National League for Nursing Accreditation Commission

The National League for Nursing Accreditation Commission (NLNAC), established in 1997, accredits 1,500 of the nation's nursing education programs granting degrees at the master's, baccalaureate, associate, diploma, and practical nursing levels. Its goals are to:

• Promulgate a common core of standards and criteria for the accreditation of nursing programs found to meet those standards and criteria;
• Strengthen educational quality through assistance to associated programs and schools, and evaluation processes, functions, publications, and research;
• Advocate self-regulation in nursing education;
• Promote peer review;
• Foster educational equity, access, opportunity, and mobility, and preparation for employment based upon type of nursing education; and
• Serve as gatekeeper to Higher Education Act Title IV programs for which NLNAC is the accrediting agency (NLNAC, 2002).

NLNAC is recognized by the U.S. Department of Education and CHEA, among other national and international organizations, as an accrediting body for a range of nursing education programs. NLNAC assesses academic quality relative to seven standards (i.e., rules established for the measurement of quantity, quality, extent, and value of educational programs), which determine:

• Institutional Mission/Governance—whether the program has a clear and publicly stated mission and/or philosophy and purposes appropriate to postsecondary or higher education in nursing;
• Faculty—whether the program has quality and credentialed faculty appropriate to accomplish its purposes and strengthen its educational effectiveness;
• Students—whether the program has ensured teaching and learning environments conducive to student academic achievement and life-long learning;
• Curriculum and Instruction—whether the program accomplishes its educational and related purposes;
• Resources—whether the program has effectively organized processes and human, fiscal, and physical resources;
• Educational Effectiveness—whether the program has an identified plan for systematic evaluation and assessment of educational outcomes; and
• Integrity—whether the program demonstrates integrity in its practices and relationships.

Of these, only the first standard (“mission and governance”) specifically addresses diversity, in stating that nursing education programs must “demonstrate commitment to the cultural, racial, and ethnic diversity of the community in which the institution and the nursing education unit exist” (Grumet, 2003). Other standards that are related to diversity include criteria regarding student policies (“student policies [must be] … non-discriminatory”).

As a broad set of objectives, NLNAC endorses the PEW Health Commission's Competencies for 2005 and the 21 Competencies for the Twenty-First Century. Among these competencies is the objective that practitioners must “participate in a racially and culturally diverse society, appreciate the growing diversity of the population and the need to understand health status and health care through differing cultural values, [and] provide culturally sensitive care to a diverse society” (NLNAC, 2002, p. 107).

NLNAC is purposefully nonprescriptive with regard to student and nursing faculty diversity, according to Barbara Grumet, NLNAC's Executive Director. NLNAC “does not require schools to practice affirmative action,” according to Grumet. At the same time, NLNAC sees its role as that of a “bully pulpit,” urging its institutions to recruit and retain a diverse student body (Grumet, 2003).

Commission on Collegiate Nursing Education

The Commission on Collegiate Nursing Education (CCNE) accredits baccalaureate and graduate nursing degree programs located in regionally accredited colleges and universities in the United States. CCNE is recognized by the U.S. Department of Education and CHEA and is a member of the Association of Specialized and Professional Accreditors. CCNE accredits 438 nursing programs at 278 institutions and reviews 75–90 program each year that seek renewal of their accreditation.

CCNE's goals are to:

• Hold nursing programs accountable to the “community of interest” (i.e., the nursing profession, consumers, employers, higher education, students and their families) by “ensuring that these programs have mission statements, goals, and outcomes that are appropriate for programs preparing individuals to enter the field of nursing” (CCNE, 2002);
• Evaluate the success of nursing programs in achieving their mission, goals, and outcomes;
• Assess the extent to which nursing programs meet accreditation standards;
• Inform the public of the purposes and values of accreditation; and
• Foster continuing improvement in nursing education programs.

The values upon which CCNE accreditation activities are premised include:

• Trust, integrity, life-long learning, review and oversight by peers, innovation, and accountability; and
• Inclusiveness in the implementation of CCNE's activities and an openness to the “diverse institutional and individual issues and opinions of the interested community” (CCNE, 2002).

