Clues for Solving
the Mystery of the
Fifth-Year Interim Report
2013 SACSCOC Annual Meeting
December 7-10, 2013
Atlanta, Georgia
UCF Team
2

Tace Crouse –coordinator of UCF’s Fifth-Year Report and
peer reviewer

Diane Chase – current SACSCOC liaison for UCF and peer
reviewer

Heidi Watt – member of UCF Fifth-Year Report leadership
team and manages on-going SACSCOC compliance activities

Denise Young – former SACSCOC liaison for UCF and peer
reviewer (including Fifth-Year reports)
University of Central Florida
• second largest university in U.S.
• one of twelve Florida state universities
60,000 students
200+ programs
Multiple campuses
3
Research I University
SACSCOC Level VI
Workshop Outcomes
To prepare for their next report, participants will analyze the
Fifth-Year Interim Report process including the:
4

previous performance of institutions

new and most challenging standards

litmus test questions

technology tools

evaluator’s perspective

organizational matrix
Workshop Agenda

background check

providing clues for preparing accreditation
reports with a focus on the SACSCOC
Fifth-Year Interim Report

input from peers
Evaluator perspectives and input into an
Organizational Matrix are embedded throughout
to provide you with clues for how your work
might be reviewed and a jump start on your next
report!
5
Background Check of
Fifth-Year Report

Why a fifth-year report requirement?



ten-year span for major review deemed too long
What is the SACSCOC Fifth-year Report?



6
response to federal oversight (Higher Education
Opportunity Act)
four or five-part report describing your institution, how it
complies with designated standards, impact of its QEP,
and action letter follow-up reports as required
may include a visit to off-campus sites initiated since
previous reaffirmation
revised in 2012
Background Check of
Fifth-Year Report…continued
7

includes many of the most challenging standards

Quality Enhancement Plan (QEP) Impact Report

rigor required equal to that of decennial report

evaluators scrutinize 10+ reports at one time

quick deadline if referral report needed

referral reports evaluated by the Compliance and Reports
Committee
SACSCOC Fifth-Year Report
Standards (2012)
8
1. CR 2.8
Number of full‐time faculty
2. CR 2.10
Student support services
3. CS 3.2.8
Qualified administrative and academic officers
4. CS 3.3.1.1 Institutional effectiveness: educational programs
5. CS 3.4.3
Admissions policies
6. CS 3.4.11 Qualified academic program coordinators
7. CS 3.11.3 Physical facilities
8. FR 4.1
Student achievement
9. FR 4.2
Program curriculum
10. FR 4.3
Publication of policies
11. FR 4.4
Program length
12. FR 4.5
Student complaints
13. FR 4.6
Recruitment materials
14. FR 4.7/CS 3.10.2 Title IV program responsibilities/financial aid
audits
15. FR 4.8
Distance and correspondence education
16. FR 4.9
Definition of credit hours
17. CS 3.13
Policy compliance
What is “new” about the
SACSCOC Fifth-Year Report?
 language changes in CR 2.8, 2.10, CS 3.2.8, FR 4.1,
4.2, and 4.7
 new standards: FR 4.8.1, 4.8.2, 4.8.3, and 4.9
 policy compliance: CS 3.13.1, 3.13.3, and 3.13.4
more on these later…
9
The Fifth-Year Report – a
Challenging Mystery, Indeed
76 percent of
2012 and 2013 institutions
were required to submit
at least one referral report
Reported in Busting Myths about SACSCOC by
Michael Johnson, SACSCOC Senior Vice President
10
2013 Institutions – Major puzzlers
% Required to Complete Referral Reports
Standard
CR 2.8
Sufficiency of Full-Time Faculty
CS 3.3.1.1 Institutional Effectiveness
11
Track A
Track B
24%
38%
33%
48%
CS 3.4.11
Qualified Academic
Coordinators
39%
18%
CS 3.13.1
Accrediting Decisions
27%
8%
CS 3.13.3
Complaint Record
12%
10%
FR 4.1
Student Achievement
33%
5%
FR 4.4
Program Length
0%
8%
FR 4.5
Student Complaints
6%
13%
CS 3.10/
FR 4.7
Financial Aid Audits/
Title IV Responsibilities
15%
20%
FR 4.8.2
Protecting Student Privacy
0%
0%
FR 4.9
Credit Hours
6%
3%
QEP
Impact Report
3%
15%
Form your Accreditation Scene
Investigator (ASI) Teams


