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National Accreditation Council (NAC)
for Agencies Serving People with Blindness or Visual Impairment
7017 Pearl Road
Middleburg Hts, Ohio
Telephone: 440-545-1601
HANDBOOK FOR
ON-SITE PEER REVIEW
TEAM MEMBERS
REVISED: March 2009
NAC PREFACE.
STAFF PREPARATION FOR AN ON-SITE PEER REVIEW.
ON-SITE PEER REVIEW TEAM.
ROLE OF THE TEAM MEMBER.
PREPARING FOR AN ON-SITE PEER REVIEW.
AN OVERVIEW OF THE EVALUATION TEAM AT WORK.
DURING THE EVALUATION TEAM VISIT.
WRITING RECOMMENDATIONS, COMMENDATIONS AND SUGGESTIONS.
WRITING THE ON-SITE PEER REVIEW TEAM REPORT.
On-Site Peer Review (OSPR) evaluations by qualified evaluators are required for initial or reaffirmation of accreditation. After granting initial accreditation, the Council continues to monitor and evaluate the school or agency through annual reports, progress reports, interim reports and visits, and comprehensive institutional self-studies followed by a full scale on-site visit. The on-site evaluation is an important step in the Council's peer review process as it makes decisions regarding the accreditation status of a school or agency.
This handbook is intended to serve as a guide for evaluation team members. It contains important general information about accreditation and the Council, but is designed primarily as a practical step-by-step guide to what must be done before, during and after the on-site visit. Although many team members will have considerable experience with evaluation teams, the handbook approaches the process without assuming any particular level of knowledge about the Council or the evaluation process.
The Council's Handbook of Accreditation, a composite of information about the evaluation and accreditation of schools and agencies that serve people with blindness or visual impairment, is a companion document of this Handbook for On-Site Peer Review Team Members. It is important for an evaluator to be familiar with both publications and have them available during an on-site evaluation.
The executive director of the Council initiates correspondence with the chief executive officer (C.E.O.) of the institution at least one year in advance of a full-scale evaluation. Dates of the on-site review are approved by the C.E.O. In most cases, team chairs are assigned by the Council at least six months prior to the on-site evaluation. Soon after the dates have been set, the executive director proceeds to make preparations for the visit with appropriate representatives of the institution by correspondence, e-mail, telephone or a preliminary on-site visit. The following topics are covered by the executive director:
1. Discussion with the C.E.O. about the person to be appointed by the Council as the on-site team chair.
2. Discussion and agreement about the numbers of evaluators to serve on the evaluation team and their respective assignments in instructional, administrative, service, and special areas to effectively cover all the activities indicated under the statement and mission and goals of the institution. If the evaluation is to be conducted with another recognized accrediting body, the executive director will contact the other accrediting body about joint arrangements for the evaluation.
3. Discussion with the C.E.O. about the cost of the evaluation.
4. It is noted that evaluation team members, other than the chair, are assigned by the NAC's executive director. The C.E.O. is asked to notify the executive director in confidence of any person who would not be acceptable to the institution or who may have a conflict of interest.
5. Local arrangements for the evaluation team are determined:
a. The institution is asked to select a motel or hotel convenient to the campus that would accommodate the evaluation team, including a meeting room for the team's orientation meeting immediately preceding the visit.
b. The institution is asked to make available a suitable meeting room for the evaluation team on campus. The room should be large enough to provide adequate working space for the team. It should be private, where confidential materials may be left safely and where conversations of team members can be conducted without intrusions.
c. The institution is asked to provide in the meeting room, at the time of the evaluation, writing materials, current class and program schedules, staff directories, bulletins, catalogs, latest reports of other accrediting bodies, audits, staff handbooks, administrator handbooks, and other supporting documents that may be helpful to members of the evaluation team.
d. The need for computers (IBM or MACINTOSH compatible), perhaps, secretarial help that may be necessary to support the work of the evaluation team.
