Program Effectiveness Plan (Pep) Manual

ABHES

PROGRAM EFFECTIVENESS PLAN (PEP) MANUAL

Updated January 2012

TABLE OF CONTENTS

The Purpose of the Program Effectiveness Plan (PEP)...... 3

Developing, Implementing, and Monitoring the Program Effectiveness Plan...... 5

Format and Content Guidelines...... 7

Subsection 1 –Program Effectiveness Plan content

Title/Cover Page...... 7

Student Population...... 7
Program Objectives...... 8
Program Retention Rates...... 10
Program Job Placement Rates...... 12
Credentialing Examination Participation Rates...... 14
Credentialing Examination Pass Rates...... 15
Program Assessment...... 16
Student, Clinical Extern Affiliate, Graduate And Employer Satisfaction Surveys...... 18
Faculty Professional Growth And In-Service Activities...... 22

Subsection 2 – Outcome Assessment

Historical outcomes...... 23
Types and Uses of Assessment Data...... 23
Initial baseline rates & measurement of results...... 24
Summary and analysis of data collected...... 25
How data is used to improve the educational process...... 25
Goal Adjustment...... 26
Activities undertaken to meet future goals...... 26

Format Examples27

Conclusion……...... 30

PURPOSE OF THE

PROGRAM EFFECTIVENESS PLAN

The Program Effectiveness Plan (PEP) is an internal quality assessment tool that evaluates each program within an educational institution by

establishing and documenting specific goals,

gathering outcome data relevant to these goals,

analyzing outcomesin relation to benchmarks and program’s short- and long-term objectives, and

designing strategies to improve program performance.

The program effectiveness assessment is expected to result in the achievement and maintenance of outcomes. For each of the outcomes identified by a program, the program establishes the level of performance that serves as a benchmark for acceptable program performance. These benchmarks meet or exceed requirements established by any applicable state or federal authority and by ABHES policies and/or standards.

Program success is based on student achievement in relation to its mission, including but not limited to consideration of the following:

Retention rates
Participation in and results of licensing and certification examinations
Graduation rates
Job placement rates
Program assessment
Survey responses from students, clinical externship sites, graduates, and employers
faculty professional growth and in-service activities

Developing and using the Program Effectiveness Program (PEP) should fulfill several purposes, including:

1.Assisting the institution in achieving internal effectiveness through establishing goals for short- and long-term successes. Further, criteria for measuring the accomplishment of these goals can be defined, allowing the institution to focus its plans and activities on the critical processes needed for effectiveness. Once defined, these goals and criteria should then be used to unify administrative and educational activities, which can achieve a high degree of commitment and common direction among all employees.

2.Assessing progress and the need for change and continuously reviewing the process to help the institution make timely changes based upon valid information to achieve even greater effectiveness.

3.Communicating key information about the institution’s goals, its degree of effectiveness, and how it plans to enhance overall quality to external publicssuch as graduates, employers, and community leaders. Information, which depicts the most important elements of the institution’s operation, communicates clearly and accurately to external publics how well the institution is meeting the needs of students and providing quality-learning experiences.

Measuring how the PEP meets the expectations and requirements of approving or accrediting organizations, including state boards and ABHES, to demonstrate regulatorycompliance. A document which defines institutional goals and educational processes is a primary focus of most accrediting agencies as they measure overall effectiveness and the quality of programs and services provided.

All goals and activities are key indicators of program effectiveness and should relate to the institution’s mission to demonstrate mission achievement and continuous improvement, as the institution’s mission is the impetus and barometer of the program’s effectiveness. The PEP requires an institution to look at its past, present, future, and strategies and to continuously ask:

Where have we been? / This data becomes the baseline for gauging and demonstrating improvements.
Where are we now? / Current data demonstrates how you will measure change from the baseline data using the caparison to identify changes needed.
Where do we want to go? / A look toward the future for goals to improve or enhance processes and/or programs.
How do we get there? / Processes used to achieve the new direction based upon the input of all relevant constituents.

DEVELOPING, IMPLEMENTING, AND MONITORING

THE PROGRAM EFFECTIVENESS PLAN

(Standards and Examples)

The standards addressing the Program Effectiveness Plan may be found in the ACCREDITATION MANUAL 17THEdition, Chapter V, Section I, pages 72-76 aspublished by the ACCREDITING BUREAU OF HEALTH EDUCATION SCHOOLS (ABHES). The standards outline the ABHESrequirements in relation to the development, implementation, and maintenance of the PEP, including the outcomes assessment requirements and (Section I, Subsection 2), which gives a detailed description and explanation of the meaning and implications on the required components of the PEP. This manual provides suggestions and examples for addressing each PEP standard.

Developing an PEP requires that each program collect, maintain, and use information reflecting the areas outlined in Chapter V, Section I of the ABHES Manual. The data should be analyzed for a specific 12 month period of timeas defined by the institution and be used as the foundation for making comparisons across future time periods. Many institutions perform its analysis in conjunction with its fiscal/calendar year or in conjunction with the ABHES annual reporting period (July 1 – June 30), since the majority of the required PEP information is also required on the ABHES Annual Report. Regardless of the selected timeframe, the data is to be updated at least annually.

