The primary source of policies and procedures governing the CASN accreditation and candidacy reviews are contained in the manual entitled, CAUSN Accreditation Program (1995). This document forms the basis of the current program and describes the structures and mandates, policies and procedures used in the implementation of the accreditation and candidacy reviews by the Board of Accreditation and the CASN National Office. Copies of the manual are available from CASN National Office. The manual is copyrighted; a further statement sets out CASN’s position on privilege and intellectual property for schools and other users of the manual.
“All rights reserved. The CASN Accreditation Program (1995) publication is the exclusive property of and copyrighted by the Canadian Association of Schools of Nursing (CASN). It contains information which is privileged and to be used only with the written authorization of CASN. No part of the publication may be reproduced, stored in a retrieval system, or transmitted in any form, by any means, without written permission from CASN. No one may copy, disseminate or distribute any of the materials without the prior written consent of CASN. No one may provide advice, counsel or information about the CASN accreditation program or the review process to any person except as authorized in writing by CASN."
(September 2001, approved by Executive Committee) AMENDMENTS TO THE PRIMARY POLICIES and PROCEDURES Since 1995, because of the changing nature of nursing education and the accreditation process, a number of policy and procedural changes have been adopted by the CASN Council and are now directing the work of the Board of Accreditation and National Office. Following is an up-to-date listing of these amendments, when they were introduced, the approval body, and the sections in the primary document to which they relate. This document should be read in conjunction with the CASN Accreditation Program (1995) manual and the reader should understand the most recently dated policies or procedures are the ones currently in use by the Board of Accreditation and National Office. POLICY UPDATES TO CAUSN ACCREDITATION PROGRAM (1995) MANUAL
Board of Accreditation Membership
Section 1.1, p. 16 – Additional member
“a student/graduate representative, nominated by the schools of nursing"
(November 2000, approved by Council)
A student/graduate representative was added to the Board of Accreditation in order to provide student representation and viewpoint. This is a voting position. The first student/graduate representative was nominated by the University of Ottawa; in future, all CASN member schools will be invited to nominate the student/graduate representative.
Section 1.1, p. 16 – Additional member
“a representative of regulatory agencies, nominated by regulatory agencies"
(November 2001, approved by Council)
A regulatory representative was added to the Board of Accreditation in order to provide the regulatory representation and viewpoint. It is a non-voting position. The first representative was nominated by the College of Nurses of Ontario in recognition of the Letter of Understanding between CASN and CNO.
Section 1, p. 16 – Board of Accreditation Member Commitment
“I, ___, as a duly elected/appointed member of the CASN Board of Accreditation agree to serve in this role according to the CASN by-laws and policies. In so agreeing I understand that my appointment allows me to vote on issues associated with decisions regarding the candidacy or accreditation status of undergraduate nursing education programs."
(December 2002, approved by Executive Committee)
Members of the Board of Accreditation are required to sign the above noted commitment. As well, they are advised of the privilege and intellectual property policy and notice. Section 3 – Composition of Reviewer Teams – Addition re: Commitment of Reviewers
Commitment to Review
“This will confirm that I commit to participate in the on-site review of the undergraduate programs at the ________, on ___. I have reviewed and understood the roles and responsibilities of CASN review team members and leaders, and I agree to abide by them during my period as a candidacy/accreditation reviewer. I shall be bound by and shall faithfully observe and abide by all rules and regulations of CASN from time to time in force."
Confidentiality
“I understand that, as a participant in a candidacy/accreditation review of CASN member school(s), I will have access to confidential material and information. I will respect the confidentiality of any materials and information which I deal with at all times during the candidacy/accreditation review process. I will also assume responsibility for disposing of any confidential materials by shredding once the decision has been taken by the Board in order to ensure the confidentiality of the candidacy/accreditation materials. I will not divulge to any third party any material or information received, directly or indirectly, during and after a candidacy/Accreditation review."
