CONDUCT A SELF-ASSESSMENT

An organization that is renewing its accreditation conducts a self-assessment. The purpose of a self-assessment for reaccreditation is to identify any relevant changes, updates, or improvements to the organization’s HRPP that may have occurred since the last accreditation period.

BUILD AND DEVELOP AN APPLICATION

When the organization has completed its self-assessment and addressed any gaps in its HRPP, the next step is to submit an Application for Reaccreditation to AAHRPP. An Application for Reaccreditation is comprised of two parts (Step 1 and Step 2) in which an organization’s written materials are reviewed (Step 1) and then additional documents are later submitted (Step 2) in preparation for a site visit.

Organizations must submit their Application for Reaccreditation (Step 1) no later than 12 months prior to their assigned Council on Accreditation (Council) review date. The Council review date is determined by the date (month and year) initial accreditation was awarded.

An organization that cannot submit their Application for Reaccreditation (Step 1) by the renewal application due date must promptly notify AAHRPP in writing. Organizations that submit an Application for Reaccreditation (Step 1) after the renewal application due date, or fail to complete the Application for Reaccreditation (Step 1 and Step 2) in time to complete the reaccreditation process before the Council meeting at which the organization is assigned to be reviewed, may be placed into Reaccreditation-Pending, on Probation, or may lose accreditation status.

EVALUATION OF WRITTEN MATERIALS (APPLICATION FOR REACCREDITATION)

An application reviewer evaluates the Application for Reaccreditation (Step 1) materials and assesses whether the organization’s policies and procedures are consistent with the Accreditation Standards, or whether revisions are needed. Policies and procedures include any written materials that the organization uses to define and communicate its practices, such as standard operating procedures, policy statements, procedure descriptions, checklists, guidelines, educational materials, job descriptions, memoranda, forms, templates, strategic plans, websites, charters, by-laws, mission statements, or other forms that are used to administer the HRPP. Following review, AAHRPP staff and the application reviewer will communicate requested changes to the organization in the Application Review report (Step 1 Review) and by email if needed.

Once the application reviewer determines that the policies and procedures are consistent with the Accreditation Standards, the organization may be asked to submit additional materials relevant to a site visit (Step 2) and a site visit is scheduled.

The Application for Reaccreditation process, i.e., the organization’s satisfactory response to the Application Review report (Step 1 Review), must be completed according to the time schedule provided by AAHRPP to ensure that the Application for Reaccreditation is reviewed at the organization’s assigned meeting of the Council. If this deadline is not met, the Council may place the organization into Reaccreditation-Pending.

EVALUATION OF PRACTICE (IN-PERSON OR REMOTE SITE VISIT)

AAHRPP site visitors review the Application for Reaccreditation (Step 1 and Step 2), including any requested revisions, and evaluate an organization’s implementation of its policies and procedures by interviewing key personnel and reviewing records during a site visit evaluation. This evaluation may be conducted on-site and/or remotely. The length of time of a site visit varies depending upon the size and nature of the research portfolio, and generally ranges from two to four days in length.

AAHRPP must have sufficient information to adequately evaluate an organization’s HRPP. In general, this requires that site visitors be permitted to interview all key personnel, enter all relevant facilities as applicable, and have access to all relevant records, policies, procedures, minutes, audits, sample protocols, consent documents, and other materials. AAHRPP will not accredit an organization that cannot be thoroughly evaluated. To perform these tasks, the site visitors must sign confidentiality agreements with AAHRPP prior to the site visit.

The organization’s Application for Reaccreditation (Step 1 and Step 2) and results of the evaluation of practice site visit forms the basis of a site visit report. AAHRPP provides a Draft Site Visit Report to the organization in approximately 30 calendar days after completion of the site visit. Within 30 calendar days of the date that the Draft Site Visit Report is sent to the organization, the organization has the opportunity to respond to AAHRPP in writing to identify any errors of fact, to describe any corrective actions it has taken in response to Areas of Concern identified by the site visitors, and to report any other changes it has made to its HRPP since the site visit. AAHRPP staff, along with the site visit team leader, reviews the organization’s response to the Draft Site Visit Report and prepares a preliminary version of the final report (known as the Final Site Visit Report) for the Council to review.

COUNCIL ON ACCREDITATION REVIEW

At its quarterly meeting, the Council reviews the Application for Reaccreditation, Draft Site Visit Report, the organization’s response, and the evaluation of the response in the preliminary Final Site Visit Report. The Council then makes a determination regarding accreditation, and this decision is communicated to the organization in writing in the Final Site Visit Report.

If an organization has not completed all the steps required to be reviewed at a Council meeting or the organization causes delays in its accreditation timeline, the Council may take one of the actions outlined in the Categories for Reaccreditation.

If the Council awards Full Reaccreditation, the reaccreditation period is five years from the Council meeting date to which the organization was assigned.