Council on Chiropractic Education, The 02/22/2017 01/10/2017 Final Review Renewal Petition

U.S. Department of Education

Staff Report

to the

Senior Department Offical

on

Recognition Compliance Issues


Recommendation Page



  1. Council on Chiropractic Education, The
  2. Renewal Petition
  3. The accreditation of programs leading to the Doctor of Chiropractic degree and single-purpose institutions offering the Doctor of Chiropractic program.
  4. Same as above.
  5. February 22, 2017
  6. Continue the agency's current recognition and require the agency to come into compliance within 12 months, and submit a compliance report 30 days after the 12 month period that demonstrates the agency's compliance with the issue identified below.
  7. It does not appear that the agency meets the following section of the Secretary’s Criteria for Recognition. The issue is summarized below and discussed in detail under the Summary of Findings section. -- The agency is requested to revise its policies related to its 12-month confidential warning to ensure that such a warning is for a much shorter period of time, is made public, and is included in the 12-18-24 month time limits specified in this section. [§602.20(a)]

Executive Summary



Part I: General Information About The Agency

The Council on Chiropractic Education is recognized as a specialized accreditor. It currently accredits 15 doctor of chiropractic programs at 18 sites in 13 states. Of these programs, CCE accredits one program that is offered through a single-purpose chiropractic institution. The agency's one single-purpose chiropractic institution uses the agency's accreditation to establish eligibility to participate in the Title IV HEA programs. Accreditation by the agency also allows its 15 programs to participate in non-Title IV programs offered through the Department of Health and Human Services (HHS).

Recognition History

CCE was first recognized by the Commissioner of Education in 1974 and has received periodic renewal of recognition since that time. The agency was last reviewed for continued recognition at the Fall 2011 NACIQI meeting. At that time, it received continued recognition and was requested to submit a compliance report on several areas of the Criteria. The agency's compliance report was reviewed at the Fall 2013 NACIQI meeting, and the agency's recognition was continued for a period of three years. The agency's next regularly-scheduled petition for continued recognition is the subject of the current staff analysis. No complaints about the agency were received this review period.


Part II: Summary Of Findings

602.15(a)(2) Competency of Representatives

(2) Competent and knowledgeable individuals, qualified by education and experience in their own right and trained by the agency on their responsibilities, as appropriate for their roles, regarding the agency's standards, policies, and procedures, to conduct its on-site evaluations, apply or establish its policies, and make its accrediting and preaccrediting decisions, including, if applicable to the agency's scope, their responsibilities regarding distance education and correspondence education;


The agency's scope of recognition does not include distance or correspondence education. Councilors The agency's council develops all standards and policies, as well as making accrediting decisions. The agency's bylaws specify that the council will be comprised of no fewer than 13 members and no more than 24 members (Ex. 9). Members are divided into four categories. Category 1 councilors include seven full-time employees of member programs/institutions. Category 2 councilors include five chiropractic practitioners. Category 3 councilors include four public members. Category 4 councilors include no more than eight at-large members from Categories 1-3. The current council has 19 members, including administrators, academics, educators, and practitioners (Ex. 10). Although the list provided in Exhibit 10 does not clearly designate public members, documentation provided under another section indicates that the council does include public representatives (Ex. 29). The agency provided sample resumes for six of its current councilors, who appear well-qualified to serve as the agency's decision-makers (Ex. 11). The agency states that new councilors receive orientation and training from the agency's staff and council chair. Additionally, newly-elected councilors are required to observe one council meeting prior to being seated on the council. Newly-elected council officers receive training in their roles from the agency's administrative staff. As documentation, the agency provided an agenda from a training session for new councilors (Ex. 15). On-Site Evaluators The agency's on-site evaluator pool is referred to as the Academy of Site Team Visitors. The agency's policy regarding on-site evaluators indicates that, prior to selection, applicants must submit an application, a current resume, letters of recommendation, and a letter of intent, as well as a letter granting release time if the applicant is employed at program/institution (Ex. 14). The agency reports that its on-site evaluator pool includes graduates and employees of all of its accredited programs, practitioners, and educators outside the chiropractic field. The pool includes evaluators with expertise in both educational and clinical settings. The agency provided a list of its current on-site evaluator pool, which includes 53 individuals, including practitioners, administrators, academics, and educators. Virtually all of the pool members hold doctorates. The agency provided sample resumes for 12 on-site evaluator pool members in a variety of categories, and all appear well-qualified to serve on on-site review teams (Ex. 13). The agency provided sample agendas of several training sessions for on-site evaluators (Ex. 16). The sessions included information on the review process, types of visits, scheduling, the self-study and the executive summary, pre-visit activities, accountability, team assignments, the team report, and post-visit responsibilities. Appeals Panel Members The agency did not provide any information in this section regarding the selection, qualifications, or training of its appeals panel pool members under this section. The agency is requested to provide additional information and documentation in this area.