CCNE's accreditation standards are focused on both nursing education program quality and effectiveness. With regard to program quality, standards address institutional mission and governance (i.e., “the mission, philosophy, and goals/objectives of the program should be congruent with those of the parent institution, should reflect professional nursing standards and guidelines, and should consider the needs and expectations of the community of interest”), institutional commitment and resources (i.e., “the parent institution demonstrates ongoing commitment and support [and] makes available resources to enable the program to achieve its mission, philosophy, goals/objectives and expected results”), and curriculum and teaching-learning practices (i.e., “the curriculum is developed in accordance with clear statements of expected results derived from the mission, philosophy, and goals/objectives of the program with clear congruence between the teaching-learning experiences and expected results”) [CCNE, 2002]. With regard to program effectiveness, CCNE standards address student performance and faculty accomplishments (e.g., accomplishments in teaching, scholarship).

CCNE's program standards do not specifically refer to racial and ethnic diversity among nursing program students and faculty. However, according to Charlotte Beason, chair of the CCNE Board of Commissioners, each nursing program is expected to define and achieve program goals that are consistent with the expectations of the program's community of interest, which includes health-care consumers.

Commission on Dental Accreditation

The Commission on Dental Accreditation (CDA) “serves the public by establishing, maintaining and applying standards that ensure the quality and continuous improvement of dental and dental-related education and reflect the evolving practice of dentistry” (CDA, 2002, p. 2). CDA accredits over 1,350 dental, advanced dental, and allied dental education programs, 56 of which are D.D.S. or D.M.D. programs. CDA is recognized by the U.S. Department of Education as the sole accreditation agency for dental education programs.

CDA's Accreditation Standards for Dental Education Programs have been developed to:

• Protect the public welfare;
• Guide institutions in developing their academic programs;
• Provide a vehicle for site visit teams to make judgments as to the quality of the program; and
• Provide students with reasonable assurance that the program is meeting its stated objectives.

In addition, CDA's standards were designed to:

• Improve the assessment of quality in dental education programs;
• Streamline the accreditation process by including only standards critical to the evaluation of the quality of the educational program;
• Increase the focus on competency statements in curriculum-related standards; and
• Emphasize educational goals to ensure that graduates are life-long learners.

CDA assesses dental program quality relative to six overarching standards: institutional effectiveness; educational programs (including admissions, instruction, curriculum management, biomedical sciences, behavioral sciences, practice management, ethics and professionalism, information management and critical thinking, and clinical sciences); faculty and staff; educational support services (including facilities and resources, student services, student financial aid, and health services); patient care services; and research programs.

Of these, two standards explicitly address diversity concerns. Standard 2-2 (Educational Program) mandates efforts to recruit and retain a diverse dental student body:

“Admissions policies and procedures must be designed to include recruitment and admission of a diverse student population” (CDA, 2002; emphasis in text).

Standard 2-17 mandates that dental graduates must possess the skills and competencies to serve a racially and ethnically diverse patient population:

“Graduates must be competent in managing a diverse patient population and have the interpersonal and communications skills to function successfully in a multicultural work environment” (CDA, 2002; emphasis in text).

Dental programs have been successful in meeting these standards. According to Karen Hart, director of the CDA, all 46 doctoral-level dental programs have been found to be in compliance with Standard 2-2, with 13 programs receiving commendations regarding their efforts to recruit and retain a diverse student body. Similarly, all 46 programs have been found to be in compliance with Standard 2-17, with two receiving commendations for their efforts to ensure that dental graduates possess multicultural competencies (Hart, 2003).

Hart noted that CDA is assessing whether the diversity standard has proven effective in encouraging dental programs to increase the percentage of qualified URM admissions and matriculants to dental programs. While the current CDA standards have been in place only since 1998, preliminary data suggest that the answer to this question is a “qualified maybe,” according to Hart. URM enrollment in U.S. dental programs has increased slightly since 1998 (see Chapter 1), but this increase may also be attributable to other efforts that the profession has undertaken to increase URM admission and enrollment (Hart, 2003).

