Austin Community College
Associate Degree Nursing Program
Systematic Plan of Evaluation (SPE)
Standards & Criteria
(revised: 1/2015)
To be complete SPE for 2014-2015 school year, to be reported on in May 2015
Standard 1: Mission and Administrative Capacity
The 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
Mission
ADN Home Page
Philosophy
ADN Faculty Handbook
Responsibility
Curriculum Committee
(http://www.austincc.edu/health/rnsgfac/resources.php)
Outcomes
Frequency Cycle
Annually (May)
Assessment Method
Review of ADN Faculty
Handbook
Review of ADN Student
Handbook
ADN Student Handbook
(http://www.austincc.edu/health/rnsg/handbooks.php)
Review of ACC Catalog &
Website
ACC Catalog & Web Site
http://www.austincc.edu/catalog
Report of Data
Component
Actions
Results
Development, Maintenance, Revision
Mission & Philosophy and
Outcomes
1
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
Nurse Administrator
Documentation
ADN Committee Minutes
Responsibility
Accreditation Committee
Frequency Cycle
Annually (May)
Department Chair
Faculty
ADN Committee Minutes
Accreditation Committee
Annually (May)
From the ADN Faculty Survey,
tabulate percentage of faculty
serving on
-college-wide committees
or task force
-ADN committees
Accreditation Committee
Annually (May)
Assessment of faculty committee
minutes indicating student
representation on ADN
committees
Faculty Data Forms
ADN Faculty Survey
Students
ADN Committees Minutes
Course & Program Evaluations
Assessment Method
Review of ADN Committee
Minutes
Response rate on course &
program evaluations
2
Report of Data
Component
Actions
Results
Development, Maintenance, Revision
Nurse Administrator
Faculty
Students
3
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
Communities of
Interest
Documentation
HWACT committee meeting Minutes
Advisory committee meeting minutes
Correspondence from THECB & BON
(electronic & written notifications)
Responsibility
Admissions
Frequency Cycle
Annually (May)
Assessment Method
Review of advisory committee &
HWACT meeting minutes
Review of advisory committee
minutes
Review of correspondence from the
THECB and BON.
Review of ADNSA minutes
ADNSA meeting minutes
http://www.austincc.edu/health/rnsg/adnsa.php
Report of Data
Component
Actions
Results
Development, Maintenance, Revision
4
Communities of
Interest – HWACT
BON
THECB
Advisory Committee
Meeting Minutes
ADNSA
Recruitment/
Admissions Specialist
5
Standard 1: Mission and Administrative Capacity
Criterion 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
Partnerships
Documentation
Partnership Agreements
Faculty Survey
Responsibility
Accreditation Committee
Frequency Cycle
Spring & Fall
(May & December)
Assessment Method
Review Bi-annual Faculty
Survey for Events attended
Changed 08/2014
Report of Data
Component
Actions
Results
Development, Maintenance, Revision
6
Partnerships
Partnerships that are
current, active and
benefit the community:
7
Standard 1: Mission and Administrative Capacity
Criterion 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
Qualifications
Documentation
Personnel File
Responsibility
Department Chair
Frequency Cycle
Annually (May)
Assessment Method
Review of Faculty Data Form
ADN Faculty Data Form
Review of Personnel File
Department Chair CV
Review license verification
on BON website.
License verification from BON
website
(https://www.bon.state.tx.us/olv/rninq.html)
Actions
Report of Data
Component
Results
Development, Maintenance, Revision
Qualifications
8
Standard 1: Mission and Administrative Capacity
Criterion 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
Qualifications
Documentation
BON & ACC qualifications
Responsibility
Department Chair
Frequency Cycle
Annually (May)
Assessment Method
Review of BON & ACC
qualifications
ADN Faculty Data Form
Review of Faculty Data Form
Personnel File
Review of Personnel File
License Verification from BON
website
Review license verification on
BON website.
(https://www.bon.state.tx.us/olv/rninq.html
Oriented and Mentored
College wide Deans &
Department Chair meetings
Department Chair
Accreditation Committee
Annually (May)
Review of ADN Nurse
Administrator Survey
Health Science Department
Chair
Actions
Report of Data
Component
Results
Development, Maintenance, Revision
Qualifications
Oriented and Mentored
9
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
Coordinators & Qualifications
Documentation
Responsibility
Personnel File
Assistant Department Chair
Annually (May)
Assessment Method
Review of Personnel File
ADN Faculty Data Form
Review of ADN Faculty Data Form
Program Coordinator CV
Review of Program Coordinator CV
License verification from BON
website
Review of License verification from
BON website
(https://www.bon.state.tx.us/olv/rninq.html)
(https://www.bon.state.tx.us/olv/rninq.html
Report of Data
Component
Frequency Cycle
Actions
Results
Development ,Maintenance, Revision
Coordinators & Qualifications
(ex: Jeanie Ward, Gwen Scott)
10
Standard 1: Mission and Administrative Capacity
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 of
Human Resources time release,
LEH, & workload release for
Department Chair
Report of Data
Component
Actions
Results
Development ,Maintenance, Revision
Authority & Responsibility
Time & Resources
11
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
Program Budget
Documentation
Responsibility
Department Chair job
description
Assistant Department Chair
Frequency Cycle
Annually (May)
General Budget Ledgers
ADN Faculty Meeting minutes
Accreditation Committee
Report of Data
Component
Review of Department Chair job
description
Review of Master plan budget
initiatives.
Program Budget
Faculty Input
Assessment Method
Annually (May)
Review of ADN Faculty Meeting
minutes
Actions
Results
Development ,Maintenance, Revision
Program Budget and Faculty
Input
12
Standard 1: Mission and Administrative Capacity
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