Analyst Remarks to Response:

In the draft staff analysis, the agency was requested to provide additional information and documentation regarding the selection, qualifications, and training of its appeals panel pool members. In response to the concerns raised in the draft staff analysis, the agency notes that the selection of appeals panel members is addressed in its policy manual under a section on criteria for selecting an appeals panel (Ex. 105). The policy states that the agency will maintain a list of potential appeals panel members, to include academics, administrators, educators, practitioners, and public members. Potential appeals panel members must have experience with the agency and its standards, as well as appropriate academic or professional experience. The agency provided a list of its eight current appeals panel pool members, as well as information as to their area of expertise (Ex. 106). The agency provided the agenda for a recent training session that was held for appeals panel pool members, which included appropriate topics for discussion. (Ex. 107). Staff accepts the agency's narrative and supporting documentation, and no additional information is requested.



602.16(a)(1)(i) Student Achievement

(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's standard under Section 2.A addresses mission, planning, and assessment (Ex. 48, p.12). The standard requires that the agency's programs/institutions have a mission statement that is approved by the board and is available to all stakeholders. Measurable goals and objectives must be developed that are congruent with the mission statement. A plan must be developed that allows the program/institution to assess the effectiveness of its goals and objectives and enables the program/institution to implement necessary changes in order to maintain and improve program quality. In addition to the applicable standard, the agency states that it has developed a policy that establishes performance benchmarks and requires the disclosure of information related to student performance on a program's/institution's web site by July 1 of each year (Ex. 44). The program/institution must provide information on the four-year average of the number of graduates who attempted the National Board of Chiropractic Education (NBCE) exam within six months of graduation, the number of graduates who passed all parts of the exam within six months of graduation, and the percentage of graduates who passed all parts of the exam within six months of graduation. The agency has established an exam pass rate benchmark of not less than 80%. The agency has also established a completion rate benchmark. For entering students, at least 70% must complete the program within 150% of the time normally designated for completion of the degree. As documentation of the implementation of its requirements in this area, the agency provided sample copies of documents related to the various stages of the on-site evaluation process, including the self-study, team report, and follow-up correspondence (Exs. 46, 47, 49, 50, 51, and 52), as well as documentation of the training provided to on-site evaluators (Ex. 16). Staff accepts the agency's narrative and supporting documentation, but requests additional supporting documentation (i.e., documentation related to multiple reviews) to demonstrate the agency's consistent implementation of its requirements under this section.


Analyst Remarks to Response:

In the draft staff analysis, the agency's narrative and supporting documentation were accepted by ED staff, but the agency was requested to provide additional examples of supporting documentation. The expectation for examples of supporting documentation related to several reviews is a function of ED's abbreviated review process and is applied to all agencies that are participating in the review process. In response to the request in the draft staff analysis, the agency provided examples of documentation related to additional reviews, in the form of self-studies and on-site review team reports, which further demonstrate its compliance with the requirements of this section (Exs. 108, 109, 110, and 111). Staff accepts the agency's additional examples of supporting documentation, and no additional information is requested.