Liaison Committee on Medical Education

The Liaison Committee on Medical Education (LCME) accredits 142 medical education programs in the United States and Canada (the latter in conjunction with the Committee on Accreditation of Canadian Medical Schools). The LCME is recognized by the U.S. Department of Education as an accrediting agency for medical education programs, but not as an institutional accrediting agency. Therefore, LCME requires medical schools to attain institutional accreditation from a regional accrediting body if not already a component of a regionally accredited institution.

LCME standards are organized to reflect five broad standards:

• Institutional Setting (with criteria related to governance and administration and academic environment);
• Educational Programs (with criteria related to educational objectives, structure, teaching and evaluation, curriculum management, and evaluation of program effectiveness);
• Medical Students (with criteria related to admissions policies and practices, student services, and the learning environment);
• Faculty (with criteria related to number, qualifications, and functions, personnel policies, and governance); and
• Educational Resources (with criteria related to finances, general facilities, clinical teaching faculties, and information resources and library services).

LCME standards, like those of many of the other professional accrediting bodies, are specific with regard to the use of language and the level of effort that medical schools are required to demonstrate in order to achieve compliance with the standards. In particular, LCME standards use the words “must” and “should” to reflect different areas of emphasis in program standards. “Use of the word ‘must' indicates that the LCME considers meeting the standard to be absolutely necessary for the achievement and maintenance of accreditation. Use of the word ‘should' indicates that compliance with the standard is expected unless these are extraordinary any justifiable circumstances that preclude full compliance” (LCME, 2002, p. ii).

Three LCME standards are directly related to student diversity and multicultural education and training. With regard to admissions policies, Standard MS-8 states, “Each medical school should have policies and practices ensuring the gender, racial, cultural, and economic diversity of its students” (LCME, 2002, p. 18). In a discussion of LCME intent for this standard, the committee notes, “The standard requires that each school's student body exhibit diversity in the dimensions noted. The extent of diversity needed will depend on the school's missions, goals, and educational objectives, expectations of the community in which it operates, and its implied or explicit social contract at the local, state, and national levels” (LCME, 2002, p. 18).

Regarding cultural competence, LCME standard ED-21 states, “The faculty and students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments” (LCME, 2002, p. 12). LCME further explicates this standard by noting that:

All instruction should stress the need for students to be concerned with the total medical needs of their patients and the effects that social and cultural circumstances have on their health. To demonstrate compliance with this standard, schools should be able to document objectives relating to the development of skills in cultural competence, indicate where in the curriculum students are exposed to such material, and demonstrate the extent to which the objectives are being achieved (LCME, 2002, p. 12).

One outcome of such training might be to address racial and ethnic biases that may affect medical care (Institute of Medicine, 2003). LCME standard ED-22 requires that medical students “learn to recognize and appropriately address gender and cultural biases in themselves and others, and in the process of healthcare delivery” (LCME, 2002, p. 12). LCME intends that the objectives of such training “include student understanding of demographic influences on health care quality and effectiveness, such as racial and ethnic disparities in the diagnosis and treatment of diseases. The objectives should also address the need for self-awareness among students regarding any personal biases in their approach to health care delivery” (LCME, 2002, p. 12).

According to David Stevens, secretary of the LCME, the appropriate role of the LCME in promoting diversity is to “advocate for the improvement of medical education and health care—including establishing expectations that lead to diversity in the physician workforce,” and to “work in every context to achieve this goal” (Stevens, 2003).

Similarly, the Accreditation Council for Graduate Medical Education (ACGME), which accredits residency education programs, has established general competencies in graduate medical education, including standards with regard to patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Of these general competencies, only the professionalism standard specifically addresses diversity concerns, noting that professionalism is “manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population” (ACGME, 2003).

Committee on Accreditation, American Psychological Association

The Committee on Accreditation of the American Psychological Association (APA) accredits doctoral-level education and training in professional psychology (i.e., clinical, counseling, and school psychology), including internship programs and postdoctoral residency programs. APA accredits more than 300 doctoral programs in over 190 institutions of higher education, as well as more than 400 internship and postdoctoral residency programs.

