For a printable version, click this skip link.
The National Accreditation Council
For Agencies
Serving People with Blindness or Visual Impairment
PROGRAM OF TRAINING
FOR
ON-SITE REVIEWERS
Copyright 2011
National Accreditation Council for Agencies
Serving People with Blindness or Visually Impairment
7017 Pearl Road
Middleburg Hts., OH 44130
www.nacasb.org
Table of Contents (Each line is a skip link to the appropriate section)
Welcome
Preface
Understanding of an Organization's Mission and Purpose
Statement of Mission and Goals
Eligibility Requirements
Summary of Steps from Application to the On-Site Review
From Self-Assessment Study to Accreditation - Overview
Organizing a Comprehensive Self-Assessment
On-Site Peer Review Team
Preparation for an On-Site Peer Review (OSPR)
Appendix A: Forms
Appendix B: Terms of Agreement
Appendix C: Reviewers Code of Conduct, Conflict of Interest, Confidentiality Agreement
A Piece of Professionalism
From the beginning of organized services for people with blindness or visual impairments, there has been an effort to share experiences in order to improved services. Leaders have guided and directed the filed to higher standards through collaboration. In 1966 the National Accreditation Council for Agencies Serving People with Blindness and Visual Impairments (NAC) became an important component for service improvements. Mary Switzer, Secretary of the United States Department of Health Education and Welfare, along with many leaders in the field who work for the blind, developed standards and a process peer-review verification leading to accreditation decisions. Most professions hold that service standards lead to improvement, accountability, and recognition of the profession.
Currently, agencies in most states are not mandated to seek accreditation for services they provide to people with vision loss in the same way as hospitals, schools, colleges, libraries and business are. Schools for the Blind are not required to focus on the unique service needs of people with vision loss. That is why NAC encourages all agencies and programs that serve the blind and visually impaired to seek accreditation and NAC provides specialized standards that include a self-review process that leads to the maintenance, development and recognition of quality services.
While the processes used for accreditation in various professions may vary, the basic need for and benefits of accreditation are the same.
3 Accountability to the Public
4 Approval from Funding Sources
Today, more than ever, there is a need for specialized standards because of a great demand for accountability, also because "umbrella" and "one stop" service models diminish the visibility and importance of services provided by our profession. Accreditation of special services for people with vision loss helps our field to be recognized as a profession.
As a peer-professional reviewer your dedication and experience in services for people with vision loss is part of the accreditation process. You are invited to become an On-Site Peer Reviewer and join with NAC in the important work of quality assurance, program improvement, and professional recognition. NAC was and is the only independent accrediting body with standards exclusively for the blind and visually impaired. The NAC Board of Directors invites all qualified professionals to become peer reviews.
On-Site Peer Reviewers find their work with NAC professionally rewarding. Reviewers have a responsibility to honestly assess an agency's performance and compliance with NAC standards and report their findings to the NAC Board of Directors. The process of the On-Site Peer Review (OSPR) helps agencies and schools develop, improve and/or maintain programs and services that meet their unique mission and outcome objectives.
NAC continues to implement the task begun over 40 years ago by revered leaders in the field. This training manual will help you understand NAC's current accreditation process. With that understanding you will be able to interpret standards, make appropriate recommendations to the Board and give input from the field for improvement of the standards and processes NAC uses. People with vision loss deserve agencies whose services are measured against standards established by professionals in the field as appropriate practices. Your expertise and service will be a great contribution to the agencies you review and the field in general.
We have extracted information from the Accreditation Handbook and provided examples, answered frequently asked questions, and made suggestions for dealing with situations reviewers may encounter.
Upon mastering this process with the help of this guide coupled with one to one instructions from the NAC executive director and selected board members, you will be added to an elite group of peer professionals who have served in the past as well as many who presently contribute their time and expertise to this important work.
Accreditation is recognition granted to agencies, educational institutions, and a diversity of organizations for their level of high quality services and integrity. This entitles them to the confidence of consumers, general public, professional community, governmental agencies, foundations, and other organizations. In the United States this recognition is extended primarily through private independent accrediting entities. All of these entities establish standards and other criteria for accreditation, conduct evaluation visits, and determine compliance with standards leading to various levels of accreditation.
The two basic types of accreditation are labeled "institutional" and "programmatic". The statement of mission and goals of the institution or agency determine the type of accreditation. Accreditation or recognition by the accrediting body applies only to those programs and activities that behave consistently with their stated mission and goals. While recognized accrediting bodies are listed or identified as either "institutional" or "programmatic", some accreditors serve both types. For example, there are regional institutional accrediting commissions that accredit universities and other educational enterprises, and programmatic accrediting agencies that accredit various service programs within an agency that provides a specific service such as activities of daily living or use of technology.
The National Accreditation Council for Blind and Low Vision Services (NAC), established in 1966, is labeled both as an institutional and programmatic accrediting body because it accredits schools and agencies as well as programs in rehabilitation and education that are activities and services for the blind or visually impaired. Eligibility for NAC accreditation is available to comprehensive state supported agencies or schools, as well as independent organizations that provide specific services in the field such as low vision clinics.
NAC's Handbook of Accreditation, is a composite of information regarding the evaluation and accreditation of agencies, schools, and programs that serve people with blindness or visual impairment, and is a companion document to the Program of Training for On-Site Reviewers. It is important for an evaluator to be familiar with information from both publications and have them available during an on-site evaluation for reference as needed.
One of the first tasks of a NAC reviewer is to understand how the organization views itself and how the mission, purposes, goals, and objectives fit the community it serves. Each agency is unique because of its social setting, political structure, location, and funding. Each agency/program is expected to have a clear mission statement as well as documentation of its purposes and activities in accordance with their mission. As a part of the review team you will be asked to make professional judgments about whether the agency, school or program meets standards for service in their attempt to fulfill their mission.
The following provides an example and is the mission statement and purposes used by NAC.
