CAPTE On-site Reviewer Training MODULE 2 The Accreditation

CAPTE: On-site Reviewer Training MODULE 2 The Accreditation Handbook April 2017 This module will introduce you to the Accreditation Handbook, which has been developed by the Commission on Accreditation in Physical Therapy Education (CAPTE) to document its procedures and rules. As an on-site reviewer, you will use this document to look up information about the accreditation process when questions arise. 1

Objectives • • • Identify the best way to access the most current version of the Accreditation Handbook Identify the purposes of the Accreditation Handbook List the individuals who might use the Accreditation Handbook Identify the types of information that is included in the Accreditation Handbook Locate relevant sections of the Accreditation Handbook Please take a moment to review the objectives for this module. 2

Accessing the Accreditation Handbook CAPTE Review CAPTE reviews the rules at each meeting www. capteonline. org Website The latest version of the Handbook can always be found on CAPTE’s website Notification Changes to the Handbook are publicized via the Accreditation Update The Accreditation Handbook is an electronic document available from the CAPTE web site. Making all rules available to all interested parties is part of CAPTE’s ongoing efforts to make all of its activities completely transparent to its stakeholders. The Handbook can be viewed online or downloaded as a PDF document. If needed, a PDF reader is available as a free download at the web site as well. It might be helpful to have access to the Handbook as we discuss it. CAPTE has a standing activity to review the rules at each of its meetings to ensure that the rules continue to meet CAPTE’s goals and to reflect best practice in accreditation. The online version is the most current version. Whenever changes are made, the rules are provided to the communities of interest through the Accreditation Update and located on CAPTE’S web site. 3

Purpose of Accreditation Handbook Guidance for operation of CAPTE Information to programs about accreditation Guidance for Staff on accreditation procedures The handbook provides information about accreditation in physical therapy education for developing and existing programs. It also guides the operation of CAPTE and its staff. The handbook includes the details of the accreditation process, the types of accreditation status decisions, methods for filing appeals and complaints, the standards, and the position papers produced by CAPTE. 4

Intended Audience Representatives of institutions & programs CAPTE On-site team members General public All of those involved in the accreditation process should have a working knowledge of the Accreditation Handbook. The accreditation handbook is intended for representatives of institutions and programs, on-site team members, CAPTE and the general public. 5

Handbook Contents Introductory information Rules of Practice and Procedure Standards Additional information for programs Position papers The Handbook begins with introductory information including an overview of accreditation, much of which was covered in the previous module on the purpose of accreditation. The majority of the handbook delineates the rules of practice and procedure under which CAPTE operates. The rules are designed to ensure that all stakeholders are treated fairly and that the processes used in accreditation are designed to lead to quality improvement in physical therapy education. Because of this, they are of necessity, detailed. The Handbook includes the Standards and Required Elements for the PTA and PT education programs. The Handbook also includes additional information helpful to programs involved in the pre-accreditation and accreditation process. This includes guidelines for the candidacy process and for on-site visits. Finally, the Handbook contains position papers adopted by CAPTE that are intended to clarify the Commission’s position on a number of issues, for example, faculty qualifications, distance education, and the PT/PTA relationship. 6

Handbook Revisions IMPORTANT! Review relevant portions prior to participation Since changes to the rules may occur twice a year, it is strongly recommended that everyone working in accreditation, including on-site reviewers, program faculty, and institutional representatives review the relevant portions of the rules whenever they participate in accreditation activities. 7

Rules: CAPTE Function and Structure Part 1 Part 2 Part 3 Part 44 Part 1: Integrity in Accreditation Process Part 2: Purpose, Tasks, Mission, Vision, & Scope Part 3: Organization, Roles and Responsibilities of CAPTE & Staff Part 4: Operation of CAPTE The first section of the Handbook addresses the rules. Part 1 addresses CAPTE’s commitment to integrity and its expectations for program and institutional integrity. Part 2 describes the mission and function of CAPTE as well as the tasks or activities to manage the accreditation processes. Part 3 includes a description of the composition of CAPTE as well as the roles and responsibilities of each group. The 31 member Commission consists of 3 panels. Each panel member represents a specific constituency that CAPTE serves, including the public, clinical practice and PT & PTA educational programs. Part 4 contains detailed rules for the day-to-day processes of CAPTE, including the procedures for meetings. The rules regarding conflict of interest and confidentiality are included here. Subpart 4. 4 delineates the components of the Summary of Action, the official report of an accreditation status decision. 8

Rules: Accreditation Procedures Part 5 Part 6 Part 7 Part 89 Part 10 Part 5: Development of Standards Part 6: Training Site Reviewers Part 7: Achieving Candidacy Part 8: Achieving Accreditation Part 9: Reporting Program Changes Part 10: Administrative Probationary Status The next section of the rules deals with the actual procedures in the accreditation process. Each part in this section will be reviewed in upcoming slides, highlighting the implications for reviewers and for programs. 9

Part 5: Development of Standards Systematic Revision of Standards Seek stakeholder comments Convene CRG Hold public hearings Adopt and notify stakeholders The Commission has responsibility for developing, maintaining, and disseminating the standards that are used to make accreditation decisions. This part of the handbook focuses on the process used to determine the content of the criteria. The process calls for a systematic revision of standards every 5 years that includes seeking stakeholder comments; convening a Standards Review Group, if necessary; holding public hearings on the proposed standards; and adopting and notifying stakeholders of the implementation of the new standards. 10