Ethical Behaviour
“I understand that, as a participant in the candidacy/accreditation review of the undergraduate programs at___________, I am representing CASN and the Accreditation Program. I will conduct myself in a professional and ethical manner at all times with the other members of the review team and with the persons whom I encounter during the course of the review, whether from the institutional, faculty, clinical or employer setting."
Privilege and Intellectual Property
“I understand that the CASN Accreditation Program (1995) is the exclusive property of and copyrighted by the Canadian Association of Schools of Nursing (CASN). I understand that it contains information which is privileged and to be used only with the authorization of CASN. I agree not to copy, disseminate or distribute any of the materials without the prior written consent of CASN. I agree not to provide advice, counsel or information about the CASN Accreditation Program or the review process to any person except as authorized by CASN." (May 2001, approved by Executive Committee and Board of Accreditation)
Conflict of Interest
“I have read, understood and agree to comply with CASN’s Conflict of Interest Guidelines. I am not living or working in the same province where the Nursing Program is delivered. I have not attended or worked at the Nursing Program or with its collaborative partners within the last five years. I have not served on an advisory, governing, research or evaluation body associated with the Nursing Program or its collaborative partners within the last five years. I do not have family relationships with members of the Nursing Program, nor its collaborative partners nor its students. I do not have financial partnerships or economic interests with members of the Nursing Program, its collaborative partners or its students.
I will not tout my connection with CASN in order to position myself for preferential treatment after the accreditation process is complete. I will not use Nursing Program review information to gain preferential treatment. I will not accept any other gifts and/or favours offered by the Nursing Program, its collaborative partners or students."
(Conflict of Interest Amendment, May 2004)
Reviewers for the CASN Accreditation Program are required to read and sign these forms in order to ensure that they understand and commit to professional and ethical conduct, confidentiality and respect for the intellectual property of the program. Section 10, page 19 - Disposition of Accredited Status
10.2.1 – No change
“grant accreditation for a seven-year period"
10.2.2 – Change
“grant accreditation for a five-year period with specific recommendations to address concerns"
(June 2002, approved by Council)
10.2.3 – No change
“deny accreditation"
The term of accreditation was changed from 3 years and 7 years, to 5 years and 7 years, to better coordinate with provincial approval periods and to respond to the concerns of schools about too frequent reviews. The option to deny accreditation was retained.
Section 10, p.19 – Addition re: extension or increase of term of _____________________________ accreditation with specific conditions
"In order to synchronize accreditation and candidacy reviews for collaborative partners, the CASN Board of Accreditation may:
extend accreditation terms, normally not longer than two (2) years, for those partners which are currently accredited, provided that this is an extension of a pre-existing nursing program and that there is written documentation of the structure established by which the collaborative partnership will be administered; and/orin the event that one or more partners receives a lesser term of accreditation or deferred candidacy, the Board of Accreditation may choose to specify conditions to be met within a designated time period. If conditions are met as specified, the Board of Accreditation may increase the term of accreditation to that of the other partners or grant candidacy status."(November 2002, approved by Board of Directors)
This new policy applies only to collaborative programs. It provides for the extension (for no longer than two years) of the term of accreditation of programs still under accreditation status, under specific conditions. For collaborative programs which receive different terms of accreditation or candidacy status, there may be an opportunity for the partner(s) receiving the lesser term or deferred candidacy to meet specific conditions set by the Board of Accreditation and synchronize their term of accreditation or candidacy status with their partners.
Section 5.1 and Section 7.2 - Options for Decision-making on Accreditation and Candidacy reviews
Options for Accreditation Decisions (View) Options for Candidacy Decisions (View)
The following options guide the decision-making by the CASN Board of Accreditation when taking decisions on accreditation reviews and candidacy reviews. They provide more flexibility, within the terms for accreditation and the candidacy status, to meet the various possibilities related to program strengths and weaknesses.
