baccalaureate degree).

Although the standards and eligibility requirements address curricula at different levels, they are not specific with regard to curricular differences at the baccalaureate level. Specifically, they are not sufficiently detailed to distinguish between the different education levels, and therefore do not demonstrate that the agency's standards are sufficiently rigorous to ensure that the agency is a reliable authority regarding the quality of education at the different levels.

The agency's evaluation process requires an institution to submit its curricula information and documentation with its self-study. The agency's Manual for Institutional Self Evaluation provides guidance to institutions on the content, structure and evidence to demonstrate compliance with standards. The self-study is available in advance and on-site for verification by the evaluation team. That information and documentation is then examined and evaluated by the evaluators to assess the institution's compliance with the agency's curricula standards. The agency's Guide to Evaluating Institutions provides evaluators with the guidance on how to evaluate self-studies to determine compliance with its standards with respect to curricula.

The agency provided example self-studies and on-site evaluation team reports that demonstrate that the agency evaluates curricula in conjunction with the agency's standards. However, the examples only included associate's degrees, and did not include a demonstration of the review of baccalaureate degrees.

Analyst Remarks to Response:
In response to the draft staff analysis, the agency states that it completed an analysis of its curricula standards for evaluating baccalaureate programs against the other recognized accrediting agencies and found them to be comparable. (Although the agency did not use the current standards for at least one of the other agencies, the updated standards and policies do not include information different than cited.)

The agency provided documentation of this comparative analysis, and the comparison is primarily between the agency's substantive change protocol (not its curricula standards) and the other recognized agencies' standards. For example, the agency states that it requires a minimum of 36 semester credits or equivalent of general education for a baccalaureate degree program and includes citations from other recognized agencies' standards. However, this minimum requirement is not included in any related standard, eligibility requirement, or policy of this agency, but is only available in the substantive change protocol. The agency's expectations regarding the level and rigor of upper division courses and integration of general education courses are only available in the substantive change protocol. This effectively precludes the agency’s review under its standards of a baccalaureate degree-granting institution seeking initial accreditation, or of an accredited institution seeking reaffirmation of its accreditation. Therefore, the agency has not demonstrated that its standards for accreditation regarding curricula are sufficiently rigorous to ensure that the agency is a reliable authority regarding the quality of the baccalaureate level education provided by the institutions it accredits.

The agency also revised its "Policy on Institutional Degrees and Credits" to include definitions of certificates, associate degrees, and baccalaureate degrees and to specify the number of units required for a baccalaureate degree.

As documentation, the agency submitted substantive change requests submitted by two institutions for the addition of baccalaureate degree programs, which include a review of the evaluation of curricula in conjunction with the agency's substantive change protocol.
 

(a)(1)(iii) Faculty.
 
The agency provides its expectations regarding faculty in the agency's Eligibility Requirement #13 and Standard III.A.

Eligibility Requirement #13 states that an institution must have a substantial, full-time core of qualified faculty, which is sufficient in size and experience to support all of the institution's educational programs. The faculty responsibilities statement must include curriculum development and review, and assessment of student learning.

Standard III.A.1 includes the requirement that faculty selection criteria include knowledge of the relevant subject matter, effective teaching, scholarly activities, and potential to contribute to the mission of the institution. Sub-section 2 further requires that an institution maintains a sufficient number of qualified faculty with full-time responsibility to the institution.

Although the standards and eligibility requirements address faculty, they are not specific with regard to differences expected of faculty at the baccalaureate level. Specifically, they are not sufficiently detailed to distinguish between the different education levels, and therefore do not demonstrate that the agency's standards are sufficiently rigorous to ensure that the agency is a reliable authority regarding the quality of education at the different levels.

The agency's evaluation process requires an institution to submit its faculty information and documentation with its self-study. The agency's Manual for Institutional Self Evaluation provides guidance to institutions on the content, structure and evidence to demonstrate compliance with standards. The self-study is available in advance and on-site for verification by the evaluation team. That information and documentation is then examined and evaluated by the evaluators to assess the institution's compliance with the agency's faculty standards. The agency's Guide to Evaluating Institutions provides evaluators with the guidance on how to evaluate self-studies to determine compliance with its standards with respect to faculty.

The agency provided example self-studies and on-site evaluation team reports that demonstrate that the agency evaluates faculty in conjunction with the agency's standards. However, the examples only included associate's degrees, and did not include a demonstration of the review of baccalaureate degrees.

Analyst Remarks to Response:
In response to the draft staff analysis, the agency states that it completed an analysis of its faculty standards for evaluating baccalaureate programs against the other recognized accrediting agencies and found them to be comparable. (Although the agency did not use the current standards for at least one of the other agencies, the updated standards and policies do not include information different than cited.)

