CAPTE: On-site Reviewer Training
MODULE 2
The Accreditation
Handbook
April 2017
This module will introduce you to the Accreditation Handbook, which has
been developed by the Commission on Accreditation in Physical Therapy
Education (CAPTE) to document its procedures and rules. As an on-site
reviewer, you will use this document to look up information about the
accreditation process when questions arise.
1
Objectives
•
•
•
•
•
Identify the best way to access the most
current version of the Accreditation
Handbook
Identify the purposes of the Accreditation
Handbook
List the individuals who might use the
Accreditation Handbook
Identify the types of information that is
included in the Accreditation Handbook
Locate relevant sections of the
Accreditation Handbook
Please take a moment to review the objectives for this module.
2
Accessing the Accreditation Handbook
CAPTE Review
CAPTE reviews the rules
at each meeting
www.capteonline.org
Website
The latest version of the
Handbook can always be
found on CAPTE’s website
Notification
Changes to the Handbook
are publicized via the
Accreditation Update
The Accreditation Handbook is an electronic document available from the
CAPTE web site. Making all rules available to all interested parties is part of
CAPTE’s ongoing efforts to make all of its activities completely transparent to
its stakeholders.
The Handbook can be viewed online or downloaded as a PDF document. If
needed, a PDF reader is available as a free download at the web site as well. It
might be helpful to have access to the Handbook as we discuss it.
CAPTE has a standing activity to review the rules at each of its meetings to
ensure that the rules continue to meet CAPTE’s goals and to reflect best
practice in accreditation. The online version is the most current version.
Whenever changes are made, the rules are provided to the communities of
interest through the Accreditation Update and located on CAPTE’S web site.
3
Purpose of Accreditation Handbook
Guidance
for
operation
of CAPTE
Information to
programs about
accreditation
Guidance for Staff
on accreditation
procedures
The handbook provides information about accreditation in physical therapy
education for developing and existing programs. It also guides the operation
of CAPTE and its staff. The handbook includes the details of the
accreditation process, the types of accreditation status decisions, methods
for filing appeals and complaints, the standards, and the position papers
produced by CAPTE.
4
Intended Audience
Representatives
of institutions &
programs
CAPTE
On-site team
members
General public
All of those involved in the accreditation process should have a
working knowledge of the Accreditation Handbook. The accreditation
handbook is intended for representatives of institutions and programs,
on-site team members, CAPTE and the general public.
5
Handbook Contents
Introductory
information
Rules of
Practice and
Procedure
Standards
Additional
information for
programs
Position
papers
The Handbook begins with introductory information including an overview of
accreditation, much of which was covered in the previous module on the purpose of
accreditation.
The majority of the handbook delineates the rules of practice and procedure under which
CAPTE operates. The rules are designed to ensure that all stakeholders are treated fairly
and that the processes used in accreditation are designed to lead to quality improvement
in physical therapy education. Because of this, they are of necessity, detailed.
The Handbook includes the Standards and Required Elements for the PTA and PT
education programs.
The Handbook also includes additional information helpful to programs involved in the
pre-accreditation and accreditation process. This includes guidelines for the candidacy
process and for on-site visits.
Finally, the Handbook contains position papers adopted by CAPTE that are intended to
clarify the Commission’s position on a number of issues, for example, faculty
qualifications, distance education, and the PT/PTA relationship.
6
Handbook Revisions
IMPORTANT!
Review relevant portions
prior to participation
Since changes to the rules may occur twice a year, it is strongly
recommended that everyone working in accreditation, including on-site
reviewers, program faculty, and institutional representatives review the
relevant portions of the rules whenever they participate in accreditation
activities.
7
Rules: CAPTE Function and Structure
Part 1
Part 2
Part 3
Part 44
Part 1: Integrity in Accreditation Process
Part 2: Purpose, Tasks, Mission, Vision, & Scope
Part 3: Organization, Roles and Responsibilities
of CAPTE & Staff
Part 4: Operation of CAPTE
The first section of the Handbook addresses the rules. Part 1
addresses CAPTE’s commitment to integrity and its expectations for
program and institutional integrity. Part 2 describes the mission and
function of CAPTE as well as the tasks or activities to manage the
accreditation processes.
Part 3 includes a description of the composition of CAPTE as well as
the roles and responsibilities of each group. The 31 member
Commission consists of 3 panels. Each panel member represents a
specific constituency that CAPTE serves, including the public, clinical
practice and PT & PTA educational programs.
Part 4 contains detailed rules for the day-to-day processes of CAPTE,
including the procedures for meetings. The rules regarding conflict of
interest and confidentiality are included here. Subpart 4.4 delineates
the components of the Summary of Action, the official report of an
accreditation status decision.
8
Rules: Accreditation Procedures
Part 5
Part 6
Part 7
Part
Part89
9
Part 10 Part 10
Part 5: Development of Standards
Part 6: Training Site Reviewers
Part 7: Achieving Candidacy Part 8:
Achieving Accreditation
Part 9: Reporting Program Changes
Part 10: Administrative Probationary Status
The next section of the rules deals with the actual procedures in the
accreditation process. Each part in this section will be reviewed in
upcoming slides, highlighting the implications for reviewers and for
programs.
9
Part 5: Development of Standards
Systematic Revision of Standards
Seek
stakeholder
comments
Convene
CRG
Hold
public
hearings
Adopt and
notify
stakeholders
The Commission has responsibility for developing, maintaining, and
disseminating the standards that are used to make accreditation decisions.
This part of the handbook focuses on the process used to determine the
content of the criteria. The process calls for a systematic revision of
standards every 5 years that includes seeking stakeholder comments;
convening a Standards Review Group, if necessary; holding public hearings
on the proposed standards; and adopting and notifying stakeholders of the
implementation of the new standards.
