Austin Community CollegeAssociate Degree Nursing ProgramSystematic Plan of Evaluation (SPE)
Standards & Criteria(revised: 1/2015)
To be complete SPE for 2014-2015 school year, to be reported on in May 2015Standard 1: Mission and Administrative CapacityThe mission of the nursing education unit reflects the governing organization’s core values and is congruent with its mission/goals. The governing organization and program have administrative capacity resulting in effective delivery of the nursing program and achievement of identified program outcomes.
Criterion 1.1: The mission/philosophy and outcomes of the nursing education unit are congruent with the core values and mission/goals of the governing organization.
Expected Level of Achievement (ELA): The mission/philosophy and outcomes of the nursing education unit are congruent with the core values and mission/goals of the governing organization
Component Documentation Responsibility Frequency Cycle Assessment Method
Mission
Philosophy
Outcomes
ADN Home Page
ADN Faculty Handbook(http://www.austincc.edu/health/rnsgfac/resources.php)
ADN Student Handbook(http://www.austincc.edu/health/rnsg/handbooks.php)
ACC Catalog & Web Sitehttp://www.austincc.edu/catalog
Curriculum Committee Annually (May)Review of ADN Faculty Handbook
Review of ADN Student Handbook
Review of ACC Catalog & Website
Report of Data Actions
Component Results Development, Maintenance, Revision
Mission & Philosophy and Outcomes
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Standard 1: Mission and Administrative Capacity
Criterion 1.2: The governing organization and nursing education unit ensure representation of the nurse administrator and nursing faculty in governance activities; opportunities exist for student representation of governance activities.
Definitions: College definition of governance : A system of decision-making processes in which trustees, administrators, faculty, staff, and students advance the
mission, goals, and values of the college through appropriate collaboration. Nursing program definition of governance : The process of guiding the actions of the faculty, staff, and students associated with the nursing program
in order to meet the outcomes of the program and its members while ensuring quality and consistency.
Expected Level of Achievement (ELA):Nurse Administrator:
The nurse administrator participates in governance activities.Faculty:
25% of full-time nursing faculty participate on college-wide committees 100% of full-time nursing faculty participate on ADN committees
Students: 100% of the ADN standing committees (Educational Resources, Curriculum Committee, Admissions Committee) have student representation in
accordance with the ADN Faculty By-Laws 75% of currently enrolled students will complete course evaluations
Component Documentation Responsibility Frequency Cycle Assessment Method
Nurse Administrator ADN Committee Minutes Accreditation CommitteeDepartment Chair
Annually (May) Review of ADN Committee Minutes
Faculty ADN Committee Minutes
Faculty Data Forms
ADN Faculty Survey
Accreditation Committee Annually (May) From the ADN Faculty Survey, tabulate percentage of faculty serving on -college-wide committees or task force -ADN committees
Students ADN Committees Minutes
Course & Program Evaluations
Accreditation Committee Annually (May) Assessment of faculty committee minutes indicating student representation on ADN committees
Response rate on course & program evaluations
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3
Report of Data Actions
Component Results Development, Maintenance, Revision
Nurse Administrator
Faculty
Students
Standard 1: Mission and Administrative Capacity
Criterion 1.3: Communities of interest have input into program processes and decision making.
Definitions: Communities of interest - Persons, groups, agencies, and organizations that influence the mission, services, and graduates of the nursing education
unit. (examples include: employers, students) Healthcare Workforce Alliance of Central Texas - is an industry-led and community sponsored group that exists to collectively address the workforce
needs of the healthcare industry in the Greater Austin community. ADN Advisory Committee - The Associate Degree Nursing Department Advisory Committee is composed of recognized leaders in the field in Austin
Community College’s service area. Members convene regularly to offer their combined expertise to influence the curriculum structure and instructional methods of the Nursing program.
Associate Degree Nursing Student Association - to serve as the pre-professional organization for future nurses
Expected Level of Achievement (ELA): The ADN program will have advisory committee meetings bi-annually with representation of persons and groups from community agencies,
organizations, and educational institutions The ADN program will provide bi-annual information sessions, open to the community allowing for input from prospective students and the public The ADNSA will hold an annual brown bag meeting to allow for input from communities of interest
Component Documentation Responsibility Frequency Cycle Assessment Method
Communities of Interest
HWACT committee meeting Minutes
Advisory committee meeting minutes
Correspondence from THECB & BON (electronic & written notifications)
ADNSA meeting minuteshttp://www.austincc.edu/health/rnsg/adnsa.php
Admissions Annually (May) Review of advisory committee & HWACT meeting minutesReview of advisory committee minutesReview of correspondence from the THECB and BON.Review of ADNSA minutes
Report of Data Actions
Component Results Development, Maintenance, Revision
4
Communities of Interest – HWACT
BON
THECB
Advisory CommitteeMeeting Minutes
ADNSA
Recruitment/ Admissions Specialist
5
Standard 1: Mission and Administrative CapacityCriterion 1.4: Partnerships exist that promote excellence in nursing education, enhance the profession, and benefit the community.Definition:
Partnership- An agreement (formal relationship) between a nursing education unit/governing organization and an outside agent/agency to accomplish specific objectives and goals over a period of time. This does not include clinical agreements for student learning experiences required by the nursing program.
Expected Level of Achievement (ELA): 100% of the community partnerships are current, active and benefit the community
Component Documentation Responsibility Frequency Cycle Assessment Method
Partnerships Partnership AgreementsFaculty Survey
Accreditation Committee Spring & Fall(May & December)Changed 08/2014
Review Bi-annual Faculty Survey for Events attended
Report of Data Actions
Component Results Development, Maintenance, Revision
6
PartnershipsPartnerships that are current, active and benefit the community:
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Standard 1: Mission and Administrative CapacityCriterion 1.5: The nursing education unit is administered by a nurse who holds a graduate degree with a major in nursing.(old standard 1.5)
Expected Level of Achievement (ELA): 100% compliance with qualifications & responsibilities designated by the college position description and the BON rules & regulations:
- Master’s degree in Nursing- Current licensure as a registered nurse in the state of Texas
Component Documentation Responsibility Frequency Cycle Assessment Method
Qualifications Personnel File
ADN Faculty Data Form
Department Chair CV
License verification from BON website(https://www.bon.state.tx.us/olv/rninq.html)
Department Chair Annually (May) Review of Faculty Data Form
Review of Personnel File
Review license verification on BON website.
Report of Data Actions
Component Results Development, Maintenance, Revision
Qualifications
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Standard 1: Mission and Administrative CapacityCriterion 1.6: The nurse administrator is experientially qualified, meets governing organization and state requirements, and is oriented and mentored to the role.(new standard)Expected Level of Achievement (ELA):
100% compliance with qualifications & responsibilities designated by the college position description and the BON rules & regulations:- Master’s degree in Nursing- Current licensure as a registered nurse in the state of Texas
The nurse administrator agrees that they were oriented and mentored to this role
Component Documentation Responsibility Frequency Cycle Assessment Method
Qualifications BON & ACC qualifications
ADN Faculty Data Form
Personnel File
License Verification from BON website(https://www.bon.state.tx.us/olv/rninq.html
Department Chair Annually (May) Review of BON & ACC qualifications
Review of Faculty Data Form
Review of Personnel File
Review license verification on BON website.
Oriented and Mentored College wide Deans & Department Chair meetings
Health Science Department Chair
Department ChairAccreditation Committee
Annually (May) Review of ADN Nurse Administrator Survey
Report of Data Actions
Component Results Development, Maintenance, Revision
Qualifications
Oriented and Mentored
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Standard 1: Mission and Administrative Capacity
Criterion 1.7: When present, nursing program coordinators and/or faculty who assist with program administration are academically and experientially qualified.
Expected Level of Achievement (ELA): Nursing program coordinators and/or faculty who assist with program administration are academically and experientially qualified
Component Documentation Responsibility Frequency Cycle Assessment Method
Coordinators & Qualifications Personnel File
ADN Faculty Data Form
Program Coordinator CV
License verification from BON website(https://www.bon.state.tx.us/olv/rninq.html)
Assistant Department Chair Annually (May) Review of Personnel File
Review of ADN Faculty Data Form
Review of Program Coordinator CV
Review of License verification from BON website(https://www.bon.state.tx.us/olv/rninq.html
Report of Data Actions
Component Results Development ,Maintenance, Revision
Coordinators & Qualifications(ex: Jeanie Ward, Gwen Scott)
Standard 1: Mission and Administrative Capacity
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Criterion 1.8: The nurse administrator has authority and responsibility for the development and administration of the program and has adequate time and resources to fulfill the role responsibilities.