The agency provided documentation of this comparative analysis, and the comparison is primarily between the agency's substantive change protocol and the other recognized agencies' standards. For example, the agency states that it requires baccalaureate degree faculty to hold a degree at least one level above the baccalaureate degree and includes citations from other recognized agencies' standards. However, this minimum requirement is not included in any related standard, eligibility requirement, or policy of this agency, but is only available in the substantive change protocol. This effectively precludes the agency’s review under its standards of a baccalaureate degree-granting institution seeking initial accreditation, or of an accredited institution seeking reaffirmation of its accreditation. Therefore, the agency has not demonstrated that its standards for accreditation regarding faculty are sufficiently rigorous to ensure that the agency is a reliable authority regarding the quality of the baccalaureate level education provided by the institutions it accredits.

As documentation, the agency submitted substantive change requests submitted by two institutions for the addition of baccalaureate degree programs, which include a review of the evaluation of faculty in conjunction with the agency's substantive change protocol.
 

§602.17 Application of standards in reaching an accrediting decision.
The agency must have effective mechanisms for evaluating an institution's or program's compliance with the agency's standards before reaching a decision to accredit or preaccredit the institution or program. The agency meets this requirement if the agency demonstrates that it--

(a) Evaluates whether an institution or program--
(1) Maintains clearly specified educational objectives that are consistent with its mission and appropriate in light of the degrees or certificates awarded;

(2) Is successful in achieving its stated objectives; and

(3) Maintains degree and certificate requirements that at least conform to commonly accepted standards;

 
The agency requires, in Eligibility Requirement #8, that an institution's principal degree programs are congruent with its mission, are based on recognized higher education field(s) of study, are of sufficient content and length, are conducted at levels of quality and rigor appropriate to the degrees offered, and culminate in identified student outcomes. The agency further requires that an institution provide student outcomes for each academic program within its curricula standards. The agency evaluates the appropriateness of the mission and objectives for the programs delivered and degrees awarded during the application review and on-site evaluation.

The agency states that it has qualitative and quantitative program effectiveness and student outcomes measures by which it assesses an institution's success in achieving its objectives and mission goals. The agency evaluates the appropriateness of the mission and objectives for the programs delivered and degrees awarded during the on-site evaluation. The examples provided verify the agency's review and evaluation of the mission and objectives of institutions and determination if they are successful in achieving those objectives, but do not demonstrate that it adequately assesses qualitative and quantitative program effectiveness and student outcomes measures. In addition, the examples do not demonstrate that the agency requires or that an institution adheres to accepted degree requirements, as the agency has not demonstrated that its standards conform to commonly accepted standards for degrees at the baccalaureate level.

The agency has set clear expectations that an institution must establish and make public its mission and educational objectives. What is not clear is that an institution must evaluate its performance as an institution with respect to those objectives.

Analyst Remarks to Response:
In response to the draft staff analysis, the agency provided additional documentation of self-studies and evaluation team reports. Although the self-studies and evaluation team reports include an institutional evaluation of its performance with respect to mission and education objectives, they do not include the agency's assessment of qualitative and quantitative program effectiveness and student outcomes measures. Therefore, the agency has not demonstrated that it evaluates an institution on its maintenance of clearly specified educational objectives that are consistent with its mission and appropriate in light of the credentials awarded, and is successful in achieving its stated objectives.

As noted in Section 602.16(a)(1)(ii), the agency has not demonstrated that its current standards are sufficient to comprehensively evaluate baccalaureate level degree programs and are comparable to commonly accepted standards for ensuring quality in baccalaureate degree programs.
 


(f) Provides the institution or program with a detailed written report that assesses--

(1) The institution's or program's compliance with the agency's standards, including areas needing improvement; and

(2) The institution's or program's performance with respect to student achievement; and 

 
The agency states that it utilizes both the evaluation team report and the commission action letter to clearly communicate the assessment of an institution's compliance with the agency's standards, to include performance with respect to student achievement. The examples provided (in this section and throughout the petition) document the use of the evaluation team report and the commission action letter to communicate areas of compliance and non-compliance, however it is not clear that the reports clearly delineate between areas of non-compliance and areas for improvement, as discussed in Section 602.18(e). In addition, the reports are deficient in providing a detailed assessment of the institution’s performance with respect to student achievement, as detailed in Section 602.16(a)(1)(i).

Analyst Remarks to Response:
In response to the draft staff analysis, the agency provided additional information concerning its use of the evaluation team report and the commission action letter to communicate areas of compliance and non-compliance, and the use of the term "recommendation." The agency also has revised its evaluation team report and commission action letter structure to clearly delineate between areas of non-compliance and areas for improvement by separating those elements in different sections. The agency also revised its policies to state that recommendations regarding compliance would be clearly separated from recommendations of improvement. The agency provided documentation of the new report format guidance provided to evaluation teams. Although the agency has made changes to its policies and procedures and provided an example evaluation team report (attached), it did not provide documentation of complete implementation, to include an example commission action letter to an institution, to demonstrate that the agency clearly delineates between areas of non-compliance and areas for improvement.

