Program Evaluation Policies, Practices and Procedures

The School of Nursing is a member of the American Association of Colleges of Nursing (AACN) and is approved by the Washington State Nursing Care Quality Assurance Commission. The Bachelor of Science in Nursing, Master of Science in Nursing, Doctor of Nursing Practice, and post-graduate APRN certificate programs at Pacific Lutheran University are accredited by the Commission on Collegiate Nursing Education  ( The Care and Outcomes Manager MSN curriculum meets requirements for the Clinical Nurse Leader national certification examination. The Family Nurse Practitioner track meets requirements for ANCC and AANP national certification examinations and the Psychiatric Mental Health Nurse practitioner track meets requirements for ANCC national certification examination.

The School of Nursing (SoN) Systematic Evaluation Plan (SEP) is a framework for program assessment and evaluation activities as required by the State of Washington Nursing Care Quality Assurance Commission (NCQAC) and by the Commission on Collegiate Nursing Education (CCNE) Accreditation Standards. The SEP was revised in June 2023 to realign evaluation activities with 2018 revisions of CCNE standards, amended on January 3, 2022, and The Essentials: Core Competencies for Professional Nursing Education (April 6, 2021). The SEP is a dynamic document and shall be reviewed as directed by Element IV-A and revised as needed. All standards are reviewed and reported in the accreditation reports/CIPR. Program evaluation data is accessible to the faculty on the SoN Sakai site and NetStor.

The SEP is organized according to the CCNE accreditation standards and key elements. Program assessment and evaluation is a shared responsibility of all SoN faculty and administrators. Specific personnel and committees are responsible for evaluating each Standard and Key Element as indicated in the “responsibility for collection and review” column of the SEP. The responsible personnel/committees should review the components to be addressed and plan for completing the required assessment activities as indicated in the “timeline” column throughout the academic year.

A written report indicating the evaluation of the “expected outcomes” must be developed and sent to the appropriate program lead (prelicensure or post-licensure) for inclusion in the School of Nursing Organizational (SNO) meetings. Bi-annual SoN Evaluation Forums will be conducted during the Fall and Spring SNO meetings. Evaluation forums provide dedicated time for faculty to receive reports and provide input and recommendations.

The responsible personnel conducting the review will provide a report indicating if the benchmark(s) were “met” or “not met.” The responsible personnel will draft a Program Improvement Plan (PIP) using the PIP form for any unmet benchmark. The PIP form generates a PIP report which will be reviewed monthly by the appropriate program leads (prelicensure or post-licensure) and included in the monthly program lead reports. Program leads will present a comprehensive report of PIP initiatives in the evaluation forums conducted in the Fall and Spring semesters in the School of Nursing Organizational (SNO) meetings.

The program leads will monitor the outcomes of the PIP implementations for the component deemed “not met” in the following evaluation cycle to note any changes in the outcome(s), thus providing evidence for “closing the loop.” If the evidence indicates no improvement, the program-level PEC will convene. Recommendations will be provided on revising the PIP, and the PIP process will continue until the issue is rectified and the benchmark is met.