Expected Level of Achievement (ELA): 100% compliance with qualifications & responsibilities designated by the college position description and the BON rules & regulations:
- Responsible and accountable for program administration- LEH & Workload
The nurse administrator will agree that they have adequate time and resources to fulfill role responsibilities
Component Documentation Responsibility Frequency Cycle Assessment Method
Authority & Responsibility Job description Department Chair Annually (May) Review and Evaluation of Department Chair Job Description duties and responsibilities.
Time & Resources Human Resources time release, LEH, & workload release for Department Chair
Department Chair Annually (May) Review and Evaluation ofHuman Resources time release, LEH, & workload release for Department Chair
Report of Data Actions
Component Results Development ,Maintenance, Revision
Authority & Responsibility
Time & Resources
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Standard 1: Mission and Administrative Capacity
Criterion 1.9: The nurse administrator has the authority to prepare and administer the program budget with faculty input.
Expected Level of Achievement (ELA): The department chair has the authority to prepare and administer the budget The department chair participates in the annual master plan budget process The faculty will have input into the program budget
Component Documentation Responsibility Frequency Cycle Assessment Method
Program Budget Department Chair job descriptionGeneral Budget LedgersProgram Budget
Assistant Department Chair Annually (May) Review of Department Chair job descriptionReview of Master plan budget initiatives.
Faculty Input ADN Faculty Meeting minutes Accreditation Committee Annually (May) Review of ADN Faculty Meeting minutes
Report of Data Actions
Component Results Development ,Maintenance, Revision
Program Budget and Faculty Input
Standard 1: Mission and Administrative Capacity
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Criterion 1.10: Policies for nursing faculty and staff are comprehensive, provide for the welfare of faculty and staff, and are consistent with those of the governing organization; differences are justified by the goals and outcomes of the nursing education unit.
Definition: Welfare of Faculty and Staff – policies affecting faculty and staff promulgated by the governing organization and nursing education unit
including, but not limited to: non-discrimination, appointment, rank, grievance, promotion, rights and responsibilities, salaries/benefits, and workload.
Expected Level of Achievement (ELA): 100% of specified nursing policies will be comprehensive and consistent with those of the governing organization:
- Non-discrimination- Faculty appointment- Academic rank- Grievance procedures- Promotion- Salary & benefits (full-time faculty)- Rights & responsibilities- Termination- Workload
Component Documentation Responsibility Frequency Cycle Assessment Method
Non-Discrimination
Faculty Appointment
Academic Rank
Grievance Procedures
Equal Employment/Affirmative Action: http://www.austincc.edu/hr/employeehandbook/college.php#eeoDisabilities Act:http://www.austincc.edu/admrule/6.01.003Guideline.htm
Faculty Appointments:http://www.austincc.edu/admrule/6.04.001.htmhttp://www.austincc.edu/board/policies/f4.php
Faculty Titles and Placement:http://www.austincc.edu/board/policies/f4.php
http://www.austincc.edu/board/policies/f5.php
ACC Faculty Handbook found on page 16 of ACC ADN Faculty Dropbox
Employee Complaints:
Admissions Committee
Annually (May) Review of Employee Handbook: http://www.austincc.edu/hr/employeehandbook/
Review of Administrative Rules: http://www.austincc.edu/admrule/
Board of Trustees: Policieshttp://www.austincc.edu/board/policies/f4.php
Review of ACC Faculty Handbook: Can be found only on ACC ADN Faculty Dropbox.(we need to get a link to this)
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Promotion
Salary and Benefits
Rights and Responsibilities
Termination
Workload
http://www.austincc.edu/admrule/6.08.005.htm
Faculty Placement & Advancement: http://www.austincc.edu/admrule/6.05.002.htm
Salary Scales:http://www.austincc.edu/hr/compensation/salaryscales.phpLeave Benefits: http://www.austincc.edu/hr/employeehandbook/leavebenefits.phpGeneral Benefits Insurance: http://www.austincc.edu/hr/employeehandbook/groupinsurance.php
Ethics/Standards of Conduct: http://www.austincc.edu/hr/employeehandbook/compliancepolicies.php#conduct
Due Process/Termination:http://www.austincc.edu/board/policies/f8.php
http://www.austincc.edu/admrule/6.08.001.htm
Progressive Discipline/Termination:http://www.austincc.edu/board/policies/f4.php
http://www.austincc.edu/admrule/6.08.003.htm
Faculty Workload:http://www.austincc.edu/admrule/4.03.004.htm
http://www.austincc.edu/board/policies/d3.php
ACC Faculty Handbook found on page 32 of ACC ADN Faculty Dropbox
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Report of Data Actions
Component Results Development, Maintenance, Revision
Non-Discrimination
Faculty Appointment
Academic Rank
Grievance Procedures.
Promotion
Salary & Benefits (full-time faculty)
Rights and Responsibilities
Termination.
Workload
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Standard 1: Mission and Administrative Capacity
Standard 1.11: Distance education, when utilized, is congruent with the mission of the governing organization and the mission/philosophy of the nursing education unit.
Definitions: Distance Education – an educational process in which the majority of the instruction occurs when a student and instructor are not in the same
place. Instruction may be synchronous or asynchronous.
Expected Level of Achievement (ELA): This standard is not applicable to our program. The ACC ADN program does not offer distance education
Component Documentation Responsibility Frequency Cycle Assessment MethodNot applicable
Report of Data Actions
Component Results Development ,Maintenance, Revision
Standard 2: Faculty and StaffQualified and credentialed faculty are sufficient in number to ensure the achievement of the student learning outcomes and program outcomes. Sufficient qualified staff are available to support the nursing education unit.
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Criterion 2.1: Full-time faculty hold a minimum of a graduate degree with a major in nursing.(Full-and part-time faculty include those individuals teaching and/or evaluating students in classroom, clinical, or laboratory settings.)
Definitions: Full-time faculty (defined by ACEN) - persons who teach and/or evaluate students and have full-time faculty employment status as defined by the
governing organization and the nursing education unit.
Full-time faculty (defined by ACC) - full-time refers to anyone paid on the full-time faculty pay scale.
Expected Level of Achievement (ELA): 100% of full –time nursing faculty will have a Master’s degree in nursing, or higher
Component Documentation Responsibility Frequency Cycle Assessment Method
Qualifications Personnel File ADNSA Bi-annually Transcript EvaluationApplication ReviewBi-annual faculty survey
Report of Data Actions
Component Results Development, Maintenance, Revision
Qualifications.
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Standard 2: Faculty and Staff
Criterion 2.2: Part-time faculty hold a minimum of a baccalaureate degree with a major in nursing; a minimum of 50% of the part-time faculty also hold a graduate degree with a major in nursing.
Definitions: Part-time faculty (defined by ACEN)- Persons who tech and/or evaluate students whose appointment is less than full-time as defined by the governing
organization and the nursing education unit. Adjunct faculty (defined by ACC) - refers to those faculty appointed on a course-by-course basis for a term not to exceed one semester per contract period,
except where the adjunct faculty member has a Multiple Semester Term Appointment, which guarantees courses during the academic year term (subject to sufficient enrollments).
Expected Level of Achievement (ELA): 100% of part-time (adjunct) faculty will have a Masters Degree in Nursing or higher
Component Documentation Responsibility Frequency Cycle Assessment Method
Faculty Credentials Personnel File Department ChairAccreditation Committee
At time of hireAnnually (May)
Transcript Evaluation Application ReviewReview of Faculty Data Form
Report of Data Actions
Component Results Development, Maintenance, Revision
Faculty Credentials
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Standard 2: Faculty and StaffCriterion 2.3: Faculty (full-and part-time) credentials meet governing organization and state requirements.
Expected Level of Achievement (ELA): 100% of full-time and part-time (adjunct) faculty credentials meet governing organization and state requirements
Component Documentation Responsibility Frequency Cycle Assessment Method
Faculty Credentials SAC RequirementsPersonnel FileFaculty Data FormBON standardsACC/SAC standards for credentialing
Assistant Department Chairs Annually (May) Transcript Evaluation Application ReviewReview of Faculty Data FormReview of SACs RequirementsReview of BON standardsReview of ACC standards for credentialing
Report of Data Actions
Component Results Development, Maintenance, Revision
Faculty Credentials.
Standard 2: Faculty and Staff
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Criterion 2.4: Preceptors, when utilized, are academically and experientially qualified, oriented, mentored, and monitored, and have clearly documented roles and responsibilities.(new standard)
Expected Level of Achievement (ELA): The Associate Degree Nursing program at Austin Community College does not utilize preceptors
Component Documentation Responsibility Frequency Cycle Assessment Method
Not Applicable None – Not Applicable
Report of Data Results
Component Results Development ,Maintenance, Revision
Standard 2: Faculty and Staff
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Criterion 2.5: The number of full-time faculty is sufficient to ensure that the student learning outcomes and program outcomes are achieved.