602.16(a)(1)(ii) Curricula

(a)(1)(ii) Curricula.


The agency's standard 2.H addresses its requirements regarding the educational program for the Doctor of Chiropractic degree (Ex. 53). The standard specifies that the educational program must require the equivalent of 4,200 hours to ensure that the program is commensurate with doctoral level training in the health sciences. The training must include a clinical component. The didactic and clinical components of the curriculum must be structured to enable graduates to demonstrate that they have attained all of the skills necessary to function as a primary care chiropractor. The curriculum must be consistent with the mission, goals, and objectives of the program. The curriculum must address foundations, such as the principles, practices, and philosophy/history of the field. The basic science portion of the curriculum must include anatomy, physiology, biochemistry, microbiology, and pathology. The clinical science portion of the curriculum must include physical, clinical, and laboratory diagnosis, diagnostic imaging, spinal analysis, orthopedics, biomechanics, neurology, spinal adjustment/manipulation, extremities manipulation, rehabilitation and therapeutic modalities, toxicology, patient management, nutrition, organ systems, special populations, first aid and emergency procedures, wellness and public health, and clinical decision-making. The curriculum must also include a professional practice component, to include ethics and integrity, jurisprudence, business and practice management, and professional communications. Information literacy and research methodology must also be addressed in the curriculum. As documentation of the implementation of its standard under this section, the agency provided a sample copy of information from a self-study and an on-site evaluation report (Exs. 54 and 55). Staff accepts the agency's narrative and supporting documentation, but requests additional supporting documentation (i.e., documentation related to multiple reviews) to demonstrate the agency's consistent implementation of its requirements under this section.


Analyst Remarks to Response:

In the draft staff analysis, the agency's narrative and supporting documentation were accepted by ED staff, but the agency was requested to provide additional examples of supporting documentation. The expectation for examples of supporting documentation related to multiple reviews is a function of ED's abbreviated review process and is applied to all agencies that are participating in the review process. In response to the request in the draft staff analysis, the agency provided examples of documentation related to an additional review, in the form of self-studies and on-site review team reports, which further demonstrate its compliance with the requirements of this section (Exs. 112, 113, 139, and 140). Staff accepts the agency's additional examples of supporting documentation, and no additional information is requested.



602.16(a)(1)(iii) Faculty

(a)(1)(iii) Faculty.


The agency's standard 2.E addresses its requirements regarding faculty (Ex. 56). The standard specifies that the program must employ faculty that are academically and professionally qualified. The faculty must develop, deliver, and monitor the program's courses and curricula and assess student learning and program effectiveness. The faculty must be involved in research, scholarship, service, professional development, and governance activities. The faculty must be of sufficient size, level of experience, and expertise to effectively deliver the curriculum. Faculty members must have appropriate credentials, including licensure. Faculty members must be provided with opportunities for professional development and have their performance evaluated on a regular basis. Faculty members must be involved in curriculum development, student admissions and advancement decisions, and academic counseling. As documentation of the implementation of its standard under this section, the agency provided a sample copy of information from a self-study and an on-site evaluation report (Exs. 57 and 58). Staff accepts the agency's narrative and supporting documentation, but requests additional supporting documentation (i.e., documentation related to multiple reviews) to demonstrate the agency's consistent implementation of its requirements under this section.


Analyst Remarks to Response:

In the draft staff analysis, the agency's narrative and supporting documentation were accepted by ED staff, but the agency was requested to provide additional examples of supporting documentation. The expectation for examples of supporting documentation related to multiple reviews is a function of ED's abbreviated review process and is applied to all agencies that are participating in the review process. In response to the request in the draft staff analysis, the agency provided examples of documentation related to an additional review, in the form of self-studies and on-site review team reports, which further demonstrate its compliance with the requirements of this section (Exs. 114, 115, 141, and 142). Staff accepts the agency's additional examples of supporting documentation, and no additional information is requested.