12
8-10 members

meet and greet

color-coded for inclusive responding
designate a reporter
Referral Trends - ASI Teamwork
(five-minute drill)
 Do
you believe the results for 2013 were unusual?
 What
do you think were the top five referral
producers for Fifth-Year Reports over the last four
years and why have they been
problem areas?
13
Top Five Referral Report Producers
2010-2013 (Combined Tracks A and B)
5 - FR 4.5 Student Complaints - 17%
4 - CS 3.10.2/FR 4.7 Financial Aid/Title IV - 21%
3 - CS 3.4.11 Qualified Academic Coordinators – 32%
2 - CR 2.8 Number of Full-time Faculty – 42%
1 - CS 3.3.1.1 Institutional Effectiveness: Educational
Programs, to include Student Learning Outcomes –
49%
14
Referral reasons
Failure to communicate compliance clearly
Failure to provide sufficient or appropriate evidence
for compliance
Make a case for compliance with the wrong criteria
due to a misinterpretation of the standard
Rarely, but sometimes, we do not comply.
15
Detecting clues
for preparing all
SACSCOC accreditation reports
16
Clues for Accreditation Leadership
It takes a village…
but it also takes a president
who is strongly committed to accreditation
through peer review
17
Clue for leadership team
All Fifth-Year Report leadership team members should attend
SACSCOC Summer Institute and/or Annual Meeting at least
once prior to their submission year.
18
Building your team - optimal
characteristics of report leaders
 effective delegators and facilitators
 able to “cut to the chase” in addressing each requirement
 pragmatic: able to move the process along; intervene
when needed
 respectful of the process and those who implement it
 extensive knowledge of institution
• well-known and respected on campus
19
Applying Optimal Characteristics ASI Individual work (five-minute drill)
Using your Organizational Matrix, identify individuals
in your institution who exhibit these characteristics
and would make good leaders for guiding the process
for each standards.
Guiding questions:
 Do you choose to have a few or many people
overseeing the report?
 Do you choose to have one coordinator with
multiple information providers?
 Do you choose to have information providers also
write?
 Do you have a succession plan for people who
leave?
20
Share your challenges and your results with your
team.
Managing the calendar
SACSCOC Fifth-Year Report schedule
 notification of report requirements sent from
SACSCOC 11 months prior to due date
 report due March 25th for Track B and
Sept 15th for Track A
 Fifth-Year Report Review Committee reviews occur in
May/June for Track B and in December for Track A
 referral reports due July-ish or January-ish and
reviewed by Compliance and Reports Committee in
December or June
21
Schedule clues

begin early

begin early

begin early

pace the data collection, writing, and internal review
processes to finish well ahead of the due date
22

monitor the progress regularly

remember Murphy’s Law
More schedule clues
An institution’s own report preparation schedule is dependent
upon the complexity of the institution and the preparers having:
 a thorough understanding of the institution
 timely access to needed data
 time to focus on the report
 previous report-writing experience
 access to reports on related issues
 access to internal/external reviewers who can respond quickly
Again, assume Murphy’s Law will apply!
23
Sample schedule
Track A schools – work backward from September 15 deadline
Track B schools – work backward from March 25 deadline

16-18 months to submission




initiate development of technology tools: Web shell,
report platform
13-16 months to submission