Although the evaluation team report (attached) includes an assessment of the institution’s performance with respect to student achievement, the majority of reports provided (in this section and in Section 602.16(a)(1)(i)) still do not demonstrate a detailed assessment of the institution’s performance with respect to student achievement. See Section 602.16(a)(1)(i) for additional discussion.
 

§602.18 Ensuring consistency in decision-making

The agency must consistently apply and enforce standards that respect the stated mission of the institution, including religious mission, and that ensure that the education or training offered by an institution or program, including any offered through distance education or correspondence education, is of sufficient quality to achieve its stated objective for the duration of any accreditation or preaccreditation period granted by the agency. The agency meets this requirement if the agency--



(e) Provides the institution or program with a detailed written report that clearly identifies any deficiencies in the institution's or program's compliance with the agency's standards.


 
The agency provides the institution with a detailed written report in response to the on-site evaluation. The agency also provides commission action letters after a review of the evaluation team report and the institution's response. However, neither report clearly identifies deficiencies in the institution's compliance with the agency's standards.

The Department stated in the August 13, 2013 CFT Complaint Decision Letter (attached) that it is not clear that the agency provides the institution with a detailed written report that clearly identifies any deficiencies in the institution's compliance with the agency's standards, as the agency uses the term "recommendation" to mean both noncompliance with standards and areas for improvement.

Analyst Remarks to Response:
In response to the draft staff analysis and the August 13, 2013 CFT Complaint Decision Letter, the agency provided additional information concerning its use of the evaluation team report and the commission action letter to communicate areas of compliance and non-compliance, and the use of the term "recommendation." The agency also revised its policies to state that recommendations regarding compliance would be clearly separated from recommendations of improvement. In addition, the agency revised its evaluation team report and commission action letter structure to clearly delineate between areas of non-compliance and areas for improvement by separating those elements in different sections. The agency provided documentation of the new report format guidance provided to evaluation teams. Although the agency has made changes to its policies and procedures and provided an example evaluation team report (attached), it did not provide documentation of complete implementation, to include an example commission action letter to an institution, to demonstrate that the agency provides the institution with a detailed written report that clearly identifies any deficiencies in the institution's compliance with the agency's standards.

 

§602.19 Monitoring and reevaluation of accredited institutions and programs.

(b) The agency must demonstrate it has, and effectively applies, a set of monitoring and evaluation approaches that enables the agency to identify problems with an institution's or program's continued compliance with agency standards and that takes into account institutional or program strengths and stability. These approaches must include periodic reports, and collection and analysis of key data and indicators, identified by the agency, including, but not limited to, fiscal information and measures of student achievement, consistent with the provisions of §602.16(f). This provision does not require institutions or programs to provide annual reports on each specific accreditation criterion.


 
The agency has multiple monitoring approaches that include the annual report, annual fiscal report, midterm report, and follow-up report for any institution deemed to need additional oversight.

The agency utilizes its annual report as the main instrument for measuring continued compliance with its standards for accredited institutions. The agency states that the annual report requests sufficient information in specific areas, such as organizational information, headcount enrollment numbers, student achievement and student learning outcomes data, information concerning specific compliance issues, and information about significant changes likely to require a substantive change approval.

The agency provided a blank annual report that appears to collect key data and indicators, including measures of student achievement. Although the agency provided a summary of annual report data, it did not provide a completed annual report nor a review of individual institution’s data to demonstrate that the annual report enables the agency to analyze and identify problems with an institution's continued compliance with agency standards.

The agency states that the staff monitors the institution’s annual report responses for trigger points (such as gross variations from the norm in student achievement numbers, inadequate levels of student learning outcomes assessment, large increases in headcount enrollment, missing information or late report filing, etc.) and may request additional information, but the agency has not demonstrated that it requires additional information from an institution when student achievement data, fiscal information, or any other key data or indicators do not meet the agency's standards. The agency also did not provide any review and action taken by the commission as a result of the review of an annual report.

The agency states that it uses a separate "Annual Fiscal Report" to collect fiscal information and institutional financial statements. The annual fiscal report requests specific information, such as student loan default rates, levels of fiscal reserves, cash flow, ability to meet contractual obligations, and stability in funding. Although the agency states that institutions with "particular levels of financial risk" are presented to the commission and further reviewed, the agency did not provide information and documentation as to how that determination is made. Nor did the agency provide documentation of the further review by the agency's "Financial Review Group," its recommendation to the commission, or any action taken by the commission. The agency provided documentation of the staff analysis of the annual fiscal report at the institutional level and presentation to the commission of that information.