602.16(a)(1)(iv) Facilities/Equipment/Supplies

(a)(1)(iv) Facilities, equipment, and supplies.


The agency's standard 2.D addresses its requirements regarding resources, to include facilities, equipment, and supplies (Ex. 59). The standard specifies that the institution must develop and maintain learning and physical resources that support the program's mission, goals, and objectives. There must be adequate access to learning resources, such as library and information technology. The institution must provide and maintain physical facilities, equipment, and other physical resources that are needed and appropriate in light of the program's mission, goals, and objectives. There must be policies governing the operation of resources and evidence of their utilization. There must be a comprehensive infrastructure master plan that includes academic and administrative computer hardware and software, as well as facilities management and maintenance plans. There must be descriptions of clinical or other facilities that have affiliation agreements with the program. There must be accommodation plans and resource allocation for students with disabilities. As documentation of the implementation of its standard under this section, the agency provided a sample copy of information from a self-study and an on-site evaluation report (Exs. 60 and 61). Staff accepts the agency's narrative and supporting documentation, but requests additional supporting documentation (i.e., documentation related to multiple reviews) to demonstrate the agency's consistent implementation of its requirements under this section.


Analyst Remarks to Response:

In the draft staff analysis, the agency's narrative and supporting documentation were accepted by ED staff, but the agency was requested to provide additional examples of supporting documentation. The expectation for examples of supporting documentation related to multiple reviews is a function of ED's abbreviated review process and is applied to all agencies that are participating in the review process. In response to the request in the draft staff analysis, the agency provided examples of documentation related to an additional review, in the form of self-studies and on-site review team reports, which further demonstrate its compliance with the requirements of this section (Exs. 116, 117, 143, and 144). Staff accepts the agency's additional examples of supporting documentation, and no additional information is requested.



602.16(a)(1)(v) Student Complaints

(a)(1)(v) Fiscal and administrative capacity as appropriate to the specified scale of operations.


The agency's standard 2.C addresses its requirements regarding administrative capacity and its standard 2.D addresses its requirements related to fiscal capacity (Ex. 62). The standard addressing governance and administration specifies that the chiropractic program must be housed in an institution that has a governing body that has the authority, structure, and organization to ensure program accountability, viability, policy and resource development, and approval of the program's mission. The program's administrative structure and personnel must facilitate achievement of the program's mission and goals, foster improvement in instruction and learning, research and scholarship, and service. There must be an appropriate governing body. The chief administrative officer must be qualified by training and experience. If the chief administrative officer is not the institution's CEO, s/he must have access to the CEO or an appropriate senior administrator. There must be a sufficient number of academic and staff administrators with appropriate training and experience to carry out their responsibilities and to assist the program in fulfilling its mission. There must be clear lines of authority, responsibility, and communication among faculty and staff. There must be periodic assessment of administrator performance. The standard addressing financial resource specifies that the institution must develop and maintain financial resources that support the mission, goals, and objectives of the program. The institution must be able to demonstrate a recent history of adequate and stable financial resources. The program must have and maintain a current operating and capital allocations budget and develop long-term budget projections. The program must demonstrate that it uses sound financial procedures and exercises appropriate control over its financial resources. The current budget and long-term budget projections must show revenue streams and financial allocations based on strategic planning. There must be policies and procedures to control the allocation of assets, and the allocation must support the program's mission and outcomes expectations. There must be an institutional investment policy that has been approved by the governing body. There must be policies and strategies related to institutional advancement and support. There must be annual audit reports prepared by a certified public accountant employing an appropriate audit guide. There must be annual financial aid audits as required by governmental regulations if the institution participates in such programs. As documentation of the implementation of its standard under this section, the agency provided a sample copy of information from a self-study and an on-site evaluation report (Exs. 60 and 61), as well as a sample program characteristics report (Ex. 66). Staff accepts the agency's narrative and supporting documentation, but requests additional supporting documentation (i.e., documentation related to multiple reviews) to demonstrate the agency's consistent implementation of its requirements under this section.