24
orient/organize – president or designee
assignment of reporting requirements and determine review
structure/editor
organizational meetings: vice presidents, deans
more complex institutions may begin readiness audit/gap
analysis (especially for CR 2.8 and CS 3.3.1.1)
Sample schedule…continued
8-12 months to submission
25

complete readiness audit and first draft of QEP Impact
report

receive letter of notification from SACSCOC (11 months
out)

review of readiness audit and act on areas of
immediate need

review CR 2.8 rationales for FT faculty numbers for all
programs
Sample schedule…continued
26

clarify necessary terms, documentation timespans

identify a representative sample of CS 3.3.1.1 IE plans and
reports

review credentials and rationales for CS 3.2.8 administrators
and officers and CS 3.4.11 academic coordinators

ensure all publications have consistent information (Web
sites, catalogs, brochures, presentations)

update boards and institutional community on progress
regularly
Sample schedule…continued
6-7 months to submission
 first draft of narratives (Parts II, III, and QEP Impact) completed
and reviewed
4-6 months to submission
 second draft of narratives reviewed
 narratives deemed “final” are uploaded to submission platform
1-3 months to submission
 final narratives reviewed
 pdf’s of all evidence documents created
 prep Final Reports; load on platform and test DVDs/drives
 test all DVDs/drives using PC’s and Apple computers
27
Sample schedule…continued
0-1 month to submission



introduction/submission letter from president
loose ends finalized
submit
Partly borrowed from Hillsborough Community College Web site
**Review UCF’s actual CS 3.3.1.1 schedule
28
Your schedule- ASI Individual and
Teamwork (five-minute drill)
Organization Matrix time!

When is your Fifth-Year Interim Report due?

Count back from that 16 or 18 months to determine when to
begin your process and then input the dates you wish to use
in as many places on the matrix as you can.
Share your challenges and your results with
your team.
29
DOs and DON’Ts
for accreditation
report preparation
30
DO

analyze each standard carefully

highlight each of its components

clarify terms and timespans to be reported
(Resource Manual is great help)
31
Analyze the Standard - ASI Teamwork
(two-minute drill)
What are the major areas that must be
addressed/clarified for CS 3.3.1.1?

The institution identifies expected outcomes, assesses the
extent to which it achieves these outcomes, and provides
evidence of improvement based on analysis of the results
in the following area:

32
3.3.1.1 educational programs, to include student learning
outcomes
Analyzing CS 3.3.1.1
Sample answers
The institution
33

identifies expected outcomes in [all] educational
programs, to include student learning outcomes,

assesses the extent to which it achieves these
outcomes

provides evidence of improvement based on
analysis of the results
Analyzing CS 3.3.1.1…continued

clarifies terms
 “student learning outcomes”
measurable, define targets
 provides “evidence of improvement based on analysis of
results”
What’s the +?

clarifies timespans for data
For example:
 Year 1: data analysis indicates a change is needed and
faculty determine what change is needed
 Year 2: change implemented; initial results [could be]
collected on change impact
 Year 3: results collected on change impact; [could]
determine if change was an improvement
34
DO

use the Resource Manual for SACSCOC reports (more
on this later)

conduct a gap analysis/readiness audit of the status of
how your institution has addressed each standard to
enable time for correction, if needed (16-18 months
before deadline)
35
DO

explore reaffirmation reports from your sister institutions –
remembering that you are unique
http://www.mcneese.edu/sacs
36
DO
assemble all the evidence:
identify and collect appropriate data for the necessary time
periods to support the case for compliance
Clue: much of the evidence can be used for multiple standards
Ex: The institution’s mission statement is used many times.
Certain components can be extracted for specific standards.
37
DO
use technical writing techniques, not creative writing
techniques that embellish the argument or cover up
inadequacies
38

use only the evidence that applies: be precise; address the
specific standard; don’t say too much; don’t say too little

analyze and assemble the information so it clearly
communicates compliance

address every standard and every part of every standard
Where did these go wrong?
 FR
4.1 Student achievement: Forty percent of the
2013 Best College nursing students passed the
NCLEX exam on their first attempt. This was up
from 2012 when thirty percent passed. Two nursing
instructors are set to retire in 2015 and we should
be able to hire more qualified faculty to help the
students do better after that.
 CR
2.8 Number of full-time faculty: All our faculty
members have appropriate credentials for teaching
in their programs as attested by the Faculty Roster
included in the addenda.
39
Let’s Investigate an example ASI Teamwork (five + minute drill)
How would you improve each of the following?
40
CS 3.3.1.1 The institution identifies expected outcomes,
assesses the extent to which it achieves these outcomes,
including student learning outcomes
41
1.
Data from assessment measures were collected from
students located on the main campus. The online and
branch campuses were not included due to their low
enrollments.
2.
The assessment process for academic programs involves
creating outcomes, implementing measures, and collecting
results. One academic year of data provided us with a
wealth of data to verify the process is being followed.
3.
Listed as an IE process improvement: Implemented a new
mathematics learning platform faculty members saw
demonstrated at the MAA conference. Student performance
increased by 25 percent on mid-term and final exam scores.
DO
use multiple reviewers (internal and external) to judge clarity
and completeness
Reminder: Reviewers add time to the process!
42
DO
ensure ease of navigation throughout the materials
(both for reading and for using the technology)
43
Technology is great when it works