Expected Level of Achievement (ELA): 75% of the nursing faculty will be full-time 100% compliance with BON guidelines re: faculty to student ratio in the clinical setting
--1 faculty : 10 students--1 faculty + 1 teaching assistant: 15 students
The number of full-time faculty is sufficient to ensure that the student learning outcomes and program outcomes are achieved
Component Documentation Responsibility Frequency Cycle Assessment Method
Staffing & Utilization Faculty RosterCollege StandardSACS requirementsFaculty Survey (overloads)
Curriculum Committee Annually (May) Calculate % full-time facultyReview Faculty RosterReview College StandardReview SACS requirementsReview Faculty Survey (overloads)
Staffing & Utilization BON requirementsTeaching Assignments
Curriculum Committee Annually (May) Review clinical alpha roster with faculty/student ratio for compliance
Report of Data Results
Component Results Development ,Maintenance, Revision
Staffing & Utilization
Standard 2: Faculty and Staff
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Criterion 2.6: Faculty (full- and part-time) maintain expertise in their areas of responsibility and their performance reflects scholarship and evidence-based teaching and clinical practices.
Definitions: Scholarship - Activities that facilitate the enhancement of expertise and achievement of goals and outcomes of the nursing education unit. This may
include, but are not limited to: application of knowledge, teaching, service, practice, and research. Functions of Scholarship -
- Scholarship of teaching – the transfer of the science and art of nursing from the expert to the novice, building bridges between the teacher’s own understanding and the student’s learning.
- Scholarship of application – the maintenance of clinical competency of faculty and the advancement of clinical knowledge, including self development to improve competency beyond the basic practice of professional nursing.
- Scholarship of integration – joining of interdisciplinary ideas, research, or practice between two or more disciplines, one of which is nursing.- Scholarship of discovery (research) – the development of new and unique knowledge through conducting research or scholarly investigation.
Evidenced based teaching – teaching based on actions, processes, or methodologies that are grounded in and flow from the translation of substantive and current research.
Expected Level of Achievement (ELA): 100% of the functions of scholarship will be demonstrated by the diversity of the nursing faculty 100% of the faculty incorporate evidenced based teaching into their teaching methodologies
100% of the faculty will comply with professional development requirements set forth by the college added 08/2014
Component Documentation Responsibility Frequency Cycle Assessment Method
Scholarship ACC Faculty Evaluation Summary Form
ADN Faculty Data Form; Faculty Portfolio
Department Chair
Assistant Department Chair
Spring & Fall added 08/2014
(May & December)
Review of Faculty Evaluation Summary Forms, Faculty Data Form, and/or Faculty PortfolioReview of Bi-annual Faculty Survey added 08/2014
Evidence-based teaching Theory - Course modules
Clinical – Clinical focus
Curriculum Committee Spring & Fall added 08/2014
(May & December)
Review of course modules and clinical focusReview of Bi-annual Faculty Survey added 08/2014
Professional development added 08/2014
Professional development website
Curriculum Committee Spring & Fall added 08/2014
(May & December)
Review of professional development websiteReview of Bi-annual Faculty Survey added 08/2014
Report of Data ActionsComponent Results Development, Maintenance, Revision
22
Scholarship
Evidence-based teaching
Professional development
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Standard 2: Faculty and Staff
Criterion 2.7: The number, utilization, and credentials of staff and non-nurse faculty with the nursing education unit are sufficient to achieve the program goals and outcomes.
Definitions: Non-Nurse Faculty - Non-nurses who are academically qualified and teach a nursing course such as dietician, pharmacologist, or physiologist.
Expected Level of Achievement (ELA): The Associate Degree Nursing program at Austin Community College does not utilize non-nurse faculty or staff
Component Documentation Responsibility Frequency Cycle Assessment Method
Not applicable None – Not applicable
Report of Data Actions
Component Results Development, Maintenance, Revision
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Standard 2: Faculty and Staff
Criterion 2.8: Faculty (full- and part-time) are oriented and mentored in their areas of responsibility.
Expected Level of Achievement (ELA): 100% of newly hired ADN full-time will attend the ACC New Faculty Orientation 100% of newly hired ADN adjunct faculty will attend the ACC New Adjunct Faculty Orientation 100% of newly hired ADN faculty (full-time and adjunct) are oriented and mentored 100% of newly hired ADN faculty (full-time and adjunct) are assigned a mentor
Component Documentation Responsibility Frequency Cycle Assessment Method
New Faculty Orientation and Mentoring
Mentor/Mentee Agreements
Mentor/Mentee Checklists
New Faculty Committee Minutes
Department Chair Annually (May) Review of Mentor/Mentee Assignments
Review of Mentor/Mentee Checklists
Review of New Faculty Committee MinutesMentee ChecklistsReview of New FacultyMarlene Meador, Ann Hearn, Nancy Walters and Gwenn Scott and provided resourceful feedback.Shadow full time faculty for semester prior to having own clinical group.
Report of Data Actions
Component Results Development, Maintenance, Revision
New Faculty Orientation and Mentoring
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Standard 2: Faculty and Staff
Criterion 2.9: Systematic assessment of faculty (full- and part-time) performance demonstrates competencies that are consistent with program goals and outcomes.(old standard 2.8)
Expected Level of Achievement (ELA): 100% of faculty (full-time & part-time) will be evaluated annually 95% of faculty (full-time & part-time) will have a performance rating of Excellent, Very Good, or Good in the evaluative areas of instructional performance
(classroom, lab, and clinical)
Component Documentation Responsibility Frequency Cycle Assessment Method
Faculty Evaluation Faculty Evaluation Summary Form, and/or
Faculty Input Form, and/or
Faculty Portfolio
Department Chair Annually (May) Review of Faculty Evaluation Summary Form, and/or
Review of Faculty Input Form, and/or
Review of Faculty Portfolio
Performance Rating ACC Faculty Evaluation Summary
Faculty Rating Reports
Student Evaluations
Department Chair Annually (May) Review of ACC Faculty Evaluation Summary
Review of Faculty Rating Reports
Review of Student Evaluations
Report of Data Actions
Component Results Development, Maintenance, Revision
Faculty Evaluation .
Performance Rating .
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Standard 2: Faculty and Staff
Criterion 2.10: Faculty (full- and part-time) engage in ongoing development and receive support for instructional and alternative methods of delivery.
Definitions: Alternative Methods of Delivery – The way in which a nursing course, track, or program is shared with students including non-traditional means of student-
faculty interaction, length required for the program of study, and/or varying intervals of class and/or clinical schedules. Examples include but are not limited to: accelerated or condensed formats, ITV, videotape/DVD learning packages, and online delivery.
Expected Level of Achievement (ELA):The faculty receive support in instructional and alternative methods of delivery
Component Documentation Responsibility Frequency Cycle Assessment Method
Hybrid Faculty - Faculty Development
Google Sites?All ADN committee minutesFaculty Survey
Educational Resources Committee
Bi-annually(May & December)Changed 08/2014
Review of Google Sites?Review of All ADN committee minutesReview of Bi-annual Faculty Survey
Report of Data Actions
Component Results Development, Maintenance, Revision
Hybrid Faculty - Faculty Development
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Standard 3: StudentsStudent policies and services support the achievement of the student learning outcomes and program outcomes of the nursing education unit.
Criterion 3.1: Policies for nursing students are congruent with those of the governing organization, publically accessible, non-discriminatory, and consistently applied; differences are justified by the student learning outcomes and program outcomes.