The mission of the National Accreditation Council for Blind and Low Vision Services (NAC) is to assure high quality services from agencies, schools, and programs in the United States and Canada that provide education and rehabilitation services to people who are blind or are visually impaired. As an accrediting organization, NAC has four complementary components to its mission.
1. To develop standards and promote effective, high quality, and publicly accountable agencies and schools in the field of blindness and visual impairment.
2. To ensure, through valid and reliable processes that specific standards are being met by eligible agencies and schools seeking accreditation.
3. To give public recognition to those agencies and schools which are in compliance with national standards.
4. To provide counsel and assistance to established and developing agencies and schools in the field.
NAC's purposes are stated in its Articles of Incorporation and Bylaws (included in the Appendix). The goals set by NAC in its evaluation and accreditation processes help to assess NAC's effectiveness in fulfilling its mission.
1. To promote excellence in agencies and schools that serve people with blindness or visual impairment by establishing goals, eligibility requirements, standards, policies, and procedures for the evaluation of agencies, programs and schools in the field for accreditation and candidates for accreditation status.
2. To provide persons with blindness or low vision a means of identifying special services that meet national standards based on, professional input, professional practices, and consumer outcome measures.
3. To ensure that the accreditation process recognizes and encourages diversity and innovation in agencies and schools that serve people with blindness or visual impairment.
4. To ensure that the accrediting process evaluates the:
-Appropriateness of the school's or program's goals,
-Adequacy of the resources and organizational structure to achieve these goals,
-Educational and/or rehabilitation outcomes which indicate these goals have been met, and
-Extent to which there is reasonable assurance that the goals will continue to be met.
5. To maintain a systematic review process of eligibility requirements, standards, policies, and procedures to ensure they continue to be relevant to the needs of people with blindness or visual impairment.
6. To confirm that policy and decision-making practices reflect the community of interests including effective and impartial public representation and the application of due process.
7. To ensure that the organization and operation of the accrediting process contains effective controls against conflict of interest and against inconsistent application of evaluative criteria.
8. To encourage the ongoing improvement of accredited and candidate agencies and schools, concomitantly disseminating information between and among agencies and schools that will stimulate program improvement.
9. To conduct periodic re-evaluations of accredited agencies and schools.
10. To require, as integral parts of the accreditation process:
-A comprehensive self-assessment study that is analytical, interpretative, and evaluative,
-A commitment of the school or agency to a continuing process of improvement through self-analysis and self evaluation, and
-An on-site peer-review visit to properly evaluate.
11. To make written materials public that clearly describe NAC's current purposes, mission, goals, standards, policies, and procedures for determining candidacy and accreditation actions.
12. To verify and publish the academic and professional qualifications of the members of its policy and decision-making bodies and the names of its administrators.
13. To make public a list of accredited agencies and schools.
NAC accepts, for consideration, applications for accreditation or candidacy from agencies schools or programs that generally:
1. Are concerned predominately with providing rehabilitation, education, and low vision services to people with blindness or visual impairment;
2. Have functions commonly associated with agencies or schools accredited by NAC;
3. Meet NAC's eligibility requirements.
Eligibility Requirements for Candidacy and Accreditation
1. AUTHORITY: Any agency or school that is authorized to operate and provide services to people with blindness or visual impairment by appropriate governmental organization, licensing agency, or controlling board as required through state or provincial jurisdiction(s) in which it operates.
2. INCORPORATION: The mission and goals of the agency or school is legally defined, including its activities, services, clientele, and its role within the blindness/visually impaired community. The mission statement is consistent with its legal authorization and adopted by its governing authority. All, or substantially all, of its gross income is devoted to supporting its mission and goals for serving the blind/visually impaired.
3. INTEGRITY: The agency or school is governed and administered with respect for the individual in a nondiscriminatory manner while responding to individual service needs, and provides evidence of legitimacy to the constituencies it serves, as determined by fulfilling its chartered purposes and accredited status.
4. LEADERSHIP: The agency or school has established and maintains responsible individuals who serve on a recognized basis for the purpose of ensuring that the mission of the agency or school is being achieved. This group has responsibility and power to enforce or cause change and/or enforce policy. The agency, school, or program employs an administrative officer whose full-time responsibility is to manage the services provided.
5. ADMISSIONS: The school or agency publishes its admissions policy which specifies the characteristics and qualifications for its programs,
6. OPERATIONAL STATUS. The school or agency will have completed at least six months of its principal program(s) and is operational with students or clients actively pursuing their program goals at the time of the NAC review for candidacy or accreditation.
NOTE: One year of previous operation is not required for candidacy status.
in cases where candidate agencies are required to be accredited or in process of receiving accreditation before they can be approved by governmental authorities to provide services.
Submitting an Application
Applicants for candidacy or accreditation must submit a letter requesting an application, complete the application form, and include with the letter documents addressing the eligibility requirements outlined above. The application, documents, and application fee are submitted to the Executive Director at:
National Accreditation Council for Agencies Serving the Blind or Visually Impaired
Middleburg Heights, Ohio 44130.
Application forms are available on-line at www.nacasb.org., or may be obtained by contacting the NAC office. Requesting an application begins the process of NAC accreditation eligibility determination. NAC's Board accepts applications with advice from the Executive Director. On-site Peer Reviews also establish or reaffirm eligibility.
Acceptance of an application begins this process which leads toward accreditation, but does not guarantee accreditation.
NAC uses a continuous improvement model consisting of a self-assessment study, on-site peer reviews, annual reporting, and periodic renewals to grant or sustain accreditation.
Once eligibility requirements are met the following documentation should be submitted to the NAC office:
-A cover letter indicating the general nature of the agency signed by the chief executive officer;
-A completed application form;
-The application fee of $400
The Executive Director of NAC, after reviewing the application and documents, will acknowledge receipt to the CEO and may request additional information considered necessary to be eligible for accreditation. The NAC Board determines final eligibility which is then communicated to the applicants.