The PEP is unique to the program and institution and the institution must evidence its efforts made to ensure continuous improvement. The process requires that the institution: (1) systematically collect data and information on each of the educational outcomes areas and achievement of its occupational objectives at least annually; (2) complete an analysis of the data and information including, but not limited to, performing a comparison with previous findings; and (3) identify what changes in educational operations or activities it will make based on the analysis.

Steps in preparing and managingthe PEP are similar to those suggested for preparing aninstitution’s self-study. Structured organization is essential. Although the exact organizational procedures will vary from institution to institution, the following suggestions may be helpful:

The program faculty (full time and part time) assisted by the president/director, director of education, and a representative from admissions and placement are the key individuals acting as a teamto initiate, guide, and direct the development and implementation of the PEP. It is their commitment to the PEP and empowerment of the team to overseethese activities that will ensure continuous improvement and the ultimate success of the planning process.

The process is a collective effort that should involve allfaculty, administrators, staff, and advisory board members. Consideration should also be given to actively recruiting student, graduate, and employer representatives in the process. It is important that all members of the administration, faculty, governing board, and student body understand and appreciate the importance of the PEPand its value to the institution.

Establish subcommittees to prepare specificPEP sections. These subcommittees should be effectively utilized to complete the various tasks in all facets of the PEP, including development, implementation, and evaluation. The consideration of subcommittee members should depend on each member’s responsibilities. Include the names of those responsible for implementing and monitoring the PEP.

Establish baseline rates developed through analyzing the results of past annual retention and placement rates, which will be used in the analysis process. The data collected each year on the ABHES Annual Report includes retention and placement percentage; therefore, it is a valuable part of the PEP. Each program should maintain these annual reports with supporting documentation, for at least three years so as to provide historical data from which goals may be set. Be specific in the data to be collected and collect data that will clearly evidence the level of educational outcomes and satisfaction experienced by current students, graduates, and employers.

The PEP may include any other elements determined to be important measures of program effectiveness such as a review of default rates in the student loan programs under Title IV of the Higher Education Act, based on the most recent data provided by the Secretary of Education. These findings may be coupled with student retention and placement rates to determine what correlation, if any, can be determined. Any correlation identified should be reviewed for correction.

Because the PEP focuses on overall program improvement, it is a work in progress as there are many potential elements of the institution’s daily operations, which are relevant and important to improving effectiveness. Each program is encouraged to collect a variety of statistical data, which will assist it in improving the educational outcomes.

The PEP team and subcommittees should adopt and implement a realistic and enforceable periodic schedule throughout the year to review the PEP and document progress through minutes of all meetings where the PEP is discussed. The meeting minutes should show the progress to date, a short summary of the data analyzed, changes anticipated, and continuation or new direction the institution is taking to improve the educational processes. Minor revisions to goals may be made during the monitoring of the PEP; however, substantial revisions should only be made at the annual review unless there is a major change in the institution’s leadership and/or mission. These periodic meetings will ensure that the PEP is utilized and evaluated on a continuing basis.

PROGRAM EFFECTIVENESS PLAN

FORMAT AND CONTENT GUIDELINES

While each program must address each element required of the Program Effectiveness Plan (PEP), the plan may be a comprehensive one which collectively represents all programs within the institution, or may be individual plans for each distinct program. The following section isto serve as a guide as it contains elements that should be incorporated into the PEP. Each standard is given, followed by examples of how an institution might demonstrate established goals and compliance.

Title/Cover Page to include the following:

ABHES I.D.CODE

Name of Institution

Address

City

Name of Program

ProgramDirector

Credentialawarded

Portion of program offered via distance learning

Length of program(clock hours,semester/quartercredits,weeks, etc.)

12 Month period covered by the plan (e.g., July 1, 20?? through June 30, 20??)

V.I.1.A program has an established documented plan for assessing its effectiveness as defined by specific outcomes.

The Program Effectiveness Plan includes(all of the following standards) clearly stated:

STANDARD

student population

A description of the characteristics of the student population is included in the Plan.

Student population demographics such as gender ratios, median age, race/ethnicity, marital status, and socioeconomic descriptions should also be included and identified by program if they differ from the overall institutional demographics.