Analyst Remarks to Response:

In the draft staff analysis, the agency's narrative and supporting documentation were accepted by ED staff, but the agency was requested to provide additional examples of supporting documentation. The expectation for examples of supporting documentation related to multiple reviews is a function of ED's abbreviated review process and is applied to all agencies that are participating in the review process. In response to the request in the draft staff analysis, the agency provided examples of documentation related to an additional review, in the form of self-studies and on-site review team reports, which further demonstrate its compliance with the requirements of this section (Exs. 118, 119, 145, and 146). Staff accepts the agency's additional examples of supporting documentation, and no additional information is requested.



602.16(a)(1)(vi) Fiscal/Administrative Capacity

(a)(1)(vi) Student support services.


The agency's standard 2.F addresses its requirements regarding student support services (Ex. 67). The standard specifies a program/institution provide services in a manner, consistent with its mission, that helps students develop their full academic potential and competent graduates. Student support services must support all learning within the context of the programs mission. Services should address a wide range of student life issues, including mental health and safety. Support services must include registration, orientation, academic advising and tutoring, financial aid counseling, career placement, academic reviews and appeals, student grievances, and disciplinary issues. Programs and services must support a diverse student body including students who are older, have international backgrounds, have disabilities, or are from economically disadvantaged or under-served backgrounds. Services may also include a student governance system, student organizations and activities, cultural programming, athletic activities, and child care. Published policies and procedures related to student support services must be published and readily available to students. As documentation of the implementation of its standard under this section, the agency provided a sample copy of information from a self-study and an on-site evaluation report (Exs. 68 and 69). Staff accepts the agency's narrative and supporting documentation, but requests additional supporting documentation (i.e., documentation related to multiple reviews) to demonstrate the agency's consistent implementation of its requirements under this section.


Analyst Remarks to Response:

In the draft staff analysis, the agency's narrative and supporting documentation were accepted by ED staff, but the agency was requested to provide additional examples of supporting documentation. The expectation for examples of supporting documentation related to multiple reviews is a function of ED's abbreviated review process and is applied to all agencies that are participating in the review process. In response to the request in the draft staff analysis, the agency provided examples of documentation related to an additional review, in the form of self-studies and on-site review team reports, which further demonstrate its compliance with the requirements of this section (Exs. 120, 121, 147, and 148). Staff accepts the agency's additional examples of supporting documentation, and no additional information is requested.



602.16(a)(1)(vii) Student Support Services

(a)(1)(vii) Recruiting and admissions practices, academic calendars, catalogs, publications, grading, and advertising.


The agency's standards 2.B and 2.G address its requirements regarding recruiting (Ex. 70). Standard 2.B is related to ethics and integrity. It specifies that the program demonstrate integrity and adherence to ethical standards relating to all aspects of interactions regarding stakeholders of the institution and the public at large. Integrity and transparency should be evident throughout the program's actions related to advertising and marketing activities, student admissions and financial aid, and recruiting. There must be policies and procedures that address student admissions, including academic prerequisites, technical standards, and financial aid. There must be documentation that such policies are implemented and consistently followed, and that violations are addressed. Standard 2.G is related to student admissions. The standard sets forth agency requirements for admission that became effective as of January 2014, which include completion of three years (or 90 semester hours) of undergraduate study at an institution accredited by an agency recognized by ED or an equivalent foreign agency, with a GPA of not less than 3.0 on a 4.0 scale. The 90 hours must include at least 24 semester hours in life and physical science courses, at least half of which have had a substantive laboratory component. The student's undergraduate preparation should also include preparation in the humanities and social sciences. As documentation of the implementation of its standard under this section, the agency provided a sample copy of information from a self-study and an on-site evaluation report (Exs. 71 and 72). Staff accepts the agency's narrative and supporting documentation, but requests additional supporting documentation (i.e., documentation related to multiple reviews) to demonstrate the agency's consistent implementation of its requirements under this section.