Loss of Candidate Status. Candidacy lapses when a school or agency fails to achieve accredited status within 18 months from the date NAC accepts its application. An agency, school, or program whose candidacy lapses may reapply as soon as it feels ready to proceed toward accreditation.
NAC reserves the right to cancel an application after due notice of 30 days. Circumstances that may lead NAC to issue cancellation of candidacy status include but are not limited to:
-Failure to maintain compliance with NAC's eligibility requirements;
-Unsatisfactory progress in designing and conducting a comprehensive self -assessment study in preparation for the OSPR.
Reconsideration: If a school or agency or program's application is denied candidacy, it may resubmit an application after addressing the stated reasons for denial. No additional filing fee is required if the application is resubmitted within 18 months.
On-Site Peer Review (OSPR): Within 18 months after initial application a comprehensive self-assessment study and on-site peer review must be completed. The NAC Board meets twice a year to make accreditation determinations based on the findings, recommendations and report submitted by the reviewing team.
Step Agency Activities NAC Activities
I. Agency contacts the NAC office to proceed with eligibility determination. NAC provides an application and an overview of NAC's eligibility criteria.
II. Agency returns completed application along with application fee of $400.00 to the NAC office. NAC will indicate eligibility or lack thereof within 30 days. When eligible NAC mails Standards, Self-Assessment Guide and Accreditation Handbook to applicants.
III. The agency and NAC determine which standards apply to that specific agency including areas that receive public or government funding). NAC provides any additional information or assistance needed to appropriately address applicable sections and standards.
IV. The OSPR date is agreed on and the agency designates a liaison person to coordinate arrangements for the on-site review. NAC identifies the on-site review team communicating with the agency to insure no conflict of interest exist between reviewers and agency.
V. The organization submits the self-assessment documents to NAC and the designated reviewers at least 30 days prior to the scheduled visit. The reviewers and the NAC office receive and analyses the document prior to the on-site visit.
VII The Agency makes hotel reservations and travel arrangement to and from the hotel to the agency for the team members. Team members make their flight or driving arrangements to the site city. The team will be reimbursed by the agency for all travel expenses.
VIII Agency plans an informal meeting the evening before the OSPR begins. OSPR team meets with the organization's leadership.
The self-assessment process is a major enterprise for the agency or school. It is an educational endeavor, which requires time to reflect and engage in critical thinking about the agency's current position with regard to its mission, activities, and outcomes. The process uses NAC's standards as a way to help evaluate the operations and services provided. The comprehensive evaluation process, which is periodically and jointly conducted by the agency, school or program, and NAC, includes the following steps:
1. The Executive Director or a representative of NAC communicates with the agency or school CEO. Eighteen (18) months before an on-site peer review (OSPR) team visit, NAC contacts the CEO regarding dates, appointment of peer review team chair, appointment of a "mentor" from NAC, and the comprehensive evaluation process.
2. The agency or school analyzes itself through a comprehensive self-assessment outline provided by NAC. The Self-assessment is completed and sent to reviewers and to the NAC office 30 days prior to the OSPR team visit. Electronic or printed copies are acceptable (NAC & most reviewers prefer electronic copies) of the self-assessment report.
Benefits of the Self-Assessment Study
-An understanding the strengths of an organization with a clearer sense of direction;
-Development of a plan for assessing the outcomes or results of programs and services offered;
-Strengthening the planning process, resulting in a workable system of ongoing analysis, improvement, and monitoring;
-A plan for the systematic evaluation of curricula, study guides, equipment and materials, financial resources, space and facilities;
-A plan for the systematic use and evaluation of the agency's policies, procedures, and records.
The Accreditation Process
1. Peer reviewers are selected from other agencies with similar experience and training to perform the on-site reviews. The team reviews the comprehensive self-assessment study, visits the agency, verifies ratings and supporting documents, evaluates findings, prepares a written report and submits it to the NAC Executive Director.
2. A draft OSPR team's report and findings is prepared by NAC and sent to the CEO. The CEO is given an opportunity to correct factual errors. Correct information with documentation or explanations provided in writing to NAC's Executive Director.
3. The Executive Director of NAC provides the institution's CEO with a copy of the final draft of the OSPR team report.
4. The CEO of the agency, school or program provides NAC with a written response to the final draft team report. The CEO's written response is attached to the report and included in the final report for the Board's review and decisions.
5. The NAC Board of Directors reviews the team's written report and any written response from the agency to the report. By teleconference the Board receives verbal statements of the evaluating team chair and the CEO of the institution, which are followed by questions from Board members. In executive session the Board considers and discusses the OSPR team's confidential recommendation before taking action on the accreditation status of the school or agency.
6. Once the Board of Directors has made a decision regarding accreditation of an agency, school or program, The NAC office will provide a finale OSPR report, a letter stating the Board's accreditation decision and a Certificate of accreditation within one month of the determination.
7. The improvement process continues as the agency, school or program considers the results of its own self-assessment study and commendations and recommendations found in the OSPR final report and creates an action plan.
Careful consideration should be given to the amount of time needed to complete the steps listed above. Complex organizations may need a full year between application and the OSPR to thoroughly conduct their self-assessment study. If done well a self-assessment study is abundantly informative, beneficial, and rewarding to the agency itself.
Options for Board Actions
-Grant full 5-year accreditation;
-An annual progress report is mandatory to maintain accreditation. Based on the annual reports the NAC Board may advise a focused interim visit or additional documentation;
-Defer action on accreditation until a correction action plans is submitted;
-Issue or continue a statement about the termination of accreditation unless the school or agency has demonstrated to the satisfaction of the Board of Directors that it has satisfied all concerns by a specified date;
-Deny accreditation due to lack of compliance;
-Terminate accreditation when compliance is refused.
