Submitting a Substantive Change Notification: Entry-to-Practice Nurse Residency Programs

Submission Guidelines

Substantive change notifications must be emailed as a PDF document to ccnesubchange@ccneaccreditation.org.

Please contact Ben Karnes, Accreditation Manager, at bkarnes@ccneaccreditation.org or 202-868-4314 x230, if you have any questions regarding substantive changes.

Substantive Change Policy

Institutions with CCNE accredited entry-to-practice nurse residency programs are required to notify CCNE of any substantive changes affecting the residency program. Substantive change notifications must be emailed as a PDF document to ccnesubchange@ccneaccreditation.org. The policy regarding substantive change notifications can be found in the CCNE Procedures for Accreditation of Entry-to-Practice Nurse Residency Programs, and is as follows:

Irrespective of required continuous improvement progress reports, compliance reports, or other reports, the CCNE-accredited program is required to notify CCNE of any substantive change affecting the entry-to-practice nurse residency program. Substantive changes include, but are not limited to:

significant change in established mission or goals of the program;
change in legal status, control, or ownership of the healthcare organization or program, including acquisition of another institution or program;
a significant reduction in resources of the healthcare organization or program;
change in status with a regulatory agency, including cases in which the healthcare organization or program is placed on warning, probationary, or show cause status;
change in status with an institutional accrediting agency or nursing accrediting agency, including cases in which the healthcare organization or program remains accredited but is placed on warning, probationary, or show cause;
development of a new nurse residency program (e.g., if the healthcare organization has an accredited employee-based nurse residency program and develops a federally funded traineeship nurse residency program, or vice versa) (CCNE’s acceptance of a substantive change notification regarding development of a new nurse residency program does not constitute an action to accredit that new program);
change in (including suspension or closure of) nurse residency program offerings or options;
the addition of courses that represent a significant change in method or location of delivery from those offered when CCNE last evaluated the program;
change in criteria for enrollment in the nurse residency program;
change in program length;
change of the chief nursing office or residency coordinator;
significant change in educator and staff composition and size;
significant change in resident enrollment;
major curricular revisions; and
significant change in the partnership between the healthcare organization and the academic nursing program(s).

The substantive change notification must be received by CCNE no earlier than 90 days prior to implementation or occurrence of the change, but no later than 90 days after implementation or occurrence of the change.

The substantive change notification is submitted by the chief nursing officer/chief nurse executive and must document the nature and scope of the substantive change. The notification also must document how, if at all, the change affects the program's compliance with the accreditation standards. The substantive change notification should not exceed 5 pages, unless otherwise approved in advance with CCNE staff.

The substantive change notification is reviewed by the Entry-to-Practice Residency Accreditation Committee (EPRAC). Upon review of the notification, the EPRAC may act to accept the change or may request additional information. If warranted, the notification is forwarded to the CCNE Board or other appropriate review committee for review and action. The Board’s review of a substantive change notification may result in acceptance of the notification, additional reporting requirements, a focused or comprehensive on-site evaluation, issuance of a show cause directive, or an adverse action.

Continued accreditation of the program is contingent upon the chief nursing officer's/chief nurse executive’s apprising CCNE of substantive changes in a timely manner. The chief nursing officer/chief nurse executive is encouraged to contact CCNE staff if there is a question about whether a particular change constitutes a substantive change.