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Maintaining CAAHEP Accreditation

CAAHEP Accredited Orthotic, Prosthetic, and Pedorthic academic programs are required to complete the following items to maintain continuing accreditation status.  For additional information, please refer to the Accreditation Manual.

Administrative Requirements

a. The program must inform the NCOPE and CAAHEP within a reasonable period of time (as defined by NCOPE and CAAHEP policies) of changes in chief executive officer, dean of health professions or equivalent position, and required program personnel.

b. The sponsor must inform CAAHEP and the NCOPE of its intent to transfer program sponsorship. To begin the process for a Transfer of Sponsorship, the current sponsor must submit a letter (signed by the CEO or designated individual) to CAAHEP and the NCOPE that it is relinquishing its sponsorship of the program. Additionally, the new sponsor must submit a “Request for Transfer of Sponsorship Services” using the Accreditation Management Portal (AMP). The NCOPE has the discretion of requesting a new self-study report with or without an on-site review. Applying for a transfer of sponsorship does not guarantee that the transfer of accreditation will be granted.

c. The sponsor must promptly inform CAAHEP and the NCOPE of any adverse decision affecting its accreditation by recognized institutional accrediting agencies and/or state agencies (or their equivalent).

d. Comprehensive reviews are scheduled by the NCOPE in accordance with its policies and procedures. The time between comprehensive reviews is determined by the NCOPE and based on the program’s on-going compliance with the Standards, however, all programs must undergo a comprehensive review at least once every ten years.

e. The program and the sponsor must pay NCOPE and CAAHEP fees within a reasonable period of time, as determined by the NCOPE and CAAHEP respectively.

f. The sponsor must file all reports in a timely manner (self-study report, progress reports, annual reports, etc.) in accordance with NCOPE policy.

g. The sponsor must agree to a reasonable on-site review date that provides sufficient time for CAAHEP to act on a NCOPE accreditation recommendation prior to the “next comprehensive review” period, which was designated by CAAHEP at the time of its last accreditation action, or a reasonable date otherwise designated by the NCOPE.

h. The sponsor must maintain, and make available to the public, current and consistent summary information about student/graduate achievement that includes the results of the following program outcomes assessments

  • Technical programs must disclose graduation rates
  • Assistant programs must disclose graduation rates
  • Practitioner programs must disclose employment rates
  • ABC pass rate

Failure to meet any of the aforementioned administrative requirements may lead to administrative probation and ultimately to the withdrawal of accreditation. CAAHEP will immediately rescind administrative probation once all administrative deficiencies have been rectified.

Annual Reports

NCOPE requires each accredited program to submit an Annual Report via the Accreditation Management Portal (AMP). The purpose of the annual report is to provide outcome-based evaluation of programs for the 5 years between full evaluations. Questions are designed to elicit self-evaluation of program compliance with the Standards. For maximum benefit to the program, the report should be discussed with the entire program faculty and should be incorporated into, or flow directly from a program’s ongoing evaluation. Annual reports provide evidence, program self-reflection and proposed updates to the program on the following outcomes to ensure compliance with the CAAHEP Standards.

Substantive Changes

CAAHEP Policy: NCOPE Board of Directors must have timely notification of expected or unexpected substantive changes within 6 weeks of occurrence. The sponsor must report substantive change(s) as described in Appendix A to CAAHEP/NCOPE in a timely manner.

A substantive change is a significant modification of the nature and scope of an O&P education program. The purpose of the report of substantive change is to maintain open communication lines with NCOPE, prevent or address potential areas of noncompliance, and safeguard students. The Program Director is encouraged to contact NCOPE if there is a question about whether a change constitutes a substantive change. Substantive changes include, but are not limited to:

1. Change in Mission or Goals of program
2. Change in accreditation of institution
3. Significant reduction in resources for the institution or program
4. Program Director changes
5. Transfer sponsorship, mergers, or consolidations
6. Change/addition/deletion of courses that represent significant departure in curriculum content. This may include a substantial increase/decrease in clock or credit hours for successful completion of a program
7. Change in method of curriculum delivery
8. Substantive change in the number of students admitted to the program
9. Significant change in faculty composition or size
10. Change or additional program locations
11. Change in degree awarded, including when an institution with one accredited O&P educational program adds a different O&P educational program
12. Change in degree-granting institution from the currently accredited program
13. Program discontinuation

Minimum Program Performance Standards (Thresholds)

NCOPE has established specific thresholds for program performance to support assessment of a program’s effectiveness, as follows:

1. Program completion rate: Retention of an average of 85% of enrolled students must have completed the program within the program’s published time frame, as averaged over the three (3) most recently completed academic years. This includes attrition due to academic dismissal, clinical dismissal or student withdrawal.

2. National examination pass rate: At least 80% of 1st-time exam takers must have passed the national written exam, as averaged over the three (3) most recently completed academic years.

3. Placement: at least 90% of program graduates must be employed in the profession or pursuing further education in the profession within 1 year of graduation, as averaged over the 3 most recently completed academic years. Positive Placement requires the graduate to be employed as a prosthetist-orthotist, assistant, pedorthist, O&P technician or continuing their education. “Placement” means that the graduate is employed full or part-time in the profession or in a related field; or continuing his/her education; or serving in the military. A related field is one in which the individual is using cognitive, psychomotor, and affective competencies acquired in the educational program.

4. Employer surveys are administered six (6) months to one (1) year post-graduation: Average scores are at least 3.5/5 in response to items related to “is your resident/graduate prepared for entry-level practice.”

5. Graduate surveys are administered six (6) months to one (1) year post-graduation: Average scores are at least 3.5/5 in response to items related to “rate your knowledge and skill preparation for an entry-level position for a P or O resident/technician/assistant/pedorthist.”