U.S.Department of Education Staff Report
Senior Department Official on Recognition Compliance Issues
The Midwifery Education Accreditation Council (MEAC) is both a programmatic and an institutional accreditor. It accredits direct-entry midwifery educational programs and institutions throughout the United States awarding certificates and degrees. MEAC currently accredits two programs and nine institutions located in eleven states. Four of the institutions have components offered via distance or correspondence education.
The agency’s accreditation enables its certificate and degree-granting institutions to establish eligibility to participate in Federal programs administered by the Department of Education under the Higher Education Act (HEA) of 1965, as amended. Currently, four institutions accredited by MEAC participate in HEA Title IV programs.
MEAC developed its accreditation standards and administrative policies and procedures in 1991 using a national consensus-building process with input from representative midwifery educators and schools. The agency began conducting its accreditation activities in 1993-94 and accredited its first institution in 1995. The National Advisory Committee on Institutional Quality and Integrity (NACIQI) considered MEAC for initial recognition at its Fall 2000 meeting and the Secretary’s letter officially conferring recognition was sent to the agency in 2001. The agency's most recent petition for renewed recognition was reviewed at the Fall 2015 NACIQI meeting. At that time, the agency's current recognition was continued, and the agency was requested to submit a report demonstrating compliance with three issues. That report is the subject of the current staff analysis.
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.
In the Fall 2015 staff analysis, the agency was requested to demonstrate that it has a set of monitoring and evaluation approaches that will allow it to identify problems related to continued compliance with agency standards, including developing a means for ensuring that programs/institutions submit all required information and that actions are taken against programs/institutions that are found to be out of compliance with the agency's standards.
Required information submitted
In response to the concerns raised in the Fall 2015 staff analysis, the agency states that it discontinued its interim reports, replaced them with monitoring reports and compliance reports, updated its policies and procedures documents accordingly, and notified its programs/institutions of the changes. Monitoring reports and annual reports are used as a means of gathering required information from programs/institutions, which may in turn lead to the identification of compliance issues that would then be addressed in compliance reports subject to the 12-18-24 month time limits found under 602.20(a)(2).
The agency provided a discussion of its monitoring reports, which it states are assigned when areas of weakness that are not compliance issues are identified as part of the accreditation/reaccreditation process, as a result of annual reports, as a result of third party information, as a result of outside investigations by other agencies, or as a result of complaints, etc. The purpose of the monitoring report is to gather additional information related to areas of weakness regarding the agency's benchmarks or when a program/institution has undertaken major changes. Programs/institutions are notified by the agency regarding the areas that are to be addressed in the monitoring reports, the information that is required, and the due date for the report. When the reports are submitted, they are reviewed by the agency staff for completeness, and the program/institution is notified if additional information is needed. If the program/institution does not submit the necessary information within the specified time limits, a late fee is assessed. If the program/institution requests additional time to submit its information and the request is granted, an extension fee is assessed. If the information is not submitted as requested, it becomes a compliance issue and may result in loss of accreditation. After the report is submitted and assessed by the agency's staff, the report is given to two board members for initial review, who in turn present their findings to the agency's entire board for a final decision. If the report identifies any areas of noncompliance, the agency's compliance review process is implemented. The agency states that it has reviewed 13 monitoring reports from six programs/institutions since 2016 and that all of the reports have been submitted as requested.
In addition to requiring monitoring reports to address specific concerns, the agency also requires all of its programs/institutions to submit annual reports. Annual reports cover the previous calendar year, are due on March 31 of each year, and are reviewed at the agency's following June board meeting. The reports require information to be submitted regarding key indicators, including fiscal information, student achievement measures, and enrollment growth. The annual reports are subject to essentially the same review process as the monitoring reports, with staff screening, followed by review by two board members, who in turn present the results of their review to the entire board for a final decision. If compliance issues are found, the agency's noncompliance procedures are implemented. As with the monitoring reports, the annual reports are now subject to fees/penalties if the required information is not submitted in a timely manner.
As noted above, the agency also requires compliance reports in addition to its monitoring reports and annual reports. Information regarding compliance reports is provided under the agency's response to 602.20(a).