More so than the other health professions noted above, APA's accreditation standards reflect considerable attention to the role of diversity in psychology education and program quality. According to Susan Zlotlow, director of the APA Office of Program Consultation and Accreditation, the APA Committee on Accreditation debated whether to address student and faculty diversity standards as a single, separate domain or to infuse diversity issues throughout the guidelines. The committee elected to adopt both approaches—diversity is addressed across several domains, as well as in a separate domain focused on cultural and individual differences and diversity (Zlotlow, 2003). “Cultural and individual diversity” in APA's standards refers to diversity with regard to individual personal and demographic characteristics. These include, but are not limited to “age, color, disabilities, ethnicity, gender, language, national origin, race, religion, sexual orientation, and socioeconomic status” (APA Committee on Accreditation, 2003, p. 5).

APA's standards begin with explicit guidelines for the composition of the Committee on Accreditation. While graduate educators hold the largest share of seats on the committee, seats are reserved for “representation of the general public's interest by persons outside the profession who have an informed, broad-gauged community perspective about matters of higher education” (APA Committee on Accreditation, 2002, p. v). In addition, appointments to the committee “shall reflect the individual and cultural diversity within our society among psychologists, and the breadth of psychology as a discipline” (APA Committee on Accreditation, 2002, p. v).

APA has established eight domains of accreditation standards: Eligibility (the educational program's purpose must be consistent with the scope of the accreditation body and the goal of training students in professional psychology); program philosophy, objectives, and curriculum plan (the program must have a clearly specific philosophy of education and training consistent with the science and practice of psychology); program resources (the program must demonstrate that it has sufficient resources to meet educational objectives); cultural and individual differences in psychology (the program recognizes the importance of cultural and individual differences and diversity in the training of psychologists); student–faculty relations (the programs' educational, training, and socialization opportunities are characterized by mutual respect and courtesy and facilitates students' learning experiences); program self-assessment and quality enhancement (the program demonstrates a commitment to excellence through self-study); public disclosure (the program appropriately represents itself to the public); and relationship with accrediting body (the program demonstrates its commitment to the accreditation process).

Within these domains, specific criteria relevant to racial, ethnic, and cultural diversity serve as benchmarks:

• Domain A (Eligibility). “The program engages in actions that indicate respect for and understanding of cultural and individual diversity…. Respect for and understanding of cultural and individual diversity is reflected in the program's policies for the recruitment, retention, and development of faculty and students, and in its curriculum and field placements. The program has nondiscriminatory policies and operating conditions, and it avoids any actions that would restrict program access or completion on grounds that are irrelevant to success in graduate training or the profession” (APA Committee on Accreditation, 2002, p. 5).
• Domain B (Program Philosophy, Objective, and Curriculum Plan). The program implements a clear and coherent curriculum plan that enables students to acquire and demonstrate competence in scientific psychology (including research methods), scientific and theoretical foundations for professional practice, diagnosis and assessment, and implementing intervention plans. “Issues of cultural and individual diversity that are relevant to all of the above” must be integrated into the curriculum plan (APA Committee on Accreditation, 2002, p. 7).
• Domain D (Cultural and Individual Differences and Diversity). Specific criteria within this standard mandate that:

The program has made systematic, coherent, and long-term efforts to attract and retain students and faculty from differing ethnic, racial, and personal backgrounds into the program. Consistent with such efforts, it acts to ensure a supportive and encouraging learning environment appropriate for the training of diverse individuals and the provision of training opportunities for a broad spectrum of individuals. Further, the program avoids any actions that would restrict program access on grounds that are irrelevant to success in graduate training.

The program has and implements a thoughtful and coherent plan to provide students with relevant knowledge and experiences about the role of cultural and individual diversity in psychological phenomena as they relate to the science and practice of professional psychology. The avenues by which these goals are achieved are to be developed by the program (APA Committee on Accreditation, 2002, p. 9).