Test every flash drive or dvd on multiple types of computers

Label each narrative clearly

Ensure every link to evidence works

Ensure you can close one standard’s narrative and go directly
to another without having to go out of the whole document and
start over
…more on technology clues later
44
DO
ensure consistency and accuracy with the use of primary
sources of evidence
Post resources used in multiple sections in a centralized site
for all writers to use.
45
DO
contact your SACSCOC Vice President
to discuss unclear requirements or uncertainties
on how you plan to address standards
46
DON’T
47

rely on one person to prepare the entire report

assume writing a portion of an accreditation report is an
intuitive process and everyone’s top priority

submit the report without reviewing for correctness and
consistency
Several accreditation standards reference the institution’s mission
statement which is to be specific to and appropriate for the
institution and must be easy to access.
DON’T
48

provide outdated or inconsistent copies of the mission

refer the reader to the whole student catalog or any other entire
document as evidence of publication of the mission

fail to rectify inconsistencies between the mission and
institutional activities
Break Time
49
Uncovering clues for
remaining general areas,
specific standards and the QEP Impact
Report.
50
General clue regarding policies
Implicit in every [Core Requirement/Comprehensive Standard/Federal
Requirement] mandating a policy or procedure is the expectation that
the policy or procedure is in writing and has been approved through
appropriate institutional processes, published in appropriate
institutional documents, accessible to those affected by the policy or
procedure, and implemented and enforced by the institution.
Principles
DO
refer to and provide copies and verify posting of policies and
procedures for all standards for which they exist
(not just for CS 3.13.A-C)
51
Ex: FR 4.5 Student complaints - Provide institutional policy document,
procedures, and a pdf of where published
Organizational Matrix
 deadlines for report drafts and reviews
 responsible persons
 organizes requirements, resources, assignments, and
deadlines in one document
 identifies SACSCOC-delineated documentation
 identifies institutional documentation
 assists with survey development
52
Let’s Investigate the Matrix
Individual Activity (5 minute drill)_

focus on standards CS 3.4.11 Qualified Academic
Coordinators and CS 3.11.3 Physical Facilities

review the matrix information

pencil in your institution’s information for the remaining
last five columns
What challenges do you predict?
53
Clues for
CR 2.8 Number of Full-time Faculty
Language Change
The number of full-time faculty members is adequate to
support the mission of the institution and to ensure the
quality and integrity of each of its academic programs.
Discussion: What’s a “program?”
54
CR 2.8 Clues
DO
55

disaggregate full-time faculty by program/discipline,
mode, and location

provide a rationale for why the number is adequate for
each program, mode, and location

provide information regarding faculty loads, including
committee work, service, advising, curriculum
development, research

provide information that students and programs have
been successful with current numbers (external
recognitions, awards, and rankings; licensure exams)
CR 2.8 Clues
DON’T
56

incorporate the faculty roster and faculty
qualifications as data for this standard

advocate for more faculty than is
considered “adequate” just to get more faculty

confuse reviewers with too much information
CR 2.8 Template
57
1
2
3
4
5
6
Location of
Instruction
Number & Percent
of Student
Undergraduate
Credit Hours
Taught by Full-time
Faculty for each
Major or Program
content area
Number & Percent
of Student
Undergraduate
Credit Hours
Taught by Parttime or Adjuncts or
Graduate
Teaching
Assistants for each
Major or Program
content area
Number & Percent
of Student
Undergraduate
Credit Hours Taught
by Part-time Faculty
or Adjuncts or
Graduate Teaching
Assistants in
General Education
Courses
Number & Percent
of Student Graduate
Credit Hours Taught
by Full-time Faculty
in each Degree
Program
Number & Percent
of Student
Graduate
Credit Hours
Taught by Part-time
Faculty or adjuncts
in each Degree
Program.
CS 2.10 Student Services
The institution provides student support programs, services, and
activities consistent with its mission that are intended to promote
student learning and enhance the development of its students.
58
CR 2.10
DO
59