ED staff notes that a lack of responsiveness on the part of some programs/institutions in submitting required information was a major concern at the time of the agency's last review. However, it appears that this reporting issue has now been resolved with the implementation of late fees, extension fees, and, ultimately, adverse actions if information is not submitted in a timely manner, as specified by the agency.
Compliance actions taken
During the Fall 2015 review, ED staff identified a concern that compliance issues identified through the agency's annual reports were not being closely tracked, with the potential that the compliance deadlines specified under 602.20(a)(2) might be exceeded. As a result of those concerns, the agency has implemented specific review deadlines, as well as a new project management tracking system for issues of non-compliance. The agency reports that no new compliance issues were identified as a result of its most recent annual reporting cycle and that the previously identified issues have been resolved within the required deadlines. ED staff accepts the agency's response to this portion of this section, and no additional information is requested regarding compliance actions taken.
As documentation in support of this section, the agency provided a copy of its letter notifying its programs/institutions of its revised procedures (Ex. 1), applicable excerpts from its policies and procedures (Exs. 2, 3, 6, and 9), its most recent annual report key indicators (Ex. 4), fee schedules related to its reports (Exs. 5 and 8), correspondence from the agency to an institution that had submitted an incomplete report (Ex. 7), a sample agency analysis of a monitoring report (Ex. 10), a sample agency analysis of an annual report (Ex. 11), and information on its new tracking system (Ex. 12). ED staff accepts all of the agency's supporting documentation. However, ED is currently requiring agencies to submit at least three sets of documentation demonstrating how it has reviewed its programs/institutions for compliance issues. In the case of this section, the agency is therefore requested to provide sets of sample monitoring/annual reports for three programs/institutions, sample agency evaluations of those same three reports, and the decision letters from the agency to the three programs/institutions regarding those reports.
Staff accepts the agency's narrative and supporting documentation. However, additional documentation is requested, since three sets of documentation are requested under ED's current abbreviated review process. The agency is requested provide additional documentation related to all stages of its complete annual report and monitoring report review process. This documentation should include complete sets for three separate programs/institutions. A set should include, for example, an annual or monitoring report, the agency's review of the annual or monitoring report, and the agency's decision letter regarding its review of the annual or monitoring report, etc.
In the draft staff analysis, ED staff accepted the agency's narrative and supporting documentation and determined that the agency had addressed the compliance issues identified in the Fall 2015 staff analysis of the agency's petition for continued recognition. However, ED noted in the draft that the agency had not provided three sets of documentation in support of its narrative, as is currently required under ED's focused review process. In response to the draft staff analysis, the agency provided the additional sets of documentation, as requested, which demonstrate the agency's compliance with the requirements of this section. ED staff accepts the agency's supplemental documentation, and no additional information is requested.
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.
In the Fall 2015 final staff analysis, the agency was requested to demonstrate that it is tracking its programs'/institutions' compliance with agency standards on an ongoing basis, that it requires corrective action of any program or institution that is found to be in non-compliance, and that it requires all programs/institutions to come into compliance with its standards within the time periods specified under this section.
As noted in the previous section, the agency modified its reporting requirements in response to concerns raised in the Fall 2015 final staff analysis. The agency is now requiring programs/institutions to submit compliance reports if the agency identifies any areas of non-compliance with its standards, either as a result of the comprehensive review process or during the period of accreditation. The agency notifies the program/institution of the compliance issue, the reasons for the finding of non-compliance, the expected corrective action, the deadline for coming into compliance, and the due date for the compliance report.
As with the agency's monitoring reports, when the compliance reports are submitted, they are reviewed by the agency staff for completeness. The program/institution is notified if additional information is needed, and a deadline is provided for supplying the information. If the program/institution does not submit the necessary information within the specified time limits, a late fee is assessed. If the program/institution requests additional time to submit its information and the request is granted, an extension fee is assessed. Late submissions or patterns of late or incomplete reporting may result in additional findings of non-compliance, as well as a show cause as to why accreditation should not be withdrawn. The agency reports that all of its programs/institutions have met their reporting deadlines since it implemented its new reporting process.
