II.b. Accreditation Process: Review Process
Initial Evaluation | Site Visits | CAA Actions on Applications | CAA Action on Other Reports
Accreditation Review Process
The steps in the CAA accreditation process are shown in Figures 1 and 2 in the appendices and are described below. All accreditation review materials, including the application and related correspondence, must be provided in and site visits conducted in English. The service of a translator or translation of documents will be the program’s responsibility and at its expense.
The CAA chair or members of the CAA are available at any time during the accreditation process to provide ongoing guidance to programs. The CAA staff is also available to provide consultation on procedural issues. CAA and staff members may be contacted through the ASHA National Office at:
Council on Academic Accreditation in Audiology and Speech-Language Pathology
2200 Research Boulevard
Rockville, MD 20850
Phone: 800-498-2071 or 301-296-5700
Additional information is available on the Accreditation section of the website.
Initial Evaluation of Application
The CAA reviews initial applications to determine whether a program appears to be in compliance with the standards. (See Standards for Accreditation of Graduate Education Programs in Audiology and Speech-Language Pathology in Chapter III of this manual.)
Observations that the CAA noted in its initial review are communicated in writing to the program. After reviewing the comments, the program director, in consultation with the faculty, decides whether to proceed with the accreditation review or to withdraw the application. This decision should be based on the program's own evaluation of its ability to demonstrate compliance with the standards by the time the site visit is conducted. Within 30 days from the date of the letter of initial observations, the program director should notify the CAA chair of the decision to either proceed with a site visit or withdraw the program's application.
The CAA makes every effort to assist programs to meet the Standards. By identifying problem areas early in the initial accreditation or reaccreditation process, the applicant program can take steps to correct deficiencies and thereby avoid the expense of a site visit that does not lead to accreditation.
All programs proceeding with the site visit should submit a written response to the CAA's concerns at least 30 days before the site visit. If the site visit is not scheduled within 6 months of the date of the letter of concern, the program will be required to submit updated information before the site visit.
The CAA, in consultation with the program director, determines the length of the site visit and the size of the site visit team. Site visits are conducted typically by 3 visitors over 2 days 1 for a single professional area, i.e. audiology or speech-language pathology. Site visit teams assigned to programs that submit accreditation applications for both professional area degree programs in the same cycle will be increased to 4 visitors. A program may require a larger site visit team or more than 2 days for the review, particularly if it is undergoing a joint site visit with another accrediting group or agency, or if it is located on more than one campus.
Site Visit Team
An individual may not serve as a site visitor to a given program if he/she (a) lives in the state in which the program is located or in close geographic proximity to the program, (b) has been a member of the faculty/instructional staff of the program, (c) was a student in the program, (d) served as a consultant or as a site visitor to the program during the last accreditation review, or (e) is a faculty member whose program was site visited within the past 5 years by a faculty member of the program currently being evaluated.
In addition, individuals who cannot ensure impartiality and objectivity because of a potential conflict of interest or appearance of a conflict of interest should not serve as a site visitor to the program. The responsibility for determining a conflict of interest is shared equally by the program and the potential site visitors. A more detailed description of the site visit team and criteria for the selection of site visitors is given in the CAA Site Visit Manual.
A site visitor trainee may be assigned to a team for his or her initial site visit after the successful completion of a two-day training workshop. The trainee is expected to actively participate as a full member of the team and will be given assignments by the site visit team chair accordingly.
Occasionally observers, such as CAA members or representatives from another accrediting agency, may accompany a site visit team. Observers do not participate in either the conduct of the site visit or the preparation of the site visit report. The program will be notified before the site visit if any observers will be present.
Site Visit Agenda
The program director must submit a tentative site visit agenda to the site visitors at least 30 days before the visit. (See CAA Site Visit Manual for a sample agenda.) Site visitors may request changes in the proposed agenda. Activities should not be scheduled during the evenings so that site visitors may have time to confer and prepare for the next day.