EXAMPLES:

There are many ways an institution may identify such information. The following examples include narrative, listing and chart formats:

Narrative Format

The institution’s student population has doubled over the last three years and is represented by a diversity of demographic characteristics. Approximately 80% of the population is independent with an average annual income below $22,000, and 20% are dependent with an average annual family/household income of $40,000. Male to female ratio is 39% to 61% respectively, and student ages range from 18 to 63. Recent business closings have resulted in an increase in the student population of dislocated workers seeking retraining. The majority of students require some form of financial assistance. The race/ethnicity composition is African American/Black 13%, American Indian/Alaskan Native 0.3%, Asian/Pacific Islander 0.7%, Hispanic 1.5%, Mexican American 0.5%, Caucasian/White 78.8%, and Undisclosed race 5.1%

Listing Format

In the 2010-2011 Annual Report year, the student body consisted of approximately:

61% female, 39% male

60% attend day classes: 40% attend evening classes

83% earned an average or above grade in high school English

75% earned an average or above grade in high school math

9% English as a second language

58% HS

12% GED

30% had prior postsecondary education

71% were first in family to receive postsecondary education

61% were employed

80% were independent with a household income of $22,00 or less

91% attended full-time classes and 9% part-time

36% were married

29% under age 25, 34% age 25-34, 26% age 35-44, 7% age 45-54, 4% age 55+

Afro-American Black 13%, American Indian/Alaskan Native 0.3%, Asian/Pacific Islander 0.7%, Hispanic 1.5%, Mexican American/Chicano 0.7%, Caucasian/White 78.8%, Undisclosed race 5%

Chart Format

PROGRAM / Gender ratios
M F / Median age / Race/
Ethnicity
W NW U / Marital status / Socio-
Economics
Independent & <$22,000
Nursing Assistant
Dental Hygienist
Massage Therapist
Medical Assistant
Medical Billing & Coding Specialist
Patient Care Specialist
Pharmacy Technician
Phlebotomy Technician
INSTITUTION TOTALS / 39 / 69 / 13 / 82 / 5

STANDARD

b. program objectives

Programs objectives are consistent with the field of study and the credential offered and include as an objective the comprehensive preparation of program graduates for work in the career field.

Program Characteristics of each currently offered program should include:

Degree level,
Program description,
Program objectives, and
Description of student outcomes, specifying the competencies students should possess upon conclusion of the program.

If an institution offers Medical Assistant, Nursing Assistant, and Surgical Technology programs, then its PEP might present the following overview:

EXAMPLE:

The Medical Assistant academic associate’s degree program prepares the student to become a multi-skilled allied health professional with diverse duties in medical offices, clinics and health centers. The program includes a balance of classroom, laboratory, and clinical experiences.

Objectives of the program are to:

Prepare a knowledgeable entry-level employee with technical skills and work habits necessary to perform effectively in various health-care related fields including medical transcriptionist, medical billing specialist, medical office manager, and medical assistant.
Provide clinical activities that include assisting the physician in patient care responsibilities by recording medical histories, taking vital signs, preparing the patient for examination, assisting physician during patient examination and surgical procedures, collecting and performing various laboratory tests, administering medications, performing diagnostic procedures such as EKGs and dressings, and providing patient education.
Teach courses in anatomy, physiology, pharmacology, computer applications, clinical procedures, interpersonal skills, confidentiality, medical ethics, professional behavior, and patient interface, as well as basic office procedures to ensure competency.

At the completion of the program, the student will be able to:

Assume a wide range of responsibilities in a medical office or ambulatory care center.
Communicate with patients to schedule appointments, receive and process payments.
Sit for the credentialing examination

The Nursing Assistant diploma program prepares the student to function under the supervision of a physician and/or a registered nurse and to participate as a member of a healthcare team in providing nursing care. The program includes classroom, laboratory, and clinical patient care experiences.

Objectives of the program are to:

Prepare a competent, nurse assistant to function effectively in acute, long-term care, and ambulatory settings.
Provide a collaborative learning environment in which the student will develop and apply principles of systematic reasoning through critical thinking.
Guide the learner in the continuing process of personal and professional growth.

At the completion of the program, the student will be able to:

Function in the delivery of care to clients.
Communicate with clients, client families, and members of the healthcare team.
Perform nursing skills applying critical thinking.
Integrate ethical, professional, legal responsibility, and accountability into actions and decisions.
Assume responsibility for personal and professional growth.
Sit for the State certification board exam.

The Surgical Technology certificate program prepares the graduate to function as an intraoperative team member under the direct supervision of a surgeon or registered nurse. The graduate is prepared for this role through didactic, laboratory, and external clinical experiences.

Objectives of the program are to:

Prepare the graduate for a professional career.
Prepare a competent surgical technologist to perform intraoperative first scrub duties.
Guide the learner in the processes for certification and professional development.

At the completion of the program, the graduate will be able to:

Effectively perform pre-, intra-, and post-operative duties
Practice aseptic and sterile technique
Practice all patient safety measures and act in an ethical manner
Assume responsibility for personal and professional growth
Sit for a national certification exam

Continue same format for all programs offered at the institution.

STANDARD

c. program retention rate

At a minimum, an institution maintains the names of all enrollees by program, start date, and graduation date. The method of calculation, using the reporting period July 1 through June 30, is as follows:

(EE + G) / (BE + NS + RE) = R%

EE
G
BE
NS
RE
R% / =
=
=
=
=
= / Ending Enrollment (as of June 30)
Graduates
Beginning Enrollment (as of July 1)
New Starts
Re-Entries
Retention Percentage

Include the retention results for the last three annual reporting years as the baseline,if available, along with goals for the upcoming year. If an institution has developed long-term goals for retention, this information should also be included with status updates.