The agency has conducted four comprehensive reviews since 2016, including one programmatic review and three institutional reviews. The programmatic review did not result in any compliance issues, but each of the three institutions had findings related to at least one of the agency's benchmarks. The agency assigned compliance reports to the three institutions, with submission deadlines. The agency reports that two of the institutions were ultimately placed on probation. Additional information regarding the two institutions that were placed on probation is provided under the agency's response to 602.20(b).
As noted under the previous section, the agency has now implemented a detailed database tracking system to enable it to track compliance with the timeframes specified under this section. The agency provided detailed sample screen shots of the tracking system. The system allows agency staff to track areas of non-compliance, tracks benchmarks that are not being met, tracks benchmarks that have been remediated, and specifies compliance deadlines. The agency reports that non-compliance issues are now reported at all of the agency's board meetings, as well as being reviewed in agency staff meetings and reported to the agency's executive director for review.
As documentation related to this section, the agency provided excerpts from its policies and procedures (Exs. 1, 3, and 5), a copy of its schedule of fees for late submissions (Ex. 2), a sample compliance report with the agency's decision letter (Ex. 4), an agency report resulting in probation (Ex. 6), an agency report resulting in the acceptance of a compliance report (Ex. 7), and information related to the agency's new tracking database (Ex. 8).
ED staff accepts the agency's narrative and supporting documentation. However, as noted in the previous section, ED requests three sets of documentation under its abbreviated review process. Since the agency noted compliance issues related to three comprehensive institutional reviews, the agency is requested to provide complete sets of documentation related to its review and tracking of the compliance issues found at each of those three institutions. The documentation should include the on-site review reports, the agency's review of the on-site review reports, the agency's decision letters, the subsequent compliance reports that were submitted by the institutions, and the agency's review of the compliance reports and final agency decision letters, etc.
In the draft staff analysis, ED staff accepted the agency's narrative and supporting documentation and determined that the agency had addressed the compliance issues identified in the Fall 2015 staff analysis of the agency's petition for continued recognition. However, ED noted in the draft that the agency had not provided three sets of documentation in support of its narrative, as is currently required under ED's focused review process. In response to the draft staff analysis, the agency provided the additional sets of documentation, as requested, which demonstrate the agency's compliance with the requirements of this section. The evidence demonstrates that the agency takes the appropriate action within the timeframes required. ED staff accepts the agency's supplemental documentation, and no additional information is requested.
(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.
In the Fall 2015 final staff analysis, the agency was requested to demonstrate that it is tracking its programs'/institutions' compliance with agency standards on an ongoing basis, that it requires corrective action of any program or institution that is found to be in non-compliance, and that it takes immediate adverse action unless the agency, for good cause, extends the period for achieving compliance.
As noted under a previous section, the agency has placed two institutions on probation since 2016, due to the fact that the institutions did not come into compliance by the agency's specified reporting deadlines. In one instance, the agency specified that the institution discontinue two programs that were out of compliance. The institution complied and was then removed from probation. In the second instance, the institution was granted an extension for good cause due to the fact that the information required by the agency would become available two weeks after the institution's reporting date. The institution submitted the information by the required extension date, was found in compliance, and was then removed from probation. ED staff concurs with the agency that this was an appropriate use of an extension for good cause.
The agency notes that at the time of its Fall 2015 review, it was granting numerous extensions for good cause due to reporting requirements that the agency had established for programs/institutions regarding required benchmarks. As a result of the concerns raised in the Fall 2015 staff analysis, the agency reconsidered its benchmark methodology and revised its reporting procedures to align with IPEDS definitions regarding calculations for retention and completion data. As a result of its revised methodologies, the agency has addressed the underlying technical issues that were resulting in the need for an excessive number of extensions for good cause. As noted above, the agency has reportedly only issued one extension since 2016.
As documentation in support of its narrative for this section, the agency provided excerpts from its policies and procedures (Exs. 1, 2, and 8), decision packets for the two institutions that had been placed on probation (Exs. 3, 4, and 5), and information regarding the database tracking system that it has implemented to ensure that its programs/institutions meet the 12-18-24 month timeframes specified under 602.20(a).
ED staff accepts the agency's narrative and supporting documentation, and no additional information is requested for this section.
The Department did not receive any written third - party comments regarding this agency.