The CAA provides the opportunity for public comment regarding the program to be site visited. A list of programs due for a site visit during a given semester is published on ASHA's Web site. Any comments received are provided to the site visit team for review and consideration during the site visit. (The CAA Policy on Public Comment is further described in the Site Visit Manual, and is available on ASHA's website and from the Accreditation Office.)
In addition, the program director must ensure that the site visit is announced to the public in a timely manner so that faculty, administrators, students, clients, community professionals, and the general public have the opportunity to address the site visit team.
Site Visitor Travel Arrangements
The program director is expected to make confirmed hotel or motel arrangements for the visitors. Site visitors make their own travel arrangements through the ASHA travel service and are responsible for all their own expenses during the visit. The program director may assist the site visitors with local transportation arrangements. Site visitors are reimbursed by ASHA for all expenses that conform to ASHA travel policies, but receive no other compensation for their services.
Conduct of Site Visit
Site visitors are responsible for a comprehensive review of the program and for identifying documentation relative to all the standards for CAA accreditation. All information gathered by the site visitors is treated in a strictly confidential manner. Site visitors may discuss the information they obtain only among themselves, with individuals interviewed during the site visit, and with the CAA. The team will perform the following duties:
- Confer with the institution's administrators on attitudes toward, and plans for, the program; verify program administrative structure;
- Review the physical facilities, available computer and technology resources, and library holdings;
- Interview the academic and clinical staff regarding the academic and clinical programs; verify instructional staff's allocation of time;
- Select and review materials and records on the curriculum and academic program;
- Select and review materials and records on clinical education;
- Select and review student records of academic and clinical experiences;
- Interview off-campus practicum supervisors and may visit off-campus practicum sites; and
- Gather information relative to CAA's identified concerns or requests for clarification from review of the application.
Throughout the site visit, open discussion between site visitors and all individuals interviewed is encouraged. The site visit team provides an exit report to the program director to clarify or verify information that has been collected. The program director is encouraged to invite interested individuals, such as the program's instructional staff and university administrators, to the exit report. During the exit report, and indeed at any time during the site visit, the site visitors must not express any opinions or recommendations concerning the program's prospects for accreditation.
Site Visit Report
The chair of the site visit team submits a written report to the CAA within 30 days of the visit. This report includes a summary of the site visitors' observations regarding each standard and any information not included in the application. The observations site visitors make in the report must be supported by factual information. Site visit reports must summarize the program's strengths and limitations and supply explanatory information. The site visit report must not include any recommendations concerning accreditation. All site visitors must sign site visit reports. Site visits that are conducted for dual professional area programs will result in one joint report from the team. (Further information on the content of the site visit report may be found in the CAA Site Visit Manual.)
The chair of the CAA sends the site visit report to the director of the program and the institution's president or designee within 10 days of receipt with an invitation to review and respond to the report. Within 30 days of the date of the letter, the program director should provide to the CAA chair a written response that comments on the accuracy of the information contained in the site visit report, any changes in the program since the site visit, and planned changes.
The program's response to the site visit report is shared with the site visit team. The site visitors have 2 weeks to provide additional comments to the CAA. The site visit report is confidential and, therefore, is provided by the CAA only to the program, the site visit team, and to the CAA members.
The CAA may contact the site visitors for clarification when the Council is considering the site visit report and at other times, as needed. To ensure confidentiality and objectivity, individual members of the Accreditation Office staff, the CAA, and the site visit team are enjoined from responding to requests from the program for information about the accreditation review. Procedural questions regarding the conduct and report of the site visit should be directed to the chair of the CAA. The CAA has sole authority to make official accreditation decisions for a program and identify any official areas of non-compliance or areas that need improvement. The citations in an accreditation decision letter may reflect findings different than those reported by the site visit team.