Non-Discrimination
Faculty Appointment
Academic Rank
Documentation
Equal Employment/Affirmative Action:
http://www.austincc.edu/hr/employeehandboo
k/college.php#eeo
Disabilities Act:
http://www.austincc.edu/admrule/6.01.003Gui
deline.htm
Faculty Appointments:
http://www.austincc.edu/admrule/6.04.001.htm
http://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
Responsibility
Admissions
Committee
Frequency Cycle
Annually (May)
Assessment Method
Review of Employee Handbook:
http://www.austincc.edu/hr/employ
eehandbook/
Review of Administrative Rules:
http://www.austincc.edu/admrule/
Board of Trustees: Policies
http://www.austincc.edu/board/poli
cies/f4.php
Review of ACC Faculty
Handbook: Can be found only on
ACC ADN Faculty Dropbox.
(we need to get a link to this)
13
Grievance Procedures
Employee Complaints:
http://www.austincc.edu/admrule/6.08.005.htm
Promotion
Faculty Placement & Advancement:
http://www.austincc.edu/admrule/6.05.002.htm
Salary and Benefits
Salary Scales:
http://www.austincc.edu/hr/compensation/sala
ryscales.php
Leave Benefits:
http://www.austincc.edu/hr/employeehandboo
k/leavebenefits.php
General Benefits Insurance:
http://www.austincc.edu/hr/employeehandboo
k/groupinsurance.php
Rights and
Responsibilities
Ethics/Standards of Conduct:
http://www.austincc.edu/hr/employeehandboo
k/compliancepolicies.php#conduct
Termination
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
Workload
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
14
Report of Data
Actions
Component
Results
Development, Maintenance, Revision
Non-Discrimination
Faculty Appointment
Academic Rank
Grievance Procedures
.
Promotion
Salary & Benefits (fulltime faculty)
Rights and
Responsibilities
Termination
.
Workload
15
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
Not applicable
Documentation
Responsibility
Report of Data
Component
Frequency Cycle
Assessment Method
Actions
Results
Development ,Maintenance, Revision
16
Standard 2: Faculty and Staff
Qualified 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.
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
Qualifications
Documentation
Personnel File
Responsibility
Frequency Cycle
ADNSA
Assessment Method
Transcript Evaluation
Bi-annually
Application Review
Bi-annual faculty survey
Report of Data
Component
Actions
Results
Development, Maintenance, Revision
Qualifications
.
17
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
Faculty Credentials
Documentation
Personnel File
Responsibility
Frequency Cycle
Department Chair
At time of hire
Accreditation Committee
Annually (May)
Assessment Method
Transcript Evaluation
Application Review
Review of Faculty Data Form
Report of Data
Component
Actions
Results
Development, Maintenance, Revision
Faculty Credentials
18
Standard 2: Faculty and Staff
Criterion 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
Faculty Credentials
Documentation
Responsibility
Assessment Method
Personnel File
Transcript Evaluation Application
Review
Faculty Data Form
Review of Faculty Data Form
BON standards
Review of SACs Requirements
ACC/SAC standards for
credentialing
Review of BON standards
SAC Requirements
Assistant Department Chairs
Annually (May)
Review of ACC standards for
credentialing
Report of Data
Component
Frequency Cycle
Actions
Results
Development, Maintenance, Revision
Faculty Credentials
.
19
Standard 2: Faculty and Staff
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
Not Applicable
Documentation
Responsibility
Assessment Method
None – Not Applicable
Report of Data
Component
Frequency Cycle
Results
Results
Development ,Maintenance, Revision
20
Standard 2: Faculty and Staff
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
Staffing & Utilization
Documentation
Faculty Roster
Responsibility
Curriculum Committee
Frequency Cycle
Assessment Method
Annually (May)
Calculate % full-time faculty
College Standard
Review Faculty Roster
SACS requirements
Review College Standard
Faculty Survey (overloads)
Review SACS
requirements
Review Faculty Survey
(overloads)
Staffing & Utilization
BON requirements
Curriculum Committee
Review clinical alpha roster
with faculty/student ratio
for compliance
Annually (May)
Teaching Assignments
Report of Data
Component
Results
Results
Development ,Maintenance, Revision
Staffing & Utilization
21
Standard 2: Faculty and Staff
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
Scholarship
Documentation
ACC Faculty Evaluation
Summary Form
Responsibility
Department Chair
Frequency Cycle
Spring & Fall added 08/2014
(May & December)
Assistant Department Chair
ADN Faculty Data Form;
Faculty Portfolio
Evidence-based teaching
Theory - Course modules
Curriculum Committee
Spring & Fall added 08/2014
Professional development
website
Review of course modules
and clinical focus
Review of Bi-annual Faculty
Survey added 08/2014
Clinical – Clinical focus
added 08/2014
Review of Faculty
Evaluation Summary Forms,
Faculty Data Form, and/or
Faculty Portfolio
Review of Bi-annual Faculty
Survey added 08/2014
(May & December)
Professional development
Assessment Method
Curriculum Committee
Spring & Fall added 08/2014
(May & December)
Review of professional
development website
Review of Bi-annual Faculty
Survey added 08/2014
Report of Data
Actions
22
Component
Results
Development, Maintenance, Revision
Scholarship
Evidence-based teaching
Professional development
23
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
Frequency Cycle
Assessment Method
None – Not applicable
Not applicable
Report of Data
Component
Responsibility
Actions
Results
Development, Maintenance, Revision
24
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
New Faculty Orientation and
Mentoring
Documentation
Mentor/Mentee Agreements
Responsibility
Department Chair
Frequency Cycle
Assessment Method
Review of Mentor/Mentee
Assignments
Annually (May)
Mentor/Mentee Checklists
Review of Mentor/Mentee
Checklists
New Faculty Committee
Minutes
