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A nursing program success story: How to ace accreditation

Jun 14, 2023, 13:38 PM
<7-min. read> Dr. Donna Penn knew she needed a better approach for her nursing program’s accreditation. With the aid of ATI, she achieved “phenomenal” results.

Consulting services made the difference for nursing program accreditation success

Holy Name School of Nursing dedication - continued accreditation successIn 1925, the Sisters of St. Joseph of Peace began an effort that would have a far-reaching impact on their small, rural village of Teaneck, N.J. Based on an appeal from 2 local physicians, the sisters funded, built, and staffed a hospital for the community’s sick and indigent. But they took their efforts a step further, founding a nursing program and welcoming their first class that fall.

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The driving force behind the effort was Sister Claire Tynan who served as an educator and mentor for nearly 5 decades. In 2019, in her honor, the school renamed its program the Sister Claire Tynan School of Nursing at Holy Name Medical Center.

That original class of 13 women has grown into a nursing program success story: one of the largest and most-respected coeducational hospital-associated diploma schools of nursing in New Jersey.

You might assume that such a successful program doesn’t need the support of third-party outsiders. Then again, knowing when to ask for outside help can be the reason for your success.

Facing nursing program accreditation after experiencing another program’s trainwreck

Dr. Donna Penn  - leader of nursing program accreditation

Before accepting the position of director at Holy Name’s nursing program, Donna M. Penn, DNP, RN, CNE, NEA-BC, had done her homework. With less than 3 years in her current position as dean at a well-known, renowned diploma program, she wasn’t sure she was ready to leave when Holy Name called. But after meeting with Holy Name’s faculty and Chief Nursing Officer, she soon saw the advantages.

“I was more comfortable with the number of students in Holy Name’s program,” Dr. Penn explained. “Plus, their outcomes! I had researched the program well; they had great NCLEX pass rates, great program outcomes.” It seemed like a serendipitous situation. So, she said farewell to her previous program and has been at Holy Name since 2018.

Not long after arriving, Dr. Penn realized an accreditation visit was about 2 years away. And while her new program had not experienced a negative accreditation visit in the past, this would be Dr. Penn’s first time in charge of a program going through the process. She was determined it would be a smooth trip after seeing the derailment of a previous employer.

“That director did not have any buy in at all and was totally disengaged from the whole site visit process,” she said. No one had attempted to organize the files site visitors would need, and the result was, simply, “just a bad experience,” she said. The result of the visit? The accrediting organization determined the program was not compliant with 2 standards: outcomes and faculty.

“It just left a very bad taste in my mouth,” Dr. Penn said. “I knew if I was ever in the director’s chair, it was not going to go the same way.”

Identifying the path for a smooth nursing program accreditation process

Facts about Holy Name School of Nursing

From the very beginning, Dr. Penn said she knew 2 steps were key to achieving her goal of a nursing education success story:

  1. Start early.
  2. Get all faculty involved.

Her efforts, then, included making sure that all faculty:

  • Understood the process
  • Knew what accreditation meant
  • Recognized the standards and criteria
  • Knew what was needed to prove compliance
  • Were on board with the plan.

“I wanted to make sure they knew it wasn’t just writing ‘nice’ paragraphs,” she explained. “We had to have evidence to back it up, and evidence meant we needed to document everything we were doing.

“We needed to have a solid process for a systematic plan of evaluation. And we had to have key people in place to oversee that process.”

Taking the first step in the nursing program accreditation process

She started by assigning staff to go through the self-study forum on nursing program accreditation offered by the Accreditation Commission for Education in Nursing (ACEN).

Next, she conferred with other diploma schools she knew based on the strong connections she had built in working with the New Jersey League for Nursing. (She is currently its President-elect, as well President-elect for the National Coalition of Hospital Associated Schools & Colleges of Nursing.)

She talked with directors who had gone through recent site visits to get advice and learn strategies that had helped them achieve successful accreditation status, gratefully reviewing their self-study reports to compare to her program’s. “We wrote our own self-study,” she explained, “but it was nice to have an example of what ACEN considered a good self-study to compare to.” For the next 2 years, her team focused on preparing, she said. “We’ve had our eye on the prize all along.”

Even so, Dr. Penn recognized that neither she nor her staff had the first-person experience to identify weaknesses in their preparations. Only about half the faculty had been with the program during the previous accreditation, and the program was handling this one very differently with standards subcommittees regularly reporting on each of the ACEN standards and other ongoing processes.

Dr. Penn wanted an objective third-party to provide some insight and ensure Holy Name was on the path to achieving a nursing program success story in terms of its accreditation status.

Ensuring a nursing education success story with expert advice from a trusted partner

Since joining Holy Name, Dr. Penn had seen the positive relationship ATI had developed with her faculty. She had been particularly impressed by the guidance ATI’s Consulting Team offered.