All Board actions set forth above are published in the minutes of the Board meeting at which the action took place.
REAFFIRMATION OF ACCREDITATION:
Members are not accredited permanently. They are to conduct a comprehensive self-assessment study and be reviewed by an OSPR team generally every five years. Accredited members are required to submit an annual progress report to the NAC office to maintain the tenure of their accreditation in good standing.
The self-assessment study is the most significant part of the accreditation process. Its aims are to understand, evaluate, and improve services to individuals with blindness or low vision, not merely to defend what already exists. The self-assessment study is viewed as an ongoing process. NAC requires an agency seeking initial accreditation or re-accreditation to complete this process prior to each on-site visit. The capability of an agency to conduct a satisfactory self-assessment study is in itself a test of the qualities and capacities of an agency.
The general purposes of the self-assessment studies are to:
-Analyze the resources and effectiveness of the agency in achieving its mission and goals;
-Determine whether the expectations of clients served are met to their satisfaction;
-Appraise the relationship of the agency's activities to its mission, goals and resources;
-Provide a sound basis for strategic planning and enhancing the quality of the agency;
Ultimately, a well-planned and executed self-assessment study suited to the complexity of the organization provides a basis for demonstrating that the agency warrants accreditation. If the agency, school or program seeks additional accreditation from another accrediting body, a joint or concurrent on-site review can often be arranged through NAC's Executive Director.
ADMINISTRATION: The self-assessment study process begins with the commitment and support of the chief executive officer and the governing board. It is the administration's responsibility to select and appoint members of a Coordinating Committee that represents the departments and structures of the agency. (This committee should reflect the selection in the standards manual that will be applied during the accreditation process.)
Agency Administrative Tasks
-Review the agency's existing committee structure and existing processes for evaluation and planning,
-Review NAC's Handbook of Accreditation.
-Create Committees for rating each applicable standard.
-Identify the focus, chair, and membership of each committee.
-Sets a schedule for completion of assignments.
-Adjusts its expectations and timelines as needed.
COORDINATING COMMITTEE: In most cases responsibility for the self-assessment study will be delegated to groups representing various departments or divisions of the agency, school or program. The committee, under direction of the administration, should outline expectations regarding characteristics of an acceptable report (e.g. format, focus, editorial style). This committee will provide documents, information, and assistance to staff to assure the self-assessment is complete and accurate and that written reports are organized for review by the OSPR team.
Responsibilities of Coordinating Committee
-Monitor progress of the groups/subcommittees;
-Develop editorial guidelines for the self-assessment report;
-Provide documents, data, and other materials needed;
-Organize and maintain a centralized file of pertinent self-assessment information and data;
-Report regularly to the agency chief executive officer on progress of the study;
-Review the draft reports of each group;
-Determine a date by which all final draft reports must be completed;
-Provide an agency-wide review of the final draft report;
-Complete final editing, printing, and distribution of the self-assessment study (at least 30 days prior to the on-site review);
-Assist with preparations for the on-site review;
-Assist with the development of a plan for follow-up to insure that an annual progress report is prepared and submitted to NAC and oversees the implementation of the on-site review recommendations.
SUBCOMMITTEES:
Members of each committee are the front line reviewers of the agency's performance in meeting its mission and goals, outcomes, and particular challenges. They evaluate and rate their performance on the NAC standards format. Each applicable standard receives a rating and/or comments that will be reviewed and verified by the OSPR team. The amount of work assigned the different committee will vary.
SUBCOMMITTEE ACTIVITIES:
-Review agency policies pertinent to their assignment.
-Conduct interviews, make observations, and verify outcomes.
-Submits reports according to established timelines.
-Meet regularly during of development of their report.
-Report progress to Coordinating Committee.
-Report on issues and questions raised by the self-assessment.
-Submit material that supports ratings.
-Assist editing and review of the final self-assessment report.
FUNCTION: Members of an on-site peer review team function as colleagues. The purpose is to produce a team report, which will be useful to the agency or school and to the NAC Board of Directors for determining an agencies accreditation status. The report should also be written with the next on-site visit in mind as repeated recommendation may result in non-accreditation.
TEAM MAKE-UP: The peer review team generally consists of two or more reviewers depending on the size of the organization and whether the review will be conducted concurrently with another accrediting body, on the complexity of the program and on the scope of the review. Reviewers are assigned primarily from professionals who come from out of state and have credentials and experience related to the services being reviewed.
Attention is given in selecting reviewers to avoid a real or perceived conflict of interest. Generally NAC's executive director matches the reviewers with the specific programs of an agency and submits names to that agency's chief executive officer six to eight weeks in advance of the on-site review. The chief executive officer is requested to notify the NAC executive director of any concern about the composition of the team. This includes past and present contacts with proposed team members that may strongly bias the team and preclude an objective review.
ROLE OF OSPR TEAM MEMBERS: The contribution of the individual members on an OSPR team is critically important. A brief review of the process, as a whole, will help to explain the role of a team member.
-Stage One: Reviewers are to read and familiarize themselves with the agency's self-assessment document as well as give careful attention to other supporting documentation provided such: as schedules, manuals, budgets, annual reports, policy manuals, previous site visit reports, etc.
-Stage Two: During the on-site visit, the team's charge is to make an independent analysis to determine whether the agency meets the NAC standards for accreditation. Each agency is to be evaluated in terms of its adherence to its mission and goals statement. Team members are to approach the task as a professional with specialized expertise and as a colleague in the field. Team members need to look for coherence between what is stated in the agency's self-assessment document and what it does in practice. Each member is advised to approach the task humbly, keeping in mind that no one has all the answers.
-Stage Three: Team members should have completed their individual reports by the end of the on-site visit. Each team member's role is to assess their assigned sections objectively, critically, constructively, and accurately with balanced professionalism. The team's focus must be on compliance with eligibility requirement and the NAC standards and policies.
