Module Five – Overseeing the Self-Study Process and Writing the Self-Study Report

It is in the interest of every institution to receive a quality peer evaluation that has been based on a cogent and rigorous self-analysis of key institutional priorities aligned with compliance with the standards for accreditation and requirements of affiliation. Therefore, for both standards-based and priorities-based approaches, an institution should develop a Self-Study process that is well-organized, with assessment information effectively incorporated to identify institutional strengths and challenges, and with appropriately identified documentation found in the Evidence Inventory where necessary.

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Overseeing the Self-Study Process (Module 5, Section 1)

Communicating with Institutional Constituencies

Engagement: A goal of the self-study process is to produce a report that fairly and honestly represents the institution, avoids institutional politics and personal agendas, and warrants and receives broad support among campus constituencies. Every campus constituency needs to feel ownership of the process and of the final Self-Study Report.

Full and frequent communication is an important prerequisite to that sense of ownership. Therefore, periodic communication with the institution’s administration, faculty, and other campus stakeholders should occur as outlined in the Communication Plan included in the institution’s Self-Study Design.

Seeking Input: Throughout the development of the Self-Study Design, it is frequently noted that the Steering Committee and Working Groups should be seeking input from campus constituencies, not just informing them about the progress of the self-study. The Steering Committee should be gathering input from key stakeholder groups when identifying institutional priorities, outcomes, charges, key resources, or evidence, etc.

Seeking Feedback throughout the Process: Feedback from administrators, faculty, staff, and students should be sought at different milestones in the self-study process.  As the Working Groups develop the narrative for their respective chapters they will need to consult with and seek guidance from those with experience and expertise.

Working with Members of the Steering Committee and Working Groups (Module 5, Section 2)

Gathering Information: The Steering Committee and Working Group Members will work with the campus community during the self-study process. This will include compiling and reviewing documents (strategic plans, reports, policies, procedures, etc.) reviewing existing data and analyses (student survey data, student learning outcomes data, institutional effectiveness data, etc.). The Working Groups will conduct interviews with people who have information and expertise relevant to the self-study.

Prioritizing Information: The structure of the relationships among the Steering Committee and Working Groups will vary by institution, but in all cases, it is the Steering Committee’s responsibility to ensure that the self-study process progresses on schedule and that there is effective communication among the Working Groups. The process leading to the Self-Study Report includes the completion of a series of written drafts, punctuated by periods of data collection, analysis, and review.

Under the leadership of the Steering Committee, each Working Group engages in evidence-based analysis, the parameters of which are determined by the lines of inquiry (significant questions that develop a particular analytical focus related to priorities, standards, and outcomes) identified in the Self-Study Design. See alignment below:

When questions arise about how to limit areas of inquiry or opportunity for improvement and innovation to a manageable number, it is often helpful to list them and go back to original questions posed when developing the Self-Study Design, such as the extent to which they directly relate to mission, institutional priorities, and the standards.

Managing Group Work: Well-defined Working Group charges are a prerequisite for Working Group success. If the Self-Study Design has provided clear, well-defined Working Group charges, the Working Group members should have an appropriate roadmap to follow in completing their tasks.

Successful Working Groups are characterized by certain behaviors:

  • Be knowledgeable, committed, and provide effective leadership.
  • Share responsibility for a task and work confidently toward a solution.
  • Communicate intensively about their assigned charges and lines of inquiry while relying on and building trust in their colleagues in the group.
  • Meet often to share progress and seek feedback on the results of their analysis.
  • Develop a strategy to manage the work and assign sections of the work to pairs so the members can support and encourage each other
  • Establish interim deadlines or benchmarks of progress will help the Working Groups stay on task.

Under the leadership of the Steering Committee, each Working Group engages in an evidence-based analysis based on the lines of inquiry identified in the Self-Study Design. From time to time, as analysis of the priorities and standards proceeds, these lines of inquiry may change; however, when they do change, they should address the institution’s intended outcomes and relate to the aligned institutional priorities and standards that were originally selected in the Self-Study Design.

The Steering Committee agenda should include time to discuss the progress of Working Groups and any challenges they encounter. The discussions should focus on the content/findings and analysis of what these findings mean for the institution and its compliance with the standards. One approach that Steering Committees take is to ask Working Group chairs to attend a meeting to discuss the initial draft of the findings and recommendations.