The midterm report is a requirement for all institutions and must document the institution's continued compliance with all standards and policies. The report is reviewed by staff and presented to the commission for review and action. The agency provided documentation of the report, the staff review, and the commission action.

The agency included a "Student Learning Outcomes Status Report" along with a scoring sheet, rubric and summary, but no narrative information was provided regarding that report or its use by the commission as a monitoring approach.

Analyst Remarks to Response:
In response to the draft staff analysis, the agency provided a completed annual report and a review of individual institution’s data to demonstrate that the annual report enables the agency to analyze and identify problems with an institution's continued compliance with agency standards.

Although the agency provided documentation of its follow-up with an institution that failed to submit its audited financial statements in a timely manner, the agency did not provide any information or documentation to demonstrate that it requires additional information from an institution when student achievement data, or any other key data or indicators do not meet the agency's standards - not that the institution has failed to provide the information. The agency also did not provide any review or action taken by the commission as a result of the review of an annual report.

With regard to the annual fiscal report, the agency provided comprehensive information and documentation of its fiscal review process, to include action taken by the commission.

The agency also provided information regarding its "Student Learning Outcomes Status Report" and its use by the commission to identify additional factors to determine continued compliance that could be included in the annual reporting process.
 

§602.20 Enforcement of standards

(a) If the agency's review of an institution or program under any standard indicates that the institution or program is not in compliance with that standard, the agency must--

(1) Immediately initiate adverse action against the institution or program; or

(2) Require the institution or program to take appropriate action to bring itself into compliance with the agency's standards within a time period that must not exceed--

(i) Twelve months, if the program, or the longest program offered by the institution, is less than one year in length;

(ii) Eighteen months, if the program, or the longest program offered by the institution, is at least one year, but less than two years, in length; or

(iii) Two years, if the program, or the longest program offered by the institution, is at least two years in length.

 
This criterion requires that an agency either initiate immediate adverse action or allow an institution a time period to come into compliance with its standards and requirements. The agency has a written policy ("Policy on Commission Actions on Institutions") that provides a time period of two years for an institution to return to compliance.

The Department stated in the August 13, 2013 CFT Complaint Decision Letter (attached) that it is not clear that the agency appropriately implements the requirements of this regulation, as the agency appears to implement the enforcement time period only after the agency has imposed a sanction on an institution, not at the point the agency finds the institution out of compliance with a standard.

The agency provided examples of commission action letters of probation (citing the specific time period to return to compliance). However, as the examples provided did not include the full cycle of the review (i.e. first determination that the institution was out of compliance to final action), the agency has not demonstrated that it enforces the required time period.

Analyst Remarks to Response:
In response to the draft staff analysis and the August 13, 2013 CFT Complaint Decision Letter, the agency provided additional background information concerning its enforcement of the time period required by this section. Specifically, the agency stated that prior to 2008, it implemented the enforcement time period only after the agency imposed a sanction on an institution. In 2008, the agency stated it began implementing the enforcement time period at the point the agency finds an institution out of compliance with a standard. In addition, the agency provided a revised policy to clearly state that the enforcement time period would be implemented at the point the agency finds an institution out of compliance with a standard.

The agency stated that it provided two examples of full cycles of review of institutions that were not under any sanction by the agency and that the enforcement time period was in effect. The two examples that include the full cycle of review are for institutions not placed on sanction, but the initial letter for one institution (example 1 of full cycle review) does not note the enforcement time period to return to compliance nor clearly indicate noncompliance in any "recommendation" (as described by the agency in Section 602.18(e)) included. However, the second letter, issued after review of the institution’s first report, does include a paragraph indicating that the institution is “expected to correct deficiencies within a two-year period” but does not clearly identify any recommendation as one addressing a finding of non-compliance. The third letter states that the institution has “resolved deficiencies” associated with one recommendation and requires more reporting in the other "recommendation" areas originally noted. This example reflects the same issue noted in the August 13, 2013 CFT Complaint Decision Letter – the lack of clarity in the agency’s communications regarding findings of non-compliance.

The agency has not demonstrated that it consistently enforces the time period to return to compliance with the agency's standards as the agency has provided inconsistent documentation concerning the implementation of the required enforcement time period required by this section.
 

(b) If the institution or program does not bring itself into compliance within the specified period, the agency must take immediate adverse action unless the agency, for good cause, extends the period for achieving compliance.
 
The agency has a written internal policy that meets the requirements of this section, and make clear the potential circumstances under which a good cause extension would be granted. The policy includes four specific circumstances under which a good cause extension would be granted, and limits the extension of a good cause extension to two years.

The agency provided a commission action letter for an institution placed on probation and granted a good cause extension (in Section 602.20(a)); however the letter alone does not demonstrate that the agency took an adverse action when an institution did not bring itself into compliance, nor that the agency abides by the time period, as required by its policy and this section.

