C. Process of Residency Accreditation (Initial/Continued
1. Residency Self-Study
The residency must develop and implement a self-study process that involves all constituencies of the residency and demonstrates achievement of
relates to effectiveness regarding its mission/purpose and , goals and objectives. The self-study report must:
a. Provide clear evidence that the residency complies with the CCE requirements for residency program accreditation.
b. Focus attention on the ongoing assessment of program outcomes, including those developed to demonstrate resident achievement of the core competencies, for the continuing improvement of academic quality.
c. Demonstrate that the residency has processes in place to ensure that it will continue to comply with the CCE requirements for accreditation.
d. Be submitted to the CCE Administrative Office no later than nine months prior to the CCE meeting wherein a decision regarding accreditation will be considered.
2. Site Team Visit and Report to CCE
Following receipt of the residency self-study report, the Council appoints a site team to review evidence contained within the eligibility documentation and self-study report relative to compliance with the CCE Residency Program Accreditation Standards. The site visit and report to the CCE are an integral part of the peer review process that uses the residency’s self-study as the basis for an analysis of the strengths, challenges, and distinctive features of the residency. This process is designed to ensure that, in the best judgment of a group of qualified professionals, the residency complies with the requirements for eligibility and accreditation and that the residency is fulfilling its mission/purpose and goals. An enduring purpose of CCE accreditation is to encourage ongoing improvement.
a. The residency must provide the site team with full opportunity to inspect its facilities and rotation sites, where feasible, and to interview all persons at the site/facilities related to the residency, and to examine all records maintained by or for the residency of which it is a part (including but not limited to budget and personnel records, and records relating to resident credentials, resident assessment of learning, resident advancement in the program, and program completion (degree, certificate, etc.).
b. A draft report is prepared by the site team and sent by the CCE Administrative Office to the residency Director and/or designated officer for correction of factual errors only.
c. Following the response of the residency to correction of factual errors, a final report is sent by the CCE Administrative Office to the residency Director and/or designated officer, governing official and site team members.
d. The residency may submit a written response to the site team report, and it must submit a written response if the report identifies areas of concern. The residency sends the response to the CCE Administrative Office which distributes it to the CCE President, Councilors and Site Team Chair. Any residency response to the site team report must be submitted to the CCE no less than 30 days prior to the Status Review Meeting.
3. CCE Status Review Meeting
a. The objective of the status review meeting is to provide an opportunity for the Council to meet with the residency representatives (if applicable) to discuss the findings of the site team in accordance with CCE policies and procedures. The Site Team Chair or other members of the site team may also be present at the request of the Council Chair.
b. Following the status review meeting, the Council reviews the self-study and supporting documentation furnished by the residency, the report of the on-site review, the residency's response to the report, and any other appropriate information, consistent with CCE policies and procedures, to determine whether the residency complies with the CCE Residency Program Accreditation Standards.
c. The Council’s action concludes with a written decision regarding accreditation status that is sent to the residency Director and/or designated officer, the governing official, and CCE Councilors.
d. The next comprehensive evaluation site visit normally is three years following the award of initial accreditation, or six years following the award of continued
reaffirmation of accreditation. If the residency’s sponsoring organization is an institution housing a CCE accredited DC program, every effort will be made to ensure the cycle of comprehensive visits coincides with the accreditation cycle of the DC program.