Evaluation of Site Visit Process
At the conclusion of a site visit, programs are asked to complete an evaluation of the members of the site visit team, as well as the site visit process. In addition, each member of a site visit team is asked to provide evaluations on each other. Individual feedback is provided to each site visitor yearly. These written site visitor evaluations form part of an ongoing assessment process that is carried out by the CAA on an annual basis.
Site visitors are also expected to complete annual professional development sessions during their term. These sessions provide general feedback to the group as a whole, provide updates on new policies and procedures, and clarify and calibrate the site visitors on interpretation of the accreditation standards.
Multiple Site Programs
Applications for programs offering academic components in more than one location will be evaluated using the same procedures as other programs and should demonstrate that all standards are met at each site. All locations at which academic instruction is provided will be reviewed during site visits and visited where practical. Site visit teams will be charged with the responsibility of reviewing and describing in particular those program aspects that are affected because of the multiple sites.
Programs that are considering establishing multiple site components to their programs should seek guidance from the CAA in advance of such actions and follow the guidelines provided in the CAA Policy on Substantive Changes, as described in Chapter V of this manual.
If additional days or site visitors are required because of the additional locations, the program will be assessed additional site visit fees.
Discontinued Accreditation Review
Programs that apply for an accreditation status with the CAA must comply with all reporting and financial deadlines to fully administer the review and decision processes for the application. This expectation also extends to programs that are designated as "applicants" and do not currently hold an accreditation status with the CAA. The CAA will discontinue an accreditation review for applicant programs when an applicant program is judged to have not met its reporting and/or financial expectations to the CAA. Such an action is taken by the CAA as a result of failure, by established deadlines, to:
- complete and file any required accreditation application materials, e.g., resubmission of candidacy application, submission of initial application for accreditation after conveying its notification of intent; including all special requests for information, or
- pay site visit fees.
Application reviews are initiated with the payment of an application fee.
A program that wishes to submit an application for initial accreditation also must officially notify the Accreditation Office no later than 5 months before submission date (i.e., by September 1 for February 1 submission or by March 1 for August 1 submission). These notification deadlines allow sufficient time for the applicant program to be scheduled in the Higher Education Data System (HES) and then be provided access to the system to complete its application for initial accreditation. If the program fails to meet the notification deadline, it will be scheduled for the next HES fielding. If the program fails to meet the identified submission deadline, and failed to request an extension in advance of that deadline, the program will be re-scheduled for the next HES fielding. Data entered as part of the application for initial accreditation will be retained in the HES. Failure to meet the submission deadline for the second scheduling will result in the discontinuation of the review and the program will be required to submit a new notice of intent and application fee.
A program that wishes to submit an application for candidacy must follow the protocols described in the Candidacy Manual. Although a notification of intent is not required for new developing programs, there are specified time frames in which materials must be provided in order for the review to continue, e.g. submission of application after readiness review. Failure to meet designated deadlines will result in the discontinuation of the candidacy review and the program will be required to submit a new application and application fee.
Site Visit Fees
When the application review has been discontinued due to non-payment of site visit fees, the CAA will defer any final review and action on the application until the fee is paid, but no longer than 90 days after the invoice date. If the program fails to pay delinquent fees by that time, the CAA will consider the review ended and the program must submit a new application and application fee.
 The CAA will not initiate a review of an application for candidacy or initial accreditation without the application fee being submitted. This policy on the discontinuation of an accreditation review assumes an application fee was paid.
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CAA Final Review of Initial and Reaccreditation Applications
The CAA reviews the application, the site visit report, the program's response to the site visit report, and the site visitors' additional comments. To avoid any actual or implied conflict of interest, the following procedures are followed: (a) members of the CAA must leave the room during discussions about any accreditation decisions involving their own institution, (b) members of the CAA may not participate in the discussion or vote on programs located in their own state or geographic proximity, and (c) members must refrain from participating in the consideration of an accreditation decision whenever, for any reason, there is a conflict of interest or the appearance of a conflict of interest.