“When I came in 2018, [Holy Name] had started a concept-based curriculum revision,” she said. “They had a medical-model-based curriculum at 78 credits that had been around for a long, long, long, long time. They were moving toward a concept-based plan, but it hadn’t really started.”

To begin making progress toward that goal, Dr. Penn invited ATI to act as curriculum consultant. ATI sent in a team member to work with Holy Name faculty, the curriculum committee, and the curriculum chair. “We really got things moving at that point,” she added. “And, despite COVID, we got it done. We got it to our board of nursing and to ACEN for approval.” As a result, the new curriculum has been in place since 2021.

That experience gave Dr. Penn and her staff confidence in ATI’s advice — advice they would soon put to the test as they began preparing for Holy Name’s accreditation visit.

“When you have a sense of trust, it’s much easier to get faculty buy-in,” Dr. Penn explained. And, with the complexities of a nursing program accreditation visit, that trust is especially important. Happily, the trusted relationship meant Dr. Penn’s faculty members were very open to listening to ATI’s consultant preparation tips.

Dr. Donna Penn testimonial nursing program accreditation success 

Achieving success with your nursing program accreditation in 3 steps

ATI’s consultant took several steps that were instrumental in the program’s accreditation success:

  1. Coordinating a faculty meeting.

    “The faculty meeting about the site visit was a big component,” she said. “Faculty felt much better after meeting with [ATI’s consultant].”

    As an expert in nursing program accreditation, the consultant made the information very clear, offering strategies and suggestions. “She just gave faculty the confidence that they knew what to expect,” Dr. Penn added.

  2. Reviewing self-study documentation.

    ATI’s specialist also helped by reviewing the self-study documentation, offering suggestions for improvement to ensure a bona fide nursing program success story happened. Dr. Penn explained that the consultant’s “outsider status” that made the difference. Having a “good, reliable, additional set of eyes on your document to point out things that maybe you don’t see” was a worthwhile investment, she said.

    The consultant’s suggestions built on what the document already included, Dr. Penn added.

    “She said, ‘Beef this up a little bit. Provide another example here.’ Things like that. Her suggestions did make it a stronger document.”

  3. Creating a mock accreditation visit.

    ATI’s mock accreditation visit pulled all the learning together.

    “I think a mock visit helps to put faculty and staff at ease a little bit, especially if they’ve never gone through a site visit before,” Dr. Penn said.

    “It is the fear of the unknown. But having the practice of going through the question session does alleviate some of that fear. It doesn’t mean you don’t read the document and know the document. But [our ATI consultant] laid it out to them. ‘This is what you need to know. You need to be familiar with this.’”

Holy Name’s nursing education success story: A near-perfect accreditation review

Holy Name graduation class of 2020By the time the accreditors arrived on campus, everyone was prepared. “It couldn’t have gone better. It was smooth as silk,” Dr. Penn said. “We had everything ready for them. They asked us for 1 piece of paper during the entire site visit.”

Dr. Penn said the accreditors were impressed with the program’s preparation. “It was night and day from the last time I had done one,” she explained. The accreditors told her that such an experience was “extremely rare.”

“It’s like I woke up from a dream,” Dr. Penn added. “It’s like not one thing went bad. There wasn’t anything they could comment on other than the fact that, despite COVID, we still had very strong NCLEX pass rates.”

What was especially impressive was that all 3 accreditors worked at diploma schools affiliated with Catholic hospitals, just like Holy Name. Their experience meant they knew where to look for potential weaknesses — where to poke into the corners.

“But they didn’t find any,” Dr. Penn acknowledged.

And the icing on the cake was the accreditors’ final words. “They said we were phenomenal,” Dr. Penn stated.

A director’s advice on the value of investing in a nursing program accreditation partner

Dr. Penn said she appreciated the advantages of having ATI prepare her staff for their nursing program accreditation visit and review their documentation.

“Schools need to realize how important accreditation is and that you do need to invest in that,” she explained. She advised having a consultant like ATI at your side before you try to go through the experience on your own. “You need to have that additional support,” she said, adding, “Why wouldn’t you have a mock survey and somebody look at your report in advance?”

She acknowledged that many deans and directors simply don’t think about asking for help. But, she pointed out, “You don’t know what you don’t know. That’s why you have somebody else look at it.”

If you don’t? And your documentation is lacking or has errors? “It’s too late when it’s already in your repository,” she said. “You can’t take it back.”

Facts about Holy Name’s Sister Claire Tynan School of NursingHoly Name School of Nursing logo

“You need to have that additional [accreditation] support. Why wouldn’t you have a mock survey and somebody look at your report in advance? … You don’t know what you don’t know. That’s why you have somebody else look at it.”
Donna M. Penn, DNP, RN, CNE, NEA-BC, Director, The Sister Claire Tynan School of Nursing at Holy Name Medical Center

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