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Faculty Newsletter

Change Initiative Newsletter

Closing the Loop: A Simple CQI Documentation System to Strengthen Accreditation Readiness

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Faculty & Staff Newsletter • Program Quality Initiative

CLOSING THE LOOP

A simple CQI documentation system to strengthen accreditation readiness—without adding unnecessary workload.

The Challenge

As we prepare our program self-study, one theme is consistent: we do a lot of meaningful improvement work, but the documentation is not always stored in a clear, consistent place. When evidence is spread across emails, folders, and meeting notes, it becomes harder to show reviewers what we found, what we changed, and whether the change worked. Accreditation expectations emphasize ongoing program evaluation and continuous quality improvement, which depends on organized, retrievable evidence (ABHES, 2026; CCNE, 2024).

This change initiative focuses on one practical goal: make CQI documentation consistent, simple, and audit-ready—without adding unnecessary workload.

We are implementing a standardized CQI process using the Plan-Do-Study-Act (PDSA) approach to help teams test improvements, review results, and adjust based on evidence (IHI, n.d.). The key change is not "more meetings" or "more paperwork." It is one shared way to document what we already do.

Closing the Loop in 4 Steps

1

Finding

What does the data show?

2

Decision

What will we change—and why?

3

Action

What did we implement?

4

Reassessment

Did it work? What is next?

Program-wide Tools We Will Use

CQI Mini Action Plan

Improvement plan, data used, and timeline

Evidence Tracker

What evidence exists and where it is saved

Decision-Log Minutes

What we decided and what happens next

These tools create a consistent CQI trail and help us present a clear improvement story aligned to standards (ABHES, 2026; CCNE, 2024).

Grant Funding Proposal — What We Are Requesting and What It Supports

To launch this initiative in a sustainable way, we are proposing grant funding to support:

  • Training and implementation support: a short workshop and optional coaching/office hours during the first cycle (IHI, n.d.).
  • Finalization of standardized templates and minimum CQI artifact expectations (ABHES, 2026; CCNE, 2024).
  • A shared evidence repository organized by accreditation standards/categories so artifacts are easy to locate (ABHES, 2026; CCNE, 2024).
  • CQI work sessions to upload artifacts, verify reassessment steps, and strengthen readiness (IHI, n.d.).

Bottom line: this funding supports a smoother rollout and makes the process easier for faculty and staff to adopt.

What to Expect

Each term, faculty and committees will:

  • Complete at least one CQI cycle using the shared templates.
  • Save supporting artifacts (minutes, action plan, and outcome summary) in the shared repository.
  • Include the "closing-the-loop" element: reassessment results or next steps.

Benefits for Faculty, Staff, and Program Quality

  • Less time searching for documentation during self-study, reporting, or audits.
  • Clearer decision-making through a consistent record of discussions and follow-through.
  • Stronger evidence of continuous improvement (finding → decision → action → reassessment) (IHI, n.d.).
  • More consistent accreditation readiness because evidence is organized and retrievable (ABHES, 2026; CCNE, 2024).

How We Will Measure Success

We will track progress with measurable targets such as:

  • At least one CQI artifact per course/committee per term.
  • Most artifacts include complete closing-the-loop documentation (finding, decision, action, reassessment).
  • High participation in the initial CQI training and improved confidence with documentation.
  • A repository that contains the key evidence categories needed for self-study and site-visit preparation.

If it isn't documented, it didn't happen—this initiative helps us show the full CQI story:

FINDING DECISION ACTION REASSESSMENT

What Happens Next

You will receive the finalized templates and brief instructions for use. We will start with one CQI cycle, collect feedback, and refine the process using PDSA so the tools stay practical and supportive (IHI, n.d.). Thank you for helping strengthen program quality and accreditation readiness.

References

  • Accrediting Bureau of Health Education Schools. (2026). Accreditation manual (19th ed., effective January 1, 2026).
  • Commission on Collegiate Nursing Education. (2024). Standards for accreditation of baccalaureate and graduate nursing programs. American Association of Colleges of Nursing.
  • Institute for Healthcare Improvement. (n.d.). Model for improvement.