provide a comprehensive list of student support
services

conduct a thorough review of all student support Web
sites to ensure the services are included in the report

ensure equivalent services are provided for all
students, everywhere, and that these are included in
the report
CS 3.13.1 Accrediting Decisions of
Other Agencies
DO
create a table listing:





60
federally-recognized agencies that currently accredit the
institution and its programs
dates of most recent reviews
any negative actions taken by the agencies and the
reasons for each
copies of statements used in describing the institution to
each agency
dates and reasons for voluntary or involuntary
termination of accreditation
CS 3.13.3 Complaint Procedures
Against the Commission or its
Accredited Institutions
Documentation of written student complaints:

What is the policy and where is it published?

What offices maintain records and what is/are their
location(s)?

What is included in the complaint record?

What is the review process for complaints?
Note: Complaint records will be reviewed during the
next decennial evaluation. Be ready!
61
CS 3.13.4 Reaffirmation of
Accreditation and Subsequent Reports
An institution includes a review of its distance learning
programs in the Compliance Certification.
DO
provide evidence of assessment of standards that apply to
distance and correspondence education programs and
courses
(Be sure distance learners are included in all appropriate
assessment populations and use examples for CS 3.3.1.1
that highlight them.)
62
QEP Impact Report Clues
DO
63

provide succinct list of initial goals and outcomes

report on what actually transpired, not on the plan merits

provide clear rationales for incomplete or changed activities

provide complete and clear assessment results
QEP Impact Report Clues…continued
DON’T
64

fail to report reasons for changes

fail to report results and their analysis

fail to report the impact(s) on student learning and/or the
learning environment
Technology
SACSCOC and other agency requirements
 management platform
 word and page counts for some sections
 report presentation
 one printed copy
 other copies usually electronic
 must not be tied to internet
 media must be labeled clearly
 media must be user-friendly
 media must work - test on various computers;
test all drives
65
Technology Tools
Internal document sharing:
 Dropbox
 SharePoint
 Google docs
 Atlassian Confluence
What others have you used?
66
Technology Tools…continued
Final preparation and presentation platforms
 Compliance Assist
 Xitracs
 LiveText
 Digital Measures
 TaskStream
 Home grown
 What others have you used?
67
Technology Tools…continued
Open communication – to share or not to share
 http://louisville.edu/institutionalresearch/accreditation/5year.html
 http://www.mcneese.edu/sacs
 http://www.virginia.edu/sacs/fifthyear.html
 http://www.tstc.edu/docs/6291.pdf
68
Litmus Test Questions
69

Is each narrative focused only on the requirements of the
standard?

Does each narrative state just enough, and not too much,
in making a case for compliance for each requirement?

Were only past and present tense verbs used to verify
compliance?

Were adjectives and adverbs limited to necessary
descriptors?

Has relevant, sufficient, reliable, verifiable, representative
evidence been provided to support a claim for compliance
for each component of each standard?
Litmus Test Questions…continued
70

Are evidence documents highlighted or pertinent sections
extracted to focus the reader on the specific information
needed to verify compliance?

Were names and identifying information redacted when
necessary?

Is each narrative clear to all readers (no jargon, acronyms,
assumptions)?

Were pertinent quotes from the mission statement provided for
most of the standards as needed?

Were the pertinent policies or procedures, including
verification of their being approved by appropriate bodies and
published, provided and highlighted where needed (which is
just about everywhere)?