-Stage Four: The primary function of the OSPR report is to give agency staff, administration, and the governing board a critical analysis of all areas measured against the standards. The OSPR report is also the instrument that provides NAC's Board a basis for deciding upon accreditation status. Members of the team complete a confidential recommendation about the level of accreditation to be sent to NAC's executive director concerning accreditation. The Board's deliberation procedure provides for the chair of the OSPR team and for the CEO of the reviewed agency to report orally to the NAC Board in an executive session to answer questions and share comments on the report and the on-site review visit via teleconference.
Dates and Arrangements: Dates for the on-site peer review are determined by the NAC's executive director in consultation with the agency's chief executive officer.
Hotel and Local Transportation: Arrangements for local transportation and hotel reservation and team meeting space is made by the host agency and communicated to the on-site review team in a timely manner either via e-mail or telephone communications.
Travel Arrangements: Team members make their own flight arrangements. All incurred travel expenses are reimbursed by the host agency. Travel costs should be parsimonious.
Detailed Schedule: A section assignment/schedule is prepared well in advance by the NAC office in consultation with the agency allotted time for interviews with key administrators, representatives of the governing board, staff, clients/students, and representatives of appropriate external agencies and the reading of agency documents.
On-Site Work Room: The Agency provides a work room for the on-site review team large enough to give the evaluators adequate private work space that is secure so confidential materials can be left safely throughout the review. In addition, the agency/school makes arrangements so as to provide for confidential interviews for each team member.
Team Member Preparation: The following ten (10) items are strongly recommended by NAC to assist team members in preparing for the visit:
-Review all materials such as the previous OSPR report if this is not the first review, the self-assessment document and the section-assignments schedule prior to on-site arrival.
-Consult with the team chair and the NAC office if you have questions after reviewing the information.
-Plan your schedule to be available for the entire evaluation, typically form Sunday afternoon to Wednesday noon.
-Prepare a general outline of your assigned areas including questions to be asked when you conduct interviews.
-List items you will want to verify from sources other than the self-assessment document or interviews.
-Evaluate the quality and thoroughness of the self-assessment document and be prepared to comment or questions at the team's organizational meeting. Give particular attention to the important involvement of staff, clients, students and consumers.
-Share a list of planned interviews with staff, clients, etc. other members of the team.
-Make your own travel arrangements to the host state. Arrive in time to participate in the evaluation team's organizational meeting.
-Keep receipts of expenses incurred during your on-site visit and submit to the host agency for reimbursement.
-The team organizational meeting is very important in setting the tone for the visit, clarifying assignments, and confirming the evaluation schedule.
Pre-Visit Meeting of the On-Site Peer Review Team: In the afternoon or evening before the first day of the on-site review, the team will convene for an organizational meeting at their hotel. The purpose of the meeting is to coordinate the team's activities during the visit:
-Charge team members with responsibility to evaluate compliance with the eligibility requirements, standards, and policies of NAC.
-Make individual assignment for report writing that will assure completion of the draft before the end of the review. (The NAC office will provide the team members with a report template to insure uniformity of format, font and style of the written report.)
-Schedule activities, conferences or interviews as needed. The agency is responsible for scheduling in-person or phone interviews with consumers and collateral agency representatives.
-Format and discuss objectives for the exit conference.
-Confirm that each team member has developed an individual schedule of evaluation activities.
-Reinforce the importance of sharing information as well as maintaining confidential communications among team members.
-Discuss the meals, transportation and reimbursement.
-Provide an opportunity for questions and interaction on topics of concern following the organizational meeting.
Some institutions will prefer to host a reception/dinner evening previous to beginning of the on-site review. If this is the case, the event can be scheduled between 6:30 - 8:00 p.m. The purpose for such a meeting is to have team members meet with key administrators, members of the agency's self-assessment coordinating committee, principal staff members, and consumer representatives on a less formal basis. This can also be accomplished at a brief early morning meeting the first day of on-site activities if a reception is not planned.
On-Site Review Activities: This section outlines a general schedule for the team's activities during the on-site visit. The team chair may modify the schedule and team's activities in accordance with unique features of the institution, local circumstances, and the composition of the team.
FIRST DAY OF REVIEW ON-SITE
Generally: Arrive at agency by 8:30 a.m.
Return to Hotel at 3:30 p.m.
Brief Meeting: Usually, the on-site review begins with a brief meeting to complete introductions of key staff. This is an opportunity for the CEO to make further introductions if needed and to speak to the purpose of the review. The team Chair will introduce the team members, indicate the areas they will be evaluating, and review the purpose of accreditation. There will be a brief overview of the procedures to be followed and the schedule. An orientation tour of the facility or campus may be scheduled.
Team Activities: The team will spend the remainder of the workday verifying the results of the self-assessment document and seeking answers to any questions they may have regarding the materials received prior to arriving. Follow the general schedule that has been developed and shared with the agency. Specifically the team will:
-Review organization documents, budges, procedure manuals and reports.
-Inspect facilities and equipment.
-Observe classes and operations.
-Meet with individuals and groups for input about the quality of services provided.
-Contact community leaders and/or related agencies.
-Contact former clients/students and/or consumer groups.
Reviewers should make sure that their schedules are reasonable and connect with an appropriate range of institutional personnel and consumers. Team members should not hesitate to consult with the chair if assistance is needed.
Team Executive Session I: After each workday, the team is to meet in private. Activities during this session normally include the following.
-Team members share general observations regarding their assignments.
-Problem areas are identified and the strengths of the organization are discussed.
-Drafts and suggestions for preliminary section descriptions, recommendations, commendations and suggestions are prepared.
-Special attention is given to the assessment of consumer involvement and staff participation in planning processes as well as in the development of the self-assessment document.
-Areas of concern needing follow-up information or attention are identified.
-The chair will review the agenda for the following day to ensure that all necessary areas are covered and to indicate what needs to be completed by the next day's executive session.