10
Revision of Standards Between
Cycles
Seek Comments
Adopt
Notify Stakeholders of Implementation
Occasionally the standards are revised outside of the 5-year cycle based on a
demonstrated need. These revisions usually only pertain to a small number of criteria.
The overall process however is the same as the full standards review. First the
Commission seeks comments from stakeholders, then adopts the change, and finally
notifies stakeholders of the implementation.
Whether the standards are being revised on the normal review cycle or because of
needed major issues, CAPTE must seek comments from stakeholders and provide ample
notice to programs to come into compliance with the new standards. Minor changes do
not need the stakeholder review.
11
Part 6: Selection and Training On-site
Reviewers
Nomination
Initial
Minimum 2 years
experience
Re-training
Selection
Training
Performance
assessment after
each visit
Assessment
Part 6 details the process of being nominated, selected, and trained as a
reviewer. Retraining occurs when the standards are revised. Assessment of
performance is part of the on-site visit process and includes self assessment,
peer assessment and assessment by the program. In addition, staff and the
Commission provide feedback on the Visit Report that the team writes.
12
Part 7: Candidacy
Not an
accredited
status
Ensures
minimal
expectations
in place prior
to student
enrollment
Does not
ensure
accreditation
Part 7 is divided into sections that address the various steps and requirements to achieve
the status of Candidate for Accreditation.
Candidacy is a non-accredited affiliation that indicates that a program is progressing
toward achieving accreditation. Although Candidacy helps to ensure proper planning, it
does NOT ensure eventual accreditation. Part 7 is particularly helpful for Candidacy
Reviewers, those reviewers specifically engaged in reviewing programs for Candidacy
status and for institutions contemplating expansion into the field of physical therapy.
13
Part 8: Achieving Accreditation
F
Compliance Reports
A
Self-study Report
B
Third party Testimony G Annual Accreditation
Report (AAR)
C
On-site Visits
D
Visit Report
H
KEY POINT!
Graphic
placeholder
E
CAPTE Decisions
Compliance with
Revised Standards
Self-study Report, the Visit Report, and the
program’s response to the Visit Report are
the central data sources for CAPTE
in making an accreditation decision
This part contains the policies and procedures related to the specific process
used by programs in achieving and maintaining accreditation. The Handbook
contains sections that address the areas delineated in the slide. Later in this
training there will be specific modules on the Self-study Report; the On-site
Visit; the Visit Report; and CAPTE decisions that will cover these areas in
more depth. The Annual Accreditation Report or AAR is used to monitor
compliance with the standards. Data collected in the AAR is also used to
develop the PTA and PT Education Fact Sheets that can be found on
CAPTE’s website under the heading Aggregate Program Data.
14
Part 9: Reporting Change
Contact Information
Substantive Changes
that must be reported
but don’t require prior
approval
Substantive Changes
requiring prior approval
Program contact
information (including
change of leadership))
Change in curriculum,
decision not to admit a
class, etc
Mode of delivery,
expansion program,
increase in class size,
etc
Part 9 of the Handbook identifies the changes that must be reported to
CAPTE. The changes fall into 3 categories. Examples are provided of the
type of change that fall into each category; Part 9 delineates all of the
changes that must be reported. The Application of Approval of Substantive
Change, also called an AASC, is the document programs submit when prior
approval is needed.
15
Part 10: Administrative Probation
✓ Not an accredited status, but a classification
✓ Not subject to reconsideration or appeal
✓ Administrative Probation is noted on all lists
✓ Part 10 delineates reasons for this status
Part 10 covers the circumstances for a program being placed on Administrative
Probation. During a period of Administrative Probationary Accreditation, a program
continues to be recognized as being accredited according to the last status decision and
is maintained on the list of accredited programs. The program will be listed as having
Administrative Probationary Accreditation in all published documents that specify the
accreditation status. Examples of reasons for administrative probation include:
• Not paying the annual accreditation fees within 60 days after being notified of a pastdue account
• Not submitting accreditation reports in a timely manner, or
• Implementing changes without prior approval, if prior approval is required
16
Part 11 - 15: Appeals and Complaints
COMPLAINTS
Part 11:
About Programs
and Institutions
Part 12:
About CAPTE
RECONSIDERATIONS
Part 13:
Of Candidacy
Decisions
Part 14:
Of Accreditation
Decisions
APPEALS
Part 15:
Of CAPTE Decisions
The handbook also contains rules for appeal procedures and the handling of
complaints. Parts 11 and 12 deal with the ability of constituents to bring
forward complaints, either about programs and institutions or about CAPTE.
Part 13 and 14 address the rules for programs asking CAPTE to reconsider its
decisions. Part 15 provides guidelines for when a program wishes to appeal
a decision made by CAPTE. Appeals are heard by an independent panel
appointed by the Executive Committee of the American Physical Therapy
Association.
17
Part 16: Fees
Preaccreditation Fees
Special Fees
FEES
Annual Fees for
Accredited
Programs
Review Fees for AASCs
Part 16 describes the different types of fees and their amounts.
18
Position Papers
Position Papers
Clarify CAPTE’s policies or expectations
Available in Accreditation Handbook
On occasion, CAPTE issues a position paper designed to clarify its policies
or expectations. These are made available in the Handbook. When a new
position paper is written, it is announced in the What’s New section on
CAPTE’s website.
On-site reviewers should be familiar with the position papers related to the
program under review.
19
Summary
• Accreditation Handbook
– Rules and Procedures
– Standards and
Required Elements
– Position Papers
As has been shown, the Handbook contains a great deal of information. It is
not intended to be fully assimilated in one reading. Be sure to see it as a vital
reference for your work in the accreditation process and visit it often!
Remember that it is important to use the most current version that is found
on CAPTE’s website.
20