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GUIDELINES FOR DEVELOPING AN ACTION PLAN
The development of an action plan to use in the improvement of program quality
and student outcomes should fulfill several purposes, including:
1. Assisting the program in achieving internal effectiveness through establishing
goals for both short- and long-term successes. Further, criteria for measuring the
accomplishment of these goals can be defined, allowing the program to focus its
plans and activities on the critical processes needed for effectiveness. Once
defined, these goals and criteria should then be used to unify administrative and
educational activities, which can help achieve a high degree of commitment and
common direction among all program personnel.
2. Assessing progress and the need for change and continuously reviewing the
process to help the program make timely changes based upon valid information
to achieve even greater effectiveness.
3. Communicating key information regarding the program’s goals, its degree of
effectiveness, and how it plans to enhance overall quality to external publics, such
as graduates, employers, health care recipients, and community leaders.
Information, which depicts the most important elements of the program’s
operation, communicates clearly and accurately to external publics how well the
program is meeting the needs of students, and providing quality-learning
experiences.
4. Measuring how the analysis of the information above meets the expectations and
requirements of approving organizations, including state regulators and ABHES,
to demonstrate regulatory compliance. A document which defines programmatic
goals and educational processes is a primary focus of most accrediting agencies as
they measure overall effectiveness and the quality of programs and services
provided.
All programmatic effectiveness goals and activities the program selects should link to
the mission to demonstrate achievement of objective and continuous improvement,
as the program’s mission is the driving force of the Action Plan. The Action Plan
requires a program to look at its past, present, and future and to continuously ask the
following:
Where have we been?
This data becomes the baseline for gauging and
demonstrating improvements.
Where are we now?
Current data demonstrates how you will measure
change from the baseline data using the
caparison to identify changes needed.
Where do we want to go?
A look towards the future for goals to improve or
enhance processes and/or programs.
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ELEMENTS OF AN EFFECTIVE ACTION PLAN
*Note: examples are provided for only one program
a. Student retention rates
Include the retention results for the last three annual reporting years as the
baseline, if available, along with goals for the upcoming year. If the program
has developed long-term goals for retention, this information should also be
included with status updates.
EXAMPLE: Retention rates for the past three years, derived from the
program’s Annual Report:
Surgical Technology (diploma)
Surgical Technology (degree)
2002-2003
67%
54%
2003–2004
72%
65%
2004–2005
78%
69%
To establish the goals for the next reporting period 2005-2006, a program may
choose to average the three previous years for each program. However, in
this example above, the goal would be below the 70% benchmark in the
degree-granting program; therefore, this would not be a practical way to
determine the next year’s program goal. A program may elect to establish its
goal by an increase of a given percentage each year, such as five percent or by
determining the percent increase from year to year of the three previous years.
Note in the example that the diploma program increased retention 6%
between 2002-03 and 2003-04 and then increased another 6% between 200304 and 2004-05. Of course, the average increase among those three years is
6%. Use the averaged percent method to determine a realistic 2006 goal. The
program may also establish intermittent goals of a percentage increase from
month to month or an increase in relation to the same month or other
predetermined time periods in the previous year—e.g., a 1% increase from
month to month or a 2% increase in April 2006 over the April 2005 rate.
Intermittent goals are advantageous as they keep everyone on target
throughout the year.
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The next step might be to develop an improvement plan as part of the Action
Plan for the 2006 retention rates for each of the two programs that will assist
the program in reaching its projected 2006 rates. The diploma program is
doing well so its goal may be to either increase by 1% or maintain the 78%
retention rate. The degree program is still below 70%, but did show increases
over the years; therefore, it would be realistic to challenge it with perhaps
another 2% increase for 2006. By establishing program goals, there is
assurance that each program is working toward the overall retention
improvement goal as part of the Action Plan.
b. Results of the Program Assessment Exam, as Applicable
Results of students on a recognized and appropriately administered program
assessment exam (see VII.B.2.b. of the Accreditation Manual) for the most current
year reported along with goals for the upcoming year is necessary. In addition,
if a program has developed long-term goals for enhancement of results, which
should focus directly on individual coursework within the program that appears
deficient, this information must be included in the Action Plan.