Expected Level of Achievement (ELA):100% of nursing student policies will be:
- Congruent with those of the college or differences justified- Publicly accessible- Non-discriminatory- Consistently applied
Component Documentation Responsibility Frequency Cycle Assessment Method
Student Policies ADN Handbookhttp://www.austincc.edu/health/rnsg/handbooks.php
Course Syllabihttp://www.austincc.edu/ITdocs/lighthouse/students/index.php
College Cataloghttp://www.austincc.edu/catalog
ACC Student Handbookhttp://www.austincc.edu/catalog
Admissions Committee Annually (May) Comparative Analysis/Policy review:ACC Student Handbook is accessible to everyone online and lists (for example) – why is this example here? (just wondering if it is necessary.. is it because it is a difference that we are pointing out. YES there are differences. that criminal record may limit students who are interested in a license (e.g. RN) and encourages them to check with the respective departments.http://www.austincc.edu/handbook/admissions/possible-effect-of-criminal-recordstatement on non-discrimination in ACC handbookhttp://www.austincc.edu/handbook/about-the-college/statement-of-non-discrimination
The college catalog has the statement of discriminationhttp://www.austincc.edu/catalog/statement-of-non-discrimination
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Report of Data Actions
Component Results Development, Maintenance, Revision
Student Policies
29
Standard 3: StudentsCriterion 3.2: Public information is accurate, clear, consistent, and accessible, including the program’s accreditation status and the contact information of the accrediting body.Expected Level of Achievement (ELA):
100% of the information regarding the program and its accreditation status as well as accrediting body contact information is accurate and publicly accessible
Component Documentation Responsibility Frequency Cycle Assessment Method
Program Information ADN Website(http://www.austincc.edu/health/rnsg/)
Admissions Committee Minutes
ACENhttp://www.acenursing.us/accreditedprograms/programsearch.asp
Admissions Committee Annually (May) Review of the ADN Webpage
Review of Admissions Committee Minutes – in dropbox
Review of ACEN website
Report of Data Actions
Component Results Development, Maintenance, Revision
Program Information
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Standard 3: StudentsCriterion 3.3: Changes in policies, procedures, and program information are clearly and consistently communicated to students in a timely manner.(old standard 3.6)Expected Level of Achievement:
The nursing program has a process in place to notify students about changes in policies, procedures, and program information
Component Documentation Responsibility Frequency Cycle Assessment Method
Policies ADN Student HandbookADN Faculty HandbookSigned amendment formsSigned student signature sheets for handbook
Admissions Committee Annually (May) Review of Student andFaculty HandbooksReview of student files
Procedures ADN Student HandbookADN Faculty HandbookSigned amendment formsSigned student signature sheets for handbook
Admissions Committee Annually (May) Review of Student andFaculty HandbooksReview of student files
Program Information ADN Student HandbookADN Faculty HandbookSigned amendment formsSigned student signature sheets for handbook
Admissions Committee Annually (May) Review of Student andFaculty HandbooksReview of student files
Report of Data Actions
Component Results Development, Maintenance, Revision
Policies
Procedures
Program Information
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Standard 3: Students
Criterion 3.4: Student services are commensurate with the needs of the nursing students, including those receiving instruction using alternative methods of delivery.
Definitions: Alternative Methods of Delivery – The way in which a nursing course, track, or program is shared with students including non-traditional means of student-
faculty interaction, length required for the program of study, and/or varying intervals of class and/or clinical schedules. Examples include but are not limited to: accelerated or condensed formats, ITV, videotape/DVD learning packages, and online delivery.
Expected Level of Achievement (ELA): The student services offered by the college are appropriate, available, and accessible to all students, including:
- Health services – provision of information regarding Optional Student Health Insurance- Counseling services- Academic advising- Career assessment and placement- Financial aid staff/services- Individual academic tutoring- Library services
Component Documentation Responsibility Frequency Cycle Assessment Method
Support Services Program Evaluations:These reflect the following services: counseling, career assessment & placement, academic advising, & financial aid. Brian Stupik summarizes all data at end of each semester. He can provide a flash drive with information. * See attached chart summarizing spring, summer & fall 2013.
Course Evaluations:These reflect academic tutoring. Brian Stupik summarizes all data at end of each semester. He can
Admissions Committee Fall Spring and Summer semesters
Reviewed Program EvaluationsReviewed Course EvaluationsReviewed ADN Student Handbooks
Reviewed ACC ADN resource pagehttp://www.austincc.edu/health/rnsg/
Reviewed ACC website for studentserviceshttp://www.austincc.edu/support-and-services/services-for-students
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provide a flash drive with information.*See attached chart summarizing spring, summer & fall 2013 data that applies to tutoring services.
Student HandbooksADN Student Handbook: http://www.austincc.edu/health/rnsg/documents/adn_student_handbook_spring_2014.pdf
ACC Student Handbook: http://www.austincc.edu/handbook
Reviewed ACC student resource links:http://www.austincc.edu/support-and-services/services-for-students
Reviewed ACC Student Services Organizational Charts by campus:Cypress Creek Student Services organizational charthttp://www.austincc.edu/orgref/pdfs/cypdean.pdf
Eastview Student Services organizational charthttp://www.austincc.edu/orgref/pdfs/evcdean.pdf
Round Rock Campus Student Services organizational charthttp://www.austincc.edu/orgref/pdfs/rrcdean.pdf
Report of Data Actions
Component Results Development, Maintenance, Revision
Health Services
Counseling services
Academic advising
Career assessment & placement
Financial aid staff/services
Individual academic tutoring
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Library Services
Library Services
Standard 3: StudentsCriterion 3.5: Student educational records are in compliance with the policies of the governing organization and state and federal guidelines.
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Expected Level of Achievement (ELA):Policies re: maintenance of education records is in compliance with college and program policies
Component Documentation Responsibility Frequency Cycle Assessment Method
Education Records Policy ADN Faculty Handbook
ACC Catalog – FERPA (2013-3014)
ACC Records Managementhttp://www.austincc.edu/records/index.htm
Texas Administrative Code Rule 215.12http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=11&ch=215&rl=12
Administrative Rules 3.03.14 - Records Management Program
http://www.austincc.edu/admrule/3.03.014.htm
3.03.014 – Disposition of College Records
http://www.austincc.edu/admrule/3.03.014GuidelineDisposition.htm
3.03.014 – Records Center
http://www.austincc.edu/admrule/3.03.014GuidelineRecordsCenter.htm
Admissions Committee Annually (May) Policy audit
Review of ACC Catalog – FERPA page 4.
Review of Records Management website
Review of BON-TAC Rule 2.15.12
Review of Administrative Rulesrelated to records
Storage audit
Report of Data Actions
Component Results Development, Maintenance, Revision
Educational Records Policy
35
Standard 3: Students
Criterion 3.6: Compliance with the Higher Education Reauthorization Act Title IV eligibility and certification requirements is maintained, including default rates and the results of financial or compliance audits.
Definitions:Title IV of the Higher Education Reauthorization Act established rules and regulations for Student Financial Assistance Programs that went into effect October 1, 1998 (ACC institution code = 012015).
Expected Level of Achievement (ELA): Compliance with the Higher Education Reauthorization Active Title IV eligibility and certification requirements is maintained
Component Documentation Responsibility Frequency Cycle Assessment Method
Compliance HER Title IV eligibility
Student loan default rate
Financial/Compliance Audits
Financial Aid Officehttp://www.austincc.edu/tuition-and-financial-aid
Student Handbookhttp://www.austincc.edu/handbook/
Admissions Committee Annually (May) Default rate review
Report of Data Actions
Component Results Development, Maintenance, Revision
Student loan default rate
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Standard 3: StudentsCriterion 3.6.1: A written, comprehensive student loan repayment program addressing student loan information, counseling, monitoring, and cooperation with lenders is available.(old standard 3.4.1)Definition:
Student Loan Repayment Program / Mapping Your Future: -is a neutral, non-proprietary, and non-commercial resource of information and services for students, families, and schools; -has no requirements for those who use Mapping Your Future to participate in any loan program, or use any guarantor or lender; -is a charitable, 501(c)3 nonprofit organization; -is a non-commercial website which does not accept any advertising; -is supported by a wide range of organizations with no marketing advantage to any one specific company or agency to support Mapping Your Future -contributes to national student loan default prevention efforts by providing information and services to students and their families, including:
i. borrow conservatively, ii. consider all options for funding higher education, and iii. understand rights and responsibilities
Expected Level of Achievement (ELA): A written, comprehensive student loan repayment program addressing student loan information, counseling, monitoring, and cooperation with lenders is
available
Component Documentation Responsibility Frequency Cycle Assessment Method
Student Loan Repayment Program
ACC web sitehttp://www.austincc.edu/
College cataloghttp://www.austincc.edu/catalog
Financial Aid Officehttp://www.austincc.edu/handbook/financial-aid
Admissions Committee Annually (May) Review web site and college catalog
Report of Data Actions
Component Results Development, Maintenance, Revision
Student Loan Repayment Program
.
37
Standard 3: Students
Criterion 3.6.2: Students are informed of their ethical responsibilities regarding financial assistance.
Expected Level of Achievement (ELA):The college’s student loan repayment program provides information regarding ethical responsibility regarding repayment of loans
Component Documentation Responsibility Frequency Cycle Assessment Method
Ethical Responsibilities re: Student loans
ACC web sitehttp://www.austincc.edu/
College cataloghttp://www.austincc.edu/catalog
Financial Aid Officehttp://www.austincc.edu/handbook/financial-aid
Admissions Committee Annually (May) Review college’s student loan repayment program on the web site and college catalogReview of Exit Counseling Documents
Report of Data Actions
Component Results Development, Maintenance, Revision
Ethical Responsibilities re: Student loans
:
38
Standard 3: StudentsCriterion 3.6.3: Financial aid records are maintained in compliance with policies of the governing organization, state, and federal guidelines.
