Conducting a Compliance Audit

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Conducting a Compliance Audit

• UTSA Compliance Audit Team Orientation
• May , 2007
• Gerry Dizinno, Co-Chair

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SACS/COC Reaffirmation

• Two Components
• Quality Enhancement Plan (QEP)
• Compliance Certification

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QEP

• A plan must be developed that
• Focuses on improving student learning
• Involves members of the university community in
  determining the topic
• Flows from our internal planning processes
• Includes recognition of best practices
• Includes a detailed evaluation/assessment plan
• Includes a detailed budget and assignment of
  responsibility for carrying out the plan
• Think of it as similar to a grant application
  that focuses on improving student learning

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Compliance Certification

• Compliance Certification Report submitted about 6
  months prior to scheduled visit for us that
  means August or September 2009
• We provide a judgments of the extent of
  compliance with Core Requirements and
  Comprehensive standards
• Certification by chief executive officer and
  accreditation liaison that the document is
  truthful, accurate, and complete.
• Report provides evidence of compliance i.e.,
  EXTENSIVE documentation required
• BEFORE the work is done on the Report, we will
  conduct a Compliance Audit

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SACS Compliance Requirements

• Compliance with the Section 1 The Principle of
  Integrity
• Compliance with Section 2 Core Requirements (16)
• Compliance with Section 3 Comprehensive
  Standards (68)
• Institutional Mission (1)
• Governance and Administration (17)
• Institutional Effectiveness (1)
• Programs
• All Educational Programs (12)
• Undergraduate Programs (4)
• Graduate and Post-Baccalaureate Programs (4)
• Faculty (5)
• Library and Other Learning Resources (3)
• Student Affairs and Services (3)
• Resources
• Financial Resources (5)
• Physical Resources (3)
• Commission Policies (3)
• Federal Requirements (7)

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Steps in Completing the Compliance Report
Step 0 Conduct Compliance Audit We are doing
this BEFORE the remaining steps

• Organize the effort and provide training
• Develop draft narratives and evidence
• Edit materials
• Obtain approvals
• Prepare printed and electronic documents
• Obtain final sign-off by SACS Liaison and
  President
• Send electronic and hard copies to SACS

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Step 0 Purposes of the Compliance Audit

• Determine where we are regarding compliance make
  a judgment
• Definitely In Compliance all documentation
  identified and located
• Probably In Compliance not all documentation
  identified and located
• Compliance In Question processes, procedures may
  not be in place and/or documentation unavailable
  or not located
• Probably Not In Compliance process and/or
  procedures may not be completely in place and
  documentation may be unavailable
• Definitely Not In Compliance processes and/or
  procedures not in place and documentation is not
  available

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Two Most Important Purposes of Compliance Audit

• To identify policies, procedures, practices,
  programs, etc., etc. that we will need to CHANGE
  in order to come into compliance.
• To produce information that can be used by the
  Compliance Report Team in preparing the
  Compliance Report.

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Example of Summary of Results to be presented to
Leadership Team/CMO
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Our Compliance Audit Team

• Co-Chairs Gerry Dizinno, Pam Bacon   
• Presidents Areas
• Presidents Office Dick Dawson
• General Counsel Gail Jensen
• Academic Affairs
• Institutional Effectiveness and Assessment
  Steve Wilkerson
• College Representatives (for consultation and
  assistance with faculty affairs and academic
  program issues)
• COA Bob Baron
• COB Dan Hollas, Bennie Wilson
• COE Mehdi Shadaram
• COEHD Art Hernandez
• COLFA Chris Wickham
• COPP Mitch Miller
• COS Dmitry Gokhman
• Honors Ann Eisenberg
• Faculty Affairs David Johnson, Elaine Sanders
• Undergraduate Studies Amir Karimi
• Graduate Studies Veronica Ramirez
• Information Technology Bill Angrove

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Determining Compliance Status

• You must carefully analyze each Core Requirement
  and Comprehensive Standard
• Many are complex statements with separate phrases
  or words that each will require documentation
• Prime Example Core Requirement 2.5
  Institutional Effectiveness
• The institution engages in ongoing, integrated,
  and institution-wide research based planning and
  evaluation processes that (1) incorporate a
  systematic review of institutional mission,
  goals, and outcomes (2) result in continuing
  improvement in institutional quality and (3)
  demonstrates the institution is effectively
  accomplishing its mission.
• So, there are actually 7 components to this Core
  Requirement!
• So, they must be read carefully and appropriate
  documentation located to support compliance

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Another Example

• 3.2.11 The institutions chief executive officer
  has ultimate responsibility for, and exercises
  appropriate administrative and fiscal control
  over, the institutions intercollegiate athletics
  program.
• So, 3 separate aspects must be documented!

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Another Example

• 3.9.1 The institution publishes a clear and
  appropriate statement of student rights and
  responsibilities and disseminates the statement
  to the campus community.
• Three aspects!

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Documents to Aid You in Making Decisions

• Principles of Accreditation Foundations for
  Quality Enhancement (Interim Edition, December
  2006)
• Resource Manual for the Principles of
  Accreditation most helpful, in my opinion!
• Handbook for Reaffirmation of Accreditation

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Division of Labor

• Each of you has received a listing of the Core
  Requirements and Comprehensive Standards for
  which you are responsible
• Representatives from the Colleges will serve as
  consultants to those in Academic Affairs
  regarding issues of academic policy, practices,
  faculty issues, etc.