6. The executive director should arrange early in the self-study process to meet with key administrators, staff, and consumer representatives who have primary responsibility for the institutional self-study. Pertinent information in the NAC ACCREDITATION HANDBOOK regarding the self-study process will be discussed. The responsibilities of the evaluation team, its chair, and the Council also will be covered.
Review the section on the "On-Site Peer Review Team" in the NAC ACCREDITATION HANDBOOK. The section, under ten headings, pages 14-18, provides basic information on the organization and operation of the evaluation team.
The contribution of the individual evaluator on an evaluation team is a critically important part of a long and somewhat complex enterprise. A brief review of the process as a whole will help to explain the role of the team member.
Stage One. The school or agency self-assessment, is a major project that usually takes a year or longer to organize, plan and complete. It is a comprehensive analysis of the institution's total effectiveness in achieving its mission and goals made by is own staff, administration, governing board and representatives of its clientele. The self-assessment culminates in a bound volume, a copy of which is mailed to each team member several weeks before the visit.
An evaluator's first responsibility is to read carefully and think about the self-study. The evaluator cannot afford to slight this part of his or her role, or to do it hurriedly, for it is the evaluator's primary source if information. Remember, the self-study is the result of a great deal of effort which the evaluator's observations can only supplement and help interpret. The evaluator should also give careful attention to the institution's catalog or bulletin and other provided materials, such as the schedules of classes and programs. If applicable, the evaluation report of the previous evaluation team should be reviewed, either before the visit or while on site.
Stage Two, is the visit by the evaluation team. The team's function is to make an independent analysis, for the institution's use, of the quality of its performance in meeting the needs of its clientele, of the effectiveness of its procedures, of the effectiveness of its programs and services, of the adequacy of its resources for continuing to improve it performance, and to determine whether the institution meets the standards for accreditation. Continually bear in mind that the institution is to be evaluated in terms of the mission and goals it seeks to achieve.
Approach the task as an evaluator and colleague. The Council has no formulas or rating scales to apply or patterns to impose. As a colleague, the team member helps to identify any areas that need improvement. Approach the task humbly. No one has all the answers. The evaluator's detached position is a distinct advantage.
Stage Three, which comes as conclusion to the visit, is the evaluator's report. Do not underestimate the importance of this report. Its primary function is to give the staff, administration and governing board a critical analysis of the areas evaluated. The role of the evaluator in writing his or her report is not to describe but to evaluate. Assess the area(s) assigned objectively, critically and constructively. Fairness and accuracy are of utmost importance. Focus on compliance with the eligibility requirements, standards and policies of the Council. Pay particular attention to the instructions included herein for writing an evaluation team report.
Stage Four, is the Council's consideration of the evaluation team's report and confidential recommendation concerning accreditation, which is not part of the report. The procedure provides for the chair of the evaluation team to report orally to the Council in executive session and for the C.E.O. of the institution to answer questions and to openly comment on the evaluation and report of the evaluation team.
Council action on the institution may be to grant or reaffirm accreditation, with or without subsequent progress or focused interim reports, to defer action, or to deny accreditation.
In general, evaluation team members will do well, to begin with, by looking for coherence between what the institution says in its self-study, and what it does in practice. For example, is there agreement among statements in the self-study and the catalog or other documents? Does actual performance reflect what is reported and confirmed through input of consumers and their routine involvement in evaluating the quality of programs and services? Is the statement of mission borne out in institutional (and individual) action? Is there evidence to support institutional claims of effectiveness?
From the perspective of the Council, the institution and the peer review team members, the key to a successful evaluation is careful and thorough preparation and planning prior to the on-site visit. As noted earlier, the institution will provide each team member with a copy of the self-study, a current schedule of classes and program activities, and basic publications pertinent to the enterprise several weeks before the visit. Following is a set of eleven items strongly recommended by the Council to assist the team member in preparing for the visit:
1. Review all materials from the institution and the Council office as soon as possible.
2. Consult with the team chair if you have questions after reviewing the information.
3. Plan your schedule to be available for the entire evaluation. If a problem develops, contact the team chair or Council executive director.