Revision of Standards Between Cycles Seek Comments Adopt Notify Stakeholders of Implementation Occasionally the standards are revised outside of the 5 -year cycle based on a demonstrated need. These revisions usually only pertain to a small number of criteria. The overall process however is the same as the full standards review. First the Commission seeks comments from stakeholders, then adopts the change, and finally notifies stakeholders of the implementation. Whether the standards are being revised on the normal review cycle or because of needed major issues, CAPTE must seek comments from stakeholders and provide ample notice to programs to come into compliance with the new standards. Minor changes do not need the stakeholder review. 11

Part 6: Selection and Training On-site Reviewers Nomination Initial Minimum 2 years experience Re-training Selection Training Performance assessment after each visit Assessment Part 6 details the process of being nominated, selected, and trained as a reviewer. Retraining occurs when the standards are revised. Assessment of performance is part of the on-site visit process and includes self assessment, peer assessment and assessment by the program. In addition, staff and the Commission provide feedback on the Visit Report that the team writes. 12

Part 7: Candidacy Not an accredited status Ensures minimal expectations in place prior to student enrollment Does not ensure accreditation Part 7 is divided into sections that address the various steps and requirements to achieve the status of Candidate for Accreditation. Candidacy is a non-accredited affiliation that indicates that a program is progressing toward achieving accreditation. Although Candidacy helps to ensure proper planning, it does NOT ensure eventual accreditation. Part 7 is particularly helpful for Candidacy Reviewers, those reviewers specifically engaged in reviewing programs for Candidacy status and for institutions contemplating expansion into the field of physical therapy. 13

Part 8: Achieving Accreditation F A Self-study Report B Third party Testimony G C On-site Visits D Visit Report CAPTE Decisions Annual Accreditation Report (AAR) H Compliance with Revised Standards KEY POINT! Graphic placeholder E Compliance Reports Self-study Report, the Visit Report, and the program’s response to the Visit Report are the central data sources for CAPTE in making an accreditation decision This part contains the policies and procedures related to the specific process used by programs in achieving and maintaining accreditation. The Handbook contains sections that address the areas delineated in the slide. Later in this training there will be specific modules on the Self-study Report; the On-site Visit; the Visit Report; and CAPTE decisions that will cover these areas in more depth. The Annual Accreditation Report or AAR is used to monitor compliance with the standards. Data collected in the AAR is also used to develop the PTA and PT Education Fact Sheets that can be found on CAPTE’s website under the heading Aggregate Program Data. 14

Part 9: Reporting Change Contact Information Substantive Changes that must be reported but don’t require prior approval Substantive Changes requiring prior approval Program contact information (including change of leadership)) Change in curriculum, decision not to admit a class, etc Mode of delivery, expansion program, increase in class size, etc Part 9 of the Handbook identifies the changes that must be reported to CAPTE. The changes fall into 3 categories. Examples are provided of the type of change that fall into each category; Part 9 delineates all of the changes that must be reported. The Application of Approval of Substantive Change, also called an AASC, is the document programs submit when prior approval is needed. 15

Part 10: Administrative Probation ✓ Not an accredited status, but a classification ✓ Not subject to reconsideration or appeal ✓ Administrative Probation is noted on all lists ✓ Part 10 delineates reasons for this status Part 10 covers the circumstances for a program being placed on Administrative Probation. During a period of Administrative Probationary Accreditation, a program continues to be recognized as being accredited according to the last status decision and is maintained on the list of accredited programs. The program will be listed as having Administrative Probationary Accreditation in all published documents that specify the accreditation status. Examples of reasons for administrative probation include: • Not paying the annual accreditation fees within 60 days after being notified of a pastdue account • Not submitting accreditation reports in a timely manner, or • Implementing changes without prior approval, if prior approval is required 16

Part 11 - 15: Appeals and Complaints COMPLAINTS Part 11: About Programs and Institutions Part 12: About CAPTE RECONSIDERATIONS Part 13: Of Candidacy Decisions Part 14: Of Accreditation Decisions APPEALS Part 15: Of CAPTE Decisions The handbook also contains rules for appeal procedures and the handling of complaints. Parts 11 and 12 deal with the ability of constituents to bring forward complaints, either about programs and institutions or about CAPTE. Part 13 and 14 address the rules for programs asking CAPTE to reconsider its decisions. Part 15 provides guidelines for when a program wishes to appeal a decision made by CAPTE. Appeals are heard by an independent panel appointed by the Executive Committee of the American Physical Therapy Association. 17

Part 16: Fees Preaccreditation Fees Special Fees FEES Annual Fees for Accredited Programs Review Fees for AASCs Part 16 describes the different types of fees and their amounts. 18

Position Papers Clarify CAPTE’s policies or expectations Available in Accreditation Handbook On occasion, CAPTE issues a position paper designed to clarify its policies or expectations. These are made available in the Handbook. When a new position paper is written, it is announced in the What’s New section on CAPTE’s website. On-site reviewers should be familiar with the position papers related to the program under review. 19

Summary • Accreditation Handbook – Rules and Procedures – Standards and Required Elements – Position Papers As has been shown, the Handbook contains a great deal of information. It is not intended to be fully assimilated in one reading. Be sure to see it as a vital reference for your work in the accreditation process and visit it often! Remember that it is important to use the most current version that is found on CAPTE’s website. 20