Analyst Remarks to Response:

In the draft staff analysis, the agency's narrative and supporting documentation were accepted by ED staff, but the agency was requested to provide additional examples of supporting documentation. The expectation for examples of supporting documentation related to multiple reviews is a function of ED's abbreviated review process and is applied to all agencies that are participating in the review process. In response to the request in the draft staff analysis, the agency provided examples of documentation related to an additional review, in the form of self-studies and on-site review team reports, which further demonstrate its compliance with the requirements of this section (Exs. 122, 123, 149, and 150). Staff accepts the agency's additional examples of supporting documentation, and no additional information is requested.



602.16(a)(1)(viii) Recruiting & Other Practices

(a)(1)(viii) Measures of program length and the objectives of the degrees or credentials offered.


The agency's standard 2.H and appendix 1 address its requirements regarding program length for the educational program for the Doctor of Chiropractic degree (Ex. 45). As noted under a previous section, the degree requires a minimum of 4,200 instructional hours. Students must not have earned less than 25% of their total credits from the program that grants the degree. The program must include both didactic and clinical components. As noted previously, the standard includes specific requirements in foundations, basic sciences, clinical sciences, professional practice, and information literacy and research methodology. Appendix 1 of the agency's standards document contains an extensive list of specific competencies that students are expected to achieve as a result of attending the agency's doctoral programs. As documentation of the implementation of its standard under this section, the agency provided a sample copy of information from a self-study and an on-site evaluation report (Exs. 46 and 47). Staff accepts the agency's narrative and supporting documentation, but requests additional supporting documentation (i.e., documentation related to multiple reviews) to demonstrate the agency's consistent implementation of its requirements under this section.


Analyst Remarks to Response:

In the draft staff analysis, the agency's narrative and supporting documentation were accepted by ED staff, but the agency was requested to provide additional examples of supporting documentation. The expectation for examples of supporting documentation related to multiple reviews is a function of ED's abbreviated review process and is applied to all agencies that are participating in the review process. In response to the request in the draft staff analysis, the agency provided examples of documentation related to an additional review, in the form of self-studies and on-site review team reports, which further demonstrate its compliance with the requirements of this section (Exs. 124, 125, 151, and 152). Staff accepts the agency's additional examples of supporting documentation, and no additional information is requested.



602.16(a)(1)(ix) Program Length

(a)(1)(ix) Record of student complaints received by, or available to, the agency.


The agency's standard 2.F on student support services addresses its requirements regarding student complaints (Ex. 67). The standard requires a program/institution to provide services that help students develop their full academic potential and become competent graduates. As noted under a previous section, the services must include an appropriate process for handling academic reviews and appeals, student grievances, and disciplinary issues. The standard specifically states that there must be policies and procedures to equitably address student complaints and grievances, student conduct issues, and academic standing reviews, which must be documented by records of hearings and proceedings related to such matters. As documentation of the implementation of its standard under this section, the agency provided a sample copy of information from a self-study and an on-site evaluation report (Exs. 68 and 69). Although the agency's standards address student complaints at the programmatic/institutional level, and the agency did provide evidence that the record of student complaints is examined during the course of the on-site review, the agency did not provide any information as to how it maintains a record of student complaints that are received by the agency itself, nor if information regarding such complaints is shared with the on-site review team prior to the on-site review. Additional information is requested in this area. Additional supporting documentation (i.e., documentation related to multiple reviews) is also requested to demonstrate the agency's consistent implementation of its requirements under this section.