Analyst Remarks to Response:
In response to the draft staff analysis, the agency provided additional documentation, to include the commission action letter in regards to the good cause extension example provided previously, and the timeline of the actions taken regarding the only institution that did not bring itself into compliance within the time period and which resulted in an adverse action.

The additional documentation provided for the institution that received a good cause extension does not demonstrate that the institution corrected the deficiencies, as more reporting was required in one of the "recommendation" areas originally noted “in order to fully meet” the standard. This example, therefore, also does not demonstrate that the agency takes immediate adverse action if the institution does not bring itself into compliance within the specified period.

The example of the institution that did not bring itself into compliance within the time period is the same one noted in the August 13, 2013 CFT Complaint Decision Letter (attached), and does not demonstrate that the agency takes immediate adverse action as the adverse action was taken beyond the enforcement time period (as required in Section 602.20(a)) and there was no good cause extension granted.
 

§602.21 Review of standards.

(c) If the agency determines, at any point during its systematic program of review, that it needs to make changes to its standards, the agency must initiate action within 12 months to make the changes and must complete that action within a reasonable period of time. Before finalizing any changes to its standards, the agency must--

(1) Provide notice to all of the agency's relevant constituencies, and other parties who have made their interest known to the agency, of the changes the agency proposes to make;

(2) Give the constituencies and other interested parties adequate opportunity to comment on the proposed changes; and

(3) Take into account any comments on the proposed changes submitted timely by the relevant constituencies and by other interested parties.

 
The agency's standard revision process, stated in this section and in Section 602.21(a)&(b), describes how it includes input of all constituencies when reviewing the validity of the standards. The agency's policies also require it to provide all relevant constituencies (accredited institutions, governing boards, students, business leaders, other communities of interest, and the public) an opportunity to provide input on proposed standards revisions.

The agency described its standards review process and provided sufficient documentation to support it (in this section and in Section 602.21(a)&(b)). The agency provided documentation that it solicited feedback both written and via public hearings and provided the summary of the comments received. In addition, the agency provided the timeline for the current standards revision, which includes the review a working draft of the standards by designated groups, including Pacific, Hawaii, and private member institutions, California Community College CEOs, CIOs, ALOs, and commission task forces on distance education, student learning outcomes, finance, and general education, in fall 2013. First reading of the standards will occur in January 2014 and the second reading and adoption is slated to occur in June 2014. This information adequately describes the process, but does not document that the agency seeks and reviews input from all of its relevant constituencies and by other interested parties, provides an opportunity to comment, and takes into account comments received in a timely manner, as the process is in progress.

The agency's policy requires that if the agency determines that it needs to make changes to its standards, the agency must initiate action within 12 months to make the changes and must complete that action within a reasonable period of time. However, the documentation was not comprehensive to include review and adoption by the commission to verify the standard review process and to support the agency's application of this requirement.

Analyst Remarks to Response:
In response to the draft staff analysis, the agency provided additional information and documentation to demonstrate that it seeks and reviews input from all of its relevant constituencies and by other interested parties, provides an opportunity to comment, and takes into account comments received in a timely manner. Specifically, the agency provided documentation of the presentations at various meetings and workshops of the proposed standards changes, and of the newsletter and website which also includes those proposed revisions.

As the comprehensive system of review of standards is in process, the agency could not yet provide documentation to include review and adoption by the commission to verify the standard review process occurs within a reasonable period of time.
 

§602.25 Due process

The agency must demonstrate that the procedures it uses throughout the accrediting process satisfy due process. The agency meets this requirement if the agency does the following:

(a) Provides adequate written specification of its requirements, including clear standards, for an institution or program to be accredited or preaccredited.

(b) Uses procedures that afford an institution or program a reasonable period of time to comply with the agency's requests for informa­tion and documents.

(c) Provides written specification of any deficiencies identified at the institution or program examined.

(d) Provides sufficient opportunity for a written response by an institution or program regarding any deficiencies identified by the agency, to be considered by the agency within a timeframe determined by the agency, and before any adverse action is taken.

(e) Notifies the institution or program in writing of any adverse accrediting action or an action to place the institution or program on probation or show cause. The notice describes the basis.

 
Overall, the agency's policies and procedures are clear and provide adequate written guidance concerning the agency's expectations. The agency's standards and requirements for accreditation and preaccreditation are specifically written and published.

The agency's procedures also provide adequate timeframes, in accordance with commonly accepted practices, to ensure that institutions have sufficient time to respond to the agency's request for information. However, it is not clear that deficiencies are specifically identified in the agency's evaluation team reports and/or commission action letters.

