CAPTE: On-site Reviewer Training

MODULE 4
On-Site Visit

April 2017

This module will address the purpose and process of the on-site visit.

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 Objectives

1. Identify the purpose and format of the on-site

visit.
2. List the participants of the on-site visit.
3. Identify the team responsibilities prior to,
during, and after the on-site visit.
4. List the activities that occur on each day of the
on-site visit.

Please take a moment to review the objectives of this module. Further information
will also be provided in the face to face training sessions.

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 Purpose of the Visit

Verify and clarify the Provide supporting

Self-Study Report evidence

• Meet with • Facilitates CAPTE’s

interested parties determination of
compliance with the
• Review on site Standards and
documentation Required Elements

The on-site visit provides an opportunity for a comprehensive review of the physical
therapy education program in its particular environment. The primary purpose of the
visit is to confirm and clarify the information provided in the Self-Study Report
through interviews and review of on-site documents. Information collected during
the visit is provided to CAPTE in the Report of the On-Site Review Team, also called
the Visit Report. This face-to-face visit allows CAPTE to have a much fuller picture
of the program.

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 Format of the Visit

• Length of Visit
– Typically four days
– Usually Sunday to Wednesday

• Timing of Visit
– Typically the semester prior to CAPTE’s review of
the program
– Must be at least 100 days prior to CAPTE meeting

The majority of on-site visits are 4 days in length although a longer visit may be
scheduled if an institution has programs at multiple sites. Teams are expected to
travel on Saturday and stay through the end of the consultation session on
Wednesday, which typically ends at 3 pm. Programs that run only on weekends are
scheduled differently so that interviews can occur over the weekend. For programs
seeking reaffirmation of accreditation, visits are scheduled in the term prior to the
meeting in which CAPTE is scheduled to act. For example, programs visited in the
fall will be on CAPTE’s spring agenda. There must be sufficient time after the visit to
allow all accreditation activities to occur.

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 Participants in the On-Site Visit

• Reviewers
• Institutional representatives

One major advantage of an on-site visit is for the on-site reviewers, who represent
CAPTE, to meet personally with the many people who contribute to the quality of the
program. Each major stakeholder is involved in the process.

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 Team Composition
Team Leader Team Member 1 Team Member 2

Educator Practitioner Other

PT Team
PT Team PT Team Higher education
PT educator PT practitioner administrator, basic
scientist or educator from
PTA Team PTA Team another health discipline
PT/PTA who is an PTA practitioner PTA Team
educator in a PTA
Higher education
program
administrator

Typically 3 team members are selected by the Accreditation staff from the list of
available reviewers. Additional team members may be assigned if the institution has
multiple programs. Both the program and the on-site reviewers have an opportunity
to identify who may be in conflict with the program. Individuals from the same state
are automatically considered in conflict. As much as possible, staff take into
account the type of institution and program to tailor the visit to best meet the needs
of the program. Where feasible, on-site reviewer preferences are also taken into
account.

Although the team leader is usually the educator, an experienced practitioner may
also serve as the team leader. In these instances, team member 1 would be an
educator.

By CAPTE’s definition, the practitioner must be employed in a clinical setting at

least 50% of the time. Team member 2 cannot be a PT or a PTA. CAPTE believes that
by including a non-PT/PTA on the team a broader perspective is provided.

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 Institutional Representatives

Faculty Administration Students Graduates Employers

1. Program Faculty
2. Institutional Administration
3. Current Students
4. Recent Graduates
5. Employers of Graduates

It is not possible to meet with everyone associated with the program, but it is
important that key informants and representatives of key groups meet with the on-
site team. CAPTE has prepared a sample schedule for an on-site visit that identifies
the participant groups who should meet with the team. Some are noted by specific
position, such as the dean of the unit within which the program resides. For others,
such as students, graduates, employers and clinical instructors, the program
director is asked to invite representatives. Although this typically includes
individuals from the geographic area, the program may also use telephone
conferencing to increase the pool of those interviewed.

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 Institutional Representatives:
Faculty

• All core faculty

• Part-time faculty with major
course responsibility (associated
faculty)
• Representative clinical education
faculty

Interviews with faculty help the team to confirm a wide range of areas related to the
Standards and Required Elements, including, but not limited to faculty workloads,
the extent to which practice matches policies, sufficiency of resources,
effectiveness of communication, strengths and weaknesses of the curriculum, and
the extent to which the program assesses outcomes.

The program director should not be present during faculty interviews. Group
interviews are used for associated faculty as well as clinical education faculty.
Clinical education faculty may be a combination of clinical instructors and center
coordinators of clinical education, also known as CCCEs. It is suggested that
interviews with clinical education faculty occur early in the visit so that the team
can obtain additional information regarding any curricular areas that may have been
raised.

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 Institutional Representatives:
Administration

• All administrators with academic

responsibility for the program (e.g.,
Dean, Provost, President)

• Administrative support (e.g.,

admissions staff, secretarial support)

Interviews with academic administrators provide information regarding support for

the program and long term institutional planning. Interviews with those involved
providing administrative and secretarial support provide an opportunity to verify the
activities and sufficiency of support personnel.