CASN Extension of Accreditation/Candidacy Status Policy
Date Approved: November 2003
Date Revised: November 2004
Approved By: CASN Executive Committee & CASN Board of Directors
Reviewed By: CASN Board of Accreditation
Date for Review and Revision: biannually
Eligibility Criteria:
The policy applies schools of nursing participating in the CASN Accreditation Program, 1995, under the following three specific conditions/situations:
New Program Development:
An accredited nursing education program is terminating or is undergoing major program or structural change, and the term of accreditation is ending before the new nursing education program or the revised program is in place and not eligible for accreditation or candidacy review.
Extension of Candidacy Term
A nursing education program that has achieved candidacy status is terminating or is undergoing major program or structural change, and the term of candidacy is ending before the new nursing education program or the revised program is in place, or the number of graduates in the first graduating class is insufficient to evaluate program outcomes for the purposes of accreditation.
Collaborative Nursing Education Programs:
In order to synchronize accreditation reviews of collaborative program partners when the collaborative education program first requires its candidacy review, accredited partner(s) may qualify to apply to have their accreditation status extended by meeting specific conditions set by the Board of Accreditation. These conditions include but are not limited to the following:
The accredited partner(s)/school(s) has/have a pre-existing nursing program; and,A written contract defines how the collaborative partnership is administered.If the specified conditions of the Board of Accreditation are met, the term of accreditation of the accredited partner(s) may be extended.
Policy Statements:
1. The Board of Accreditation is the decision making body regarding whether to grant an extension of the term of accreditation or candidacy.
2. The Board of Accreditation makes a decision on extension of the accreditation or candidacy based on the school eligibility (see “Eligibility Criteria), submitted documentation, current accreditation status, previous accreditation review reports and information from the CASN School file.
3. The decision options are denial, extension for one (1) year, extension for two (2) years, or extension for another period of time not to exceed two (2) years.
4. The Board of Accreditation may request periodic progress reports and/or another on site review during the period of the granted extension.
5. Decisions regarding extension cannot be appealed.
6. If an extension of accreditation or candidacy is granted, at the end of the extension period, the School(s) must undertake an accreditation review.
7. During the period of the extension of accreditation or candidacy, the School(s) status is designated “Conditional Extension of Accreditation or Candidacy Status".
8. CASN will note this change of status on the CASN web site, List of Accredited Schools and other relevant documents.
9. The school must openly communicate this status with an explanation/rationale to the public and their students.
10. An administrative fee of $200 to process the application is paid by the school at the time of the application for extension.
11. If an extension is granted, an extension fee of $2000 for each year of the extension granted is paid at the time the school receives the decision.
12. Failure to pay any of the fees will result in the decision being null and void.
CASN Policy: Applicability of Previous Reviews
Date Approved: May 2004
Approved By: CASN Executive Committee
Reviewed By: CASN Board of Accreditation
Date for Review and Revision: biannually
Eligibility Criteria:
All CASN Schools of Nursing participating in the CASN Accreditation Program which have previously participated in an accreditation or candidacy review.
Policy Statements:
1. CASN Reviewers and CASN Board of Accreditation members will receive information on the School’s last accreditation or candidacy recognition decision and follow up, as applicable.
2. Schools are required to include their last accreditation or candidacy decision in their self-study report, and outline their response to previous recommendations made by the CASN Board of Accreditation, if applicable.
3. CASN Reviewers will include the School report on previous decisions and recommendations in their assessment during the on-site visit and the Review Team Report.
4. CASN Board of Accreditation members will consider the Schools’ response to previous decisions and recommendations in their discussions to reach a recognition decision.
Process:
1. In preparing their Self-study for the review, the School will include a copy of the School’s last accreditation or candidacy decision and recommendations, if applicable, and will prepare a report outlining their actions taken to address previous Board of Accreditation recommendations, and if not, providing explanation for not addressing recommendations (for example, if there has been a program change).
