The Compliance Certification is the document completed by the institution that demonstrates its judgment of the extent of its compliance with each of the Core Requirements, Comprehensive Standards, and federal regulations as presented in the Principles of Accreditation. ...

 
Institutions may choose to give the responsibility for conducting the institutional analysis of compliance to a committee formed specifically for this purpose, or they may assign this task to an existing committee or council. In either case, it is recommended that the group charged with this responsibility be composed of a director or chair and a relatively small number of members and involve:

• The institution’s accreditation liaison in either an oversight or support role.
• Individuals who have access to the data and information required to prepare a report that substantiates the institution’s assessment of compliance.
• Knowledgeable representatives from areas such as

■ Institutional research,
■ Finance and business,
■ Educational programs,
■ Student services,
■ Institutional effectiveness,
■ Libraries and other learning resources,
■ Enrollment management, and
■ Governance.

In choosing the members of the group to conduct the institutional compliance review, the goal should be to select those individuals who understand the institution’s mission and who have extensive knowledge of its history, culture, practices, policies, procedures, and data sources. Achieving widespread institutional participation for the compliance review is not a goal.
 

Conducting the Compliance Review

Those conducting the compliance review should begin their analysis by careful interpretation of the Core Requirements and Comprehensive Standards to understand each aspect and what information and data must be assembled to document compliance.

As a part of the Compliance Certification, the institution is required to record its judgment of the extent of its compliance with each aspect of each Core Requirement and Comprehensive Standard.
The institution has three alternatives in describing its determination:

• Compliance. The institution concludes that it complies with each aspect of the requirement or standard and supports this judgment in a narrative response supported by documentation.

• Partial Compliance. The institution judges that it complies with some but not all aspects of the requirement or standard and supports this judgment in a narrative response supported by documentation justifying its claim of partial compliance, an explanation for its partial non-compliance, and a detailed action plan for bringing the institution into compliance that includes a list of documents to be presented to support compliance and a date for completing the plan.

• Non-Compliance. The institution determines that it does not comply with any aspect of the requirement or standard and provides a thorough explanation for its non-compliance and a detailed action plan for bringing the institution into compliance that includes a list of documents to be presented to support compliance and a date for completion of the plan.

The following is illustrative of the approach an institution may wish to use in examining each Core Requirement and Comprehensive Standard to determine its extent of compliance. ... This standard is an example of one that is complex and therefore calls for extensive analysis, judgment, multiple assessment modes, and identification of patterns of evidence in order to present a persuasive case for compliance.

Illustrative Example

Comprehensive Standard 3.9.3 The institution provides services supporting its mission with qualified personnel to ensure the quality and effectiveness of its student affairs programs. This standard covers four critical issues: The relationship of the student affairs services and programs to the mission of the institution. The qualifications of student affairs services and programs personnel. The quality of student affairs services and programs. The effectiveness of student affairs services and programs. ... In order to determine its compliance with the four components of this standard, the institution may wish to consider the following questions: In what ways do student affairs services and programs support our mission? What are the appropriate qualifications for personnel who provide the student affairs programs and services that the institution offers? Do student affairs personnel possess these qualifications? If student affairs personnel are supposed to be sufficiently well qualified to assure the quality and effectiveness of the student affairs program, how are the “quality” and “effectiveness” of these services defined? What types of evidence are needed to ascertain the quality and effectiveness of the student affairs programs and services? What methods of assessment are employed to produce this evidence? How are the results of assessment used to improve these programs and services?

 
Documenting Compliance: Sources of Documentation

The institution should first develop a thorough understanding of what documentation is needed to assist in determining and supporting the institution’s extent of compliance with each Core Requirement and Comprehensive Standard. The institution should then begin to inventory available records, documents, databases, policy manuals, curriculum documentation, assessment records, committee minutes, board of trustee minutes, planning documents, reports to external audiences, case studies, and other sources of information relevant to assessing compliance with the Core Requirements and Comprehensive Standards.

Some of the more obvious sources of evidence are documents such as the following:

• College catalog.
• Organizational chart.
• Bylaws of the governing board.
• Description of institutional effectiveness methods and results.
• Evaluations and documents addressing student achievement.
• Faculty files containing credentials denoting qualifications.
• Faculty handbook.
• Documentation that describes the library holdings and services as well as other learning resources, services, and facilities available to students, including electronic access to information.
• Description of off-campus/distance learning programs and faculty, staff, and learning resources to support them.
• Documentation of all consortium memberships and other inter-institutional agreements for providing instruction or sharing resources.
• Student handbook.
• Financial audits, management letters, financial aid audits for the current and recent fiscal years, and any other relevant financial statements.

These sources should provide evidence to demonstrate compliance with a large number of the Core Requirements and Comprehensive Standards.