4. Prepare a general outline of your assigned areas and develop questions to be asked when you conduct interviews.
5. List items you will want to verify from sources other than the self-study or interviews during the evaluation, such as the staff handbook, the student and consumer handbook, audit reports or other pertinent documents.
6. Prepare a list of staff members (by name or title) you need to interview, and request interviews with a representative number of students and consumers of the institution during the first full day of the evaluation, indicating the order and amount of time needed for each interview, usually 15 to 30 minutes. Some interviews usually can be arranged in groups. The team chair may request a copy of this list and notify the institution in advance. Bring the list of planned interviews and times to the organizational meeting of the evaluation team.
7. Evaluate the quality and acceptability of the self-study and be prepared to comment at the organizational meeting the quality and usefulness for the evaluation team.
8. In your preparation, give particular attention to the assessment of programs and services offered, staff evaluation, and the meaningful involvement of students and consumers in planning and evaluating the effectiveness of the institution.
9. Make your own arrangements for transportation. Be sure and arrive in time to participate in the evaluation team's organizational meeting.
10. Plan carefully for the organizational meeting of the evaluation team. This meeting is very important to setting the tone for the visit, clarifying assignments, and confirming the evaluation schedule.
11. Keep a record of expenses in connection with the visit which will be reimbursed by the institution.
An evaluation team usually consists of three to six members, depending on the size and statement of mission and goals of he institution to be evaluated. In considering team members, attention is directed to assigning persons whose background enables them to provide an understanding liaison with the institution to be evaluated.
The evaluation team works as a unit. Its members have particular assignments to ensure coverage of all programs and services, but each evaluator also has an equal responsibility for the report as a whole. Close cooperation and frequent conferences among team members are essential.
The team chair is definitely in charge of the evaluation. The chair is responsible for seeing that all important aspects of the institution are covered, all appropriate staff members are consulted, colleagues thoroughly understand one another, they persist until they are at least sure of the facts when their interpretations differ, a broad representation of students and consumers are interviewed, and the evaluation is conducted in accordance with the Council's instructions. The chair is the team's official spokesperson during the visit.
A detailed set of operating procedures for team members is not possible. Although NAC accredits only schools and agencies that serve people with blindness or visual impairment, no two institutions are the same. Team members must adapt themselves to the circumstances and use the techniques which suit them best. Their effectiveness is directly proportionate to their ability to work as a team. They need to confer with each other frequently.
Keep in mind that the team evaluations are conducted at the invitation of the school or agency. The hosts have their own daily work to do while the team is there. Adjust the team's work schedule at the host's convenience. Particularly in a small institution, all staff members and a higher percentage of students and consumers expect an opportunity to talk with a team member. In larger institutions arrangements should be made in advance to establish a specific time and place where representatives of the team can be seen by any staff member, student or consumers who wish to do so. Arrangements should be communicated by the administration to the staff, students and consumers. The chair should ensure that the coverage is as wide as possible. In addition to the various conferences and interviews, team members must remember to follow through on all aspects of their responsibilities. This means looking at appropriate learning resources, reviewing the uses made of adaptive technology and the media, going over pertinent budget reports, etc.
Interviewing students and consumers is apt to be more rewarding in some respects than in others. Interview, in private, as many students and consumers as possible regarding their satisfaction with the quality of teaching and programs offered, of necessary advising in relation to their program, and institutional practices regarding admissions, registration and grading. Interview them about timely availability of program materials, the actual usage of learning resources for programs, and knowledge of and effectiveness of procedures for handling grievances or complaints. Many evaluators also find that stopping in recreation centers or places where students and consumers congregate is useful.
Team members should seek supplemental materials, documents and interviews which will substantiate claims made in the self-study. Focus on evidence and the verification of achievement of goals. Team members should respect the confidentiality of the self-study report and any other institutional documents. Documentary materials such as admission and registrar's records, order lists for learning materials, course and program syllabi, tests, term papers or program projects are valuable because they are prepared for home consumption rather than for outside use. Departmental faculty/staff, committee, and governing board minutes usually offer a means of determining whether or not these bodies understand and exercise their proper functions.