Review of New Faculty
Committee Minutes
Mentee Checklists
Review of New Faculty
Marlene 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
Component
Actions
Results
Development, Maintenance, Revision
New Faculty Orientation and
Mentoring
25
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
Faculty Evaluation
Documentation
Responsibility
Faculty Evaluation Summary
Form, and/or
Department Chair
Frequency Cycle
Assessment Method
Review of Faculty Evaluation
Summary Form, and/or
Annually (May)
Faculty Input Form, and/or
Review of Faculty Input Form,
and/or
Faculty Portfolio
Review of Faculty Portfolio
Performance Rating
ACC Faculty Evaluation
Summary
Department Chair
Review of ACC Faculty
Evaluation Summary
Annually (May)
Faculty Rating Reports
Review of Faculty Rating
Reports
Student Evaluations
Review of Student Evaluations
Report of Data
Actions
Component
Results
Faculty Evaluation
.
Performance Rating
.
Development, Maintenance, Revision
26
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 studentfaculty 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
Hybrid Faculty - Faculty
Development
Documentation
Google Sites?
All ADN committee minutes
Responsibility
Educational Resources
Committee
Frequency Cycle
Bi-annually
Review of Google Sites?
(May & December)
Review of All ADN committee
minutes
Changed 08/2014
Faculty Survey
Assessment Method
Review of Bi-annual Faculty
Survey
Report of Data
Component
Actions
Results
Development, Maintenance, Revision
Hybrid Faculty - Faculty
Development
27
Standard 3: Students
Student 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:
Component
Student Policies
-
Congruent with those of the college or differences justified
-
Publicly accessible
-
Non-discriminatory
-
Consistently applied
Documentation
ADN Handbook
http://www.austincc.edu/health/
rnsg/handbooks.php
Course Syllabi
http://www.austincc.edu/ITdocs
/lighthouse/students/index.php
College Catalog
http://www.austincc.edu/catalog
ACC Student Handbook
http://www.austincc.edu/catalog
Responsibility
Admissions Committee
Frequency Cycle
Annually (May)
Assessment Method
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-ofcriminal-record
statement on non-discrimination in
ACC handbook
http://www.austincc.edu/handbook/
about-the-college/statement-ofnon-discrimination
The college catalog has the
statement of discrimination
http://www.austincc.edu/catalog/st
atement-of-non-discrimination
28
Report of Data
Component
Actions
Results
Development, Maintenance, Revision
Student Policies
29
Standard 3: Students
Criterion 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
Program Information
Documentation
Responsibility
ADN Website
Admissions Committee
Frequency Cycle
Annually (May)
Assessment Method
Review of the ADN Webpage
(http://www.austincc.edu/health/rnsg/)
Admissions Committee Minutes
Review of Admissions Committee
Minutes – in dropbox
ACEN
Review of ACEN website
http://www.acenursing.us/accreditedpro
grams/programsearch.asp
Report of Data
Component
Actions
Results
Development, Maintenance, Revision
Program Information
30
Standard 3: Students
Criterion 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
Policies
Documentation
ADN Student Handbook
Responsibility
Admissions Committee
Frequency Cycle
Annually (May)
Assessment Method
Review of Student and
ADN Faculty Handbook
Faculty Handbooks
Signed amendment forms
Review of student files
Signed student signature
sheets for handbook
Procedures
ADN Student Handbook
Admissions Committee
Annually (May)
Review of Student and
ADN Faculty Handbook
Faculty Handbooks
Signed amendment forms
Review of student files
Signed student signature
sheets for handbook
Program Information
ADN Student Handbook
Admissions Committee
Annually (May)
Review of Student and
ADN Faculty Handbook
Faculty Handbooks
Signed amendment forms
Review of student files
Signed student signature
sheets for handbook
Report of Data
Component
Actions
Results
Development, Maintenance, Revision
Policies
Procedures
Program Information
31
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 studentfaculty 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:
Component
Support Services
-
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
Documentation
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
Responsibility
Admissions Committee
Frequency Cycle
Fall Spring and Summer
semesters
Assessment Method
Reviewed Program Evaluations
Reviewed Course Evaluations
Reviewed ADN Student
Handbooks
Reviewed ACC ADN resource
page
http://www.austincc.edu/health/rn
sg/
Reviewed ACC website for
student
services
http://www.austincc.edu/supportand-services/services-forstudents
32
provide a flash drive with
information.
*See attached chart
summarizing spring, summer &
fall 2013 data that applies to
tutoring services.
Reviewed ACC student resource
links:
http://www.austincc.edu/supportand-services/services-forstudents
Student Handbooks
ADN Student Handbook:
http://www.austincc.edu/health/
rnsg/documents/adn_student_h
andbook_spring_2014.pdf
Reviewed ACC Student Services
Organizational Charts by
campus:
Cypress Creek Student Services
organizational chart
ACC Student Handbook:
http://www.austincc.edu/handb
ook
http://www.austincc.edu/orgref/pdf
s/cypdean.pdf
Eastview Student Services
organizational chart
http://www.austincc.edu/orgref/pdf
s/evcdean.pdf
Round Rock Campus Student
Services organizational chart
http://www.austincc.edu/orgref/pdf
s/rrcdean.pdf
Report of Data
Component
Actions
Results
Development, Maintenance, Revision
Health Services
Counseling services
Academic advising
Career assessment &
placement
Financial aid staff/services
33
Individual academic tutoring
Library Services
Library Services
34
Standard 3: Students
Criterion 3.5: Student educational records are in compliance with the policies of the governing organization and state and federal guidelines.
Expected Level of Achievement (ELA):