After the team executive session, members should work on a preliminary draft of their reports. The team chair may schedule a joint dinner for the entire team to resume discussions. But if agency representatives are present at the dinner the team will meet privately to resume discussions on the day's findings.
Discover and Provide the Evidence. Evidence is the foundation for a 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 on-site visit. It may consist of information drawn from the institution's self-assessment document, interviews, documents examined or missing, or observations.
The evidence provided in the narrative for any recommendation must be:
-applicable to the NAC standard.
SECOND DAY
Generally: Arrive at agency by 8:30 a.m.
Return to Hotel by 3:30 p.m.
Further Evaluation Activities: Continue with the assigned section evaluations and interviews as needed. Team members may return to their report writing as the schedules allow.
Team Executive Session II: The team meets privately after the second full day to discuss day's findings. The chair will guide activities to accomplish tasks listed below.
-Reach consensus on major recommendations and commendations or suggestions to be included in the team report. (the most noteworthy accomplishment of the agency and the most significant issues that need to be addressed).
-Ensure that all recommendations are adequately supported with narrative and at least one NAC Standard reference is assigned. (If a statement can not be supported by a standard but viewed by a reviewer to be helpful to the agency it should be listed as a suggestion.)
-Review the time and format of the Exit Conference scheduled for the next day.
-Review the last day's agenda including materials still needed to be reviewed, insure that your draft report is submitted to the chair and procedures and times for check-out.
-Reach and submit a consensus on the confidential accreditation status recommendation that will be submitted to the NAC office.
THIRD DAY
Generally
Meets for exit interview by
The team meets briefly in executive session to clarify any remaining tasks and to determine how they will be completed, including unfinished writing or solutions to difficult issues. The OSPR daft report should be finalized and the Exit Conference should be planned.
The executive session is the team's opportunity to hear and/or review all sections of the Draft Report. All sections of the draft report including commendations and recommendations must be given to the team chair before the end of the review. This usually means before noon of the third day. Depending on the nature of the work needed, executive meetings may take place before leaving the hotel or on-site.
Final Team Activities
-Discuss and approve any reports that have not been made previously. This includes an overview of the findings.
-Review commendations and recommendations, which were agreed to during earlier executive session.
-Add additional commendations and recommendations if needed.
-Select the Major Commendations and the Major Recommendations.
-Complete any additional interviews if needed.
-Verify information from institutional sources as needed.
-Edit each team member's report.
Final Executive Session: The final executive session will be held with all team members to cover the following topics:
-The chair will summarize for the team the general points to be covered in the Exit Conference, including the major commendations and recommendations.
-All recommendations and commendations are to reflect the consensus of the team and all recommendations supported by the appropriate NAC standard.
-The chair should summarize the evaluation of the self-assessment document based upon the evaluations of team members and supporting documentations reviewed throughout the on-site visit.
-The chair will present a written draft of the summary section and the major recommendations and commendations to be discussed and approved by the entire team and that will be presented to the agency personnel at the Exit Conference.
-Review options for confidential recommendation to the NAC Board (Handbook page 18).
-Have a formal motion and vote on the team's recommendation for accreditation status.
-The team chair will collect the draft reports from each team member or each team member can directly e-mail their report to the NAC office where they will be combined and complied into a final draft report.
-Identify and draft language for any stipulations or sanctions related to the recommendation including suggested times for re-evaluation.
NOTE: There will be only limited time for writing; however, it is essential for drafts to be given to the team chair before returning home.
Exit Conference: The team chair may review the major commendations and recommendations with the CEO prior to the Exit Conference. This is also an opportunity to convey observations of the team that may not be appropriate for the Exit Conference. The team chair and the agency CEO establish the time and circumstances for the Exit Conference. The entire evaluating team is expected to attend. The team chair will be the spokesperson for the team at the Exit Conference.
Points Covered at Exit Conference
-Extend a thank you for the hospitality to the agency on behalf of the team and NAC.
-Present a summary of Major Commendations and Recommendations.
-Limit discussion on points presented in summary
-Discrepancies if any, are to be resolved but if the team and the organization cannot come to a mutual understanding, the chair must notify the NAC executive director prior to leaving the facility
-Outline the procedures for reviewing the OSPR team report by the NAC Board.
-Review the options the Board has and when an accreditation determination might be expected based on when the next NAC board meeting is to be held.
Confidential Recommendation of On-Site Peer Review Team
Agency, School or Program: _________________________________________
Date of OSPR on-site visit: From _____________ to _________________.
Review Type: Accreditation ___ Re-accreditation ___ Focused Visit ___
The team's recommendation to the Board of Directors is (Please check action and fill in date; where appropriate.)
___ Defer action until _________ (Recommend date.)
___ The team recommends accreditation for ______ years.
___ Deny Accreditation
___ A Progress Report required by (date) ____________ to address major recommendation(s) __________________. (Please list numbers.)
Comments:
__________________________________________________________________
__________________________________________________________________
Signed _________________________________, Chair, on behalf of the OSPR team.
Please summarize, on the reverse side or on a separate sheet, the major considerations that caused the OSPR team to make the above recommendation(s), being sure that the concerns are including in, and supported by the OSPR team report.
End of this form
Annual Progress Report
2009-2010
Please complete the form, attached requested documentation and send to the NAC office after the closing of your most recent fiscal year (FY).
Name of school or agency:
Mailing address:
Phone number and website:
Phone -
Website--
Name title and phone and email of the chief executive officer:
Name:
Title: E-mail:
Significant Changes
Any changes in your Articles of Incorporation and/or Bylaws in the most recent fiscal year?
Yes ____ No ____ (If Yes, please attach a revised copy.)
Any changes in the mission or goals statements?
Yes ____ No ____ (If Yes, attach a revised copy.)
List key changes in administrative personnel with a brief description of their education training and experiences.
Any major changes in the composition of the governing board?