2. The Self-study report will be made available to the CASN Review Team.
3. The CASN Review Team will reference the information in the Self-study report, and their on-site observations in their Review Team Report.
CASN Conflict of Interest Guidelines
Approved by Executive Committee and CASN Board of Directors. May 2004
To be administered by CASN Board of Accreditation and CASN National Office
To be complied with by CASN Reviewers, CASN Board of Accreditation Members and Nursing Programs participating in the CASN Accreditation Program
These guidelines deal with “conflict of interest" which refers to prejudice based specifically on self-interest.
A conflict of interest is present when an individual has an outside interest that can be reasonably expected to influence how the individual might conduct CASN business. A conflict of interest exists (if identified) whether or not the individual is actually swayed by the competing interest.[1]
Reviewers and Board of Accreditation members are selected by CASN.
Reviewers and Board of Accreditation members are expected to serve CASN faithfully, strictly adhere to the highest standard of integrity and honesty, exercise due diligence in performing CASN business and inform CASN of any known potential conflicts of interest.
When notified of their selected Review Team, a Nursing Program is expected to identify known potential conflicts of interest.
Each potential conflict of interest/grounds for disqualification of a reviewer or Board of Accreditation member is individually and carefully considered by CASN to ensure that it is justified. If the Nursing Program identifies the conflict of interest, Reviewers and Board of Accreditation members have the right to know and will be informed of the nature of the conflict of interest.
General Conflict of Interest Guidelines:
Each CASN Reviewer signs a Reviewer Commitment form for each Nursing Program review; signature indicates commitment to professional and ethical conduct, and compliance with CASN policy related to conflict of interest, confidentiality and respect for intellectual property;Each CASN Board of Accreditation member signs a Board of Accreditation Commitment form for their 3 year membership term; signature indicates commitment to professional and ethical conduct, and compliance with CASN policy related to conflict of interest, confidentiality and respect for intellectual property;Assigned and confirmed reviewers or Board of Accreditation members should disclose the following, if:
They are currently living or working in the same province where the Nursing Program is delivered;
They have attended or worked at the Nursing Program or with its collaborative partners within the last five years;
They have served on an advisory, governing, research or evaluation body associated with the Nursing Program or its collaborative partners within the last five years;
They have family relationships with members of the Nursing Program, its collaborative partners or its students;
They have financial partnerships or economic interests with members of the Nursing Program, its collaborative partners or its students.Assigned and confirmed reviewers or Board of Accreditation members should act as follows:
They must not tout their connection with CASN in order to position them for preferential treatment after the accreditation process is complete;
They must not use Nursing Program review information to gain preferential treatment; and,
They must not accept any other gifts and/or favours offered by the Nursing Program, its collaborative partners or students.As Nursing Programs may extend their hospitality to Reviewers in the form of a reception before, during or after the review, reviewers are expected to use their discretion in accepting to attend these events.References
CASN Code of professional Conduct and Conflict of Interest
CASN Reviewer Commitment Forms, 2003
CASN Board of Accreditation Commitment Forms, 2003
CCHSA Surveyor Code of Ethics
RNABC Code of Conduct for RNABC Board of Directors and Committee Members, June 1997
Marc Denhez, December 2002
CASN Policy: Term of Candidacy
Date Approved: November 2004
Approved By: CASN Board of Directors
Reviewed By: CASN Board of Accreditation
Date for Review and Revision: biannually
Eligibility Criteria:
All CASN Schools of Nursing which were granted candidacy status under the 1995 CASN Accreditation Program.
Policy Statements:
Term of Candidacy
1. A Nursing Program with Candidacy status is expected to apply for Accreditation review within the year after the first class graduates.
2. A Nursing Program may retain Candidacy for only two years after the first class graduates, in order to facilitate school preparation for the accreditation review and CASN National Office review and reviewer scheduling.