Policies re: maintenance of education records is in compliance with college and program policies
Component
Education Records Policy
Documentation
Responsibility
ADN Faculty Handbook
Admissions Committee
ACC Catalog – FERPA (2013-3014)
Frequency Cycle
Annually (May)
Assessment Method
Policy audit
Review of ACC Catalog – FERPA
page 4.
ACC Records Management
http://www.austincc.edu/records/index.htm
Review of Records Management
website
Texas Administrative Code
Review of BON-TAC Rule 2.15.12
Rule 215.12
http://info.sos.state.tx.us/pls/pub/readtac$ext.TacP
age?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_plo
c=&pg=1&p_tac=&ti=22&pt=11&ch=215&rl=12
Review of Administrative Rules
Administrative Rules
3.03.14 - Records Management Program
related to records
http://www.austincc.edu/admrule/3.03.014.htm
3.03.014 – Disposition of College Records
http://www.austincc.edu/admrule/3.03.014Guidelin
eDisposition.htm
Storage audit
3.03.014 – Records Center
http://www.austincc.edu/admrule/3.03.014Guidelin
eRecordsCenter.htm
Report of Data
Component
Actions
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
Compliance HER Title IV
eligibility
Documentation
Responsibility
Financial Aid Office
Admissions Committee
Frequency Cycle
Annually (May)
Assessment Method
Default rate review
http://www.austincc.edu/tuitionand-financial-aid
Student loan default rate
Student Handbook
Financial/Compliance Audits
http://www.austincc.edu/handb
ook/
Report of Data
Component
Actions
Results
Development, Maintenance, Revision
Student loan default rate
36
Standard 3: Students
Criterion 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
Student Loan Repayment
Program
Documentation
Responsibility
ACC web site
Admissions Committee
Frequency Cycle
Assessment Method
Review web site and college
catalog
Annually (May)
http://www.austincc.edu/
College catalog
http://www.austincc.edu/catalog
Financial Aid Office
http://www.austincc.edu/handbook/
financial-aid
Report of Data
Actions
Component
Student Loan Repayment
Program
Results
Development, Maintenance, Revision
.
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
Ethical Responsibilities re:
Student loans
Documentation
Responsibility
ACC web site
Admissions Committee
Frequency Cycle
Assessment Method
Review college’s student loan
repayment program on the web
site and college catalog
Annually (May)
http://www.austincc.edu/
Review of Exit Counseling
Documents
College catalog
http://www.austincc.edu/catalog
Financial Aid Office
http://www.austincc.edu/handbook/
financial-aid
Report of Data
Component
Actions
Results
Development, Maintenance, Revision
Ethical Responsibilities re:
Student loans
:
38
Standard 3: Students
Criterion 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
Financial Records Policy
Documentation
Responsibility
ADN Faculty Handbook
Admissions Committee
Frequency Cycle
Annually (May)
Assessment Method
Policy audit
ACC Records Management
Review of Records Management
website
http://www.austincc.edu/records/index.
htm
Review of BON-TAC Rule 2.15.12
Texas Administrative Code
Rule 215.12
http://info.sos.state.tx.us/pls/pub/readta
c$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
Review of Administrative Rules
Administrative Rules
related to records
3.03.14 - Records Management
Program
http://www.austincc.edu/admrule/3.03.0
14.htm
3.03.014 – Disposition of College
Records
Storage audit
http://www.austincc.edu/admrule/3.03.0
14GuidelineDisposition.htm
3.03.014 – Records Center
http://www.austincc.edu/admrule/3.03.0
14GuidelineRecordsCenter.htm
Report of Data
Component
Actions
Results
Development, Maintenance, Revision
Financial Records Policy
39
Standard 3: Students
Criterion 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
Complaints
Documentation
Complaint File
Responsibility
Department Chair
Frequency Cycle
Annually (May)
Assessment Method
File Review
ADN Handbook
Health Science Grievance
Policy
ACC Grievance Policy
Report of Data
Component
Actions
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
Tech Support
Documentation
Responsibility
Student Theory Course
Evaluation
Educational Resources
Frequency Cycle
Annually (May)
Assessment Method
Student Theory Course Evaluation
Survey
ACC Website
Review of ACC Website
(http://www.austincc.edu/health/rnsg/)
Review of ACC Student Handbook
ACC Student Handbook
Report of Data
Component
Actions
Results
Development, Maintenance, Revision
Tech Support
41
Standard 3: Students
Criterion 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
Not applicable
Documentation
Responsibility
Assessment Method
Not applicable
Report of Data
Component
Frequency Cycle
Actions
Results
Development, Maintenance, Revision
42
Standard 4: Curriculum
The 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 objectives
o Incorporate professional standards , guidelines, and competencies
Component
Curriculum
Documentation
Curriculum Design
Responsibility
Curriculum Committee
Annually (May)
Assessment Method
Review of Curriculum
Curriculum Committee meeting
minutes
Review of Curriculum
Committee Meeting
Minutes
Program Educational Outcomes
Course Syllabi
Review of Program
Educational Outcomes
Course Syllabi
Report of Data
Component
Frequency Cycle
Actions
Results
Development, Maintenance, Revision
Curriculum
Program Outcomes and
course objectives
Professional standards,
guidelines, competencies
43
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
Curriculum development
Documentation
Course syllabi
Responsibility
Curriculum Committee
Frequency Cycle
Annually - May
Program Educational
Outcomes
Course objectives
Assessment Method
Comparative Analysis of Course
Syllabi
Clinical Evaluation Tools
Comparative Analysis of Clinical
Evaluation Tools
Curriculum committee minutes
Review of Curriculum Committee
Minutes
ADN website
Review of ADN website
Course Syllabi
Conceptual Framework
(http://www.austincc.edu/health/rnsg/ )
Report of Data
Actions
Component
Results
Development, Maintenance, Revision
Course objectives
Course Syllabi
Conceptual Framework
44
Standard 4: Curriculum
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
Curriculum development
Documentation
FOC and curriculum
committee minutes
Responsibility
Curriculum Committee
End of Year Reports
from Committee
Frequency Cycle
Annually - May
Assessment Method
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
45
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
Curriculum (general
education) courses
Documentation
Current degree plans
Responsibility
Curriculum Committee
SACS General Education
Requirements
Frequency Cycle
Annually - May
Assessment Method
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
46
Standard 4: Curriculum
Criterion 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
Curriculum
(Cultural/Ethical/Socially
Diverse)
Documentation
Degree plans
Responsibility
Curriculum Committee
Frequency Cycle
Assessment
Method
Annually (May)
Review of degree
plans
Course Syllabi
Review of course
syllabi & modules
Course Modules
Course projects
Review of course
projects
Report of Data
Component
Actions
Results
Development, Maintenance, Revision
Curriculum
(Cultural/Ethical/Socially
Diverse)
47
Standard 4: Curriculum
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 Method
Simulation
Lab
Simulation
Coordinator
ANNUALLY (MAY)
Course and Lab Calendars
 Electronic version of Patient
Simulation Evaluation Tool was
piloted in the Spring 2014: Google
Research and Best
Simulation objectives

