Narrative Writing and Documenting Compliance

Documenting Compliance

Writing the Narrative

     Finding Documentation      Determining Compliance
     Evaluating Evidence
     Building the Case for Compliance
     Presenting Documentation
     Finding the Right Length

 

 

Documenting Compliance

After the institution is satisfied that it understands each standard, it is ready to identify documentation of compliance to be submitted for each. Most of this documentation should already exist and simply needs to be located. In some instances, however, such as when an institution realizes that its governing board’s policy for dismissing members does not describe the process for dismissal as required by CS 3.2.5, the institution may need to take formal action in order to develop evidence of compliance with one or more of the variables in a standard. All materials must be presented in English, and all financial documents must exhibit amounts in U.S. dollars.

 

Finding Documentation

The institution might begin its identification of the documentation to be included in its Compliance Certification by inventorying available records, documents, databases, policy manuals, curriculum files, assessment records, committee minutes, board of trustee minutes, planning documents, reports to external audiences, case studies, and other sources of information relevant to assessing compliance with the requirements and standards.

 

Some of the more obvious sources of evidence are documents such as the following, which typically provide evidence of compliance with multiple Core Requirements, Comprehensive Standards, and Federal Requirements:

  • Standard publications, such as the catalog, student handbook, faculty handbook, departmental policy manuals, organizational chart, bylaws of the governing board, and class schedules
  • Standard administrative lists and inventories of buildings, equipment, library holdings, faculty resources, etc.
  • Institutional effectiveness policies, calendars, handbooks, and reports
  • Personnel files containing credentials and evaluations
  • Contracts and consortial agreements for providing instruction or sharing resources
  • Financial audits, management letters, and financial aid audits for the current and recent fiscal years, as well as any other relevant financial statements

 

More difficult to pinpoint is documentation of compliance that is embedded in large documents (such as years of minutes of the governing board or an institutional committee), in letters or memoranda about which institutional memory has grown vague, and in e-mails residing in unknown computers. Nonetheless, searching through board and committee minutes frequently yields important documentation of discussions engaged in and decisions taken, and memoranda and e-mails may provide important evidence, for example, of improvements made as a result of assessment.

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Evaluating Evidence

An institution determines its compliance with the standards by making an honest evaluation of the evidence it possesses at the time it has chosen to
make that determination. Because the Compliance Certification requires that the institution demonstrate that it has based its compliance decisions on compelling and appropriately documented evidence, the institution needs to evaluate the evidence it has assembled to support a claim of compliance with a requirement or standard. This evaluation should be based on a careful interpretation of the Core Requirements, Comprehensive Standards, and Federal Requirements and on the cogency of the evidence to be presented supporting compliance with them. Evidence should not be viewed simply as a mass of facts, data, or exhibits. Instead, it should be viewed as a coherent and focused body of information supporting a judgment of compliance.

 

Institutions should ensure that the evidence it presents is:

  • Reliable. The evidence can be consistently interpreted.
  • Current. The information supports an assessment of the current status of the institution.
  • Verifiable. The meaning assigned to the evidence can be corroborated, and the information can be replicated.
  • Coherent. The evidence is orderly, logical, and consistent with other patterns of evidence presented.
  • Objective. The evidence is based on observable data and information.
  • Relevant. The evidence directly addresses the requirement or standard under consideration and should provide the basis for the institution’s actions designed to achieve compliance.
  • Representative. Evidence must reflect a larger body of evidence and not an isolated case.

 

Additionally, the body of evidence provided throughout the Compliance Certification should (1) be shaped, through reflection and interpretation, to support the level of compliance cited by the institution for each standard, (2) represent a combination of trend and “snapshot” data, and (3) draw from multiple indicators.

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Presenting Documentation

For some requirements and standards, a single document or two or an excerpt from a single document or two will constitute sufficient evidence of compliance. For example, compliance with the Core Requirement 2.3, which specifies that the institution have a president who is not simultaneously the chair of the governing board, might be supported by a written policy covering this issue or by documentation that two different individuals serve in those capacities.

 

For standards that are more complex, such as CR 2.5 (Institutional Effectiveness) and the related Comprehensive Standards (3.3.1 Institutional Effectiveness and 3.5.1 College-level competencies), several sources of relevant evidence may need to be identified in order to justify a claim of compliance. When documenting compliance with multiple compliance components related to two or more standards, an institution should look for a pattern of evidence -- a set of multiple measures/indicators that exhibit coherence and a unifying theme -- to support its argument for compliance. Although patterns of evidence will differ according to the standard and the nature of the institution, a pattern of evidence that could demonstrate compliance with Core Requirement 2.5 might focus on strategic planning as the driving force behind the setting of priorities that not only provide the direction for systematic mission-driven, institution-wide evaluation and use of the results for continuous improvement but also guide resource allocation. Skillful meshing of separate measures/indicators -- such as trend data, student satisfaction indices, institutionally developed or commercially available surveys like NSSE or CCSSE, licensure/certification rates, and focus group findings -- into a pattern of evidence can be a powerful tool for documenting compliance.

 

Reliable, current, verifiable, coherent, objective, relative, and representative evidence that is not presented in a reader-friendly format, however, may fail to produce in the off-site reviewer the anticipated finding of compliance. Documentation must not only be easy to access, it must also be easy to read. Off-site reviewers should not be expected, for example, to strain to read poor quality reproductions of academic transcripts, to rearrange documents that are collated out of order, or to read through an entire page or document in search of the relevant sentence or paragraph. They expect institutions to organize documentation so that, for example, the trends embedded in pages and pages of assessment results or columns of operational expenses are efficiently displayed in easily digested summary tables. In short, after identifying the best evidence of compliance for each standard, the institution needs to invest another moment or two in designing a presentation that will display that documentation in a reader-friendly fashion. Building a reader-friendly format can often be accomplished quite easily through small actions -- highlighting relevant passages in a paragraph or on a page, for example, or using boldface, shading, and color-coding to impose order on a complex table. To assist institutions in the presentation of information, the Commission has developed a number of templates that
institutions may use to display expected evidence of compliance. Use of these templates, which are available on the Commission’s website, http://www.sacscoc.org, under Institutional Resources, is optional.