(briefly describe changes on a separate sheet.)
Financial Status
1. Enclose a summary of the budget report for your last completed FY and also for your current FY.
FY ______ FY ______
Income:
Client/Service Fees
Donations
Grants
Investments
Total Income
Expenses
Personnel
Operations
Fund Raising
Total Expenses
Subtract expenses from income: $
Provide a brief explanation if expenses are more than income or if there has been a significant reduction in overall financial status.
Clint/Student and staff Count
Please provide numbers of unduplicated Client/Student count served in all location for the completed fiscal year.
Location Direct Indirect Total
Total of Unduplicated Count
Note: To add locations press tab after entering a number in total
Number column.
Please provide a listing of all full and part time Certified Instructors/Faculty (all locations).
Describe substantive changes (additions or deletions) in: Services, facilities, or equipment and materials.
Describe the progress or accomplishments achieved toward full standards compliance with references to the most recent on-site report (OSR) major and minor recommendation.
(Optional) Describe the developments in areas that could be deemed 'best- practices' which may have been commendations in the last on-site accreditation peer review.
Thank you for your participation in supporting national standards of operation for agencies, school and program service people with vision loss.
Agency Name
Executive Director
Address
Phone Number
e-mail address
Chair:
Team Members:
MANAGEMENT SERVICE STANDARDS
Underlying Considerations - Team
Policy and Administration -
Financial Management -
Staff and Volunteers -
Buildings and Grounds -
Public Ed., Public Relations, and Financial Development -
REHABILITATION SERVICE STANDARDS
Other Service Programs -
Technology Instruction -
EDUCATION SERVICE STANDARDS
Infant and Preschool Programs -
K12 Programs (K12) -
Programs for Students with Multiple Disabilities -
Outreach Services -
Consumer Report - Team
Sunday, Date
6:00 PM Team orientation meeting with agency
personnel at place to be determined?
Monday, Date
8:30 AM -9:00 AM Brief orientation to facility (Team)
9:00 AM -10:00 AM Underlying Considerations -
10:00 AM -11:00 AM Policy and Administration -
Financial Management -
Staff and Volunteers -
11:00 AM -12:00 PM Building and Grounds -
Public Ed. Public Relations & Financial
Development
Other Service Programs
12:00 PM - 1:00 PM Lunch
1:00 PM - 2:00 PM Technology Instructions
Enfant and Preschool
K- 12 Programs
2:00 PM - 3:00 PM Planning the Consumer Conference
interviews Team, NAC wishes to emphasize
consumer input; therefore, the team will
discuss and plan on obtaining useful
consumer input. The completed Consumer
Question will be sent from the NAC - Team
3:00 PM - 5:00 PM Team members prepare draft reports based
on the day's observations, and readings
6:00 PM -7:00 PM Dinner
7:00 PM - ? Team members present, discuss, and compose draft reports.
Tuesday, Date
9:00 AM - 10:00 AM Programs for Children with Multiple
Disabilities
Outreach Services
CEO & Staff Interviews - Chair
10:00 AM - 12:00 PM Consumer interviews
12:00 PM - 1:00 PM Lunch
1:00 PM- 2:00 PM Review documents gather info still needed
2: 00 PM - 6:00 PM Team works on drafts of individual section
6:00 PM-8:00 PM Dinner Break (with discussion on
impressions)
8:00 PM Team members continue work as needed,
Wednesday, Date
8:00 AM Team members finalize report
10:00 AM Exit Conference (team) (All)
It is suggested that the each team member report their respective sections' Commendations and Recommendations during the Exit Conference in a manner that is alternating.
End of this form
NAC Reviewer Information Form
1. Name _________________________________________________________________
2. Present Position and Title__________________________________________________
3. Business Address________________________________________________________
__________________________________________________________
Business Phone_________________________________________________________
Email Address__________________________________________________________
4. Home Address__________________________________________________________
__________________________________________________________
Home Phone___________________________________________________________
Email Address__________________________________________________________
5. Preference for correspondence? Home______ Office______ Email_________
6. Please explain your experience in accreditation. ______________________________
_____________________________________________________________________
7. Do you require any special accommodations? If so, what?
__________________________________________________________________
Please check those functions you feel most capable of evaluating:
Administrative
General Administrative____ Public Relations____ Access Technology (new)___
Financial Accounting ____ Personnel Administration ___ Volunteer Services ___
Fund Raising ____ Service Management ____ Physical Facilities ____
Services
Agencies Schools
Low Vision Services _____ Infant and Preschool Programs ____
Orientation & Mobility _____ Kindergarten - Grade 12 Programs _____
Reading Materials _____ Residential Living Program _____
Recreation Services _____ Multiple Handicapped Services _____
Residential Services _____ Outreach Programs _____
Social Work Services_____
Vocational Services _____
Rehabilitation Teaching Services ______
Please also submit the following with this application:
1. Resume or curriculum vitae
2. Letter of reference from a supervisor or professional colleague
Agencies, schools or programs granted accreditation status must agree to the following terms:
The accredited body shall:
1. Designate a person to act as liaison and coordinate activities and preparation for the on-site peer review, and keep NAC's Executive Director informed when new designations occur.
Display, where appropriate, the NAC logo.
3. When only a program within an agency is accredited by NAC, that status is made clear in publications
4. File an annual report with the executive director of NAC.
5. Engage the agency/school in the periodic self-assessment
study process.
6. In consultation with the executive director of the agency or school schedule the on-site review dates.
NAC shall:
1. NAC can provide a CD and provide one printed and one electronic copy of the self-assessment study materials.
2. Appoint a mentor to assist with the process of self- assessment study activities as needed in preparation for the on-site peer review.