Per lab policy faculty
 Mandatory Sim Lab
survey was used and most user
practices
are required to submit
Orientation was provided
friendly for students and faculty. This
Course Objectives
Simulation Lab request
to students prior to
evaluation is done after each
Interdisciplinary
at least 2 weeks prior to
attending their scheduled
simulation.
collaboration
scheduled simulation
Simulation day.
 Patient Simulation Surveys were used
Course Modules
day. Simulation lab

Attempt will be made to
to revise simulation day. This is a
Simulation
request form is available
encourage the use of the
collaboration between Simulation Lab
Level Meeting Minutes
 Simulation Lab Hours
electronically on ADN
EHR with all scenarios
coordinator and faulty.
available to faculty and
website. Faculty submits
used starting Fall 2014.

Statically data from the Patient
students Monday-Friday
tentative Simulation days 
Revision to scenarios is
Simulation Evaluation Tool is read by
8:00-5:00 pm
Simulation Objectives
at the end of the
done by either faculty or
faculty.
 are created by Faculty
semester for the
Sim Lab Coordinator
 Patient Simulation Surveys after each
Research and Best
and Simulation Lab
following semester.
before the end of the
scenario.
Practices
Coordinator

Sim Lab Orientation
semester of Fall 2014.
 Simulation Surveys were used to
Simulation Objectives
will be provided by Sim

One hour of EHR is
revise simulation day.
 Pilot Study of breakout
are posted on Bb 1 week
Lab Coordinator.
scheduled for the Fall of

Fall 2014; Simulation Surveys will be
session for Physical
prior to Simulation Lab