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 Institutional Representatives:
Students

• Representatives of
current students
across the years in
the program

The team meets with representatives from each class. Some programs select who
will be interviewed; other programs ask each class to pick representatives. If the
class is small, the team may meet with the entire class. If a cohort is out in clinic,
the team usually meets with class members that are in the geographic area.

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 Institutional Representatives:
Graduates

• Recent graduates
• Practicing in the area
• Outside of geographic
area via telephone
conference

The program may choose to supplement those graduates that are in the geographic
area by telephone conferencing in graduates that live in other areas. Interviews with
graduates allows the team to confirm how well prepared graduates were for entry-
level practice. However, whenever an individual identifies an area of weakness,
whether it be a graduate, current student, clinical instructor or employer, every effort
should be made to provide CAPTE with additional information regarding how the
content is taught and what content is included. Faculty interviews and review of
course materials can provide details that will assist CAPTE in determining
compliance.

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 Institutional Representatives:
Employers

• Representatives of
employers of program
graduates
• In the region
• Outside the region

Again, telephone conferencing can increase the number and variety of individuals
being interviewed. Employers help to triangulate curricular strengths as well as
areas that might need enhancement.

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 Overview of Reviewer Responsibilities

Collect and
analyze data

Participate in the Prepare Visit

consultative Report
session
Participate
in the Oral
Report

NOTE: Reviewers do NOT make evaluative judgments

about actual compliance.

On-site reviewers have a great responsibility to be the ‘eyes and ears’ of CAPTE.
Their role in gathering data to augment and clarify the Self-Study Report is vital to
the accreditation process. However, it is important to recognize that only CAPTE can
make the actual compliance and accreditation status decisions.
Reviewers facilitate CAPTE’s decision by summarizing the data collected on site
into a concise Visit Report. Reviewers also participant in an Exit Summary at the end
of the visit that summarizes their findings for each of the eight standards. The Exit
Summary is given only to the core faculty and institutional administrators at the
conclusion of the visit. The reviewers then have an opportunity, if requested by the
program, to provide consultation.

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 Activities Prior to the Visit

Thoroughly reads the Self-Study Report

Identify areas that need to be clarified

Determine how best to clarify information

In order to maximize the utility of the on-site visit it is essential that each team member
has thoroughly read the Self-Study Report and identified the areas that need to be
clarified while on site. Planning should include the identification of specific questions for
the different groups that will be interviewed.

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 Team leader activities prior to the visit

Program Director to establish the

schedule and discuss need for
specific on-site materials

Other team members to assign

Team Leader responsibilities and discuss any
preliminary concerns, questions, or
communicates issues
with:

Other team members to

identify any missing material

Team leaders are encouraged to make early contact with individuals to ensure
ample time for planning. The team leader communicates with the Program Director
to establish the schedule and discuss the need for specific on-site materials.
Programs must have ample notice of any additional materials being requested for
on-site review as well as which materials the team would like to have at the hotel to
review on Sunday. The Team Leader also communicates with the other team
members

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 Logistics of the Visit

Team
Program members
If a car
makes the make flight
rental is
arrangements
hotel necessary,
through
reservations contact staff
Concur
and provides for approval
preferably at
the details in
least 6 weeks
the On-site
before visit.
Visit Travel Travel is from
Form Saturday to
Wednesday.

The program makes the hotel reservations and provides the details in the On-site Visit
Travel Form, which also includes information about local airports and local
transportation. This form is sent to each team member by the program.
Flight arrangements are made by the individual team member and must be made through
APTA’s travel agency, Concur. In order to keep costs down, flight arrangements need to
be made early. The letter confirming your appointment for an on-site visit will indicate the
date by which travel arrangements must be made. Air travel is always directly billed to the
APTA. Travel to the program is usually done on Saturday to ensure the team is available
to start work early Sunday afternoon. Flights home must accommodate the consultative
session scheduled for Wednesday afternoon. Team members may stay an additional night
(either at the program site or closer to an airport) to accommodate flight schedules and
the consultative session; no prior approval for this situation is necessary.
As a rule APTA will not reimburse for rental cars; please contact staff for approval should
a rental car be necessary. When a rental car is necessary, travel arrangements will need
to be coordinated. Since only one rental car will be approved per visit, if the team will be
arriving at very different times, it may be necessary to stay at a hotel near the airport
Saturday night. The team is responsible for any needed changes to the hotel reservations
made by the program. For insurance purposes, you should not use cars belonging to the
faculty during the visit.