Analyst Remarks to Response:

In the draft staff analysis, the agency was requested to provide additional information about how it maintains a record of student complaints that are received by the agency and whether information regarding such complaints is shared with the on-site review team prior to the on-site review. Additional supporting documentation (i.e., documentation related to multiple reviews) was also requested to demonstrate the agency's consistent implementation of its requirements under this section. In its response to the draft staff analysis, the agency references its policy manual, which provide information related to complaints regarding its programs/institutions that it receives directly (Ex. 126). In order for the agency to consider such complaints, the institutional level complaint process must have been exhausted. The agency's complaint process specifies the process for filing the complaint, as well as timeframes for consideration of the complaint and its resolution. The policy specifies that if there is evidence of non-compliance with the agency's standards, the agency will authorize a special committee to visit the campus or include the complaint for evaluation by an on-site review team if an upcoming site visit is scheduled. Following any visits, the site visit report will be considered by the agency's Council. The policy specifies that the agency will retain individual complaints in its files. If a number of complaints suggest a pattern of non-compliance, the Council will take appropriate action. The agency notes that it has not received any direct complaints and therefore has no supporting documentation to provide, other than its policy. As requested, the agency did provide additional self-studies (Exs. 127 and 153) and team reports (Exs. 128 and 154) as documentation that its on-site review teams review complaints during the course of on-site visits. Staff accepts the agency's narrative and supporting documentation, and no additional information is requested.



602.17(a) Mission & Objectives


(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's standard 2.A is the primary source of its requirements regarding mission, planning, and assessment (Ex. 43). The standard requires that the program have a mission statement that has been approved by its governing body and is made available to all stakeholders. The mission statement should provide for an educational program leading to the Doctor of Chiropractic degree. Measurable goals and objectives must be developed that are congruent with the mission statement. The goals and objectives should shape the program and be used to create a plan to establish programmatic and operational priorities, as well as resource allocation. The plan should be used to assess the effectiveness of the goals and objectives, permit changes, and improve program integrity. Although the agency provided a copy of its standard related to mission and objectives, it did not provide any documentation to demonstrate the implementation of its standard. The agency is requested to provide supporting documentation (i.e., documentation related to multiple reviews) to demonstrate the agency's consistent implementation of its requirements under this section.


Analyst Remarks to Response:

In the draft staff analysis, the agency's narrative and policy was accepted by ED staff, but the agency was requested to provide examples of supporting documentation related to the implementation of its policy. In response to the request in the draft staff analysis, the agency provided examples of documentation related to its review of the requirements of this section, in the form of self-studies and on-site review team reports, which demonstrate the implementation of its policies and its compliance with the requirements of this section (Exs. 129, 130, 131, 132). Staff accepts the agency's examples of supporting documentation, and no additional information is requested.



602.17(f) Report on Compliance & Student Achievement

(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 


Report on Compliance with Standards The agency's standards document provides information on the processes for accreditation, including information on the site team visit and the team's report to the council (Ex. 78). It states that an on-site review team will evaluate the information contained in the program's/institution's self-study. A draft report will be prepared by the on-site review team and sent to the program/institution for corrections of fact. Following the receipt of any factual corrections, a final on-site review report is sent by the agency to the institution's CEO, governing body chair, and the on-site review team members. The program/institution may then submit a response, and is required to submit a response if there are any areas of concern identified in the report. The program's/institution's response must be submitted back to the agency no less than 30 days prior to a Status Review Meeting. The purpose of the meeting is to provide an opportunity for the council to meet with program representatives to discuss the findings. Following that meeting, the council reviews the self-study and supporting documentation, the final report, the program's response to the final report, and determines whether the program complies with the agency's standards. The agency then sends the council's written decision to the program's CEO, governing body chair, and the council. As documentation of the implementation of its standard under this section, the agency provided a sample copy of a council action letter to an institution regarding its compliance with the agency's standards (Ex. 52). Although ED staff accepts the agency's narrative and supporting documentation related to reports on compliance, the agency is requested to provide additional supporting documentation (i.e., documentation related to multiple reviews) to demonstrate the agency's implementation of its requirements under this section. Report on Performance with Respect to Student Achievement Although the agency has noted in previous sections that it has set benchmarks for its programs regarding completion rates and exam pass rates, no information was provided under this section as to the agency's processes and procedures for collecting this information on an ongoing basis, how that information is evaluated, or when/how the program/institution receives a report from the agency with respect to its performance with respect to student achievement. The agency provided documentation with this section (Ex. 79) that appears to indicate that the agency has processes and procedures in place for collecting this information, evaluating it, and reporting its findings back to the program/institution, but more information and supporting documentation are needed regarding its practices in this area.