Utilizing appropriate assessment and evaluation information: Effective Steering Committees leverage existing processes or institutional resources to evaluate institutional priorities and to garner documentation to demonstrate compliance with Commission standards for accreditation, requirements of affiliation, policies and procedures, and federal compliance requirements. Some successful strategies are:

  • Rely on at least one member of the Steering Committee or one member of each Working Group who understands how to gather documentation in the Evidence Inventory, to label it effectively, and to communicate duplication of information among Working Groups in the interest of achieving efficiencies and to strategize about elegance of presentation.
  • Review existing institution-level data (surveys, strategic plan goals and results, academic program review results, academic program assessment results, administrative unit data, etc.) that is appropriate and aligns to the standards. Collaborate with others to use appropriate assessment and evaluation information for the purposes of self-study.
  • Include a person on the Steering Committee with expertise in assessment and evaluation who can liaise with Working Groups. This person can address the analytical needs of the missing standards and Working Groups.
  • Working Groups, identify duplication of efforts, and suggest ways that Working Groups might work together to address overlapping lines of inquiry.

Developing a comprehensive, representative Evidence Inventory: As discussed in Module Seven of this Self-Study Guide, the Evidence Inventory should be used as an organizational tool that allows an institution to arrange existing institutional documentation gathered for use during self-study by standard, criterion, and Requirement of Affiliation (RoA). We suggest the Steering Committee identify Working Groups whose charges solely include refinement of the Evidence Inventory and management of the Verification of Compliance process to achieve efficiencies in the self-study process. These Working Groups report to the Steering Committee so that it can assist the other Working Groups in addressing lines of inquiry, answer questions about appropriate documentation, and ensure the self-study process is comprehensively managed by the Steering Committee.

The evidence should naturally align with the associated standards, priorities, or RoA. For example, Standard III: Design & Delivery of the Student Learning Experience, criteria aligns to evidence to demonstrate the extent to which an institution meets the standard. Some types of evidence include program and/or annual report analyses, the percentage of full-time faculty, student survey data, teaching (or course) evaluations, outcome rubric results and analyses, or student portfolio results and analyses.

Generally, institutions review the standards and criteria to conduct and develop an initial inventory of the available evidence. Once the Working Groups begin, the evidence inventory may be expanded, refined, or some evidence deemed not relevant.

Achieving efficiencies by leveraging interactions among Working Groups: The role of the Steering Committee is to oversee the progress of the Working Groups. Some institutions have managed this process by either assigning a member of the Steering Committee to liaise with one or two Working Groups or by integrating the leaders of the Working Groups into the Steering Committee. Regardless of the approach, periodic discussions in which Working Groups can share their findings, analysis, and documentation can result in a more cohesive final Self-Study Report.

Working Group Reports (Module 5, Section 3)

Clear and concise Working Group Reports that address all the elements of the Working Group charge and lines of inquiry are critical to an effective self-study process. These reports serve as a formal method of reporting the results of the Working Group’s efforts and might include the following:

  • An overview of how the Working Group addressed aligned institutional priorities;
  • A synopsis of how lines of inquiry were addressed, how they have changed over time, and their connection to the institutional priorities;
  • Indications of how the Working Group collaborated with other Working Groups and how it engaged in the institution’s strategies to populate the Evidence Inventory and provide information relevant to the Verification of Compliance process, where applicable;
  • Evidence utilized to evaluate the institution’s lines of inquiry;
  • An analytical narrative, with evidence of how assessment information has been used for continuous improvement of student learning, unit, and institutional goals; and
  • Opportunities for improvement and innovation, as well as suggested initial strategies to address them.

The Steering Committee should review the Working Group reports to ensure that all assigned institutional priorities are addressed and should ascertain to what degree the Working Groups have developed and presented sufficient information and evidence to support their conclusions. If the Steering Committee finds insufficient topic coverage or inadequate demonstration of the institution’s ability to meet the expectations of the standards for accreditation and requirements of affiliation, relevant Working Groups should be asked to address these needs within specified time periods.

