Denied but Not Discouraged — Moving Forward to NCCA Accreditation Success
By Janice Moore
9.24.20
Each year, the National Commission for Certifying Agencies (NCCA) denies, approximately one-third of first-time applications for accreditation[1]. Denied applications often represent months of planning, hours of work and significant financial investment. Organizations that apply for NCCA accreditation set an ambitious goal of meeting rigorous standards. Understandably, receiving a denial causes frustration and discouragement.
While a denial decision is disappointing, program staff can avoid feeling discouraged by changing their mindset and consider opportunities to re-evaluate and further strengthen the program. This article provides a process for doing just that by examining the common grounds for a denial and providing a method for understanding the decision, leveraging feedback to create a response plan and developing a feasible re-application timeline.
First Seek to Understand
As Stephen Covey said, “Seek first to understand, then to be understood.” It’s reasonable, in response to denial, to wonder if the NCCA reviewers fully understood the information provided in the application. Is it possible information was missed? Do they understand the program? Is this an error?
Before reacting, carefully examine the basis for the decision. Review each citation carefully, taking time to understand the underlying issues. Examine the corresponding standard (including the essential element and commentary), the initial submission, staff or NCCA inquiries received in the review process, and the responses to those inquiries. Looking at each citation in this context, and with fresh eyes, often helps reveal gaps in compliance.
Seek expert guidance if the reasons for each citation are still unclear. The program’s testing vendor, psychometrician and consultants experienced with accreditation requirements are valuable resources. In order to provide guidance on a response, these individuals will need information including the initial submission and exhibits, inquiries from the review processes and responses, as well as the denial information.
Understanding why the application was denied provides the foundation of a response plan, allowing the program to develop action items, a realistic timeline for corrective actions and a strategy to submit new information to the NCCA. Often the best chance of success involves investing additional time to make corrective actions before re-submitting.
Determine the Cause
Citations present opportunities for improvement. Use them to strengthen the program as you prepare for re-submission. Citations generally fall into two categories:
- Compliance Gaps: Citations caused by lack of compliance with all, or part, of a standard. Examples include:
- Missing policy rationales for eligibility, recertification or retesting requirements
- Missing policies and procedures
- Incomplete or outdated test development activities
- SME panels that are too small or lack adequate diversity or representativeness
- Insufficient separation of certification and education functions, including requiring training, approving training providers or providing training without the necessary separation
- Lack of autonomy and authority for the governing body
- Inadequate quality management activities
- Documentation Gaps: Citations based on missing or insufficient information, inconsistent documentation, or lack of evidence that policies and procedures were implemented as written. Examples include:
- A quality improvement policy without evidence that required internal audits occurred
- Psychometric reports without detailed subject matter expert (SME) rosters
- No evidence to demonstrate the recruitment, nomination and selection process for new certification board members
The categories above assume that the applicant is a traditional certification program eligible for NCCA accreditation, rather than an assessment-based certificate program that combines training and assessment.
Understanding whether citations are based on gaps in compliance, documentation or both helps guide the response plan. When citations result from a compliance gap, the organization’s response depends on first implementing corrective actions to achieve and document compliance. When citations result from a documentation gap, the remedy may be as simple as gathering existing information and compiling it into a report or policy. The graphic below illustrates response planning for each type of citation.
Responding vs. Reacting
The pressure to respond quickly and reapply for the next NCCA deadline often overcomes the need for thoughtful analysis and planning. However, failure to identify the cause of each citation and the steps needed to achieve full compliance with the standards may result in another denial.
When the NCCA denies a first-time application for initial accreditation, the applicant can reapply at one of the next two deadlines without additional fees. The temptation to reapply immediately is understandable; however, responding purposefully increases the likelihood of success. Faster is not necessarily better and the opportunity to reapply within a few months may not be the best option depending on the time needed to fully address the citations.
Using the process illustrated above, take time to determine the cause of each citation, the actions needed to fully address each issue and the time and resources needed to implement those actions. Submitting evidence of completed actions proves much more effective than submitting a plan for intended changes. In other words, stating what you plan to do is not as effective as actually doing it. After analyzing the issues and identifying corrective actions, develop a timeline and set a target date for reapplication.
Know When the Time is Right
Reapply when the program meets all of the standards with sufficient documentation to prove it.
Plan adequate time to prepare a complete, clear and well-organized application. Review the application carefully for accuracy, clarity and completeness. Ask a co-worker or consultant to review your work from an objective point-of-view for added benefit.
Organize the application to a point of obsession. Make it easy for reviewers to find what they need in each of the documents provided by pointing them directly to information for each portion of each standard, including page numbers, section items, etc.
Keep in mind that standards for accreditation, and interpretations, evolve over time. Monitor changes and emerging information from the NCCA as you prepare to re-submit and throughout the process.
Manage Expectations
Think of accreditation as a continuing journey, not a single destination. Earning accreditation involves much more than submitting an application. The journey includes the up-front preparation and planning; completing, reviewing and refining the application; and the ongoing work of maintaining accreditation compliance once that status is granted. A successful accreditation journey involves coordinated efforts by a team of staff, volunteer leaders, psychometricians and consultants. When all personnel involved understand the reasons for change, timeline, required resources, accreditation process and possible outcomes, the accreditation journey is better supported.
Leverage Resources
The credentialing community provides valuable resources to help organizations understand the accreditation process. There are a number of resources available for applicants seeking assistance with denial citations, policy development, completing required exam development activities or strengthening exam administration security.
Keep in mind that the NCCA’s role is evaluating compliance with the standards, not providing consulting to applicants. To avoid conflicts of interest, the commissioners make determinations about what does, or does not, meet the standards but they are not in a position to provide specific advice.
Many certifying organizations bring in consultants, additional staff and other experts to assist with addressing citations, developing policies, improving exam development and other key activities. Engaging outside assistance to supplement available staff resources may also speed up your reapplication timeline.
The ICE website provides a starting point for finding resources that include the Consultant/Industry Partner Directory, webinars, workshops, networking, the ICE Handbook and online courses.
Make It Worthwhile
Certification programs seek accreditation based on expected value. The decision driver may originate from a competitive situation, marketing strategy, regulatory issue or need for ongoing quality improvement. Regardless, accredited programs regularly report that the outcome is well worth the effort. Returns include improved efficiency, legal defensibility and credibility. Often the journey toward accreditation, with milestones marked by improvements to governance systems, policies and procedures, training, documentation management, quality improvement, exam development, and security bring as much value as the achievement of accreditation.
[1] Based on data in the last 8 years of ICE annual reports of the number of new applications and newly accredited programs.
NCCA Resources
Looking for more information on NCCA accreditation? Click here to view ICE’s NCCA Accreditation page – which includes information on the application process, first steps, resources and the maintenance and renewal processes.