Simulation Lab
2014. Prior to training
used to evaluate EHR experience.
Assessment skill using
activity for students to
Coordinator spearheaded
students are assigned

Beginning in the Spring of 2015
simulators for level 1
review
project to enter scenario
EHR videos by Cerner.
Level 1 nursing students will be the
students
 Electronic version of
information onto Cerner

Plans to collaborate with
only students required to have EHR
Coordinated by
Simulation Evaluation
template so that EHRs
Radiology, Surgery and
training.
Simulation Lab
Tool was piloted in the
are ready for Fall 2014.
Microbiology disciplines 
Create an electronic survey for
Coordinator.
Spring 2014: Google
 Fall 2014; Sim Lab
for future
student
and faculty feedback.
Drive survey was most
Coordinator will be
Interdisciplinary
user friendly for students
scheduled to provide
scenarios.

Statically data from the Patient
and faculty than hand
EHR training for Levels
Interdisciplinary
Simulation
Evaluation Tool is read by
written version.
1-3
Scenarios once a
faculty.
 Core measures and Joint 
Simulation Lab
semester.
Commission patient
Coordinator contacts
 Student evaluations are
safety goals reference
other disciplines to
filled after each
Research and Best Practices
were provided for all
inquire their interest in
simulation day. Results
simulations during
interdisciplinary
are filed on Google
simulation or during
simulation.
Drive; faculty has access  Student completed evaluations
debriefing.

Simulation Lab
after completion of session.
to evaluation results.
48
Coordinator has up to 20
laptops available to
students to fill out the
“Simulation Evaluation
Tool” on Google Drive
after each simulation.
Report of Data
Actions
Component
Simulation
 3 Simulation Rooms each with a oneway 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
Results

Development , Maintenance, Revisions

49


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.
Criterion 4. RRC
Standard 4 Curriculum
Criterion 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 Method
Simulation Lab Hours
Simulation lab calendar
Simulation Lab Coordinator
1(a). Google Simulation
1(a). Google Simulation calendar was
1(a).Simulation Lab Hours
1(a). Google Simulation Lab
1(a). Per lab policy faculty are
calendar is updated
created on Spring 2014 to help faculty
available to faculty and students
Calendar is available to
required to submit Simulation Lab
weekly and as needed by
schedule Simulation days. Faculty is able
Monday-Friday
faculty to schedule
request 2 weeks prior to scheduled Simulation Lab
to view open slots on the calendar at their
8:00-5:00 pm
simulation days.
simulation day. Simulation lab
Coordinator.
convenience. Conflicts in scheduling of
(b). Mandatory Simulation
( b). Faculty scheduled their
request form is available
(b). Mandatory Sim Lab
Sim Lab days are resolved quickly due to
Orientation was implemented in
students for mandatory
electronically on Google Drive.
Orientation was provided
the communication between faculty and
the Spring of 2014.
Simulation Lab Orientation.
Faculty submits tentative
to students prior to
Sim Lab Coordinator.
2. EHRs are to include:
Simulation days at the end of the
attending their scheduled
(b) Spring of 2014 there was a 98%
Simulation Learning
semester for the following
Simulation day.
attendance for the Mandatory Simulation
Research and Best Practices
2. Simulation Coordinator
Objectives, Scenario
semester.
2. EHR will be used in all Lab Orientation.
contacted staff at Cerner to
information, Core measures
(b). Mandatory Sim Lab
scenarios starting Fall
Beginning in the Fall of 2014; Level 1
gather information needed to set and National Safety Patient
Orientation was provided by Sim
2014.
nursing students will be the only level
up all scenarios on Cerner
Goals.
Lab Coordinator.
3. Revision to scenarios
required to attend Simulation Lab
(EHR). A template was sent to
* Hard copies of scenarios
2. Simulation Lab Coordinator
are done by either faculty
Orientation.
faculty with the information
are available as a PDF on
spearheaded project to enter
or Sim Lab Coordinator
2. Patient Simulation Surveys after each
needed to create patient’s chart
Google Drive. Revisions of
scenario information onto Cerner
before the end of the
scenario.
in EHR form.
scenarios will be added to
template so that EHRs are ready
semester.
3. Patient Simulation Surveys were used to
3. Spring 2014: Sim Lab
these files.
for Fall 2014.
4. One hour of EHR is
revise simulation day.
Coordinator met with faculty
3. Students prep sheet is
3. Revised scenarios for Level 1-3
scheduled for the Fall of
4. Fall 2014; Patient Simulation Surveys
Level leads to discuss revising
posted on Bb one week prior
were completed by faculty and Sim 2014. Prior to training
will be used to evaluate EHR experience.
scenarios:
to Simulation Lab activity for Lab Coordinator.
students are assigned
Beginning in the Spring of 2015
Learning objectives were created students to review (Level 14. Fall 2014; Sim Lab Coordinator EHR videos by Cerner.
Level 1 nursing students will be the only
by faculty and students prep was 3).
is scheduled to provide EHR
5. Plans to collaborate
students required to have EHR training.
created by Simulation Lab
4. Cerner training for
training for Levels 1-3
with Radiology, Surgery
5. Create an electronic survey for student
Coordinator.
students is scheduled for the
5. Simulation Lab Coordinator
and Microbiology
and faculty feedback.
50
4. EHR training for students
5. Interdisciplinary
Collaboration
Spring 2014-Pilot
Interdisciplinary
Scenario with nursing and
sonography students
coordinated by Simulation Lab
Coordinator and Sonography
Director
6. Create an electronic version of
the “
“Patient Simulation Evaluation
Tool”
6. Improvement of Simulation
experience for students and
faculty
Report of Data
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.
Survey Monkey was most
user friendly for students and
faculty.
Component
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