Prior to taking any adverse action, the agency provides an institution an opportunity to respond. The agency also notifies the institution in writing of any adverse accrediting action or an action to place the institution on probation or show cause, and describes the basis of such decision.

The agency provided documentation (in this section and throughout the petition) to demonstrate implementation of the due process and procedures.

Analyst Remarks to Response:
In response to the draft staff analysis, the agency provided additional information concerning its clear identification in the agency's evaluation team reports and/or commission action letters of deficiencies, and the use of the term "recommendation." The agency also revised its policies to state that recommendations regarding compliance would be clearly separated from recommendations of improvement. In addition, the agency revised its evaluation team report and commission action letter structure to clearly delineate between areas of non-compliance and areas for improvement by separating those elements in different sections. The agency provided documentation of the new report format guidance provided to evaluation teams. Although the agency has made changes to its policies and procedures and provided an example evaluation team report (attached), it did not provide documentation of complete implementation, to include an example commission action letter to an institution, to demonstrate that the agency provides written specification of any deficiencies identified at the institution examined.
 

§602.26 Notification of accrediting decisions

(b) Provides written notice of the following types of decisions to the Secretary, the appropriate State licensing or authorizing agency, and the appropriate accrediting agencies at the same time it notifies the institution or program of the decision, but no later than 30 days after it reaches the decision:

(1) A final decision to place an institution or program on probation or an equivalent status.

(2) A final decision to deny, withdraw, suspend, revoke, or terminate the accreditation or preaccreditation of an institution or program;

(3) A final decision to take any other adverse action, as defined by the agency, not listed in paragraph (b)(2) of this section;

 
The agency's policies and procedures regarding accreditation decisions are not clear to require the agency to provide written notice of final negative decisions to the Secretary and the other entities listed in this section at the same time it notifies the institution but no later than 30 days after the negative decision is made. Specifically, the agency’s “Policy on Public Disclosure and Confidentiality in the Accreditation Process” and “Policy on Relations with Government Agencies” both state that the notification of negative decisions will be made within 24-hours of the notification of the institution, which is not considered the “same time” as required by this section.

The agency provided an example commission action notification letter to demonstrate that the notification is provided within 30 days to the Secretary and other entities listed in this section. However, the example does not demonstrate that the notification occurs at the same time as the notification to the institution.

Analyst Remarks to Response:
In response to the draft staff analysis, the agency revised its policies and procedures to clearly provide written notice of final negative decisions to the Secretary and the other entities listed in this section at the same time it notifies the institution but no later than 30 days after the negative decision is made. The agency also developed a memo to accompany the notification of such decisions and to ensure that the notification was made at the same time.

Although the agency states that it provided documentation to demonstrate the same time notification to the entities required by this section, the documents provided do not reflect that the notification occurred at the same time as the notification to the institution.
 
 

PART III: THIRD PARTY COMMENTS

 
Staff Analysis of 3rd Party Written Comments
Over 100 written third-party comments were received regarding this agency. All of the comments recommend against the agency's continued recognition.

Most of the comments are related and from individuals in the San Francisco community in support of the Community College of San Francisco (CCSF). The roles of the commenters range from CCSF faculty and current students to former students and the general public, all from a wide range of occupations. Most of the commenters did not tie their areas of alleged noncompliance to specific sections of the Secretary’s Criteria for Recognition.

Besides the individual commenters, there were comments from four faculty senates for California institutions, three California-wide faculty organizations and two national faculty organizations, which primarily questioned the wide acceptance of the agency’s standards, policies, procedures, and accreditation decisions by faculty. The Department noted concerns related to this issue in Section 602.13 of this analysis. One of the national faculty organizations stated that the expansion of scope requested by the agency is not appropriate at this time.

Almost all of the comments question whether ACCJC is a reliable authority regarding the quality of education offered by the institutions accredited by them, and many requested that the Department remove the agency from the list of nationally recognized accrediting agencies. Our review of the agency's petition revealed many areas where the agency does not meet the regulatory requirements; however those areas do not rise to the level for the Department to recommend denying recognition.

A majority of the comments also question whether CCSF was evaluated by ACCJC in light of its mission. Many commenters stated that the agency required CCSF to change its mission, specifically to remove reference to remedial and non-credit courses, continuing education, etc., to meet the agency’s requirements, as opposed to evaluating the institution in light of its mission. The Department reviewed the information and documentation submitted by the agency (in response to the complaint submitted by the CFT) concerning its review of CCSF and found this assertion to be inaccurate. Based the materials provided, the agency did not require CCSF to revise its stated mission, but rather noted that the institution did not appear to have sufficient funds to support the current mission of the institution. Therefore, the Department found that the agency enforces standards that respect the stated mission of the institution, as noted in Section 602.18(a).