Team members should be prepared to do a great deal of objective listening. They must take special care not to get involved in either personal problems or institutional politics. Pertinent information from disgruntled informants should be carefully and thoroughly checked for accuracy. When a "problem" is uncovered, it should be reviewed with the entire team. Further, weaknesses should be openly discussed with the entire team.
Team members lead a double life. They cannot help thinking about their own school or agency while seeking to understand and evaluate another. The experience is really rewarding in this respect, but evaluators can neither give their own problems right-of-way nor allow themselves to become advocates for their own way of things. Evaluators who spend considerable time talking about their schools or agencies take the chance of being ineffectual bores.
A conference of the entire team is held each day and an extended meeting is scheduled at the conclusion of the second day to agree upon commendations, recommendations and suggestions, and to reach a consensus on the confidential recommendation to the Council concerning accreditation. It is important for members to remain through the entire evaluation. Avoid the temptation to save an hour or two at the expense of an uncompleted job.
The last scheduled event is the concluding meeting with institutional officials, at which time the team chair summarizes orally the team's conclusions and major recommendations and invites comments. The team chair and C.E.O. will decide who from the institution should be present or if the meeting is to be open. Because team members may be asked to make comments or to answer questions, it is important to be thoroughly prepared for the exit meeting.
The Council executive director will have notified team members of the time and location of the organizational meeting usually held at the hotel where the team is housed. This section outlines the suggested schedule for the team's activities during the evaluation visit. While the team chair may modify the schedule and team's activities somewhat, in accordance with unique features of the institution, local circumstances, and the composition of the team, this is a general schedule which the evaluation team will normally follow:
The Day Before the Evaluation Begins
Organizational Meeting (4:00 p.m.)
The evaluation team convenes for organizational purposes at 4:00 p.m. on the day before the evaluation begins. Occasionally the Council executive director schedules this meeting somewhat later when it is learned that some team members need more time for travel. A 4:00 p.m. meeting works well because there will be at least two hours available for the meeting, leaving sufficient time for dinner or further study of institutional documents. Later in the evening there still will be time for team members to commute with the team chair or other team members if necessary.
Following are the topics normally considered at the organizational meeting:
1. The specific work and responsibilities of the evaluation including the type of evaluation (initial accreditation or reaffirmation of accreditation) and the charge to the evaluation team (e.g., evaluate compliance with the Eligibility Requirements, the Standards, and Policies of the Council, the quality of the self-study, and provide assistance and helpful suggestions) are reviewed.
2. Team member evaluation and writing assignments are reviewed. The team chair will want to be sure that everyone clearly understands these matters. The chair will stress that the draft report must be in his or her hands by the end of the visit. Telephone numbers and e-mail addresses of the team members will be verified for ease of contact when the draft report is being edited.
3. The team chair will note the importance NAC places on consumer involvement and input in the standards and self-study process, and the on-site peer review team evaluations and team reports. In addition to each team member identifying consumer involvement and input in his or her assignment area(s), the OSPR report will include a separate section for the institution concerning consumer involvement and input. During the meeting either the team chair or a team member will need to be assigned the task of drafting this separate section by drawing on contributions from all team members.
4. The team chair will review the schedule of activities for the team, especially any prearranged conferences or interviews on campus. Expectations regarding the team's sessions are noted. (see "First Day On-Site" and "Second Day On-Site" later in this section).
5. The exit conference regarding format and objectives will be discussed (see "Third Day On-Site" later in the section).
6. The team chair will want to confirm that each team member has developed an individual schedule of evaluation activities and is prepared to establish a schedule of individual interviews with appropriate staff members and consumers in relation to his or her assigned area(s).
7. The team chair should encourage each team member to begin drafting reports on assigned sections early in the visit.
8. The team's workroom on campus and the materials available with be noted. Additional
information and arrangements for word processing may be requested as needed.
9. Arrangements for meals and transportation, as well as for the reimbursement of expenses
will be reviewed.
