Search

Removing Roadblocks and Clearing The Way For Accreditation Success: Part 1

By Cynthia Allen and Janice Moore, Seacrest

Disclaimer: The information provided in this article is based on experience preparing more than 190 applications for accreditation. This article does not represent the opinions of the NCCA Commission.

Successfully navigating the complex path to National Commission for Certifying Agencies (NCCA) accreditation is a rewarding experience. Achieving accreditation requires full compliance with each of the 24 NCCA Standards for the Accreditation of Certification Programs. Awareness of potential roadblocks helps to clear the way for an experience that is more likely to result in a successful accreditation decision, but builds an organizational culture that values quality improvement and a commitment to best practices. 

In this two-part series, we discuss removing common roadblocks in the accreditation process to position organizations applying for initial accreditation, or re-accreditation, for success. Part 1 focuses on governance, administrative, and operational challenges and part 2 focuses on psychometric roadblocks. Addressing these roadblocks brings wider benefits beyond our specific focus on the NCCA Standards, which is discussed throughout. 

Understanding the overarching themes weaved throughout the Standards helps bring context in clearing roadblocks and integrating changes into the organization’s culture; for example, the concept of fairness. The policies and procedures required of accredited programs promote fairness to candidates, consistent policy implementation, equal access to the exam, and transparency in published information regarding the application process, examination content, requirements for certification and recertification, and disciplinary information. “Show and tell” is another theme. The NCCA requires that you demonstrate (or “show”) how you meet the standard and, in many cases, provide evidence (or “tell”) what you did to meet the requirement. “Showing” might include a policy and “telling” might include meeting minutes or psychometric reports. 

These are not just requirements to be met. Understanding these themes and building best practices into management of the certification program supports efforts to achieve accreditation and successfully maintain it moving forward. 

We have identified four roadblocks that present the most significant administrative challenges: governance, separation of education and certification functions, policies, and published information. We discuss each below followed by our seven tips for avoiding other operational challenges. Clearing these roadblocks help move certification programs more quickly along the path to accreditation.

1. Governance

The certification program must have a governing body with authority over what the NCCA Standards document refers to as “essential” certification decisions related to the program(s) seeking accreditation. At the same time, the governing body should have no authority over unrelated activities, like required training, membership, accrediting educational programs, or other competing interests. The governing body might be a stand-alone organization or part of a parent organization. It may be a certification board, council, or committee—the name is less important than the governing body’s specific roles and authority. 

Establishing the required authority, balanced with an appropriate level of independence, often requires structural changes. The certification governing body should operate impartially, without undue influence from internal or external pressures. Some groups, particularly those housed within a parent organization and involved in multiple activities such as membership, education, and research, find establishing the required level of authority and independence difficult. Making these changes requires strategic discussion and transition planning. 

The roadblock of undue influence presents challenges, even for programs with sufficient authority, and can come from various sources. For example, when a program fails to include broad perspectives representing the community it serves, an influential stakeholder that exerts disproportionate influence on the program may create undue influence. 

Even certification programs housed independently, meeting all of the requirements related to governance, can stumble over roadblocks. The first step in clearing the way for accreditation involves providing formal, written documents that clearly define the governing body’s structure and authority. Typically in the form of bylaws, a governance charter and/ or internal policies, these documents establish and protect the governing body’s authority. 

Boards considering creating a new certification governing body, or expanding the authority and independence of an existing certification committee or council, often express anxiety that the new group will go ‘rogue’ and lead the program off in a direction that the Board might oppose. Mitigating this risk depends on creating detailed and specific governing documents that clearly define the roles and responsibilities, as well as limitations. 

The policies should address the composition of the governing body, officers, terms and qualifications for each position. They should also identify the program’s stakeholders and how their interest is represented. Finally, they should specify how the governing body’s members are recruited, screened and selected (or elected) to ensure a fair process that prevents undue influence. 

Organizational benefits: Formal, written policies clarify roles and responsibilities and provide a clear picture of the governing body’s authority. Clearly defined policies are particularly helpful for groups facing difficulties related to undue influence or those housed within a more complicated structure. They provide directions to the volunteer and staff leadership on processes for maintaining the structure.

2. Separation of Education and Certification Functions

The ICE Digest article, “The Separation of Certification and Education” (Q4, 2016), discussed in detail the separation of education and certification activities within an organization. In 2016, the NCCA published an interpretation on how the Commission evaluates sample items and practice exams. These resources are valuable tools for understanding the requirements summarized below. 

Documentation must show the established separation between certification and education and provide evidence that a clear, appropriate firewall between the two functions exists. The practice of separating the two functions is just as important as documenting the separate lines of authority, roles and responsibilities. Education functions are not limited to just exam prep courses, and might also include the development/delivery of study guides, textbooks, webinars, flashcards, practice tests, etc. 