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Writing the Narrative

On the Compliance Certification, the institution must make two entries for every Core Requirement, Comprehensive Standard, and Federal Requirement (except PR 1.1, CR 2.12, CS 3.3.2, and CS 3.13.1). The first records the institution’s assessment of its level of
compliance; the second presents the narrative, the institution’s argument in support of that assessment of compliance.


Determining Compliance

An institution’s determination of its level of compliance reflects its honest evaluation of the pattern emerging from the body of evidence it has assembled. Some of those patterns will be strong and convincing; others may be incomplete or, in rare instances, so insubstantial as to be virtually non-existent. For this reason, the institution has three alternatives in describing its determination of compliance:
  • Compliance. The institution concludes that it complies with each aspect of the requirement or standard. Appendix II-2 presents a narrative that asserts compliance.
  • Partial Compliance. The institution judges that it complies with some but not all aspects of the requirement or standard. When an institution selects this option, the narrative must justify the partial compliance and provide a detailed action plan for bringing the institution into compliance, including identification of the documents to be presented to support compliance and a date for completing the plan. Appendix II-3 presents a narrative that asserts partial compliance.
  • Non-Compliance. The institution determines that it does not comply with any aspect of the requirement or standard. When an institution selects this option, the narrative must justify the non-compliance and provide a detailed action plan for bringing the institution into compliance, including identification of the documents to be presented to support compliance and a date for completing the plan. Appendix II-4 presents a narrative marked non-compliance.

Building the Case for Compliance

Narratives should provide a clear, succinct, and convincing justification for the level of compliance identified by the institution. A good narrative folds the assembled documentation -- the publications, policies, processes, inventories, evaluations, financial documents, etc. -- into a description of the individuals and processes that create or implement or manage the documentation in a manner that addresses the compliance components previously identified for the standard. By summarizing attached documentation, linking it to the variables in the standard, and interpreting complex documentation, an institution builds its case for compliance. Building a case for compliance means making copious use of past tense verbs to describe actions previously taken by the institution and present tense verbs to describe current policies and procedures that support the maintenance of compliance. Because future tense verbs signal an action not yet taken, future tense is typically found only in the action plans included for standards marked Partial Compliance or Non-Compliance.

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Finding the Right Length

Throughout the Compliance Certification, the length of individual narratives varies widely from standard to standard. Those standards that are
crisp and focused, such as CR 2.6 (Continuous Operation), may require just a sentence or two; those that are broad and complex, such as CR 2.5 (Institutional Effectiveness), may require several pages. The challenge is to find the “right size” for each standard. To minimize the possibility of writing too little, institutions should keep an eye on the list of compliance components developed for each standard and ensure that the narratives address them. To minimize the possibility of losing the off-site evaluator in a lengthy narrative addressing a complex issue, the institution might employ the following techniques: (1) using various levels of sub-heads to separate key ideas and show relationships among component parts, (2) creating flow charts to illustrate complex processes, (3) using summary tables to provide an overview of masses of data, and (4) interpreting extensive or complex documents.

 

Because the individuals who develop Compliance Certifications focus so very intently on the language of the Core Requirements, Comprehensive Standards, and Federal Requirements, many institutions submit Certifications that have not adequately addressed the special documentation requirements established for standards that mandate a policy or procedure, such as CS 3.2.3 (Conflict of Interest). Often overlooked because it is placed above the first numbered standard in Sections 2, 3, and 4, rather than being embedded within any of the applicable standards, this special documentation requirement specifies that the policy or procedure be (1) in writing, (2) approved through appropriate channels, (3) published in appropriate documents accessible to those affected by it, (4) implemented, and (5) enforced. At the June 2009 Summer Meeting, the Executive Council made the following determination regarding this requirement:

  • For all standards that require a policy, institutions must document publication in appropriate institutional documents.
  • For four standards – CS 3.2.3 (Board conflict of interest), CS 3.2.5 (Board dismissal), CS 3.7.5 (Faculty role in governance), and FR 4.5 (Student complaints) – institutions must explicitly document implementation and enforcement.

 

Institutions that are a part of a system or corporate structure and those that engage in off-site instruction and distance education must incorporate additional narrative and documentation of compliance as they seek the “right” size for their submission. If an institution is part of a system or corporate structure, the Commission policy “Reaffirmation of Accreditation and Subsequent Reports,” which is available at http://www.sacscoc.org, requires that a description of the system be submitted as part of the Compliance Certification so that the evaluators can understand the mission, governance, and operating procedures of the system and the institution’s role within that system. Since the Core
Requirements, Comprehensive Standards, and Federal Requirements apply to the entire institution, a Compliance Certification must include the evaluation of not only all services and programs offered on the main campus but also those programs offered off-campus, by correspondence, or through electronic distance learning. The Commission has two documents to assist institutions in addressing these programs under relevant standards -- “Distance Education: A Policy” and “Distance Education and the Principles of Accreditation: Documenting Compliance.” Both documents can be found at http://www.sacscoc.org under Institutional Resources.

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Information obtained from The Handbook for Institutions Seeking Affirmation by the Southern Association of Colleges and Schools Commission on Colleges.