10. The chair will provide an opportunity for inexperienced team members to interact, on an
informal basis with him or her, and with experienced team members regarding any topic of concern following completion of the organizational meeting.
The First Day On Site: Breakfast with Institutional Representatives (7:30 - 8:30 a.m.)
Typically, there will is a planned get-acquainted session with the evaluation team, key institutional personnel, and representatives of the governing board attending. Institutions which desire to host such a function are encouraged by the Council executive director to do so at a breakfast meeting the first day of the evaluation. Some institutions will prefer to host a reception/dinner the previous evening. If this is the case, the Council executive director will request the event be scheduled between 6:30 - 8:00 p.m.
1. Initial Meeting on Campus (8:30 - 9:00 a.m.) The Council executive director arranges for the initial meeting of the evaluation team with institutional representatives on campus, typically at 8:30 a.m. of the first day. It is usually a brief meeting to have team members meet with key administrators, members of the self-study coordinating committee, principal staff members, and consumer representatives. Normally the C.E.O. will welcome the evaluation team, make announcements, and introduce the local members present. The evaluation team chair will introduce the team members and indicate the areas they will be evaluating, review the purpose of accreditation and quickly cover the procedures to be followed. Following the introductions and remarks, the team members pair off with the institutional representatives and the on-site evaluation begins.
2. Evaluation Activities (9:00 a.m. - 3:45 p.m.) Team members conduct interviews and
review materials, facilities, equipment and other resources to ascertain compliance with
the Council's standards and policies. Evaluators should be sure they are on a reasonable.
schedule and interviewing an appropriate range of institutional personnel and consumers.
As the visit progresses, the chair may review some writing samples and offer guidance.
Do not hesitate to consult with the chair if assistance is needed.
3. Executive Session (4:00 - 6:30 p.m.) The team is scheduled to meet in private, usually
at 4:00 p.m. on the first full day. This session usually does not last longer than two to
three hours. Activities during this session normally include the following:
a. Sharing general observations about each evaluator's assignment. Be prepared. Normally, about ten minutes are allotted for each evaluator.
b. Problem areas will be identified and strengths discussed.
c. The chair will guide the team to begin to identify preliminary recommendations, commendations and suggestions.
d. Special attention will be given to the assessment of the areas as assigned and consumer involvement throughout the planning and assessment processes of the institution.
e. An opportunity for team members to exchange information will be provided.
f. Areas of concern that require follow-up the next day will be identified. Be prepared to make suggestions.
g. The chair will determine which institutional personnel and representatives of the institution's clientele have been interviewed and those who still need to be , to ensure broad representative coverage. Remember, the next day is the last opportunity for interviews.
h. The chair will review the agenda for the next day, particularly the expectations regarding the next day's executive session.
Team members should begin preliminary drafts of their written report after this private session if they have not already done so. The team chair may schedule dinner for the entire team for this evening. If so, the conversation about the evaluation may continue. Only team members are to be present for evening meals.
The Second Day On Site
1. Further Evaluation Activities (8:00 a.m. - 4:00 p.m.) Interviews and other evaluation activities should be concluded in so far as possible. In some instances this can be done by early afternoon. Team members may be able to return to their writing activities at different times during the afternoon.
2. Executive Session (4:00 p.m. - 6:30 p.m.) The team is again scheduled to meet privately the afternoon of the second full day. Be prepared to share findings with the total team. Proposed recommendations, commendations and suggestions should be presented at this session for review by the full team. The chair during the session will guide the team to accomplish the following:
a. Reach consensus on major recommendations and commendations to be included in the
team report, although the complete narrative for the report will not have been finished
at this point. Commendations should be considered only for truly noteworthy
practice, not for good intentions.
b. Reach consensus on the confidential recommendation to the Council regarding the
accreditation status of the institution.
c. Ensure that all recommendations: 1) have adequate supporting narrative, 2) derive
from the Council's eligibility requirements, standards or policies for accreditation,
and 3) are not prescriptive.
d. Determine who will draft language for the recommendations and commendations after
consensus has been reached.
e. Review the time and format of the exit conference scheduled for the next day.
f. Review the next day's agenda, including: 1) submission of draft reports to the team chair, 2) procedures and times for check-out and other related matters, and exit conference.