And, of course, was everything in the report accurate?
Input from our peers
What did you find most challenging in completing the
SACSCOC Fifth-Year Interim Report?
 ambiguity
of terms/expectations and what that
might mean to the reviewers
 time
management; managing internal deadlines
 starting
the report. Narrative content, quality, length,
etc.; gathering appropriate evidence documentation
and uploading electronically; and the QEP Impact
71
Input from our peers
What was the biggest surprise you found during the
SACSCOC Fifth-Year Interim Report process?
 The
approach taken with the [decennial] report five
years prior was insufficient at the time of the FifthYear report even when there had been no change
in the standard.
 The
abbreviated [Fifth-Year] review was very labor
intensive, the logistics of a 5 vs. 10 year- committee
organization & constituent review- not much
different.
 inclusion
72
of new standards (several responses)
Input from our peers
What advice would you give to those preparing a
2014 SACSCOC Fifth-Year Interim Report?
 start
 use
early- particularly on CR 2.8 and CS 3.3.1.1
the Resource Manual
 develop
a consistent method of labeling evidence
files
 employ
 perform
an editor
gap analysis and policy inventory on each
standard at least a year before report is due and
discuss progress monthly with administrators
73
Advice from peers cont.
 There
is no off-site/on-site double review to
encourage consistency with meeting standards.
 It
is not [just] an interim report but a reaffirmation
report.
 Give
serious consideration to a management
system (s.a. Compliance Assist or Xitracs) to
streamline the process and allow you to focus on
content.
 When
completing any standard that could be
relevant to distance education offerings, ensure that
you’ve mentioned how distance ed students are
served/supported. This makes CS 3.13.C easier.
74
Advice from peers cont.
 Build
in way more time than you think you will need;
anticipate that standards will be added or
significantly revised.
 Stay
current with SACSCOC website and ask
questions; communicate regularly with your VP.
 Fashion
your narrative for a reviewer who does not
know your institution at all.
 Have
 Allow
75
IT nearby at all times. [Make sure it works!]
as much time as possible for editing. Have
independent readers critique the semi-final drafts of
the report.
What opportunities arise from the
Fifth-Year Report preparation?
76

collaboration of a team from across the institution with a
common goal

communication and education of institutional strengths
to internal and external audiences

validation of quality by peers

clarification of definitions, policies, and procedures
What opportunities arise from the
Fifth-Year Report preparation?
…continued

identification of areas where improvements can be made
even when currently in compliance

gap analysis/preparation for the next decennial report

thorough review of all Web pages and publications to ensure
they are consistent and correct
What are other opportunities arising from the report?
77
Resources

The Fifth-Year Interim Review Process & Included Standards
- Crystal Baird’s 2013 Summer Institute Presentation
http://www.sacscoc.org/cbaird.asp

Busting Myths About SACSCOC - Michael Johnson’s 2013
Summer Institute Plenary Presentation
http://www.sacscoc.org/institute/2013/Institute13/Plenaries/johnson1.PDF

SACSCOC Templates for the Compliance Certification
http://www.sacscoc.org/cctemplates.asp
78
Resources…continued

Handbook for Review Committees
http://www.sacscoc.org/pdf/handbooks/Exhibit%2018.HandbookForR
eviewCommittees.pdf

Evaluator Training Modules: Institutional Effectiveness
http://www.sacscoc.org/trngmods/IEModules.pdf

Evaluator Training Module: Student Services
http://www.sacscoc.org/trngmods/SSModules.pdf

Analyzing a Case for Compliance rubric
http://www.sacscoc.org/pdf/ANALYZING%20A%20CASE%20FOR%20COMPLI
ANCE_SEPT2010%20_2_.pdf
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Resources…continued
SACSCOC Listserv
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…and the reason we do all this
81
University of Central Florida
82
Dr. Tace Crouse
Director, Special Projects
Fifth-Year Report Coordinator
Academic Affairs
tace.crouse@ucf.edu
Dr. Diane Chase
Executive Vice Provost
SACSCOC Liaison
Academic Affairs
diane.chase@ucf.edu
Ms. Heidi Watt
Director, Accreditation and
Quality Assurance
Academic Affairs
heidi.watt@ucf.edu
Dr. Denise Young
Associate Vice President
Former SACSCOC Liaison
Regional Campuses
denise.young@ucf.edu
http://afia.ucf.edu/accreditation