• Domain E (Student–Faculty Relations). This criterion mandates that training programs must “show respect for cultural and individual diversity among their students” by treating them in accordance with the above standards (APA Committee on Accreditation, 2002).

In evaluating how training programs perform relative to diversity standards, the APA Committee on Accreditation focuses on the effort that programs display, according to Zlotlow. Recruitment and retention plans, for example, must be systematic, coherent, and long-term, and “not a one-year effort prior to completing the self-study” (Zlotlow, 2003). Programs are asked to evaluate the success of the plan as part of overall efforts at self-assessment and enhancement. Should training programs fail to meet the standard, the Committee on Accreditation offers “multiple levels of encouragement,” according to Zlotlow. These include:

• annual report response—the program is asked to provide additional information in an annual report to the committee to document its steps toward remedying problems;
• “flag” response—programs found to have continued deficiencies are required to respond to specific issues for review by the committee, which may then either deem the response to be adequate, request additional information, or request an invitation for a special site visit;
• years of accreditation—the committee may elect to award a shorter period of accredited status (minimally, 3 years, or a maximum of 6 years) to programs with a history of not improving in any area of the guidelines; or
• adverse decision—programs that fail to improve after increasing sanctions (above) may be placed on probation (Zlotlow, 2003).

APA's accreditation standards have contributed to an increased level of attention and effort among psychology education and training constituencies in addressing diversity concerns, according to Zlotlow. New websites devoted to promoting and enhancing diversity-related institutional policies and curriculum have been developed, and the standards have promoted greater sharing among training programs regarding strategies to improve minority recruitment and retention efforts. This change has been slow, Zlotlow notes, given that APA's approach is developmental in nature (i.e., the Committee on Accreditation seeks to promote incentives for change and is willing to work with training programs over time to foster the long-term enhancement of diversity efforts). Once in place, however, “recruitment efforts have longer term dividends and the training curriculum generally is a more permanent part of the educational program,” according to Zlotlow (2003).

Accreditation and the U.S. Department of Education

As noted earlier in this chapter, the U.S. Department of Education is charged with recognizing national accrediting agencies that the secretary determines to be reliable authorities as to the quality of education or training provided by institutions of higher education. An accrediting body seeking national recognition by the secretary must meet the procedures and criteria established by the department for the recognition of accrediting agencies. These procedures and criteria include organizational and administrative requirements, operating policies and procedures, and required standards and their application. Among the required standards, an accrediting body must demonstrate that it has standards for accreditation “that are sufficiently rigorous to ensure that the agency is a reliable authority regarding the quality of the education or training provided by the institutions or programs it accredits” (U.S. Department of Education, 2003, accessed from Internet website http://www.ed.gov). An accrediting agency meets this requirement if its standards effectively address the quality of the institution or program in areas such as:

• “success with respect to student achievement in relation to the institution's mission, including, as appropriate, consideration of course completion, State licensing examination, and job placement rates” (U.S. Department of Education, 2003, accessed from Internet website http://www.ed.gov);
• curriculum;
• faculty;
• student support services;
• recruiting and admissions practices; and other relevant program areas.

The department therefore exerts broad influence over the scope and tenor of accrediting bodies' standards and can play a significant role in encouraging accreditation bodies to adopt diversity-related standards. Because the department's standards are not (and must not be) proscriptive with regard to specific standards of accreditation bodies, the department can encourage the development of diversity-related standards by raising awareness among accrediting bodies of the value of diversity in health professions education and the role of diversity in increasing Americans' access to culturally competent care. In addition, the department could identify “best practices” regarding diversity-related standards and promulgate these among health professions education accrediting bodies.

Recommendation 4-1: The U.S. Department of Education should strongly encourage accreditation bodies to be more aggressive in formulating and enforcing standards that result in a critical mass of URMs throughout the health professions.

The increasing diversity of the U.S. population requires that accreditation bodies be responsive to demographic changes and develop and enforce standards that ensure that health professionals are prepared to serve diverse segments of the population. As one accreditation official noted during a public workshop hosted by the study committee, “Our role is to serve the public.” Given that almost all accreditation bodies view public service and accountability as central to their mission, establishing and monitoring goals related to diversity among health-care professions can be unambiguously viewed as an important aspect of this effort.