The individual commenters also questioned the agency’s compliance with the Secretary’s Criteria for Recognition in areas related to the wide acceptance of the agency’s standards, policies, procedures, and accreditation decisions, “separate and independent” requirements, academic representation, conflict of interest, retention of records, accreditation standards, commission independent analysis, effective controls against the inconsistent application of standards, clear notification of deficiencies, standards review process, publicly available materials, complaint review process, due process, and appeals process. The Department has noted in this analysis that it has concerns related to these issues in Sections 602.13, 602.14(b), 602.15(a)(3), 602.15(a)(6), 602.15(b), 602.16(a), 602.18(e), 602.21(a)(b)&(c), 602.23(a), 602.23(c), 602.25(a-e), and 602.25(f).

Regarding the effective controls against the inconsistent application of standards, a few commenters stated that there is no consistency and that the agency’s commission acts independently of the on-site evaluation team. The Department reviewed the agency in Section 602.18(b) and did not find evidence of the inconsistent application of standards.

With regards to the independent analysis by the commission, Federal regulations require the agency to conduct its own analysis of the institution’s information and documentation within Section 602.17(e). A few of the commenters stated that the agency’s commission should not review the institution independently and should only implement the observations and recommendations of the on-site evaluation team. Federal regulations provide for, and require, such independent review by the agency.

Regarding the appeals process, Federal regulations require an accrediting agency to provide an opportunity to appeal an adverse action prior to the action becoming final, as noted in Section 602.25(f). A few commenters stated that CCSF should have been able to appeal the show cause order, but that is not considered comparable to the adverse actions listed within the Federal definition included in Section 602.3.

Other issues raised regarding the agency include governance requirements, involvement in local and State politics, compliance with State laws, Lumina Foundation grant money, and sanctioning of institutions.

With regard for governance issues (to include union agreements, board of trustee issues, etc.), the Department does not review such issues as Federal regulations do not require standards related to governance. The Department cannot find an agency out of compliance with respect to agency accrediting standards not required by law, and this issue is therefore outside the scope of the review for continued recognition for the agency.

Regarding political activity, the agency provided letters of support sent on behalf of the Commission on the student success legislation, referenced by many of the commenters as against the mission of CCSF and other community colleges. The Commission, via the president of ACCJC, encouraged support for the legislation and CCSF withdrew its opposition to it after revisions were made. No documentation has been provided to evidence that the agency supports candidates for public office or particular political parties, or that the agency spends significant time and resources on lobbying efforts.

With regard for compliance with State laws, it is not the role of the Department to interpret State laws or enforce them. As an independent, voluntary, membership organization, the agency makes its own standards, as approved by its members. In addition, the HEA allows for ACCJC to adopt standards not provided for in the Federal law.

Regarding Lumina Foundation grant money, the agency provided information and documentation in Section 602.15(a)(1) that it received a $450,000 grant in the fall of 2012 from the Lumina Foundation. The grant is to fund research in examining associate degree-level student learning outcomes. All grant funds are for grant activities, including two temporary part-time staff members, and are not reflected in the agency’s budget or financial statements. Neither the funds nor staff members are used for accreditation activities or the regular operations of the agency. Therefore, the Department did not find any conflict of interest in the receipt of this grant funding.

With regards to the sanctioning of institutions, Federal regulations do not require that an agency follow a specific order of sanctions, from lesser to greater. In fact, Section 602.20(a) requires an agency to initiate an adverse action as soon as it finds an institution out of compliance with any standard, or provide a limited timeframe to return to compliance.
 