During this survey of available documents, the institution will also need to identify areas where evidence may be insufficient to demonstrate compliance and develop strategies to address these gaps. ...

 
Presentation of Documentation

For some requirements and standards, a single document or excerpt from a document, along with a brief narrative placing it in context, will constitute sufficient evidence of compliance. Such evidence can often be excerpted from policy manuals, handbooks, and other official documents. For example, compliance with the Core Requirement specifying that the institution have a president who is not simultaneously the chair of the governing board can be supported by the existence of a written policy covering this issue.

For Core Requirements and Comprehensive Standards that are more complex, a more extensive analysis must be provided, and several sources of relevant evidence may need to be identified in order to justify a claim of compliance. For these, in addition to the list of documents containing evidence of compliance or electronic access to those documents, the institution should provide a convincing narrative explaining how the evidence submitted supports the claim of compliance. The narrative should also include a summary as well as an interpretation of extensive or complex documents and data cited as supporting the claim.

Examples of separate measures/indicators that may be combined to produce a pattern of evidence to support compliance include the following:

• Trend data,
• Survey data,
• Benchmarking,
• Student satisfaction indices,
• National norms of student learning outcomes results,
• Major field test scores,
• Licensure/certification rates,
• Program accreditation results,
• Program peer review results, and
• Focus group findings.

Illustrative Example

Core Requirement 2.5 The institution engages in ongoing, integrated, and institution-wide, research-based planning and evaluation processes that (1) incorporate a systematic review of institutional mission, goals, and outcomes; (2) result in continuing improvement in institutional quality; and (3) demonstrate the institution is effectively accomplishing its mission. In documenting its response to this requirement, the institution should look for a pattern of evidence to support compliance. A “pattern of evidence” is a set of multiple measures/indicators that exhibit coherence and a unifying theme. Patterns of evidence will differ according to the requirement or standard and the nature of the institution. A pattern of evidence to demonstrate compliance with Core Requirement 2.5 might be identified in the following: Strategic planning, Resource allocation based on planning and setting priorities, Public accountability reports, and Systematic, mission-driven, institution-wide evaluation and use of the results for continuous improvement.

The narrative, including summaries and interpretations of lengthy and complex data, and the list of documents available on campus, should provide an adequate amount of information and a sufficient, convincing case to allow the Off-Site Review Committee to determine compliance with most of the requirements and standards without having to review all the actual documents. ... The institution should be judicious in determining the extent of information to be sent and, for the most part, should provide only summaries or limited pertinent pages from full documents.

 
Evaluating the Evidence Supporting Compliance

... The institution will need to evaluate the evidence it intends to submit supporting its claim of compliance with each requirement and standard. This evaluation should be based on a careful interpretation of the Core Requirements and Comprehensive Standards and on the cogency of the evidence to be presented supporting compliance with them. Evidence is not simply an amassed body of facts, information, data, or exhibits. Instead, it is a coherent and focused body of information supporting a judgment of compliance.

Institutions should ensure that the evidence it presents has the following characteristics. Evidence must be:

• Reliable. The evidence can be consistently interpreted.

• Current. The information supports an assessment of the current status of the institution.

• Verifiable. The meaning assigned to the evidence can be corroborated, and the information can be replicated.

• Coherent. The evidence is orderly, logical, and consistent with other patterns of evidence presented.

• Objective. The evidence is based on observable data and information.

• Relevant. The evidence directly addresses the requirement or standard under consideration and should provide the basis for the institution’s actions designed to achieve compliance.

• Representative. Evidence must reflect a larger body of evidence and not an isolated case.

Additionally, evidence should:

• Entail interpretation and reflection; those responsible for submitting the evidence should have thought about its meaning and be able to interpret it appropriately to support a conclusion.

• Represent a combination of trend and “snapshot” data.

• Draw from multiple indicators.

 
Making the Case for Compliance

As stated previously, institutions are expected to present a narrative that summarizes and interprets documentation presented to support an assertion of compliance with a requirement or standard. It is in the narrative that an institution presents its “case” for compliance.

In reviewing its rationale for claiming compliance, the institution should determine whether these narratives constitute accurate and adequate summaries and interpretations of the data to which they refer and whether the narratives and the data combined support the institution’s claim of compliance. It is the responsibility of the institution to establish its extent of compliance. It is the responsibility of peer reviewers to determine whether the institution has established compliance. ...

Whether the documents are presented in electronic or paper formats, it is important for institutions to provide narratives including summaries and analyses of lengthy and complex documents and data. ... Institutions should refrain from sending entire documents unless otherwise instructed to do so. Off-Site Committees should be able to determine compliance with most of the Core Requirements and Comprehensive Standards from the narratives, the list of documents available on campus to support compliance, excerpts of documentation incorporated into the narrative, and summaries, samples, and analyses of appropriate documents.