The evaluation team chair and the C.E.O. will have established the time and circumstances for the exit conference early during the visit. The entire evaluation team is expected to attend.
Developing the Team's Confidential Recommendation to the Council
The chair is responsible for guiding the evaluation team to consensus concerning its confidential recommendation status to the Council, including two elements: 1) a recommendation regarding the accreditation status of the institution, and 2) the type and proposed timing for any future action regarding the institution. The recommendation should be consistent with the content and tone of the evaluation team report.
The evaluation team chair will have a copy of the confidential recommendation form which is in the NAC Accreditation Handbook, October 2004 (pages 20-21), and provides a list of possible Council actions. The evaluation team will need to decide on the recommended action and, if appropriate, the proposed date for a progress report or focused interim report and visit and the issues involved. The evaluation team will also need to submit a brief explanation for the proposed action. This explanation should include several elements:
1 An explanation of the rationale for the proposed action. In case of a sanction, this should include and explanation of why this action is more appropriate than alternative actions.
2 A rationale for the proposed date for a progress report, a focused interim report and visit, or other action.
3 If a progress report or a focused interim report and visit is recommended, specify carefully the major recommendation(s) in the evaluation team report which need to be addressed.
Team Members Complete Writing a Draft Report. During the evening of the second full day, team members are expected to complete drafts of their respective reports. While there may be time to conduct a limited number of interviews and verify information in institutional documents the following morning there will be only limited time for writing.
The Third Day On Site
Brief Meeting (8:00 - 8:30 a.m.) The team meets briefly to clarify any remaining tasks and to determine how they will be handled. Draft language of the recommendations and
Commendations which were agreed to during the executive session the previous day will be reviewed.
Wrap-Up Activities (8:30 - 10:30 a.m.) Team members can use the two hours to complete any remaining tasks. This may include final interviews, verification of information from institutional sources, and final editing of the report by each team member.
Final Executive Session (10:30 - 11:30 a.m.) The final executive session will be held with all team members and cover the following topics:
1. The chair will summarize for the team the general points to be covered in the exit conference including the major recommendations and major commendations. Team members are expected to be present for the exit conference.
2. All recommendations and commendations are to reflect the consensus of the team. No team member may introduce recommendations not previously agreed to by the team.
3. Recommendations and commendations should stand alone (i.e. they should be understandable and grammatically complete and should not allude to ambiguous references) and their focus should be clear.
4. The chair should summarize the evaluation of the self-study based upon the evaluations of the team members throughout the on-site visit.
5. The chair will present a written draft of the summary section and the major recommendations and commendations which can be discussed and approved in principle by the team so they can be presented to those present in the exit conference.
6. The chair will review the Council policy on initial or reaffirmation of accreditation as covered in the NAC Accreditation Handbook, page 18, and request a motion concerning the accreditation of the institution being evaluated. A formal vote will be taken on that confidential motion.
7. The team chair will collect draft reports from each team member.
Courtesy Meeting with the C.E.O. (11:30 - 11:45 a.m.) The team chair will likely review the major commendations and major recommendations with the C.E.O. prior to the conference. This also is an opportunity to convey observations of the team that may not be appropriate for the exit conference.
Exit Conference (12:00 Noon) The exit conference is a very important aspect of the evaluation process. It is imperative that the tone and content of the exit summary report be consistent with the written report. The exit report should reference appropriate eligibility requirements, standards and policies of the Council, and should leave no doubt about weaknesses as judged by the evaluation team.
At the exit conference the team chair usually opens with an appropriate statement of thanks on behalf of the team and then presents the summary section, major recommendations and major commendations. Discussion among those present may follow but should be limited to the points in the summary; discussion of details should be avoided. Disagreements on details should await discussion between the C.E.O. and the team chair after the institutional review of the draft evaluation team report.