3. A Nursing Program whose nursing education program has candidacy status is eligible to apply and move forward for Accreditation if all conditions and/or recommendations set out by the Board of Accreditation have been met to the satisfaction of the Board of Accreditation.
Status of Graduates
1. If a Nursing Program held Candidacy status and was subsequently granted Accreditation, the status of “graduate of an accredited program" will be retroactive and will apply to all those who have graduated from the time of application for Candidacy to the date granting of Accreditation.
2. A school of nursing granted Accreditation may insert the phrase on transcripts and documents “graduate of an accredited program" for the duration of the awarded Accreditation term.
3. Once the term of Accreditation has ended for a program the term “graduate of an accredited program" may not be used.
4. If a Nursing Program’s participation in the CASN Accreditation Program is uninterrupted, the Board of Accreditation may allow retroactive use the term “graduate of an accredited program" once a new term is awarded.
CASN Policy: Board of Accreditation Review of the School Self-study
Date Approved: November 2004
Approved By: CASN Board of Directors
Reviewed By: CASN Board of Accreditation
Date for Review and Revision: biannually
Policy Statements:
One member of the CASN Board of Accreditation will read the School Self-study: this member will be a resource for the other CASN Board of Accreditation members.
PROCEDURES UPDATES TO CAUSN ACCREDITATION PROGRAM (1995) MANUAL
Section 4, Application and Preparation for Candidacy
Section 7.2, Application for Accreditation
Schools must apply, in writing, to National Office when requesting candidacy and/or accreditation reviews. An application form is available from National Office or on the CASN web site. The application form must be completed and signed by the head of the nursing school(s) in which the program(s) to be reviewed are located. In the case of a collaborative partnership, all heads must sign the application form.
(May 2001, approved by Board of Accreditation)
Checklist for Collaborative Programs
There is an insert in the front pages of the 1995 Manual entitled Accreditation of New and Emerging Models of Baccalaureate Nursing Education. This was developed in order to assist the Board of Accreditation and National Office to understand the nature of the collaborative partnership and program. The Board of Accreditation established a requirement for the school(s) to complete a checklist of information key information, including the number of sites and years offered at each site; description of program and special features; number of students at each site; curriculum; faculty; teaching standards; library/computers and other learning resources; administrative issues; academic decision-making; clinical settings; and evaluation of students. On the basis of the information received through the checklist, the Board of Accreditation and National Office are able to recommend any necessary adaptations of the usual procedures and preparation by schools and reviewers, sites visited, reports prepared, accreditation fees and decisions to apply.
(May 1998, approved by Board of Accreditation)
(Initial checklist implemented in 1998)
(Current checklist revised November 2002)
School Kit
A School Kit of information related to accreditation and candidacy review procedures and policies was developed at National Office and is provided to schools which are interested in applying for reviews. This kit is available from National Office or through the CASN web site. The kit is periodically updated to reflect new policies and/or procedures.
Specific instructions for preparation for candidacy reviews were developed and are contained in a document which is provided with the School Kit for schools undergoing candidacy review. The document outlines the requirements for the self study (Appendices I, II and III in the CAUSN Accreditation Program 1995 manual) and has been modified to reflect the fact that the program will not have graduated students yet, and that the schools are not required to provide detailed evidence under each of the 40 indicators in Appendice III; rather, they are required to provide a summary of the evidence under each of the 4 criteria.
(May 2001, approved by Board of Accreditation)
Section 3 – Composition of Reviewer Teams
Reviewer Kit
A Reviewer Kit of information related to the responsibilities and time commitments of reviewers during accreditation and candidacy reviews, as well as the procedures and policies, was developed at National Office and is provided to reviewers who are interested in applying to be a reviewer or who are scheduled for reviews. This kit is available from National Office or through the CASN web site. The kit is periodically updated to reflect new policies and/or procedures.
(May 2001, approved by Board of Accreditation)
[1] Adapted from RNABC Code of Conduct for RNABC Board of Directors and Committee Members, June 1997 |