The concept of “insider trading” is a helpful analogy. The firewall must protect confidential information and prevent anyone with access from sharing it to give candidates an advantage. For example, an item reviewer cannot use his/her “insider” knowledge of the exam content to teach a prep course. 

When an organization provides both certification and education, evidence of an established and protected firewall includes an appropriate structure that prohibits all individuals with access to confidential exam information from participating in the development and/ or delivery of educational activities designed to prepare candidates for certification. Other tools that help clear the path include written policies, outlining confidentiality and conflict of interest requirements; evidence of signed forms (for organization staff and for volunteers, such as Subject Matter Experts [SMEs] and Board members) where these individuals agree in writing to abide by the policies; and disclaimers on all types of educational/training products.

Organizational benefit: Establishing and maintaining a robust firewall helps protect the integrity of the certification program and increase its value to multiple stakeholders.

3. Policies 

Formal, written policies are essential—it is that simple. Or is it? 

NCCA requires a comprehensive set of internal policies to guide the governance, development, and administration of a certification program. The policy manual is not static—it should be a living, dynamic document that the program uses regularly and reviews periodically. Policies ensure fairness and consistency and support staff decision-making. Policies are different than operational procedures and it is important for programs to understand the difference and use each correctly. 

Depending on the size and complexity of the program, and the organization’s portfolio of services and products, the program may have a few key policies or a multi-volume manual. The table below summarizes examples of recommendations for overcoming some common policy roadblocks. 

ICE_230035-18_CredInsightFeb18_RemovingRoadblocks1-Chart1.png

Grandfathering and reciprocity are especially tricky policy roadblocks to navigate. Once a certification program is NCCA-accredited, grandfathering is not permissible. Limited grandfathering early in the certification program’s development may be acceptable, under the right conditions. With regards to reciprocity, if a program accepts certificants from other organizations, the applying program must demonstrate that the certification requirements and exam content are equivalent; this demonstration must be based on the application of formal, nationally-accepted methods for determining requirements and exam content equivalency. To avoid creating a roadblock that can become extremely difficult to remove, careful advance consideration of the long-term implications of grandfathering or offering reciprocal certification is essential.

Organizational benefits: A well-organized policy manual is a valuable tool for memorializing the most essential program information, training new staff, orienting volunteer leaders, succession planning, and providing fairness and consistency for candidates and other stakeholders.

4. Published Information

Lack of transparency creates another roadblock to overcome. Applicants must have easy access to requirements for earning and maintaining certification. This includes published information describing the exam content, development, scoring, test-taking rules and information related to disciplinary actions and appeals. 

The best way to demonstrate compliance is by leveraging a well-organized and complete website, and/or a Candidate Handbook that is easily found on the organization’s website. Whether directly on the website, in a Candidate Handbook, or both—the key is providing easy to find information. Burying information, or having a difficult to navigate site, hinders accreditation compliance and discourages applicants.

Transparency also includes publishing a summary of certification activities— the number of test takers, pass/ fail statistics, and the total number of individuals certified. Two or three years’ worth of annual data should be published.

Organizational benefits: A centralized place for published information, such as the candidate handbook or website, supports transparency to stakeholders, allows the general public to better understand the program requirements, provides fairness, and helps applicants make informed decisions.

ICE_230035-18_CredInsightFeb18_RemovingRoadblocks1-Chart2.png

Our 7 Tips for Avoiding “Other” Roadblocks 

  1. Document, document, document. Document the steps taken to develop and administer the exam. If the staff walked away from the program today, could someone else pick up the documentation and keep the program going? The answer should be yes.
  2. Consistency is key. Information must be correct and consistent across all documents, both internal and those available to the public. For example, the policy manual should not contradict what is in the handbook.
  3. Use samples with caution. Samples and templates are helpful, but all organizations/ programs are different. Be careful of blindly copying a sample from another program. While “best practices” exist across programs, each organization, program, and stakeholder group is unique and needs attention.
  4.  Balance specifics with flexibility. Bylaws and policies should be specific enough to provide the necessary framework, but can still give some flexibility for implementation.
  5.  “Show and tell” is not just a game for kids. Evidence demonstrating the policy has been implemented is often required.
  6.  Education is key. Educate program volunteers and staff early and often. The more they understand about the accreditation process and requirements, the more open they can be to taking the steps to earn and maintain accreditation.
  7.  Ask for help. Know when to seek expert help to keep the process on track.

 
Continue reading: Removing Roadblocks and Clearing the Way for Accreditation Success Part 2 


 

Janice Moore and Cynthia Allen founded SeaCrest in 2006 and have completed more than 190 successful accredited applications for NCCA, ABSNC, and ANSI.

 

0 Comments
1 Like
Recent Stories
A Behind the Scenes Look at Succession Planning: Part II

A Behind the Scenes Look at Succession Planning: Part I

An Update from the Right to Safe Care Coalition