Expected Level of Achievement (ELA):Policies re: maintenance of financial records is in compliance with college policies
Component Documentation Responsibility Frequency Cycle Assessment Method
Financial Records Policy ADN Faculty Handbook
ACC Records Managementhttp://www.austincc.edu/records/index.htm
Texas Administrative Code Rule 215.12http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=11&ch=215&rl=12
Administrative Rules 3.03.14 - Records Management Program
http://www.austincc.edu/admrule/3.03.014.htm
3.03.014 – Disposition of College Records
http://www.austincc.edu/admrule/3.03.014GuidelineDisposition.htm
3.03.014 – Records Center
http://www.austincc.edu/admrule/3.03.014GuidelineRecordsCenter.htm
Admissions Committee Annually (May) Policy audit
Review of Records Management website
Review of BON-TAC Rule 2.15.12
Review of Administrative Rulesrelated to records
Storage audit
Report of Data Actions
Component Results Development, Maintenance, Revision
39
Financial Records Policy
Standard 3: StudentsCriterion 3.7: Records reflect that program complaints and grievances receive due process and include evidence of resolution.(old standard 1.9)Definitions:
Complaints and Grievances – a formal allegation against a party or program usually expressed in a written, signed statement. A grievance is a wrong or hardship suffered which is the grounds for complaint; the formal expression of a grievance is a complaint. The record of student complaints must include all complaints filed during the time period since the last accreditation review.
Expected Level of Achievement (ELA):100% of complaints about the program are addressed, available for review, and include evidence of resolution
Component Documentation Responsibility Frequency Cycle Assessment Method
Complaints Complaint File
ADN Handbook
Health Science Grievance Policy
ACC Grievance Policy
Department Chair Annually (May) File Review
Report of Data Actions
Component Results Development, Maintenance, Revision
Complaints
40
Standard 3: Students
Criterion 3.8: Orientation to technology is provided and technological support is available to students.
Expected Level of Achievement (ELA): Orientation to technology is provided and technological support is available to students
Component Documentation Responsibility Frequency Cycle Assessment Method
Tech Support Student Theory Course Evaluation
ACC Website(http://www.austincc.edu/health/rnsg/)
ACC Student Handbook
Educational Resources Annually (May) Student Theory Course EvaluationSurvey
Review of ACC Website
Review of ACC Student Handbook
Report of Data Actions
Component Results Development, Maintenance, Revision
Tech Support
41
Standard 3: StudentsCriterion 3.9: Information related to technology requirements and policies specific to distance education is clear, accurate, consistent, and accessible.(old standard 3.8)Definitions:
Distance Education – an educational process in which the majority of the instruction occurs when a student and instructor are not in the same place. Instruction may be synchronous or asynchronous.
Expected Level of Achievement (ELA): This standard is not applicable to our program. The ACC ADN program does not offer distance education
Component Documentation Responsibility Frequency Cycle Assessment Method
Not applicable Not applicable
Report of Data Actions
Component Results Development, Maintenance, Revision
42
Standard 4: CurriculumThe curriculum supports the achievement of the identified student learning outcomes and program outcomes of the nursing education unit consistent with safe practice in contemporary health care environments.Criterion 4.1: The curriculum incorporates established professional standards, guidelines, and competencies, and has clearly articulated student learning outcomes and program outcomes consistent with contemporary practice.
Expected Level of Achievement: 100% of the faculty will strongly agree or agree that the theory and clinical nursing courses:
o Have clearly articulated program outcomes and course objectiveso Incorporate professional standards , guidelines, and competencies
Component Documentation Responsibility Frequency Cycle Assessment Method
Curriculum Curriculum Design
Curriculum Committee meeting minutes
Program Educational OutcomesCourse Syllabi
Curriculum Committee Annually (May) Review of Curriculum
Review of Curriculum Committee Meeting Minutes
Review of Program Educational Outcomes Course Syllabi
Report of Data Actions
Component Results Development, Maintenance, Revision
CurriculumProgram Outcomes and course objectives
Professional standards, guidelines, competencies
43
44
Standard 4: Curriculum
Criterion 4.2: The student learning outcomes are used to organize the curriculum, guide the delivery of instruction, direct learning activities, and evaluate student progress.
Expected Levels of Achievement: The educational outcomes are used to:
- organize the curriculum- guide the delivery of instruction- direct learning activities- evaluate student progress
Component Documentation Responsibility Frequency Cycle Assessment Method
Curriculum developmentProgram Educational OutcomesCourse objectivesCourse SyllabiConceptual Framework
Course syllabi
Clinical Evaluation Tools
Curriculum committee minutes
ADN website(http://www.austincc.edu/health/rnsg/ )
Curriculum Committee Annually - May Comparative Analysis of Course Syllabi
Comparative Analysis of Clinical Evaluation Tools
Review of Curriculum Committee Minutes
Review of ADN website
Report of Data Actions
Component Results Development, Maintenance, Revision
Course objectives
Course Syllabi
Conceptual Framework
Standard 4: Curriculum45
Criterion 4.3: The curriculum is developed by the faculty and regularly reviewed to ensure integrity, rigor and currency.
Expected Levels of Achievement: The curriculum is developed by the faculty and regularly reviewed to ensure integrity, rigor and currency
Component Documentation Responsibility Frequency Cycle Assessment Method
Curriculum development FOC and curriculum committee minutes
End of Year Reports from Committee
Curriculum Committee Annually - May Review of FOC and curriculum committee minutes
Review End of Year Reports from Committees
Report of Data Actions
Component Results Development, Maintenance, Revision
Curriculum development
46
Standard 4: Curriculum
Criterion 4.4: The curriculum includes general education courses, included in the degree plan, that enhance professional nursing knowledge and practice.
Expected Levels of Achievement: 100% compliance with SACS general education requirements The curriculum includes general education courses, included in the degree plan, that enhance professional nursing knowledge and practice
Component Documentation Responsibility Frequency Cycle Assessment Method
Curriculum (general education) courses
Current degree plans
SACS General Education Requirements
Curriculum Committee Annually - May Review of current degree plans
Review of SACS
Report of Data Actions
Component Results Development, Maintenance, Revision
Curriculum (general education) courses
Insert attachments here – need word versions of the degree plans
47
Standard 4: CurriculumCriterion 4.5: The curriculum includes cultural, ethnic, and socially diverse concepts and may also include experiences from regional, national, or global perspectives.
Expected Level of Achievement: The curriculum includes cultural, ethnic, and socially diverse concepts and may also include experiences from regional, national, or global
perspectives
Component Documentation Responsibility Frequency Cycle Assessment Method
Curriculum(Cultural/Ethical/Socially Diverse)
Degree plans
Course Syllabi
Course Modules
Course projects
Curriculum Committee Annually (May)Review of degree plans
Review of course syllabi & modules
Review of course projects
Report of Data Actions
Component Results Development, Maintenance, Revision
Curriculum(Cultural/Ethical/Socially Diverse)
Standard 4: Curriculum48
Criterion 4.6: The curriculum and instructional processes reflect educational theory, inter-professional collaboration, research, and current standards of practice. (EVC)
Expected Level of Achievement: The curriculum and instructional processes reflect educational theory, inter-professional collaboration, research, and current standards of practice Each Level in ADN Program will participate in simulated learning experience
Component Documentation Responsibilities Frequency Cycle Assessment MethodSimulation
Research and Best practices
Interdisciplinary collaboration
Simulation Simulation Lab Hours
available to faculty and students Monday-Friday8:00-5:00 pm
Research and Best Practices
Pilot Study of breakout session for Physical Assessment skill using simulators for level 1 studentsCoordinated by Simulation Lab Coordinator.
Course and Lab Calendars
Simulation objectives
Course Objectives
Course Modules
Level Meeting Minutes
Simulation Objectives are created by Faculty
and Simulation Lab CoordinatorSimulation Objectives are posted on Bb 1 week prior to Simulation Lab activity for students to review
Electronic version of Simulation Evaluation Tool was piloted in the Spring 2014: Google Drive survey was most user friendly for students and faculty than hand written version.
Core measures and Joint Commission patient safety goals reference were provided for all simulations during simulation or during debriefing.
Simulation Lab Coordinator
Per lab policy faculty are required to submit Simulation Lab request at least 2 weeks prior to scheduled simulation day. Simulation lab request form is available electronically on ADN website. Faculty submits tentative Simulation days at the end of the semester for the following semester.
Sim Lab Orientation will be provided by Sim Lab Coordinator.
Simulation Lab Coordinator spearheaded project to enter scenario information onto Cerner template so that EHRs are ready for Fall 2014.
Fall 2014; Sim Lab Coordinator will be scheduled to provide EHR training for Levels 1-3
Simulation Lab Coordinator contacts other disciplines to inquire their interest in interdisciplinary simulation.
Simulation Lab Coordinator has up to 20 laptops available to
ANNUALLY (MAY)
Mandatory Sim Lab Orientation was provided to students prior to attending their scheduled Simulation day.
Attempt will be made to encourage the use of the EHR with all scenarios used starting Fall 2014.
Revision to scenarios is done by either faculty or Sim Lab Coordinator before the end of the semester of Fall 2014.
One hour of EHR is scheduled for the Fall of 2014. Prior to training students are assigned EHR videos by Cerner.