EXAMPLE: Program Assessment Exam results for the most recent reporting
year taken from the program’s ABHES Annual Report are:
%
Anatomy & Physiology
Asepsis
Basic Case Preparation
Micro/Wound
%
72
85
79
88
Orientation
Pharmacology
PT Care Concepts
Surgical Procedures
Terminology
90
85
69
72
87
Since the examination is designed to measure, as a class, overall student achievement in
the program according to the Core Curriculum (see VIII.A.1.f. of the Accreditation
Manual) and it is important that the final analysis of results pinpoint areas of the
program in need of enhancement.
ABHES requires a program to submit an Action Plan for those areas in which the
average score is less than 85%, so in the example above, the Action Plan would need to
assess the Anatomy & Physiology, Basic Case Preparation, PT Care Concepts, and
Surgical Procedures courses in an effort to identify what may be leading to the lower
scores.
The program could consider for the courses identified above a number of areas,
including, the didactic and clinical instruction, qualifications and effectiveness of
faculty, and appropriateness of texts and other educational materials.
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c. Graduate placement rates
Placement results for the same annual reporting years identified above for
retention are used as your baseline data, if available, along with goals for the
upcoming year. In addition, if a program has developed long-term goals for
placement, this information should also be included with status updates.
EXAMPLE: Placement rates for the past three years, beginning with 20022003, taken from the program’s ABHES Annual Reports are:
Surgical Technology (diploma)
Surgical Technology (degree)
2002-2003
2003–2004
2004–2005
65%
60%
69%
69%
72%
78%
These rates indicate a steady annual increase and both of the most recent rates
exceed the 70 percent ABHES benchmark. The program may elect to just
maintain the rates for 2006 or the institution may elect to increase a given
percentage for 2006 such as two percent or use an average of the increases. A
2006 overall placement rate could be developed for the two programs using
the same method of calculation. However, if there is great disparity among
program placement rates, the program level (degree, non degree) not placing
students well might be given a higher placement goal than those programs
that are achieving acceptable rates so as to achieve the overall institutional
rate.
c. Graduate credentialing results
This review should include the results of periodic reviews conducted
throughout the reporting year of credentialing exam results along with goals
for the upcoming year. If results are not easily accessible without student
consent, the program should consider incentive procedures or devise alternate
methods to make a concerted effort to obtain results, which can be
documented to assess effectiveness. Again include the three most recent years
of data collection, as follows:
PROGRAM
Surgical
Technology
diploma
GRADS
NUMBER
PERCENT
NUMBER
’03 ’04 ‘05 TOOK EXAM GRADS TOOK PASSED
EXAM
20 26 24 15 20 21 75 77 88 12 15 16
4
PERCENT
PASSED
80
75
76
From this data, establish two goals, one for the percentage taking the exam
and one for the percent passing the exam. The goals may be developed from
the trends over the past three years or by averaging the last three years.
EXAMPLE:
Looking at the graduate percentage of those who took the exam versus those
who have taken the exam for the last three years would be lower than the
2005 pass rate. Therefore, it would be more advantageous to calculate the
percentage increase between ‘03/’04 and ‘04/’05 to get an average to establish
the percent increase for ‘05/’06 [2% (percent increase between 2003 & 2004) +
11(percent increase between 2004 & 2005) ÷ 2 = 6.5]. So the goal for the number
taking a credentialing exam in 2006 would be 94.5%. Since passing rates
have not steadily climbed, setting a reasonably achievable passing goal could
be established by merely averaging the three most recent passing rates (80+
75+ 76÷ 3 = 77), which would give a goal of 77% passing for the exam.
Other data to demonstrate student-learning outcomes may include entrance
and exit assessments, pre- and post-tests, course grades, GPA, CGPA,
standardized tests, and portfolios.
d. Graduate satisfaction
Using ABHES’ required Graduate Satisfaction Survey, describe how data was
collected and provide a summary and analysis of the surveys results and how
data was used to improve the learning process.
e. Employer satisfaction
Using ABHES’ required Employer Satisfaction Survey, describe how data was
collected, provide a summary and analysis of the surveys results, and describe
how data was used to improve the learning process.
Because graduate and employer satisfaction surveys provide valuable
information for timely program revision and development, they must be
conducted on an on-going basis, summarized at least annually, and reported
to ABHES on the Annual Report. The information from these surveys is vital
to the evaluation of educational outcomes and setting short- and long-term
goals.
Attachments: Graduate and Employer Satisfaction Surveys
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