NLNAC - Opportunity to Comment on Change to Policy #1

Opportunity to Comment on Change to Policy #1

The Board of Commissioners approved a revision to POLICY #1 CODE OF CONDUCT AND CONFLICT OF INTEREST at their recent meeting. Pursuant to Commission Policy #11, proposed policy changes are submitted to accredited programs for review and comment prior to implementation.

Please provide any comments by email to Patricia Barlow at pbarlow@nlnac.org no later than September 7, 2010. The Commissioners will consider these comments prior to implementation of the policy.

Thank you for reviewing this policy change. We appreciate your interest and support of the accreditation process.

POLICY #1
CODE OF CONDUCT AND CONFLICT OF INTEREST

To ensure that all matters dealing with the accreditation of programs by the National League for Nursing Accrediting Commission (NLNAC) are conducted with integrity, fairness, impartiality, and objectivity, NLNAC has adopted this policy addressing conflict of interest, conduct, and confidentiality.

CONFLICT OF INTEREST

In all circumstances, not only conflicts of interest but also the appearance of conflicts of interest must be avoided. All site visitors, Evaluation Review Panel members, Commissioners, Appeal Panel members, NLNAC staff members, or any other individual who acts on behalf of NLNAC shall not have direct involvement with and/or participate in any decision-making capacity for a nursing education unit if they have an actual or potential conflict of interest with the program. An actual or potential conflict of interest may include, but is not limited to, the following:

Having a close, active personal association with a program being considered for official action by the NLNAC;
Employment, enrollment as a student, or service including service as a graduate advisee/advisor or service in any other capacity by the governing organization that is under review;
Current employment in the same state as the nursing education unit under review;
Having served as a consultant on any accreditation matters involving the governing organization which is under review;
Jointly authored research or literature, participated in a common consortium, or have special research involvement with current program faculty of the program under review;
Served in evaluation roles for evaluators other than the NLNAC regarding the same governing organization that is under review including membership on state visit teams, regional accreditation teams, or evaluation committees for boards of trustees or regents in the past five (5) years;
Having been paid as a consultant, served as a commencement speaker, received an honorary degree, or otherwise profited or appeared to profit from service to the program which is under review;
Having maintained close personal or professional relationships or affiliations with the governing organization under review or with key personnel in the governing organization under review within the past ten years;
Having an immediate family member(s) who is (are) a current employee(s), board member(s), or student(s) enrolled in a degree program at the governing organization under review; or
Having a financial interest in the governing organization under review including, but not limited to, ownership of shares of stock in the governing organization or in any parent of the governing organization, excepting shares or interests held indirectly such as in mutual funds, insurance policies, or blind trusts. In addition, having any immediate family member(s) with any of the above financial interests.

CONDUCT AND ETHICAL GUIDELINES

Responsibilities of Programs Seeking Accreditation

It is the responsibility of each program to facilitate a thorough and objective appraisal of its education unit.
Programs are allowed to veto site visit team members if it can be demonstrated in writing that a potential conflict of interest exists.
Any perceived inadequacies of the National League for Nursing Accrediting Commission procedures or processes should be reported by the program to the Chief Executive Officer at the time of the occurrence rather than withheld until action has been taken.

Responsibilities of Site Visitors, Commissioners, and Staff

Any Commissioner or member of the Evaluation Review Panel who was a member of a site visit team for a program under consideration or resides in or is currently employed in the same state as the program under consideration must absent her/himself from the Evaluation Review Panel or Commission discussion about the program and abstain from voting.
When the program of a member of the Evaluation Review Panel is being considered for accreditation or appeal, the individual may not serve on the Evaluation Review Panel or Appeal Panel during that accreditation cycle. When a program of a Commissioner is being considered for accreditation or appeal, the Commissioner will absent her/himself from the portion of the Commission meeting agenda concerned with the evaluation of that program and abstain from voting.
Commissioners and program evaluators will be reminded of the confidentiality of all information pertaining to the review of applications and the need to avoid any actions that might give the appearance of a conflict of interest or could reasonably be perceived as affecting the reviewer’s or Commissioner’s objectivity. At each level of review, reviewers and staff are required to refrain from accepting membership on a team, absent themselves from the discussion during the review of any application if their presence would constitute or appear to constitute a conflict of interest, and abstain from voting.