Agency Response to 3rd Party Comments
The Department’s analysis of third party comments received about the ACCJC concluded "[m]ost of the commenters did not tie their areas of alleged noncompliance to specific sections of the…Criteria" and were "outside the scope of the [Department's] review." It further noted that most of the 100 submissions were related and in support of City College of San Francisco (CCSF), the subject of a recent adverse action by the ACCJC. This provides explanation for the unusual number of written comments received and the requests for oral comment at the NACIQI meeting.¶ Most of the letters had recurring themes. The staff report evaluated and found to be inaccurate the claims of ACCJC’s interference with the CCSF mission. The analysis found no evidence of the claimed inconsistency in application of standards, of inappropriate political involvement, or of any conflict of interest arising out of ACCJC’s Lumina Foundation grant. ¶ The analysis also noted that actions requested by third party writers did not comply with Federal regulations: by example, accreditors may not rely solely on the findings of a team; rather, the Commission must complete an independent review before acting on the accredited status of an institution. Similarly, while individuals claimed CCSF should have been able to appeal the earlier show cause decision, this is not an adverse action for which appeals are required by regulation. Also, there is no requirement in regulation for agencies to follow a specific order of sanctions, from lesser to greater; in fact, adverse action must be begun as soon as an institution is found noncompliant with any standard, or a limited time may be given for a full return to compliance. Further, on governance and other issues, the Higher Education Act permits accreditors to adopt standards in addition to those required by Federal law. ¶ ACCJC noted in its Representative Overview attachment and in its response to the draft staff report in 602.13 on acceptance of the agency, with rare exceptions the information in comments was supplied to the Department by the ACCJC's adversary in highly contentious litigation, the California Federation of Teachers (CFT), and other organizations and individuals associated with it. The litigation challenges the ACCJC's authority to enforce its own and the Department's standards/criteria for accreditation – in other words, to do the very job of enforcement that the federal government expects. Such comments reflect the understandable self-interest of the commenters in representing faculty at CCSF and in avoiding any significant action that might have an adverse financial effect on the faculty. As such, the comments are not credible on the issue of whether ACCJC is widely accepted (or on other issues) and cannot responsibly be used by the Department as a basis to make a negative finding on this criterion. ¶ The staff analysis stated four faculty senates from California institutions, three California-wide faculty organizations, and two national faculty organizations submitted comments. This notation bears clarification: [TAB] The reported four faculty senates actually included only one academic senate from a college other than CCSF. The others were in fact the academic senate of CCSF and two college faculty unions (the academic senate from one of those colleges wrote a letter in support of the ACCJC clarifying that the faculty association was a union and did not speak for the faculty’s senate organization on accreditation issues). Only one non-CCSF academic senate, from among the ACCJC’s 134 member institutions, submitted negative third party comments. [TAB] The three California-wide faculty organizations include a statewide association of faculty unions which stands in solidarity with the faculty union at CCSF, an association which works with faculty unions as a part of its mission, and the State Academic Senate, which was responding to an erroneous public report as discussed below. [TAB] The two national faculty organizations included one which submitted comments specifically connected to the Commission action on CCSF. The other was concerned the ACCJC’s change in scope would increase the number and type of institutions accredited by ACCJC; as explained in the ACCJC response narrative, the change in scope to add a degree type is for institutions which would also qualify for accreditation by ACCJC geographic and institutional type. There would be no increase in the number or type of institutions accredited by ACCJC as a result of the change in scope. ¶ Most of the comments submitted by these organizations pertain to matters which have been erroneously reported in the press and by spokespersons from the faculty bargaining unit at CCSF, rather than to direct knowledge or experience with ACCJC. For example, the State Academic Senate submitted a comment concerning reports that there were only single members of faculty on external evaluation teams, as had been reported publicly. In fact, as documented by ACCJC in the response to draft staff analysis, there are generally three teaching faculty (25 to 30% of the group) on a comprehensive team, amid a total representation by academics of more than 60%. The ACCJC is pleased to have worked collaboratively with the State Academic Senate to increase the pool of teaching faculty available to serve on evaluation teams. The State Academic Senate further asked for the ability to appoint members to the Commission’s selection committee; however, this would not comply with regulations. ¶ As is the norm during the recognition renewal review of a regional accrediting agency, there were numerous issues raised by the Department warranting clarification from ACCJC regarding its compliance with particular elements of regulation. Even prior to a response by ACCJC, the Department noted: “those areas do not rise to the level for the Department to recommend denying recognition,” as was asked by many of the commenters. The ACCJC has, within its response to the staff analysis, addressed each of the Department's concerns raised in the draft staff report, including those raised as preliminary findings in the August 13, 2013 letter on the CFT complaint to the Department concerning ACCJC.¶ The ACCJC has supplied in its response to the draft staff report substantial evidence that ACCJC's standards, policies, procedures, and decisions are widely accepted by the required entities. Acceptance is demonstrated by the hundreds of persons who participate in workshops offered by ACCJC and in partnership with other organizations; wide participation in providing input on the standards; broad representation on evaluation teams and Commission; and, in response to the draft staff report, several dozen letters of support for ACCJC in addition to those previously submitted. It is especially noteworthy that the letters of support for ACCJC include a letter from the chief executive officer of CCSF, Dr. Robert Agrella, State Trustee, and from the institution’s Interim Chancellor, Dr. Thelma Scott Skillman, stating that their agreement with and support for ACCJC’s standards, policies, procedures, and accreditation actions. There are letters of support for ACCJC from the chief executive officer of the California Community College System, and from the chief executive of the Hawaii Community College System. Support has come from colleges, multi-college districts, state and national organizations, associations, and individual educators.
 
Staff Analysis of Agency Reponse to 3rd Party Comments
In response to the draft staff analysis, the agency provided a response to the third-party comments. That response included the attachment of numerous letters of support, also submitted in Section 602.13. As noted in Section 602.13, the letters are primarily from ACCJC-accredited institutions and only include one educator.

The agency must remedy the noncompliance findings (which sometimes overlap with third-party commenters' concerns) as outlined within the relevant sections of this analysis.