Accreditation bodies may take varying approaches in efforts to accomplish these goals. First, accrediting bodies must accept diversity as a core component of high-quality health professions education and care giving. Subsequently, a number of strategies may be adopted to stimulate institutional diversity efforts. The standards and practices adopted by the APA are instructive and offer several approaches for accreditation standards to address diversity concerns:

1.

Develop a plan to achieve diversity, consistent with the institutional mission, and demonstrate efforts to reach diversity goals. APA's standards emphasize that programs should develop a plan and demonstrate effort toward recruiting and retaining a diverse faculty and student body. The plan should be consistent with the institutional mission and should articulate a rationale for how and why diversity is important to the mission (e.g., research-oriented training programs should consider how diversity may enhance the range and scope of research at the institution).

2.

Develop standards that encourage the development and infusion of diversity-related curricula throughout the training program.

3.

Regularly monitor and evaluate the efforts of accredited institutions in achieving their diversity goals. APA's Committee on Accreditation seeks annual reports from institutions, particularly to document steps toward remedying any problems in achieving accreditation goals. Educational programs found to be deficient in meeting diversity standards may face additional site visits on a yearly basis to ascertain progress toward meeting the standards.

4.

Use graduated sanctions and reinforcement from the accrediting body to help “shape” appropriate diversity efforts. APA's Committee on Accreditation works collaboratively with institutions to help them reach their diversity goals. Sanctions for failure to achieve diversity standards are graduated, such that first-time or isolated infractions result in institutions being asked to report to the committee the steps planned to rectify the infraction. Repeated instances of failure to meet standards are met with increasing sanctions.

5.

Seek community representation on standard-setting bodies. APA's Committee on Accreditation reserves seats for nonprofessional community members, who often bring a broader perspective to accreditation efforts. Their presence on the committee also helps to ensure pubic accountability and transparency.

6.

Seek diverse representation on peer review teams. Anecdotally, the study committee is aware of instances in which peer review teams have lacked significant racial and ethnic diversity. Even in the face of strong accreditation standards related to diversity, the absence of racial and ethnic diversity on peer review teams can send a signal that may undermine the accreditation body's intent. Peer review teams should reflect the same goals and objectives that the accrediting body adopts, including in areas of diversity.

Many of the standards and practices adopted by the APA are also reflected in diversity-related standards of the other health professions accrediting bodies reviewed here. In particular, the CDA's requirement that dental schools develop admissions policies and procedures that attend to recruitment and admission of a diverse student population and its mandate that dental graduates must possess the skills and competencies to serve a racially and ethnically diverse patient population are consistent with the goal of encouraging student diversity and diversity-related curriculum. In addition, CDA's efforts to assess the impact of accreditation standards on dental school student diversity are an important to evaluate the effectiveness of program standards. Similarly, LCME's standards require attention to diversity in recruitment and retention of students, as well as in curriculum to improve students' cross-cultural competencies and reduce individual biases.

Recommendation 4-2: Health professions education accreditation bodies should develop explicit policies articulating the value and importance of providing culturally competent health care and the role it sees for racial and ethnic diversity among health professionals in achieving this goal.

Recommendation 4-3: Health professions education accreditation bod ies should develop standards and criteria that more effectively encourage health professions schools to recruit URM students and faculty, to develop cultural competence curricula, and to develop an institutional climate that encourages and sustains the development of a critical mass of diversity.

Recommendation 4-4: Accreditation standards should require HPEIs to collect and report data relevant to diversity criteria. Data should include the number and percentage of URM candidates, students admitted and graduated, time to degree, and number and level of URM faculty.

Recommendation 4-5: Accreditation-related advisory boards and accreditation bodies should include URMs and other individuals with expertise in diversity and cultural competence.

Recommendation 4-6: If diversity-related standards are not met, the institution should be required to declare formally what steps will be put in place to address the deficiencies. Repeated deficiencies should result in accreditation-related sanctions.