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 Logistics of the Visit

All costs are reimbursed

Costs by CAPTE and travel
advances are available

Contact Information, including cell

numbers, is shared with
Information the team and program

Travel Changes must be made

Emergencies through Concur

All costs associated with the visit are ultimately paid by CAPTE. However, each
team member is responsible for the costs at the time of the visit and must submit a
Travel Expense form within 30 days of the visit. On-site reviewers may request a
travel advance of up to $500 prior to a visit; travel advances are requested on the
CAPTE Accreditation Portal. Please allow time for processing these requests!
Your contact information is sent to the other team members and the program at the
time the team is confirmed. In order to ensure that you can be contacted should
there be any last minute, unexpected changes, you should make sure this
information is up to date and provide a cell phone number. It is also a good idea to
share your travel itinerary with the other team members and the program.
Should any travel changes need to be made during the visit, they need to be made
through Concur. Make sure that you take Concur’s 800 number, as well as their 24
hour emergency number with you. The 24-hour emergency number is only to be
used if calling at times other than usual working hours. Should you need to cancel a
flight, this must be done through Concur in order to secure credit for the cancelled
flight, which then would be available for your next flight (assuming it is on the same
carrier).

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 Overview of On-site Activities

On-site Day 1 Day 2 & 3 Day 4

Visit Sunday Monday Wednesday
Schedule &
Tuesday
•Initial team
preparation for
visit •Interviews & •Visit Report
review of •Exit Report
• Tour of materials •Consultation
facilities

This slide provides an overview of the on-site visit. The schedule is a very busy
one, designed to help the reviewers and participants share as much information as
possible.

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 Day One: Sunday

Identifying materials to be reviewed on site

Some materials can be reviewed at the hotel

Identifying issues; refining and prioritizing questions

Assigning specific analysis and writing responsibilities

Campus tour; tour of facilities

The team uses Sunday to plan its activities for the three day visit, usually meeting
for the first time early in the afternoon. Having on-site materials at the hotel, for
those that can leave the campus, will significantly facilitate your review. However, it
is imperative that this request be made by the team leader well in advance of the
visit. The team also uses this time to identify & prioritize issues, plan the interviews,
and confirm writing responsibilities.
It is expected that Sunday activities will also include meeting the program director
for a preliminary discussion and touring the campus and program facilities if it is
feasible.

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 Day Two & Three: Monday and Tuesday

Review additional Interviews with all Evenings are used

materials on site involved with the to discuss findings
program and write Visit
Report

Review Materials Conduct Interviews Write Report

On Monday and Tuesday the team will review additional materials on-site. The team
will also meet with all of the various program representatives. Interviews with
students and clinical education faculty should occur early in the visit in order to
allow time to discuss with the core faculty any curricular issues raised by students
or clinical instructors. The team will use evenings to continue its analysis and write
the Visit Report.

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 Day Four: Wednesday

Visit Report Oral Report Consultation

Review report
Report is Team provides
with program
finalized consultation
director
to core
Overview Give core faculty, if
must be faculty & requested by
completed administrators program

Exit
Summary
format

On Wednesday morning, either at the hotel or at the school, the team continues to write
the Visit Report, completing as much as possible. The team must complete the Exit
Summary section of the Visit Report, as this is used in the Exit Report. Prior to giving the
Exit Report to administrators and core faculty, the team meets with the program director
to review its findings. The purpose of this meeting is to ensure that the program director
is not caught unaware during the Exit Report. If the team is requesting that the program
send additional materials to CAPTE, the last page of the Visit Report identifying these
items is given to the program director at this time.
An Exit Report format is provided by Accreditation staff; it is accessible from the Portal.
The team needs to add the date that CAPTE will review the program; this information is
provided in the initial team assignment letter. This format should be used to ensure
consistency across visits.
After the Exit Report, a consultation session can be scheduled if requested by the
program. Usually the program identifies the areas to be discussed. If requested, the team
can also provide suggestions, including items that would have been too prescriptive to
include in the Visit Report. Teams should always indicate that the views presented are
those of the team and not the Commission.

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 Activities After the Visit

✓ Never leave a copy of the Visit Report with the program

✓ Submit Visit Report to staff within 10 days of visit

✓ Share information with CAPTE when contacted

✓ Comment on the first Compliance Report, if applicable

✓ Receive Summary of Action

✓ Destroy all materials when instructed to do so by staff

A copy of the Visit Report is NEVER left with the program at the conclusion of the visit.
Final editing or writing is done after the visit. The report must be submitted to the
Accreditation staff within 10 working days following the visit. After it is edited by
Accreditation staff, it is sent to the program. A final copy of the report that includes the
program’s responses will be sent to each team member.
The primary CAPTE reviewer typically contacts the team leader prior to the CAPTE
meeting. This enables CAPTE to clarify issues if need be. New information cannot be
provided at this time; CAPTE can only act on information that the program is aware of
and had an opportunity to respond to.
The last responsibility of a team leader will be to comment on the first Compliance Report
submitted by the program. Once this is done and you receive CAPTE’s actions in a report
called the Summary of Action, you will be instructed to destroy all program materials. It is
very important that you destroy program materials when you are requested, including
any e-mail correspondence with other team members, staff or the program.

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 Summary

• Purpose of the site visit

• Site visit participants
• Site visit schedule
• Role of the reviewers

This module has described the structure and purpose of the on-site visit and has
identified the main activities for the on-site visit. You are now ready to proceed
Module 5, which will address on-site interviews in more detail.

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