Plans to collaborate with Radiology, Surgery and Microbiology disciplines for futureInterdisciplinary scenarios. Interdisciplinary Scenarios once a semester.
Student evaluations are filled after each simulation day. Results are filed on Google Drive; faculty has access to evaluation results.
Electronic version of Patient Simulation Evaluation Tool was piloted in the Spring 2014: Google survey was used and most user friendly for students and faculty. This evaluation is done after each simulation.
Patient Simulation Surveys were used to revise simulation day. This is a collaboration between Simulation Lab coordinator and faulty.
Statically data from the Patient Simulation Evaluation Tool is read by faculty.
Patient Simulation Surveys after each scenario.
Simulation Surveys were used to revise simulation day.
Fall 2014; Simulation Surveys will be used to evaluate EHR experience.
Beginning in the Spring of 2015Level 1 nursing students will be the only students required to have EHR training.
Create an electronic survey for student and faculty feedback.
Statically data from the Patient Simulation Evaluation Tool is read by faculty.
Research and Best Practices
Student completed evaluations after completion of session.
49
students to fill out the “Simulation Evaluation Tool” on Google Drive after each simulation.
Report of Data ActionsComponent Results Development , Maintenance, Revisions
Simulation 3 Simulation Rooms each with a one-
way glass that seats 1-2 faculty members
2 of the simulation rooms are equipped with 1 SimMan Essential Bleeding manikin. The third sim room is equipped with 1 Noelle, and 1 Baby Hal, and 1Simbaby, vital simbaby infant manikins. 2 status manikins. Also available for use are 2 child manikins (Tim)
Each simulation room has 1 laptop for EHR, 1 cardiac monitor with pulse oximetry, V/S, simulated CO2 and arterial monitoring
Each room has white erase bulletin board
20 Dell laptop computers are available on COW’s for students to use for EHR documentation
Cerner EHR 3 medication carts filled with syringes,
needs, gloves, saline etc. 2 stocked crash carts with AED’s and simulated medications to run a code. Isolation cart with isolation protocol are available for each lab.
50
Criterion 4. RRCStandard 4 CurriculumCriterion 4.6 The curriculum and instructional processes reflect educational theory, inter-professional collaboration, research, and current standards of practice.Expected Level of Achievement:
The curriculum and instructional processes reflect educational theory, inter-professional collaboration, research and current standards of practice. Each Level in AND Program will participate in simulated learning experiences.
Component Documentation Responsibilities Frequency Cycle Assessment MethodSimulation Lab Hours1(a).Simulation Lab Hours available to faculty and students Monday-Friday8:00-5:00 pm(b). Mandatory Simulation Orientation was implemented in the Spring of 2014.
Research and Best Practices2. Simulation Coordinator contacted staff at Cerner to gather information needed to set up all scenarios on Cerner (EHR). A template was sent to faculty with the information needed to create patient’s chart in EHR form.3. Spring 2014: Sim Lab Coordinator met with faculty Level leads to discuss revising scenarios:Learning objectives were created by faculty and students prep was created by Simulation Lab Coordinator.4. EHR training for students5. Interdisciplinary CollaborationSpring 2014-Pilot InterdisciplinaryScenario with nursing and sonography studentscoordinated by Simulation Lab Coordinator and Sonography Director6. Create an electronic version of the ““Patient Simulation Evaluation Tool”
Simulation lab calendar1(a). Google Simulation Lab Calendar is available to faculty to schedule simulation days.( b). Faculty scheduled their students for mandatorySimulation Lab Orientation.2. EHRs are to include: Simulation Learning Objectives, Scenario information, Core measures and National Safety Patient Goals. * Hard copies of scenarios are available as a PDF on Google Drive. Revisions of scenarios will be added to these files.3. Students prep sheet is posted on Bb one week prior to Simulation Lab activity for students to review (Level 1-3).4. Cerner training for students is scheduled for the Fall 2014.
5. A 45-minute scenario was piloted. They were two nursing students and seven sonography students, 2 nursing and 2 Sonography faculty participated in the scenario. 6. Two electronic versions of Patient Simulation Evaluation Tool were piloted in the Spring 2014: Google survey and Survey Monkey.
Simulation Lab Coordinator1(a). Per lab policy faculty are required to submit Simulation Lab request 2 weeks prior to scheduled simulation day. Simulation lab request form is available electronically on Google Drive. Faculty submits tentative Simulation days at the end of the semester for the following semester.(b). Mandatory Sim Lab Orientation was provided by Sim Lab Coordinator.2. Simulation Lab Coordinator spearheaded project to enter scenario information onto Cerner template so that EHRs are ready for Fall 2014.3. Revised scenarios for Level 1-3 were completed by faculty and Sim Lab Coordinator.4. Fall 2014; Sim Lab Coordinator is scheduled to provide EHR training for Levels 1-35. Simulation Lab Coordinator contacts other disciplines to inquire their interest in interdisciplinary simulation.6. Simulation Lab Coordinator has 10-15 laptops available to students to fill out the “Patient Simulation Evaluation Tool” on Survey Monkey.
1(a). Google Simulation calendar is updated weekly and as needed by Simulation Lab Coordinator.(b). Mandatory Sim Lab Orientation was provided to students prior to attending their scheduled Simulation day.2. EHR will be used in all scenarios starting Fall 2014. 3. Revision to scenarios are done by either faculty or Sim Lab Coordinator before the end of the semester.4. One hour of EHR is scheduled for the Fall of 2014. Prior to training students are assigned EHR videos by Cerner.5. Plans to collaborate with Radiology, Surgery and Microbiology disciplines for futureInterdisciplinary scenarios. Interdisciplinary Scenarios once a semester.6. Student evaluations are filled after each simulation day. Results are filed on Google Drive; faculty has access to evaluation results.
1(a). Google Simulation calendar was created on Spring 2014 to help faculty schedule Simulation days. Faculty is able to view open slots on the calendar at their convenience. Conflicts in scheduling of Sim Lab days are resolved quickly due to the communication between faculty and Sim Lab Coordinator.(b) Spring of 2014 there was a 98% attendance for the Mandatory Simulation Lab Orientation.Beginning in the Fall of 2014; Level 1 nursing students will be the only level required to attend Simulation Lab Orientation.2. Patient Simulation Surveys after each scenario.3. Patient Simulation Surveys were used to revise simulation day.4. Fall 2014; Patient Simulation Surveys will be used to evaluate EHR experience.Beginning in the Spring of 2015Level 1 nursing students will be the only students required to have EHR training.5. Create an electronic survey for student and faculty feedback.
6. Statically data from the Patient Simulation Evaluation Tool is read by faculty.
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6. Improvement of Simulation experience for students and faculty
Survey Monkey was most user friendly for students and faculty.
Report of Data Actions
Component Results Development , Maintenance, Revisions
Simulation Lab: 4 Simulation Rooms and1 control room seats 4-6
faculty members Each conference room has 1 computer,1 projector,1
large screen, 1 large dry erase board, 1 table with 8 chairs
3 simulation rooms are equipped with 1 SimMan3Gs. Fourth sim room is equipped with 1 Noelle, and 1 Baby Hal, and 2 child manikins
Videotaping capability in all 4 Simulation rooms Each simulation room has 1 laptop for EHR, 1 HD
TV, 1 cardiac monitor with pulse oximetry, V/S, CO2 and arterial monitoring, sharps container, hand sanitizers and 1 phone
All desktops and laptop have internet access 4 Emergency (crash) carts with emergency
medications
1 Isolation cart supplied with isolation gowns, goggles, masks, isolation signage and biohazards bags
Each room has 1 drop down work station for nursing students, and 1 large bulletin board
All simulation are equipped with sinks, electronic towel dispenses and gloves
20 Dell laptop computers are available to students for EHR
Cerner EHR 1 nurses station equipped with 2 desktop computers
and 2 phones 8 Heart Starter devices for training 8 IV plum pumps 2 medication carts filled with syringes, needs, gloves,
saline etc. 1 Electronic medication dispenser with bar code
used for narcotics 4 medication dispensers mounted on walls that
contain medications used in scenarios. Medications are listed by generic and brand names.
Two large cork bulletin boards in Sim hallway that
Simulation Lab: Simulation labs are requested 2 weeks in
advance via electronic from crated by Simulation Lab Coordinator and Senior Technology Tech. Faculty had input in revisions of the form.
Videotaping scenarios used for debriefing has enhanced simulation experience for students.
Re-organizing simulation lab area is more conducive to learning by the students.