CAA members will vote on program accreditation decisions only in their own professional area (i.e., audiology members will vote on audiology programs and speech-language pathology members will vote on speech-language pathology programs). The public member also will participate in all accreditation decisions, consistent with the conflict of interest policy.
The CAA will vote to: (a) award initial accreditation for 5 years or reaccreditation for 8 years, (b) place the program on probation for one year if it is applying for reaccreditation, or (c) withhold accreditation if the program is applying for initial accreditation, or withdraw accreditation if the program is applying for reaccreditation.
The CAA's decision is transmitted in writing to the program director and to the university president or designee within 30 days of the decision. In addition, in order to provide site visitors with ongoing training and opportunities for self-assessment, the final CAA accreditation decision and rationale regarding a specific program will be provided to the individuals who conducted the site visit to that program on behalf of the CAA. This information will be sent to the site visitors with a request that the information be kept confidential and not divulged to any outside party.
The CAA may defer making a final decision on accreditation if there is insufficient information upon which to base a decision. In such case, the decision is deferred until a time specified by the Council. The CAA will notify the program when a decision is being deferred and may request that a program submit additional information or materials by a specified date for consideration by the members of the Council in making a final accreditation decision. The CAA may also, at its discretion, conduct a special evaluation site visit to further investigate a particular issue to determine whether the program is in compliance with specific standards. The CAA will indicate to the program the explicit reasons that such a visit is necessary. Such visits may be conducted by members of the site visitor pool or by members of the CAA. These site visitors will write a report to be considered by the full Council at its next regularly scheduled meeting. A program's accreditation status remains unchanged during a period of deferral.
CAA Action on Initial and Reaccreditation Applications
Upon completion of its review, the CAA will take one of the following accreditation actions described below.
Initial accreditation is awarded for 5 years, subject to annual review by the CAA, to programs that are judged to be in compliance with all accreditation standards. Reaccreditation is awarded for 8 years, subject to annual review by the CAA. A statement of concerns may accompany the letter awarding accreditation, to assist the program in conducting self-evaluation before the first annual report. Continuation of accreditation is dependent upon approval of an annual report and timely payment of annual accreditation fees.
Place Program on Probation
An accredited program is placed on probation when it is judged to be not in compliance with the accreditation standards and when there is clear evidence of circumstances that jeopardize the capability of the program to provide acceptable educational experiences for the students. A program also may be placed on probation because the program has not corrected deficiencies noted earlier by the CAA. This decision option is not available when considering initial accreditation applications, either for a program in candidacy or an applicant; this option is available only for actions on currently accredited programs. A probation decision may not be appealed.
A program placed on probation must demonstrate compliance with the standards within one year. A program on probation is considered to be an accredited program. Because programs on probation continue to be accredited, a new accreditation cycle will be awarded if the decision is based on the review of an application for reaccreditation. There are no changes in a program’s accreditation cycle if placed on probation as a result of an annual report or other review. The probationary status remains in effect until the CAA makes a decision, based on the Probation Report, to continue accreditation, withdraw accreditation, or to extend probation for one year. See Probation Report section in this chapter for the reporting obligations and decision options of probation reports.
Withhold or Withdraw Accreditation
The CAA withholds accreditation or withdraws reaccreditation from a program when it judges that the program is not in compliance with all Standards for Accreditation. The program's director and the institution's president or president's designee are informed that accreditation has been withheld or withdrawn when this decision is made.
Notification also includes justification for the decision and informs the program of its opportunity to request a Further Consideration review of the decision by the CAA and subsequently to appeal the decision. A copy of the current further consideration and appeal procedures are made available to the program. The program may apply to the CAA for an accreditation status in future without prejudice.
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CAA Review and Action on Other Reports
In order to maintain accreditation, programs must submit various reports for CAA approval, as described below.