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How We Will Report on Each Requirement and
Standard

• Rating Sheet asks you to determine
• Definitely In Compliance
• Probably In Compliance
• Compliance In Question
• Probably Not In Compliance
• Definitely Not In Compliance
• Also provide a BRIEF summary of basis upon which
  decision is made and description of what needs to
  be done to bring institution into compliance
• To be Definitely In Compliance we need to have
  BOTH the processes, programs, etc. AND the
  documentation supporting those available we are
  NOT IN COMPLIANCE without documentation!!!!

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Lets Briefly Review EACH Core Requirement and
Comprehensive Standard

• Refer to printed hand-out (Compliance Audit
  Responsibilities) AND the Resource Manual for
  the Principles of Accreditation that was sent to
  you

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Assignments Core Requirements

• 2.1 through 2.3 Dick Dawson and Gail Jensen
• 2.4 through 2.6 Steve Wilkerson
• 2.7.1 and 2.7.4 Sally Bench
• 2.7.2 Amir Karimi and Veronica Ramirez
• 2.7.3 Amir Karimi
• 2.8 Elaine Sanders
• 2.9 David Johnson
• 2.10 Gail Carbajal
• 2.11.1 and 2.11.2 Janet Parker

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Assignments for Comprehensive StandardsInstituti
onal Mission, Governance Administration

• 3.1.1 Steve Wilkerson
• 3.2.1 through 3.2.6 Dick Dawson and Gail Jensen
• 3.2.7 through 3.2.10 Barbara Baran-Centeno
• 3.2.11 Dick Dawson and Gail Jensen
• 3.2.12 and 3.2.13 Dick Dawson, Gail Jensen,
  Craig Evans
• 3.2.14 Dick Dawson and Gail Jensen

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Assignments for Comprehensive StandardsInstituti
onal Effectiveness

• 3.3.1 Steve Wilkerson

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NOTE For Sections 3.4 (All Educational
Programs), 3.5 (Undergraduate Programs), 3.6
(Graduate Programs), and 3.7 (Faculty)The
College Representatives will assist the person(s)
in charge of compiling information as it pertains
to their college
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Assignments for Comprehensive StandardsApplying
to ALL Educational Programs

• 3.4.1 and 3.4.11 Amir Karimi and Veronica
  Ramirez
• 3.4.2 Bob McKinley
• 3.4.3 George Norton and Veronica Ramirez
• 3.4.4, 3.4.6 and 3.4.8 Sally Bench and Veronica
  Ramirez
• 3.4.5, 3.4.7, 3.4.9 and 3.4.10 David Johnson
• 3.4.12 Bill Angrove

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Assignments for Comprehensive StandardsApplying
to Undergraduate Programs ONLY

• 3.5.1 Steve Wilkerson
• 3.5.2 Sally Bench
• 3.5.3 Amir Karimi
• 3.5.4 Elaine Sanders

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Assignments for Comprehensive StandardsApplying
ONLY to Graduate/Post-Baccalaureate Programs

• 3.6.1 through 3.6.4 Veronica Ramirez and
  College Representatives

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Assignments for Comprehensive Standards Faculty

• 3.7.1 3.7.5 Elaine Sanders

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Assignments for Comprehensive Standards Library
Other Learning Resources

• 3.8.1 through 3.8.3 David Johnson

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Assignments for Comprehensive Standards Student
Affairs Services

• 3.9.1 and 3.9.3 Gail Carbajal
• 3.9.2 Sally Bench

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Assignments for Comprehensive Standards
Financial Resources

• 3.10.1 and 3.10.2 Janet Parker and Candie
  Sagehorn
• 3.10.3 through 3.10.5 Janet Parker

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Assignments for Comprehensive Standards Physical
Resources

• 3.11.1 through 3.11.3 Janet Parker

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Assignments for Comprehensive Standards
Adherence to Commission Policies

• 3.12 through 3.14.1 Gerry Dizinno

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Assignments for Comprehensive Standards Federal
Requirements

• 4.1 Steve Wilkerson
• 4.2 and 4.4 Amir Karimi, Veronica Ramirez and
  College Representatives
• 4.3 Sally Bench
• 4.5 Gail Carbajal
• 4.6 George Norton and Veronica Ramirez
• 4.7 Janet Parker

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Assignments by individual are provided in handout
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Schedule of Activities

• May 10th Orientation of Compliance Audit Team
• June 1st First Progress Report Due (see report
  format provided to you)
• July 1st Second Progress Report Due
• August 1st Third Progress Report Due
• August 15th Draft of Final Report Due
• August 31st Final Report Completed
• September 2007 through Summer 2009 Completion of
  Compliance Report

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Other Issues

• Additional meetings
• I will be available for individual meetings if
  necessary
• You will need to involve others
• College representatives should be prepared to
  assist others in gathering documentation and
  making decisions regarding academic programs,
  policies, and procedures
• If you need assistance in getting the cooperation
  of any other individuals, let me know and I will
  work with you, Sandy Welch, the Provost, and the
  President to ensure that you get the information
  you need