Analyst Remarks to Response:

In the draft staff analysis, the agency was requested to 1) provide additional supporting documentation to demonstrate the agency's consistent implementation of its requirements under this section related to compliance with its standards and 2) provide information and documentation about its processes and procedures for collecting student achievement information on an ongoing basis, how that information is evaluated, and when/how the program/institution receives a report from the agency with respect to its performance with respect to student achievement. In response to the concerns raised in the draft staff analysis, the agency provided additional information related to its assessment of performance with respect to student achievement, as well as three program accreditation letters (Exs. 155, 156, and 157) as documentation related to compliance with the agency's standards. In its response related to the collection of student achievement information, the agency states that PCRs are required to be submitted every two years, based upon the agency's schedule of accreditation activities. The comprehensive site visit occurs, a PCR is submitted two years after the comprehensive site visit, an interim site visit takes place two years after the first PCR (in other words, four years after the comprehensive site visit), and a second PCR is submitted two years after the interim site visit. The accreditation cycle then begins anew. The agency provided a copy of its review schedule, which documents the timeframes described in the agency's narrative (Ex. 133). The agency's manual describes the requirements related to the submission of the PCRs (Ex. 134), and letters are sent to programs/institutions explaining the PCR requirements and providing instructions for the completion of the PCR (Ex. 135). The agency provided copies of sample PCRs (Exs. 136 and 137), which require the program/institution to provide information regarding: its accreditation cycle; headcount data; typical completion period; licensing exam completion rates; completion rates; planning and substantive changes; performance thresholds and outcomes; clinical education; research and scholarly activities; faculty; and finances (Exs. 136 and 137). The agency also provided sample meeting minutes and letters to programs/institutions regarding the Council's review of PCRs (Ex. 138). Staff accepts the agency's narrative and supporting documentation regarding the requirements of this section related to performance with respect to student achievement, and no additional information is requested.



602.20(a) Enforcement Timelines

(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.


The requirements of this section are addressed in the agency's accreditation standards (Ex. 98). A section on accreditation decisions and actions addresses the enforcement of standards. It references ED's requirements and states that the agency will immediately initiate adverse action if the council's review of a program or institution indicates non-compliance with a standard. The two-year time limit applies to all of the agency's programs/institutions, as noted in the agency's standards. The standards note that if a program/institution does not bring itself into compliance within the initial two-year time limit, the council must take immediate adverse action unless the time period is extended for good cause. The standards then further explain the definition and conditions for good cause. As documentation, the agency provided a sample copy of the tracking report that the council receives noting areas of non-compliance for programs/institutions (Ex. 110) and sample action letters referencing the two-year enforcement timeframe and the resolution of areas of non-compliance within the required limits (Ex. 99). Staff accepts the agency's narrative and supporting documentation, and no additional information is requested.


Analyst Remarks to Response:

Although not noted as an issue in the draft staff analysis, during its observation of an agency Commission meeting in January 2017, ED staff became aware of an issue related to the requirements of this section. The agency's policy manual makes provision for a "confidential warning" to doctoral programs that need to address agency concerns regarding accreditation. The warning may be issued if the agency determines that the deficiencies may be corrected by the program in a "short period of time." The warning is a non-public procedural action that may be continued for a period of up to twelve months. ED staff does not feel that twelve months constitutes a "short period of time" and also has concerns that the action is not publicly noted, which presents the possibility that the warning period might not be counted against the 12-18-24 month time limits specified under this section. The agency is requested to revise its policies related to its 12-month confidential warning to ensure that such a warning is for a much shorter period of time, is made public, and is included in the 12-18-24 month time limits specified in this section.



Part III: Third Party Comments


The Department did not receive any written third-party comments regarding this agency.