Module Five – Writing the Self-Study Report

MSCHE Self-Study Institute

Regardless of whether an institution selects a standards-based or priorities-based approach, it is important to develop a Self-Study Report that is well-organized, with assessment information effectively incorporated to identify institutional strengths and challenges, and with appropriately referenced documentation found in the Evidence Inventory where necessary.  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.

Because the Self-Study Report and On-Site Evaluation Visit result from careful analysis that has incorporated feedback from multiple stakeholders, the Report has the potential to influence institutional decision making for several years. As a “living” document, a well-organized, evidence-based Self-Study Report can serve as a significant resource for institutions as they engage in planning to address their institutional priorities, initiate innovative solutions, and find ways to impact the student experience most positively.

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Strategies for Overseeing the Self-Study Process before the Self-Study Report

Communicating with Institutional Stakeholders

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.

Working with Members of the Steering Committee and Working Groups

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 identified in the Self-Study Design. 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, priorities, and Standards for Accreditation (see Figure 1 below).

Figure 1.  Main Sources for Self-Study Lines of Inquiry

Figure 1.  Main Sources for Self-Study Lines of Inquiry

Managing Group Work: Successful Working Groups are characterized by certain behaviors. They share responsibility for a task and work confidently toward a solution. Successful Working Groups communicate intensively about their assigned charges and lines of inquiry while relying on and building trust in their colleagues in the group. When Working Groups reach consensus on the approach to their work, all members demonstrate the same sense of commitment to the task.  Also, it is important to have Working Groups meet often to share their progress and seek feedback on the results of their analysis. A successful strategy to manage the work is to assign sections of the work to pairs so the members can support and encourage each other.  Additionally, establishing interim deadlines or benchmarks of progress will help the Working Groups stay on task.

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.
  • 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 Working Groups, identify duplication of efforts, and suggest ways that Working Groups might work together to address overlapping lines of inquiry.

Learning from the Evidence Inventory: As discussed in Module Six, 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. 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 that the self-study process is comprehensively managed by the Steering Committee.

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

Working Group reports are of central importance to the self-study process. Their purpose is to 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; 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 the Steering Committee 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.

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 Toolkit at the end of this module.

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.

Figure 2. Working Group Reports: A Suggested Iterative Process

Figure 2. Working Group Reports: A Suggested Iterative Process

Interim and refined Working Group reports could also specify the connections they have made with other Working Groups and collaborative efforts after discovering such connections. 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 together 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 can alert the Steering Committee to a need to organize the Self-Study Report in ways that are not unduly duplicative.

Working Group Reports should describe the evidence used in the report. 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 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.

Discussion(s) about Final Working Group Reports by the Steering Committee

Once all Working Groups have submitted their reports, members of the Steering Committee carefully read through them to gather a general sense of issues that need to be discussed, such as:

  • Are there any common themes, areas of strength, or opportunities for improvement and innovation in the Working Group reports that should be discussed by the Steering Committee and perhaps addressed in the final draft of the Self-Study?
  • Does each Working Group report discuss the assigned standards and priorities?
  • Does each Working Group’s approach to the Evidence Inventory seem complete? Is there information that is overly duplicative, or are there significant gaps?
  • Are there any “unanswered questions” that need to be addressed?

When answering these questions in advance of organizing and writing the final report, the Steering Committee’s purpose is to observe from the Working Group reports if there are any issues that might be common across the Standards and/or institutional priorities as these could be important findings to note in the final report.

Writing 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 create a concise, readable, and substantial draft document for review and comment by the campus community. The final Self-Study Report should be no longer than 200 double-spaced or 100 single-spaced pages.

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. The final report should be edited for accuracy, consistency, and continuity. 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 and the Self-Study Report at various stages. 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.

The Team Chair receives the latest draft of the Self-Study Report prior to the Team Chair’s Preliminary Visit at least four months before the 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.

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.

Before completing the final Self-Study Report, the Steering Committee ensures that the final draft is organized, analytical, concise, fair, and honest (Figure 3). 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.

Figure 3. Features of a Well-Written Self-Study Report

Figure 3. Features of a Well-Written Self-Study Report

 

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 brief summary of the history, type, size, and student population; a brief discussion of what led the institution 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; and
  • 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 final Self-Study Report should be ready for distribution no later than six weeks prior to the scheduled On-Site Evaluation Visit. The Self-Study Report and Evidence are uploaded to the MSCHE portal.

Keys to Success

  • Know your audiences. The self-study process and report include the participation of numerous stakeholders and audiences and the Self-Study Report should be written so that these various audiences can understand its content and use it effectively. Beyond the institutional stakeholders, evaluation team members and Commissioners, both who play a part in evaluating an institution need to understand the report. See Figure 4.
  • Consider including a glossary of key institutional terms and acronyms to help readers understand the content of the Report.
  • Interim Working Group Reports. Below is a sample of an (Interim) Final Working Group Report.
Self-Study Report Audiences

Figure 4: Audiences of the Self-Study Report

 

Sample - (Interim) Final Working Group Report

 

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.

 

 

 

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.