Accreditation Process

The Four Phases of Accreditation: Process & Department Responsibilities

CAB = CAPPA Accreditation Board

Phase 1  >>>
Phase 2  >>>
Phase 3 >>>
Phase 4

Preparation & Intent


Preparing for Site Visit

Site Visit


· Department Agreement

· Present CAPPA videos on the value of accreditation to department

· Consultation with CAB Chair/Advisor

· File Intent to proceed with CAB or decide to postpone

· Identify any potential reviewers with a conflict of interest



· Review CAPPA information with department

· Candidly assess readiness for accreditation noting strengths and weaknesses

· Make any possible  and necessary changes

· Collect information and complete self-study template

· Submit final self-study and signal readiness for site visit


· Review Self-Study with CAPPA advisor

· Review Self-Study with department 

· Identify key messages for reviewers







· Schedule Site visit of 2 reviewers

· Divide visit responsibilities among department members

· Host visit and ensure strengths of program are known

· Be frank about weaknesses and possible fixes

· Provide any further documentation


Spring/Early Summer


December/Early January



Phase 1: Pre-Accreditation Preparation & Intent to Proceed (Spring/early Summer)

In this phase of accreditation, the department reviews the importance of accreditation for their program(s). The CAPPA website documentation and video will be helpful in explaining accreditation and its value to the departments. The Head or Director or designated lead on accreditation should outline the stages of accreditation. Ideally, the CAPPA Accreditation process should be conducted at the same time as another review to minimize workload to the department and to avoid “review fatigue.”

The department member in charge of the process, should consult the CAPPA Accreditation Board Chair and/or a CAPPA accreditation advisor to discuss the eligibility of the program for accreditation. At this stage, it may be useful to provide a short (5-10) page document outlining the key characteristics of the program(s) being considered for accreditation and the program mission statement if available. If the Board Chair and department representative decide that the program is not ready for accreditation, then they should identify what the department needs to do to begin the process and the appropriate timing for accreditation. If the program appears ready for accreditation and department chooses to go ahead, then it will send a formal request to the CAPPA Board Chair identifying which program(s) it would like accredited. 

NOTE: In this stage, it is critical for departments to assess the strengths and weaknesses of the program(s) being considered for accreditation and the objectives of the program. The designated lead on the process should to discuss them candidly with the CAPPA Accreditation Board Chair or advisor. CAPPA recognizes that programs may have weaknesses or areas requiring improvement that may be due to factors beyond the department’s ability to address in the short term but will be interested in understanding how the department plans to address any such weaknesses or areas for improvement.


Phase 2:  Conducting the Self-Study (September – November)

In this phase, the department should discuss the self-study template and prepare the relevant documentation. It will be helpful if the designated department member in charge of the process has reviewed the template and filled in any easily accessible information in advance of the department review. The department may wish to have a meeting dedicated to accreditation during which they identify the core strengths of the program and areas for improvement, keeping in mind the department mission statement since it will be critical to the program review. If the department does not have a mission statement, then developing one should be the first step in the self-study. The mission statement will state the goals of the department and thus provide the rationale for the programs it offers. Learning objectives then flow from the mission statement.

If the department is undergoing another review, much of the information prepared for that review may just require a summary document that can be inserted into the CAPPA Accreditation Self-Study template. The referenced material may then be included in an appendix using the format of either review. Be sure to include all of the areas identified on the CAPPA template.

The self-study should not exceed 45 pages excluding appendices. During the preparation of the self-study, the department may wish to consult the CAPPA accreditation advisor regarding any questions or uncertainties. If the department identifies critical omissions in its program during the discussion with the CAPPA advisor, it may elect to pause the accreditation process until changes can be made. The department should inform the CAPPA Accreditation Board Chair of this decision. The process will recommence when the department signifies its intention to resume the process to the Chair.

Once the self-study is completed to the satisfaction of the department, then the department head or designate submits it to the CAPPA Accreditation Board Chair and indicates readiness for a site visit.


Phase 3: Preparing for site visit

In Phase 3, the department head or designate should meet by phone/zoom with the CAPPA Accreditation Board Chair to advise the Chair of any concerns and any special conditions with the self-study. The CAPPA Accreditation Chair will advise the department of the two reviewers for the program(s), taking into account any reviewers with possible conflicts of interest as identified by the department.

The department should review the responsibilities of the department members during the visit. It is important to encourage faculty, staff, students and administrators to be candid and to understand the perspective of the department as expressed in the self-study. The site visit should be scheduled by the department designate with a clear itinerary for the reviewers including a block of time towards the conclusion of the visit for the reviewers to meet to discuss their report and obtain any additional material they require to conclude their review. It is also helpful to reserve time for the reviewers mid-review to consult on what they are hearing and review or request any new documentation.


Phase 4: Site Visit

The department will host the reviewers and supply any additional information that the reviewers deem necessary. The department should ensure the reviewers have time to confer and structure the outline of their report. Prior to their departure, the reviewers will give the department an indication of their assessment. The department may then supply any additional information that they believe is relevant to respond to any concerns expressed by the reviewers.