Interim Reports: It may be useful to require the Working Groups to submit outlines and interim drafts at various points during the Self-Study process before they submit their final reports. The Commission does not require Steering Committees to mandate the submission of interim reports, although they can be helpful tools for providing and receiving feedback, identifying areas of commonality and duplication, and discovering assessment, documentation, and other resources that can be shared among several Working Groups. A sample interim report template can be found in the Resource Toolbox at the end of this module. A suggested process is identified below:

Interim Reports. Steering Committee Feedback. Refined Reports. Self-Study Report Draft

Interim and refined Working Group reports could also specify the connections and common themes they have made with other Working Groups and collaborative efforts after discovering these. For example, a Working Group whose lines of inquiry focus on Standard V (Educational Effectiveness Assessment) might note that much of the work it is doing is already being accomplished by a Working Group assigned to Standard III (Design and Delivery of the Student Learning Experience) and brainstorm about ways to streamline their efforts. Being explicit about such connections and collaboration may have consequences for developing more efficient approaches to populating the Evidence Inventory, for collaborating in evidence-based inquiry for lines of inquiry that are similar, among other benefits. In addition, explicit mention of such connections and common themes can alert the Steering Committee to a need to organize the Self-Study Report in ways that are not unduly duplicative.

Final Reports: Working Group Reports should describe the evidence used in the report with an emphasis on how evidence has regularly and systematically used to improve or sustain improvements in institutional, unit, and student learning goals. Including proposed or utilized evidence in the report can be especially beneficial if it is an Interim Report. After reviewing these reports, Steering Committee members might be able to identify areas where a Working Group may not be aware of certain evidence that other Working Groups have already identified or used. Evidence to be used might greatly assist the Steering Committee as it moves toward a final draft, especially in cases where it applies to more than one standard or more than one priority.

As the timeline for self-study proceeds, Working Groups conduct an analysis of their assigned standards and priorities, using evidence to demonstrate ongoing compliance with the Commission’s standards and requirements, and to learn about strengths and weaknesses related to the standards and priorities to which they are assigned. This analysis leads to discussions about areas of strength and opportunities for improvement and innovation that each Working Group notes in its reports to the Steering Committee.

Writing the Self-Study Report (Module 5, Section 4)

The Self-Study Report serves the following purposes:

  1. Serves as primary foundation of evidence for both the institution and evaluation team members.
  2. Provides analytically based narrative aligned with standards and institutional priorities.
  3. References additional documentation to be found in the Evidence Inventory.

Initial Draft of the Self-Study Report

After the Working Group reports and other relevant information have been reviewed, compiled, and discussed, the Steering Committee begins to draft the Self-Study Report. The Steering Committee should carefully review the Working Groups’ interim reports to ensure that all appropriate topics have been addressed. The Steering Committee should determine whether the Working Groups have developed and presented sufficient information and evidence to support the writing of the Self-study Report itself. If the Steering Committee find insufficient topic coverage or inadequate demonstration of the institution’s ability to meet the expectations of the Commission’s Standards for Accreditation and Requirements of Affiliation, relevant Working Groups should be asked to address these needs within a specified period of time.

A concise, coherent Self-Study Report is more than a collection of Working Group reports. If the Steering Committee chooses to have each Working Group write a chapter of the Self- Study Report, the working group reports should be consistent in style, format, and structure. Alternatively, the report writers can use the Working Group reports to provide the analysis of evidence that they use in writing the entire report.

An initial draft of the Self-Study Report should follow the approach outlined in the Self-Study Design. It should be written in such a way that it reflects the evidence-based findings of the Working Groups, although the Steering Committee should seek to write the initial draft in one voice. Some institutions do this by including an editor on the Steering Committee and others feel comfortable writing a consensus draft under the supervision of the Steering Committee co-chairs.

Involving the entire campus community in the process is one of the prerequisites of meaningful self-study. The Steering Committee should provide opportunities for the community to review and respond at key points throughout the self-study process. Students, faculty members, trustees, staff, administration, and others can provide more informed and valuable suggestions if they are involved in reviewing the drafts of the Working Groups at various stages. Finally, the Steering Committee should create a concise, readable, and substantial draft document for review and comment by the campus community. Careful consideration of the ideas expressed by the campus community, and modification of the report, where warranted, helps ensure that the final document reflects a common institutional perspective and that it will be widely accepted across the institution.