Simulation Lab Coordinator: Simulation Lab Coordinator is responsible for the
maintenance of equipment in the Simulation Lab and submitting supply request to Director of AND program
Simulation Lab was reorganized in the Spring of 2014. Equipment was ordered 2 medication carts and 1 isolation
cart. Narcotic programmed into Electronic Medication
Dispenser. Develop 3-4 Simulation Objectives Provide 1Simulation education session to faculty once a
semester by Simulation Coordinators
52
has “Patient National Safety Goals.” 3 Supply carts: IVFs, dressings, phlebotomy caddy’s,
etc. 2- 36”X43” white dry erase broads located in the hall
used for posting simulation activity for the day
53
Standard 4: CurriculumCriterion 4.7: Evaluation methodologies are varied, reflect established professional and practice competencies, and measure the achievement of student learning outcomes.(old standard 4.5)Expected Level of Achievement:
Evaluation methodologies are varied, reflect established professional and practice competencies, and measure the achievement of student learning outcomes
Component Documentation Responsibility Frequency Cycle Assessment Method
Evaluation Methodologies
Student clinical evaluations
Clinical assignments
Grading Rubrics
Exams
Curriculum Committee Annually May Review of Student evals Careplans Grading rubrics Exams
Report of Data Actions
Component Results Development, Maintenance, Revision
Student evaluations
Varied Methodologies
Professional and Practice Competencies
Achievement
54
Standard 4: CurriculumCriterion 4.8: The length of time and the credit hours required for program completion are congruent with the attainment of identified student learning outcomes and program outcomes and consistent with the policies of the governing organization, state and national standards, and best practices.
Expected Level of Achievement: The ADN program will have between 60 and 72 hours in its curriculum which is consistent with the national standards for AD nursing
Component Documentation Responsibility Frequency Cycle Assessment Method
Program length
Credit hours
Program Outcomes (Student Learning)
Degree Plan
College requirements for graduation
ADN curriculum
Curriculum Committee Annually (May) Review of degree plan
Review of college requirements for graduation
Review of THECB requirements for AD Nursing curricula
Review of ADN curriculum
Report of Data Actions
Component Results Development ,Maintenance, Revision
Program length and credit hours
Program Outcomes (Student Learning)
55
Standard 4: CurriculumCriterion 4.9: Practice learning environments support the achievement of student learning and program outcomes.
Expected Level of Achievement: Practice learning environments support the achievement of student learning and program outcomes
Component Documentation Responsibility Frequency Cycle Assessment Method
Student learning environments
Student Clinical Course Evaluation
List of Clinical sites by level
Educational Resources Annually (May)
Student Evaluations(each semester)
Clinical site review(each semester)
Student clinical course evaluations
Review of List of Clinical sites by level
Report of Data ActionsComponent Results Development ,Maintenance, Revision
Student learning environments
1) Student clinical course evaluationResults of Student Clinical Course Evaluations demonstrate that practice environment support the achievement of student learning and program outcomes.
2) List of clinical sites by level – review completed May 2014
Level 1: St David’s (SD) Main Medical Center (SDM) SD North Austin Medical Center (SDN) SD South Austin Medical Center (SDS) SD Georgetown Hospital (SDG) SD Williamson Hospital (SDW) SD Round Rock Medial Center (SDRR) Cedar Park Regional Hospital Texas NeuroRehab Center
56
Level 2: SDM SDN SDS SDW SDRR SD Heart Seton Northwest Hospital Seton Hays Hospital Central Texas Medical CenterLevel3 SDN SDM Seton Hays Hospital Dell Children’s Medical Center Austin State Hospital Shoal Creek Hospital
Level4 University Medical Center at Brackenridge (UMCB) Seton Medical Center SDN SDM SDS
Mobility SDM SDN Seton Main Medical Center UMCB Hill Country Memorial Hospital Hill Country Medical Center Austin State Hospital Kerrville State Hospital
57
Dell Children’s Medical Center
58
Standard 4: Curriculum
Criterion 4.10: Students participate in clinical experiences that are evidence –based and reflect contemporary practice and nationally established patient health and safety goals.
Expected Level of Achievement: Students participate in clinical experiences that are evidence –based and reflect contemporary practice and nationally established patient
health and safety goals Hospital nationally established patient health and safety goals are incorporated into the curriculum
Component Documentation Responsibility Frequency Cycle Assessment MethodClinical experiences
Evidence- based and contemporary practice
National patient health and safety goals
Clinical syllabi
Clinical objectives and foci
Curriculum Committee Annually (May) Review of clinical syllabi, objectives, and clinical foci
Report of Data Actions
Component Results Development ,Maintenance, Revision
Clinical experiences
Evidence- based and contemporary practice
National patient health and safety goals
59
Standard 4: Curriculum
Criterion 4.11: Written agreements for clinical practice agencies are current, specify expectations for all parties, and ensure the protection of students.
Expected Level of Achievement: 100% of clinical affiliation agreements are current and specify expectations and ensure protection of students
Component Documentation Responsibility Frequency Cycle Assessment MethodClinical practice agencies
Affiliation agreements ADNSA Annually (May) Affiliation agreements
Report of Data Actions
Component Results Development ,Maintenance, Revision
Clinical practice agencies
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Standard 4: Curriculum
Criterion 4.12: Learning activities, instructional materials, and evaluation methods are appropriate for all delivery formats and consistent with the student learning outcomes.(old standard 4.9)
Expected Level of Achievement: Learning activities, instructional materials, and evaluation methods are appropriate for all delivery formats and consistent with the student
learning outcomes
Component Documentation Responsibility Frequency Cycle Assessment MethodLearning activitiesInstructional materialsEvaluation methods
Course syllabi
Course objectives
Course projects
Course evaluations
Accreditation Committee(this committee to get this Criterion started)
Leona to complete
Annually-May Review of course Syllabi Objectives Projects Evaluations
Report of Data Actions
Component Results Development ,Maintenance, Revision
Learning Activities
Instructional materials
Evaluation methods
61
Report of Data Actions
Component Results Development ,Maintenance, Revision
Fiscal Resources
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Standard 5: ResourcesFiscal, physical, and learning resources are sustainable and sufficient to ensure the achievement of the student learning outcomes and program outcomes of the nursing education unit.Criterion 5.1: Fiscal resources (personnel, supplies, materials, equipment, and services) are sustainable, sufficient to ensure the achievement of the student learning outcomes and program outcomes, and commensurate with the resources of the governing organization.Definition:
Fiscal Resources: The financial support required for securing the personnel, supplies, materials, equipment, and services necessary to ensure the achievement of the program outcomes.
Expected Level of Achievement: The fiscal resources will:
- Support the number of faculty needed for student enrollment- Purchase equipment and supplies- Supplement faculty development- Be commensurate with resources of the governing organization
Component Documentation Responsibility Frequency Cycle Assessment MethodFiscal Resources Program/college
budget
FOC minutes
Department Chair Annually (May) Comparative analysis
Review of FOC minutesStandard 5: Resources
Criterion 5.2: Physical resources (classrooms, laboratories, offices, etc.) are sufficient to ensure the achievement of the nursing education unit outcomes, and meet the needs of the faculty, staff, and students.
Definition: Physical Resources: Classrooms, laboratories, offices, and other common spaces that are used by the program.
Expected Level of Achievement: Physical resources (classrooms, laboratories, offices, etc.) are sufficient to ensure the achievement of the nursing education unit outcomes, and meet
the needs of the faculty, staff, and students 75% of students surveyed strongly agree or agree that the physical resources are appropriate to support the achievement of program outcomes 90% of faculty surveyed strongly agree or agree that the physical resources are appropriate to meet the needs of the faculty and staff
Component Documentation Responsibility Frequency Cycle Assessment Method
Instructional SpaceNon-instructional Space
Student Overall Program Evaluation
ADN Faculty Survey
Educational Resources Committee
Students-Every SemesterFaculty-Annually
Review Student Overall Program Evaluation
Review ADN Faculty Survey
Report of Data Actions
Component Results Development, Maintenance, and RevisionsInstructional SpaceNon-instructional Space
Standard 5: ResourcesCriterion 5:3: Learning resources and technology are selected with faculty input and are comprehensive, current, and accessible to faculty and students.(old standard 5.3)Definition:
Learning Resources: the materials, activities, and technologies that facilitate the development of student knowledge and skills.- Examples include, but are not limited to: library resources, nursing skills laboratory, nursing tutor
Expected Level of Achievement: Learning resources and technology are selected with faculty input and are comprehensive, current, and accessible to faculty and students 75% of the students surveyed strongly agree or agree that the learning resources (library resources, nursing skills laboratory, and nursing tutor) are
comprehensive, current, and accessible
Component Documentation Responsibility Frequency Cycle Assessment Method
Library Resources
Nursing Skills Laboratory
Nursing Tutor
Theory Course Evaluations
Educational Resources Committee Meeting Minutes
FOC Meeting Minutes
Educational Resources Committee
Annually (May)
Students (Every Semester)
Theory Course Evaluations
Review of Educational Resources Committee Meeting Minutes
Review of FOC Meeting Minutes
Report of Data Actions
Component Results Development, Maintenance, Revision
Library Resources
Nursing Skills Laboratory
Nursing Tutor
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Standard 5: ResourcesCriterion 5.4: Fiscal, physical, technological, and learning resources are sufficient to meet the needs of the faculty and students engaged in alternative methods of delivery.(old standard 5.4)
Definition: Alternative methods of delivery: The way in which a nursing course, track, or program is shared with students including non-traditional means of
student-faculty interaction, length required for the program of study, and/or varying intervals of class and/or clinical schedules. Examples include, but are not limited to: accelerated or condensed formats, ITV, videotape/DVD learning packages, and online delivery
Fiscal Resources: The financial support required for securing the personnel, supplies, materials, equipment, and services necessary to ensure the achievement of the program outcomes.