For the benefit of those present at the exit conference, the team chair explains the Council policy
on accreditation and notes that the team recommendation on accreditation is confidential and is divulged only to the Council. The Council executive director will notify the C.E.O. as to the time and place the evaluation team report will be considered by the Council. The C.E.O. will be requested to join in a conference telephone call with the Council to discuss the evaluation and to respond to questions. The team chair will also be requested to join in the conference telephone call.
A well developed evaluation team report contains a limited amount of description - only enough to provide context - and an analysis of the institution's strengths and weaknesses related to the Council's eligibility requirements, standards and policies. The analysis should include statements of evidence based upon information verified in the self-study and in other institutional documents, and ascertained through interviews with institutional constituencies. This analysis then leads to commendations, recommendations and suggestions to assist the institution in its efforts toward continuous improvement.
Discussing and evaluating evidence and writing appropriate commendations and recommendations are critically important to the evaluation process and the evaluation team report. To assist the team chair in the mentoring role, the following underlined topics are presented:
Definitions
Recommendation. A recommendation is a formal written statement by an evaluation team of an action that it believes an institution must take in order to comply with an eligibility requirement, a standard or a Council policy.
Because a recommendation identifies an institution's possible noncompliance with an eligibility requirement, a standard or a policy (this is never stated directly, except for noncompliance with an eligibility requirement) and because the institution must take corrective action, it is important for the evaluation team to provide, in the narrative, specific evidence of noncompliance. This evidence clearly sets forth the reasons for the recommendation to be offered.
Evaluation team reports include two types of recommendations: 1) Recommendations offered at the end of each section of the report, and 2) Major Recommendations at the end of the evaluation team report following the summary. Major recommendations are used when, in the judgment of the evaluation team, a recommendation is of sufficient importance for the institution as a whole or when a recommendation is critically important to the functioning of the institution.
Commendation. A commendation is a laudatory statement by an evaluation team concerning an institutional practice. A commendation is included in the report when the team agrees that an institution has demonstrated exemplary performance in a particular area. Commendations should not be given merely for good intentions. Again, the narrative should sufficiently explain the reasons for giving the commendation.
Suggestion. A suggestion is a formally written statement by an evaluation team of an action that it believes an institution should take, not because the action is necessary to comply with a standard or policy statement but because it would be in the best interest of the institution to do so.
The June 2007 NAC Board meeting it was decided that the OSPR reporting format will include a feature called SUGGESTIONS in each section of the report. Suggestions will constitute the third component of the usual format of "Commendations" and "Recommendations."
There have been a number of occasions where Recommendations are made that do not strictly fall into a compliance or non-compliance category with the standards. These suggestions are often good ideas that may make the program better and the organization is encouraged to consider.
Suggestions do not have to comply with any specific NAC Standard and the reviewers are free to exercise good judgment in suggesting matters that are pertinent, appropriate and significant to the organization.
The purpose for the "SUGGESTION" component is to enable the exchange of useful information that a reviewer may wish to share with the personnel during the on-site visit. "Cross-pollination" is a useful method for professionals to share information without having to justify such by standards or other criteria. The SUGGESTIONS will not effect the accreditation decision of the level of the accreditation decision.
The reviewers are not under any obligation to make suggestion in any or every category but are encouraged to do so, based on their finding during the OSPR process and its preparation.
Developing the Narrative Support for the Recommendation
Discover and Provide the Evidence.
Evidence is the foundation for the recommendation.
Without evidence to support it, the recommendation is not valid. Evidence used to support a
recommendation can be quantitative or qualitative, consisting of facts discovered or verified by the evaluation team during the site visit. It may consist of information drawn from the institution's self-study, interviews, other documents, or observations.
The evidence provided in the narrative for any recommendation must be: 1) objective, 2) current, 3) authoritative, 4) specific, and 5) sufficiently supportive of the recommendations.