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.
disciplines for future
Interdisciplinary
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.
6. Statically data from the Patient
Simulation Evaluation Tool is read by
faculty.
Actions
Results
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.
Development , Maintenance, Revisions
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
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
51











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
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
52
Standard 4: Curriculum
Criterion 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
Evaluation
Methodologies
Documentation
Student clinical evaluations
Responsibility
Curriculum Committee
Frequency Cycle
Annually May
Assessment
Method
Review of
Student evals
Clinical assignments
Careplans
Grading rubrics
Grading Rubrics
Exams
Exams
Actions
Report of Data
Component
Results
Development, Maintenance, Revision
Student evaluations
Varied
Methodologies
Professional and
Practice
Competencies
Achievement
53
Standard 4: Curriculum
Criterion 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
Curriculum Committee
Frequency Cycle
Review of degree plan
Program length
Degree Plan
Credit hours
College requirements for
graduation
Review of college requirements for
graduation
ADN curriculum
Review of THECB requirements for AD
Nursing curricula
Program Outcomes
(Student Learning)
Annually (May)
Assessment Method
Review of ADN curriculum
Report of Data
Component
Actions
Results
Development ,Maintenance, Revision
Program length and
credit hours
Program Outcomes
(Student Learning)
54
Standard 4: Curriculum
Criterion 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
Student learning
environments
Documentation
Student Clinical Course
Evaluation
Responsibility
Educational Resources
Frequency Cycle
Annually (May)
Student Evaluations
(each semester)
List of Clinical sites by
level
Assessment
Method
Student clinical
course evaluations
Review of List of
Clinical sites by level
Clinical site review
(each semester)
Report of Data
Component
Results
Actions
Development ,Maintenance, Revision
Student learning environments
1) Student clinical course evaluation
Results 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
55
Level 2:
SDM
SDN
SDS
SDW
SDRR
SD Heart
Seton Northwest Hospital
Seton Hays Hospital
Central Texas Medical Center
Level3
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
56
Dell Children’s Medical Center
57
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
Clinical experiences
Documentation
Clinical syllabi
Evidence- based and
contemporary practice
Clinical objectives and foci
Responsibility
Curriculum Committee
Frequency Cycle
Annually (May)
Assessment Method
Review of clinical syllabi,
objectives, and clinical foci
National patient health
and safety goals
Report of Data
Component
Actions
Results
Development ,Maintenance, Revision
Clinical experiences
Evidence- based and
contemporary practice
National patient health
and safety goals
58
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
Clinical practice
agencies
Documentation
Affiliation agreements
Responsibility
ADNSA
Report of Data
Component
Frequency Cycle
Annually (May)
Assessment Method
Affiliation agreements
Actions
Results
Development ,Maintenance, Revision
Clinical practice
agencies
59
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
Learning activities
Instructional materials
Evaluation methods
Documentation
Course syllabi
Course objectives
Course projects
Responsibility
Accreditation Committee
(this committee to get this
Criterion started)
Leona to complete
Frequency Cycle
Annually-May
Assessment Method
Review of course
Syllabi
Objectives
Projects
Evaluations
Course evaluations
Report of Data
Component
Actions
Results
Development ,Maintenance, Revision
Learning Activities
Instructional materials
Evaluation methods
60
Standard 5: Resources
Fiscal, 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
Fiscal Resources
Documentation
Program/college
budget
Responsibility
Department Chair
Frequency Cycle
Annually (May)
Assessment Method
Comparative analysis
Review of FOC minutes
FOC minutes
Report of Data
Component
Actions
Results
Development ,Maintenance, Revision
Fiscal Resources
61
Standard 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
Instructional Space
Non-instructional Space
Documentation
Student Overall Program
Evaluation
Responsibility
Educational Resources
Committee
ADN Faculty Survey
Frequency Cycle
Students-Every Semester
Faculty-Annually
Assessment Method
Review Student Overall
Program Evaluation
Review ADN Faculty
Survey
Report of Data
Actions
Component
Results
Development, Maintenance, and Revisions
Instructional Space
Non-instructional Space
62
Standard 5: Resources
Criterion 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
Library Resources
Theory Course Evaluations
Nursing Skills Laboratory
Educational Resources
Committee Meeting Minutes
Responsibility
Educational Resources
Committee
Frequency Cycle
Assessment Method
Annually (May)
Theory Course Evaluations
Students (Every Semester)
Review of Educational
Resources Committee Meeting
Minutes
Nursing Tutor
FOC Meeting Minutes
Review of FOC Meeting
Minutes
Report of Data
Component
Actions
Results
Development, Maintenance, Revision
Library Resources
Nursing Skills Laboratory
Nursing Tutor
63
Standard 5: Resources
Criterion 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
64
Alternative Methods of
Delivery
Fiscal Resources
Educational Resources
Committee
Program/college budget
Annually (May)
FOC minutes
Comparative analysis
Review of FOC minutes
Students-Every Semester
Instructional Space
Non-instructional Space
Student Overall Program
Evaluation
Faculty-Annually
ADN Faculty Survey
Review ADN Faculty Survey
Library Resources
Theory Course Evaluations
Nursing Skills Laboratory
Educational Resources
Committee Meeting Minutes
Nursing Tutor
Review Student Overall
Program Evaluation
Annually (May)
Theory Course Evaluations
FOC Meeting Minutes
Students (Every
Semester)
Review of Educational
Resources Committee Meeting
Minutes
Review of FOC Meeting
Minutes
Actions
Report of Data
Component
Results
Development, Maintenance, Revision
Alternative Methods
of Delivery
Fiscal
Physical
Learning
65
Standard 6: Outcomes
Program 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
Component
Actions
Results
Development, Maintenance, Revision
Written plan for systematic
program review
66
Standard 6: Outcomes
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
Evaluation Findings
Documentation
Responsibility
AdHoc Evaluation Committee
SPE
Findings of data in End of Year
Reports
Course Evaluation Response
Forms from Levels
Report of Data
Component
Frequency Cycle
Annually (May)
Assessment Method
Review of SPE
Review of End of Year Committee
Reports
Review of Course Evaluation
Response Forms from Levels
Actions
Results
Development, Maintenance, Revision
Written plan for systematic
program review
67
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
Communities of interest
Documentation
Responsibility
Minutes from the advisory
committee meetings
Department Chair
Minutes from the HWACT meetings
Report of Data
Component
Results
Frequency Cycle
Annually (May)
Assessment Method
Review of minutes from the
advisory committee meetings
Review of minutes from the
HWACT meetings
Actions
Development, Maintenance, Revision
Communities of interest
68
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
Outcomes
Documentation
See 6.4.1 – 6.4.5
Responsibility
Accreditation Committee
Frequency Cycle
End of Spring & Fall
Semesters
Report of Data
See 6.4.1 – 6.4.5
Actions
Component
Outcomes
Assessment Method
Results
See 6.4.1 – 6.4.5
Development, Maintenance, Revision
See 6.4.1 – 6.4.5
69
Standard 6: Outcomes
Criterion 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
NCLEX Pass Rates
BON NCLEX reports
National Means:
BON Website
www.bon.state.tx.us
Responsibility
Accreditation Committee
Report of Data
Component
Frequency Cycle
End of Spring & Fall
Semesters
Assessment
Method
Analysis of NCLEX
pass rates
Actions
Results
Development, Maintenance, Revision
NCLEX Pass Rates
National Means:
70
Standard 6: Outcomes
Criterion 6.4.2: Program Completion: Expected levels of achievement for program completion are determined by the faculty and reflect student
demographics and program options.
Expected Level of Achievement:

Expected levels of achievement for program completion are determined by the faculty

Expected levels of achievement for program completion reflect the student demographics

Expected levels of achievement reflect program options

80% of Traditional Track graduates will complete the program within 2.5

80% of Mobility graduates will complete program within 2 years
Component
Expected Levels of
Achievement in SPE
(program completion)
Documentation
ADN FOC minutes
Responsibility
Accreditation Committee
Frequency Cycle
End of Spring & Fall
Semesters
Assessment Method
Review of ADN FOC
minutes
Datatel
Review of Datatel
Actions
Report of Data
Component
Results
Development, Maintenance, Revision
ELA determined by
faculty
Student demographics
Program options
Completion rate
-
RRC
-
Hybrid
-
CEC
-
EVC
-
Mobility
71
Standard 6: Outcomes
Criterion 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
Graduate Program
Satisfaction
Documentation
Graduate Survey
Responsibility
Accreditation Committee
Annually-May
Assessment Method
Graduate Survey in survey
monkey
Alumni Reunion Luncheon?
Alumni Reunion Luncheon?
Report of Data
Component
Frequency Cycle
Actions
Results
Development ,Maintenance, Revision
Graduate Program
Satisfaction
-
EVC
-
Mobility
-
RRC
72
-
Hybrid
-
CEC
Overall Program
Satisfaction
73
Standard 6: Outcomes
Criterion 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
Employer Program
Satisfaction with
Graduates
Documentation
Employer Survey
Responsibility
Accreditation Committee
Report of Data
Component
Frequency Cycle
Annually-May
Assessment Method
Employer Survey in survey
monkey
Actions
Results
Development ,Maintenance, Revision
Employer Program
Satisfaction with
Graduates
74
Standard 6: Outcomes
Criterion 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
Post-Graduation
Employment
Documentation
FOC minutes
Responsibility
Accreditation Committee
Frequency Cycle
Each Semester
Graduate
Employment form
Graduate Employment form
Report of Data
Component
Assessment
Method
FOC minutes
Actions
Results
Development ,Maintenance, Revision
Post-Graduation
Employment
-
RRC
-
Hybrid
-
CEC
-
EVC
-
Mobility
75
76