Physical Resources: Classrooms, laboratories, offices, and other common spaces that are used by the program. Learning Resources: the materials, activities, and technologies that facilitate the development of student knowledge and skills.
- Examples include, but are not limited to: library resources, nursing skills laboratory, nursing tutor
Expected Level of Achievement: The fiscal resources will:
- Support the number of faculty needed for student enrollment- Purchase equipment and supplies- Supplement faculty development- Commensurate with resources of the governing organization
Physical resources (classrooms, laboratories, offices, etc.) are sufficient to ensure the achievement of the nursing education unit outcomes, and meet the needs of the faculty, staff, and students
75% of students surveyed strongly agree or agree that the physical resources are appropriate to support the achievement of program outcomes 90% of faculty surveyed strongly agree or agree that the physical resources are appropriate to meet the needs of the faculty and staff Learning resources and technology are selected with faculty input and are comprehensive, current, and accessible to faculty and students 75% of the students surveyed strongly agree or agree that the learning resources (library resources, nursing skills laboratory, and nursing tutor) are
comprehensive, current, and accessible
Component Documentation Responsibility Frequency Cycle Assessment Method
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Alternative Methods of DeliveryFiscal Resources
Instructional SpaceNon-instructional Space
Library Resources
Nursing Skills Laboratory
Nursing Tutor
Program/college budget
FOC minutes
Student Overall Program Evaluation
ADN Faculty Survey
Theory Course Evaluations
Educational Resources Committee Meeting Minutes
FOC Meeting Minutes
Educational Resources Committee
Annually (May)
Students-Every SemesterFaculty-Annually
Annually (May)
Students (Every Semester)
Comparative analysis
Review of FOC minutes
Review Student Overall Program Evaluation
Review ADN Faculty Survey
Theory Course Evaluations
Review of Educational Resources Committee Meeting Minutes
Review of FOC Meeting Minutes
Report of Data Actions
Component Results Development, Maintenance, Revision
Alternative Methods of Delivery Fiscal Physical Learning
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Standard 6: OutcomesProgram evaluation demonstrates that students and graduates have achieved the student learning outcomes, program outcomes, and role-specific graduate competencies of the nursing education unit.
Criterion 6.1: The systematic plan for evaluation of the nursing education unit emphasizes the ongoing assessment and evaluation of each of the following:- Student learning outcomes;- Program outcomes;- Role-specific graduate competencies; and- The Accrediting Body Standards
The systematic plan of evaluation contains specific, measurable expected levels of achievement; appropriate assessment methods; and a minimum of three (3) years of data for each component within the plan.
Expected Level of Achievement: A written plan for systematic program evaluation is published for faculty use and is used to guide all of the ADN Faculty Committee’s end of year reports 100% of required elements are included in the systematic plan of evaluation
Component Documentation Responsibility Frequency Cycle Assessment method
Written plan for systematic program review
Systematic Plan of Evaluation Accreditation Committee Each semester Comparative analysis of SPE data
Report of Data Actions
Component Results Development, Maintenance, Revision
Written plan for systematic program review
Standard 6: Outcomes66
Criterion 6.2: Systematic plan of evaluation findings are aggregated and trended by program option, location, and date of completion and are sufficient to inform program decision making for the maintenance and improvement of the student learning outcomes and the program outcomes.
Expected Levels of Achievement: Trended and aggregated evaluation findings are utilized to maintain or improve student learning outcomes and program outcomes
Component Documentation Responsibility Frequency Cycle Assessment Method
Evaluation Findings SPE
Findings of data in End of Year Reports
Course Evaluation Response Forms from Levels
AdHoc Evaluation Committee Annually (May) Review of SPE
Review of End of Year Committee Reports
Review of Course Evaluation Response Forms from Levels
Report of Data Actions
Component Results Development, Maintenance, Revision
Written plan for systematic program review
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Standard 6: Outcomes
Criterion 6.3: Systematic plan of evaluation findings are shared with communities of interest.
Expected Level of Achievement: 100% of the evaluation findings are available for sharing with communities of interest
Component Documentation Responsibility Frequency Cycle Assessment Method
Communities of interest Minutes from the advisory committee meetings
Minutes from the HWACT meetings
Department Chair Annually (May) Review of minutes from the advisory committee meetings
Review of minutes from the HWACT meetings
Report of Data Actions
Component Results Development, Maintenance, Revision
Communities of interest
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Standard 6: Outcomes
Criterion 6.4: The program demonstrates evidence of achievement in meeting the program outcomes.
Expected Level of Achievement: The program demonstrates evidence of achievement in meeting the program outcomes, including:
- Performance on licensure exam- Program completion- Graduate Program Satisfaction- Employer Program Satisfaction- Job Placement Rates
Component Documentation Responsibility Frequency Cycle Assessment Method
Outcomes See 6.4.1 – 6.4.5 Accreditation Committee End of Spring & Fall Semesters
See 6.4.1 – 6.4.5
Report of Data Actions
Component Results Development, Maintenance, Revision
Outcomes See 6.4.1 – 6.4.5 See 6.4.1 – 6.4.5
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Standard 6: OutcomesCriterion 6.4.1 Performance on licensure exam: The program’s 3 year mean for the licensure exam pass rate will be at or above the national mean for the same 3 year period.
Expected Level of Achievement: Annual NCLEX program pass rate will be > or equal 95%. The program’s 3 year mean pass rate will be > or equal to the national mean
Component Documentation Responsibility Frequency Cycle Assessment Method
NCLEX Pass Rates
National Means:
BON NCLEX reports
BON Website www.bon.state.tx.us
Accreditation Committee End of Spring & Fall Semesters
Analysis of NCLEX pass rates
Report of Data Actions
Component Results Development, Maintenance, Revision
NCLEX Pass Rates
National Means:
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ELA determined by faculty
Student demographics
Program options
Completion rate- RRC- Hybrid- CEC- EVC- Mobility
Standard 6: OutcomesCriterion 6.4.3: Graduate Program Satisfaction: Qualitative and quantitative measures address graduates six to twelve months post-graduation.Expected Level of Achievement:
90% of graduating students surveyed will strongly agree or agree that they were satisfied with their educational experience in the nursing program
Component Documentation Responsibility Frequency Cycle Assessment Method
Graduate Program Satisfaction
Graduate Survey
Alumni Reunion Luncheon?
Accreditation Committee Annually-May Graduate Survey in survey monkeyAlumni Reunion Luncheon?
Report of Data Actions
Component Results Development ,Maintenance, Revision
Graduate Program Satisfaction
- EVC
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- Mobility
- RRC
- Hybrid
- CEC
Overall Program Satisfaction
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Standard 6: OutcomesCriterion 6.4.4: Employer Program Satisfaction: Qualitative and quantitative measures address employer satisfaction with graduate preparation for entry level positions six to twelve months post-graduation.(old standard 6.5.3 & 6.4)Expected Level of Achievement:
90% of employers surveyed will strongly agree or agree that they are satisfied with the graduates educational preparation for entry level Registered Nurse positions
Component Documentation Responsibility Frequency Cycle Assessment MethodEmployer Program Satisfaction with Graduates
Employer Survey Accreditation Committee Annually-May Employer Survey in survey monkey
Report of Data Actions
Component Results Development ,Maintenance, Revision
Employer Program Satisfaction with Graduates
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Standard 6: OutcomesCriterion 6.4.5: Job placement Rates: Expected levels of achievement are determined by the faculty and are addressed through quantified measures six to twelve months post-graduation.
Definition: Job Placement Rates: % of graduates who seek employment within 6 months to 12 months of graduation who are employed as a Registered
Nurse
Expected Level of Achievement: Expected levels of achievement for job placement rates are determined by the faculty 90% of graduates who seek employment within 6 months to 12 months of graduating will be employed as a registered nurse
Component Documentation Responsibility Frequency Cycle Assessment Method
Post-Graduation Employment
FOC minutes
Graduate Employment form
Accreditation Committee Each Semester FOC minutes
Graduate Employment form
Report of Data Actions
Component Results Development ,Maintenance, Revision
Post-Graduation Employment
- RRC- Hybrid- CEC- EVC- Mobility
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