Before completing the final Self-Study Report, the Steering Committee ensures that the final draft is organized, analytical, concise, fair, and honest. The Self-Study Report is written in such a way that the Report’s multiple audiences—institutional stakeholders, evaluation team members, and Commissioners—can understand the Report, can utilize a well-organized Evidence Inventory, and are able to understand conclusions and inferences made in the report. Below is a summary of the final draft elements:

Organized: Organizational approach is clear, Includes an executive summary, Uses headings and subheadings. Analytical: Narrative is not purely descriptive, Assessment information leads to appropriate conclusions. Concise: Uses bullet points to summarize findings, Includes graphics and tables strategically, Refers the reader to the corresponding evidence. Fair and Honest: Presents a realistic picture of the current status of the institution. Represents a consensus of feedback received from constituents

Main Elements of the Self-Study Report (Module 5, Section 5)

Within the Self-Study Report, chapters may be organized in different ways. One of these ways is to use the Standards for Accreditation. The standards may, however, be reordered and the report may be structured to reflect the institutional priorities selected to be addressed in the self-study. If an institution has adopted the institutional priorities approach, it is important that the Self-Study Report indicate clearly how the analysis and evidence presented in each section relate to the standards because the team must determine and indicate in its report whether the institution meets each of the Standards for Accreditation and Requirements of Affiliation. Below are the main elements of the Self-Study Report.

Executive Summary. The final Self-Study Report includes an executive summary, which provides a brief description of major findings and opportunities for improvement and innovation identified in the self-study.

Introduction. This section includes a summary of the history, type, size, and student population; a brief discussion of processes used to choose its institutional priorities; and a description of the approach the institution has chosen for self-study. Also included is a paragraph about how the remaining chapters are organized (by standard, how Evidence Inventory will be used, etc.).

Chapters for Each Standard/Priority. Each chapter includes:

  • A heading indicating standard/priority under consideration
  • Cross-references to relevant materials in other parts of the report and within the Evidence Inventory
  • Analytically based inquiry and reflection
  • Conclusions, including strengths and challenges, with references to appropriate Criteria
  • Opportunities for ongoing institutional improvement and innovation

For priorities-based self-studies, the narrative must show a clear connection with the Standard(s) associated with the priority. Also, where applicable, include additional chapters covering Standards not addressed in prior chapters.

Conclusion. Summary of the major conclusions reached and the institution’s self-identified opportunities for improvement and innovation. The conclusion also outlines initial plans for the institutional initiatives that will address identified opportunities, as well as concluding observations on how this process is being used to continuously improve student achievement and the institution’s mission and goals.

The Team Chair receives the latest draft of the Self-Study Report prior to the Team Chair’s Preliminary Visit, which should occur three to four months before the evaluation team visit. The Chair reads the draft report and may recommend modifications to better present the institution’s strengths or compliance with Commission expectations, to refocus the report on analysis of results instead of descriptions, or to make the report more accessible for the team. Responses to suggestions by the Team Chair should be incorporated prior to finalizing the Self-Study Report.

Finalizing the Self-Study Report (Module 5, Section 6)

The final report should be edited for accuracy, consistency, and continuity. It is important to build into the Self-Study schedule adequate time for the review and revision of the final report. Design elements and publishing needs should be established and arranged well before the final Self-Study Report has been completed. After the report has been revised considering feedback from institutional stakeholders and the Team Chair, it should be endorsed by the institution’s governing body.

The final Self-Study Report should be no longer than 200 double-spaced or 100 single-spaced pages.

The final Self-Study Report should be ready for distribution no later than six weeks prior to the scheduled Evaluation Team Visit. The Self-Study Report and Evidence are uploaded to the MSCHE portal. It is recommended that the responsible parties begin the uploading process well before the six-week deadline. If the institution encounters difficulties uploading Self-Study materials, please contact support@msche.org for assistance. The institution does not need to send a hard copy of the report to the Evaluation Team members.

MSCHE treats all Self-Study materials authored by the institution as the property of the institution, and the dissemination and publication of these materials are at the discretion of each institution. All MSCHE Self-Study evaluation team reports and related materials produced by appointed peer reviewers and evaluation team chairs are considered confidential by the Commission.