3. Provide appropriate recognition of accreditation to agency specified entities.
4. Provide newsletter, annual reports, and a copy of NAC publications.
5 Provide information on data collected by NAC.
6. Provide electronic notices of meetings and events.
Reviewers Code of Conduct, Conflict of Interest, and Confidentiality Agreement
The National Accreditation Council for Blind and Low Vision Services (NAC) is committed to the concept of ethical behavior by its reviewers and all persons who represent NAC.
NAC reviewers/representatives are expected to read, understand, and agree to adhere to all the policies set forth in this document.
The reviewer's code of conduct is the foundation of the compliance process and guides professional and ethical behavior. It is built on the precept of quality customer service and driven by NAC's mission and values. No code of conduct can identify all appropriate moral conduct and ethical behavior for every situation reviewers may encounter; reviewers must also rely on good judgment and support, encourage and help one another to comply with this code.
As a reviewer you must agree to follow all the policies and procedures in the current NAC Reviewer Policies and Procedures Manual and emulate the following behavior.
Customer Service
A NAC reviewer's success depends on recognizing and responding to the needs of all customers as a priority, throughout the review process.
Examples:
-Avoid confusing customers; apply standards in a manner consistent with NAC interpretations.
-Provide useful, bias-free consultation based on active listening.
-Remember that you are at the facility by invitation; minimize interference with the organization's regular operations.
Conflict of Interest
Reviewer independence is essential to the integrity of the review process and desired outcome. Avoid all actual, potential, and insinuated conflicts of interest.
Examples:
-Avoid accepting any assignment in which a conflict of interest exists or may be insinuated.
-Avoid soliciting employment, personnel, or business opportunities (e.g., distributing business cards for personal gain.)
-Avoid working for or providing professional services to any entity that accredits in any of the same fields as NAC.
-Avoid accepting from the organization any goods or services.
-Avoid marketing or selling any products or services to the organization or its employees.
-Avoid accepting any assignment not in line with your area of expertise.
In a timely manner, identify and declare to NAC any relationships with an organization or individual that would impair, or could be perceived to impair, full and fair application of standards.
Confidentiality
All information disclosed to a reviewer by an organization, it customers and funding and referral sources is to be considered private and confidential.
Examples:
-Comply with all applicable privacy and confidentiality laws set forth by NAC and the visited organization's internal policies.
-Dispose of materials in a manner that will protect confidentiality.
-Avoid disclosing to the organization information learned during interviews with persons served, funding sources and referral sources when confidentiality has been promised or requested.
Cooperative Relationships
Developing cooperative relationships is integral to a constructive and successful review process. Appropriately engage stakeholders in a professional manner.
Examples:
-Limit all contact with individuals related to or associated with the organization to review-related business.
-Treat all persons with dignity and respect.
You represent NAC and are on-site to serve the organization. Devote your full time and attention to the organization during the review and in line with NAC's policies and procedures.
Examples:
-Avoid conducting non-review-related business during the review, except as necessary to respond to an emergency.
-Avoid distraction from or interference with the review process due to the presence of reviewer family members.
-Avoid non-review-related use of cellular telephones during the review hours, except as necessary to respond to an emergency.
Treat each person in a caring and respectful fashion, mindful of individual differences and cultural and ethnic diversity.
Examples:
-Avoid discrimination in any manner based on any individual's race, color, national origin, religion, citizenship status, veteran status, age, gender, sexual orientation, disability, or any other status protected by law.
-Avoid any personal or preconceived ideas, notions, or beliefs that may affect the review process.
-Acknowledge and allay fears and concerns of organizations and persons served related to the review process.
Dignity and Respect
All people have the right to be treated with dignity and respect. Maintain a positive review environment free from any form of harassment.
Example:
-Avoid sexual or other harassment of employees or other representatives of organizations, persons served, or other reviewers, such as oral or written communications or other conduct, including physical conduct that tends to insult, degrade, tease, intimidate, or otherwise harass.
Safety
Help establish and maintain a safe environment by exercising good judgment and common sense.
Examples:
-Avoid inattentive, reckless, or unlawful driving during and on route to and from the review.
-Avoid the use of unlawful drugs.
-Avoid the use of alcohol while on-site or in excess at other times during the review.
-Avoid taking unnecessary risks while on the review.
Safeguarding NAC Assets
NAC's assets are funded almost entirely by the organizations it serves, and its stability is critical to NAC's ability to fulfill its mission. Protect NAC's reputation and safeguard its financial, intellectual, technological, and all other assets.
Examples
-Submit for payment only actual review-related expenses.
-Use and disclose NAC proprietary materials (e.g., standards manuals, checklists, lists of discriminatory and frequently cited standards, and copyrighted materials, etc.) provided to you solely in your capacity as a reviewer only in connection with the assigned reviews.
-Avoid violating any laws, and immediately inform NAC of any criminal charges.
-Avoid accepting review assignments outside areas of your competency.
Reporting
Reporting improper reviewer behavior allows NAC to take appropriate remedial actions that promote professionalism and support on going compliance. Report to NAC any event you reasonably and in good faith believe is a violation of NAC's reviewer code of conduct.
Reviewer' Conflict of Interest, Confidentiality and Code of Conduct Form.
I have read NAC's reviewer's code of conduct, conflict of interest policy and confidentiality policies. I understand and agree to conduct myself in accordance with all the policies outlined in this document. Further I understand and agree to contact NAC's Executive Director if a conflict of interest arises during my services as a reviewer and pledge to not divulge any confidential information entrusted to me in my capacity as a NAC reviewer. I fully understand NAC's code of conduct as a reviewer and by signing this form and returning it the NAC office agree to abide by all said policies.
Name (please print): _________________________
Signature: __________________________________
Date signed: ________________________________
(For NAC use only) Date form Received: _______________________________
Drafted JUNE 2008
End of this form
THE END OF THIS MANUAL
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 Blind and Low Vision Services (NAC)
Steven K. Hegedeos Executive Director
7017 Pearl Road
Middleburg Hts., Ohio 44130
Phone: 440-545-1601
Cell: 440-724-9781