Demonstrate the Link Between the Evidence and the Recommendation. The writer must provide good reasons for the recommendation. In what ways does the evidence demonstrate that the institution is not in compliance with an eligibility requirement, standard or policy statement? The professional judgment of the evaluation team must be brought to bear. In many cases the
NAC
evaluation team will not be able to make use of quantitative requirements but will be called upon to judge "adequacy" or what is "appropriate" or "sufficient." These judgments are unavoidable and are necessary in carry out the accreditation process.
Writing the Recommendation
1. Ensure that the recommendation is linked directly to an eligibility requirement, a standard or policy statement. It is helpful to use the phraseology from the standard as much as possible.
2. Ensure the recommendation is clearly stated. Use specific language which identifies the deficiency (accompanied in most cases by language from the standard or policy.
3. Ensure that the recommendation is not prescriptive. It requires a correction of a deficiency but, if there are several approaches to making the correction does not specify one. Where there are several ways the deficiency may be corrected, the evaluation team may offer a suggestion in the narrative regarding a particular course of action. Remember, institutions are not required to comply with suggestions.
4. Ensure that the recommendation calls for action to remedy an actual violation of an eligibility requirement, a standard or a policy, and that it does not require the institution to "appoint a committee to study" a problem or to "consider" remedying a deficiency.
5. Ensure that the appropriately applicable standard, policy, and eligibility requirement is referenced for each recommendation noted in the evaluation team's report.
The final written report of the evaluation team is a major part of the accreditation process. Team members are responsible for preparing reports on their assigned areas. The team chair will want at least a draft of each report before the team members leave for home. He or she will set deadlines for possible revisions, in consultation with the group. Remember, the best reports are written immediately after the experience. Delay makes the task more difficult and dulls the sharpness of the writing.
While the team chair will be responsible for writing the introduction, summary, and the section on the role played by institutional clientele in preparing the self-study, and in the development and implementation of plans for enhancing the quality of the institution, the other team members are individually responsible for their assigned standards, plus an additional assignment for one team member to draft a paragraph on the team's assessment of the quality of the self-study report. The team chair should not be required to spend considerable time in editing and rewriting individual reports. A well-written report will:
1. Provide an accurate description and analysis of the institution which is understandable to those having little or no knowledge of the institution, i.e. Council members who are assigned as primary reviewers of the report.
2. Evaluate both the strengths and weaknesses of the institution, reads easily and clearly but is not so brief as to leave out important details or explanations.
3. Deal with issues of compliance with eligibility requirements and issues that may be significant but which are not related to Council requirements. Evaluate clearly whether or not the institution meets the standards and related policies of the Council.
4. Sufficiently explain in the preceding narrative all recommendations, commendations and suggestions. Commendations are to be reserved for truly noteworthy practice, not for good intentions.
5. Comment on the nature and quality of the self-study and its component parties including
Supporting documentation.
6. Comment on institutional clientele involvement and input in the self-study process, and in the development and implementation of plans to enhance the quality of the institution.
7. Contains no errors in word processing, spelling or grammar.
8. Maintain a consistent and appropriate format throughout the report. Commendations and recommendations are numbered following each section of the team report. Major commendations are numbered and follow the summary at the end of the report. Suggestions offered to the institution are included in the narrative of in the various sections throughout the evaluation team report.
9. Represent evaluation team consensus in the wording of recommendations, commendations and in the tone of the narrative.
10. Avoid the use of terms like inspector or inspection in favor of evaluator(s), visitor(s) or team member(s).
11. Contain no language that indicates what the evaluation team's recommendation will be as to the accreditation status. Use the term compliance only when referring to one or more of the eligibility requirements where the institution is found to be in violation and noncompliance is noted in the narrative and a major recommendation is made. In all other instances the correct terminology indicates the institution meets or does not meet accreditation standards and/or related policies.
THE END
Please contact the NAC office if you have any questions or need more information.
You may use our contact form by clicking hereor contact us using the information below:
National Accreditation Councilfor Agencies Serving
People with Blindness or Visual Impairment (NAC)
Steven K. Hegedeos Executive Director
7017 Pearl Road
Middleburg Hts., Ohio 44130
Phone: 440-545-1601
Cell: 440-724-9781