It is the Evaluation Team’s responsibility to access Self-Study materials through the MSCHE secure portal. For more information, please see the Commission’s Communication in the Self-Study Process Policy and Procedures.

Keys to Success (Module 5, Section 7)

  • Look up! Ensure that you are addressing the standard, not just the criteria.
  • Interim reports should be as comprehensive as possible. It is always easier to cut or reduce than to try to add missing information.
  • More is not always better! Think strategically about the quality and quantity of information provided in the final group reports.
  • Be sure to consult with constituencies throughout the process, and not just “once and done.”
  • Working Groups should keep each other informed about their findings. Some findings may be addressed in a different standard than originally planned.
  • Take advantage of the times your governing board is already scheduled to be on campus to update them on self-study progress.
  • Know your audiences. The self-study process and Self-Study Report (SSR) include the participation of numerous stakeholders and audiences and the SSR should be written so various audiences can understand its content and use it effectively.
  • Beyond the institutional stakeholders, Evaluation Team members and Commissioners, both of whom play a part in evaluating an institution, need to understand the report.
  • Consider including a glossary of key institutional terms and acronyms to help readers.
  • Show clear connections between the narrative, the Evidence Inventory, and how such connections are linked to budgeting, planning, and resource allocation.
  • Tips of Revising/Editing:
    • Refer to the Self-Study Design
    • Eliminate jargon and trite phrases
    • Eliminate redundancies
    • Seek the opinions of diverse institutional community members
    • Carefully analyze seemingly contradictory data
    • Read from the perspective of an outsider

Resource Toolbox (Module 5, Section 8)

 

Sample – (Interim) Final Working Group Report
I. Overview of Working Group’s Charge

A brief description of the Standards and Priorities assigned to the Working Group and their alignment with one another and the institution’s mission.

II. Description of Lines of Inquiry
Overview of the lines of inquiry addressed by the Working Groups and how these enable the Working Group to fulfill its charge and the institution’s self-study outcomes.

III. Collaboration, Connections and Evidence Inventory Approach

Overview of the Working Group’s collaborations with those refining the Evidence Inventory and, where applicable, Verification of Compliance process, and a list of documentation to be included in the Evidence Inventory. In addition, a description of collaborative discussions with members of other Working Groups and, where needed, strategies for avoiding undue duplication.

IV. Assessment Information Utilized

Description (or listing) of assessment information utilized to conduct analyses consistent with the lines of inquiry.

V. Analytical Report

Analytical report that addresses lines of inquiry.

VI. Areas of Strength

Based on analytical report, evidence-based areas of strength consistent with the Working Group’s charge and assigned Standards and Priorities.

VII. Opportunities for improvement and innovation

Based on analytical report, evidence-based opportunities for improvement and innovation consistent with the Working Group’s charge and assigned Standards and Priorities.

VIII. Initial Strategies on Continuous Quality Improvement

Suggested institutional strategies for improvement.

The following questions are essential to ask when revising the Self-Study Report.

1. Does the report

  • address the articulated priorities and outcomes for the self-study?
  • honestly represent the institution?
  • avoid individual agendas?
  • provide ample evidence for the assertions made?
  • provide ample evidence to show compliance with MSCHE Standards and Requirements of Affiliation?
  • provide ample evidence to show compliance with MSCHE policies, procedures and guidelines and applicable federal regulatory requirements?

2. Do you need more evidence to support your points? Is your evidence convincing?

3. Does the report conform to the outlines proposed in the SSD?

4. Are the future plans for the institution cited in the self-study realistic?

5. Does the report read as a unified document?

6. Does the report identify opportunities for improvement and innovation?

7. Do you anticipate the questions of the on-site evaluation team?

For additional information on how to upload information, please see the video below:

Uploading Evidence (updated as of 2020)

 

 

Disclaimer: The material provided in this guide was developed to provide clarity for the self-study process. Commission Policy and Procedures will govern in the case of a conflict with this material. For any questions about an institution’s accreditation status or for additional information about MSCHE’s standards for accreditation, requirements of affiliation, policies, and procedures, you should contact MSCHE staff. This material is not intended as a substitute for professional advice from MSCHE staff and use of the material does not guarantee any specific accreditation outcome.