An accredited program must submit an annual report to the CAA on or before the anniversary date of accreditation to document continuing compliance with the accreditation standards. Programs are expected to file annual reports by February 1st or by August 1st; due dates are assigned based on the program's anniversary date of accreditation.
|Annual Report Due Date:
|Anniversary or Reporting Date:
Programs in the initial 5-year accreditation period must file an application for reaccreditation in lieu of the fourth annual report. Programs accredited for 8 years must file an application for reaccreditation in lieu of the seventh annual report. The CAA reviews the annual reports to determine whether a program appears to remain in compliance with the standards. If an obvious omission is noted in an annual report, the program will be notified and asked to supply additional information within 4 weeks of the date of notification.
If the annual report is not received within 45 days of the due date, the program's director and the institution's president or president's designee are notified that if the annual report is not received within 30 days of the date of notification, a special site visit will be conducted at the program's expense. The purpose of the special site visit is to verify compliance with the standards.
After reviewing the annual report and any additional information submitted by the program, the CAA takes one of three possible actions: (1) continues the program's accreditation, (2) places the program on probation, or (3) withdraws accreditation. (See the description of these types of actions above.)
The CAA may also, at its discretion, conduct a special evaluation site visit to further investigate a particular issue to determine whether the program is in compliance with specific standards. The CAA will indicate to the program the explicit reasons that such a visit is necessary. Such visits may be conducted by members of the site visitor pool or by members of the CAA. These site visitors will write a report to be considered by the full Council at its next regularly scheduled meeting. In the case of a special visit, the program's current accreditation status will continue until the CAA makes a final accreditation decision.
After the CAA has placed a program on probation for non-compliance with accreditation standards, the program must demonstrate compliance by submitting a Probation Report no later than one year from the date of the letter transmitting the probation decision. If compliance with the accreditation standards is not demonstrated within one year, accreditation will be withdrawn. Probation may be extended for one additional year only under extenuating circumstances. Probation status may not exceed 2 years. However, if, at any time during the year, the program is able to rectify the deficiencies noted and achieve compliance with the standards, the program may submit its Probation Report. The probationary status remains in effect until the CAA makes a decision, based on the Probation Report, to continue accreditation, to withdraw accreditation, or to extend probation for one year.
Substantive Change Plans
At times, substantive changes occur in a program that may have a direct and significant impact on the program's ability to comply with the accreditation standards. To assess the continued quality of education being provided to students in CAA-accredited and candidate programs and the programs' continued compliance with the Standards for Accreditation, the CAA must review and approve substantive changes that occur between scheduled review periods. The CAA requires that, prior to the implementation of a proposed substantive change, the program submit a Substantive Change Plan to the Council describing the proposed change(s). Programs are expected to submit these materials in accordance with the CAA Policy on Substantive Changes and the accompanying submission procedures, as described in Chapter V. of this manual.
The CAA will evaluate whether the proposed change affects the accredited program's ability to maintain compliance with the accreditation standards. Site visits will be conducted if necessary in accordance with CAA procedures to assure that the program component is in compliance with the CAA standards. If multiple sites are affected, a sample will be selected for visitation. An additional fee will be assessed for site visits.
In addition to its review of the substantive change plans, the Council will consider impact of the plans on the accredited program. If the substantive change plan is approved the CAA can take the following additional actions, depending on the type of substantive change, number of sites or programs involved, and the degree area of the accredited program, and would be communicated in the approval letter.
For programs that are adding a distance education component, adding a satellite location or branch campus, or developing a contractual arrangement, the CAA will take separate actions on the proposed change and the accreditation status of the established program. The CAA may approve, deny, or defer for additional information the substantive change submitted by the program. The CAA can take the following actions on the established program: (1) continue accreditation, (2) place the program on probation, or (3) withdraw the program's accreditation. A decision to deny approval of the substantive change or withdraw accreditation status can be made final only after the program has been offered the opportunity to request Further Consideration by the CAA and subsequently to appeal the decision.
1. Transition from 2-member site visit teams (both academics) to a 3-member site visit team (2 academics and 1 practitioner) was implemented Fall 2002.
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