To avoid the appearance of a conflict of interest, serving as a site visitor for another specialized accrediting agency shall preclude serving as a site visitor or Commissioner for the NLNAC. A site visitor or member of the Evaluation Review Panel who has served in a similar capacity for another specialized accrediting agency may be eligible to serve as an NLNAC site visitor or member of the Evaluation Review Panel after a period of two (2) years has elapsed since the last review activity for the other organization.

Actions to be Avoided by Program Evaluators, Including Site Visitors and Commissioners

Advertising of one’s status as a program evaluator, Evaluation Review Panel member, Commissioner, or Appeal Panel member for the purpose of consulting;
Soliciting of consultation arrangements with programs preparing for accreditation review;
Engaging in consultation for a program reviewed for at least a period of five (5) years, including serving as a consultant to a program one has recently visited as a member of an accreditation site visit team; or
Implying definitive answers related to NLNAC policies and procedures or Accreditation Standards and Criteria.

CONFIDENTIALITY AND CONDUCT OF COMMUNICATIONS

To ensure that all matters dealing with the accreditation of nursing education units are conducted with integrity, fairness, impartiality, and objectivity, the NLNAC has adopted this confidentiality policy. Those who participate in NLNAC activities including, but not limited to, site visitors, Evaluation Review Panel members, Commissioners, Appeal Panel members, and staff members must maintain confidentiality of all non-public information related to the accreditation review and consideration of a nursing education unit by NLNAC. Accordingly, site visitors, Evaluation Review Panel members, Commissioners, Appeal Panel members, and staff members shall conduct themselves as follows:

Documents, reports, and other materials prepared by the program for NLNAC action should be treated as private documents in the absence of specific policies which make clear the degree and extent of their exposure. The NLNAC will release documents in response to a valid court order or as otherwise may be required by law.
All materials pertinent to the applications under review are considered confidential materials and/or communications prepared for use by Commissioners, evaluators, and NLNAC staff and should not be shown or discussed with anyone other than Commissioners, evaluators, and NLNAC staff as appropriate and when necessary.
The accreditation decision of the Board of Commissioners will be communicated to the program in writing. Under no other circumstances may a Commissioner, evaluator, or NLNAC staff member advise deans, program directors, faculty, or anyone else of the review proceedings.
Except prior to and during the site visit or Evaluation Review Panel meeting, and except during an Appeal Hearing by members of the Appeal Panel under Policy # 10, there shall be no direct communication between program evaluators and governing organizations/programs under review. Any need for additional information from governing organizations/programs must be directed to the NLNAC Chief Executive Officer who will handle all such communications.

DISCLOSURE MEMORANDUM AND COMMITMENT TO COMPLY WITH NLNAC CODE OF CONDUCT AND CONFLICT OF INTEREST POLICY # 1
(To be signed prior to each assignment or at each meeting; signed by staff annually)

TO: Site Visit Team Member, Evaluation Review Panel Member,
Commissioner, Appeal Panel Member, and NLNAC Staff

DATE: (Each NLNAC activity)

I have received and read the NLNAC Code of Conduct and Conflict of Interest Policy #1 and agree to comply in all respects with this Policy.

I understand my duties to avoid any actual conflict of interest or the appearance of a conflict of interest regarding NLNAC’s review of nursing education units. I understand that I shall not ever have direct involvement with and/or participate in any decision-making capacity for a nursing education unit if I have an actual or potential conflict of interest with the program under review. I further understand that I have a duty to disclose an actual or potential conflict of interest as described in Policy #1 that must exercised as soon as the conflict becomes apparent. Accordingly, (1) I will not vote on any program status in which I have an actual or potential conflict of interest; (2) I will not participate in a site visit to a program in which I have an actual or potential conflict of interest; (3) I will absent myself and will not participate in the discussion of, visit to, or vote on any program in which I have an actual or potential conflict of interest.

I also understand and agree to all of Policy #1’s provisions related to my conduct and my obligation to maintain confidentiality of information related to programs under review. I understand that material furnished for review purposes and discussion during a site visit or review meeting is considered confidential information.

I understand and agree that should I have any questions regarding the application of NLNAC’s Code of Conduct and Conflict of Interest Policy #1, I shall direct these questions as soon as possible to the NLNAC Chief Executive Officer.

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