Accreditation: Get Accredited - Part 1: Conduct a Self-Assessment

Applying for accreditation primarily involves conducting a self-assessment. The self-assessment is a critical, introspective examination of a Human Research Protection Program (HRPP) in which the program is evaluated according to each element of the AAHRPP Accreditation Standards.

At the heart of the accreditation process is a comprehensive self-assessment during which an Organization reviews its HRPP and evaluates its compliance with the AAHRPP Accreditation Standards and Elements. Given the scope of these Standards and Elements, it is not surprising that one of the most frequent questions that AAHRPP receives is “Where do we begin?”

Tips for Completing the Self-Assessment

Once you start the self-assessment, you will be surprised at how quickly everything falls into place—and how valuable the self-assessment proves in strengthening your HRPP.

The following are some tips designed to answer that question. As you move forward with accreditation, keep in mind that the process is meant to be rigorous, not overwhelming.

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Download and review the Evaluation Instrument for Accreditation.

Read through the entire document before tackling any of the steps in earnest. Familiarize yourself with the Standards and Elements.

Download the Evaluation Instrument for Accreditation.

Gather all written policies and procedures and organize them by topic.

Remember to think in terms of the entire HRPP, and, if applicable, include policies and procedures for areas such as human resources, budgeting, counseling services, pharmacy, student orientation, corporate ethics, and corporate compliance. In most cases, your HRPP will have a policy, procedure, or practice to demonstrate that you meet the Element and the Standard.

Share the load.

As you read over the self-assessment, identify experts for each Domain and even for each Standard within a Domain. Then, enlist their help.

If you have an internal IRB or ethics committee, start with Domain II.

This Domain will be most familiar to you and, therefore, easiest to complete.

Tackle the Evaluation Instrument Element by Element.

For each Element, identify the policies and procedures that spell out how your HRPP meets the Element. If someone in your Organization is an expert in the requirements covered by a particular Element, assign the Element to that expert. If an Element does not apply to your Organization, just indicate that it is not applicable.

Don’t write.

Instead, list. Most Elements can be addressed by your existing documents. Examples include policy statements, procedures, checklists, guidelines, educational materials, job descriptions, bylaws, memoranda, forms, templates, strategic plans, slide presentations, websites, charters, and mission statements. Find the appropriate document, and cite the name and relevant section.

If you must write, do it for your Organization – not for AAHRPP.

If you find yourself writing a detailed explanation in response to an Element, chances are you need to create a document for your own Organization. Once you have done that, reference the document for the applicable Element.

Some Elements do not require documentation.

These Elements are evaluated during the site visit, through interviews with members of your Organization. For these Elements, provide a brief description of your practice.

Identify and fill in the gaps.

Most self-assessments identify a number of gaps between the AAHRPP Standards and your Organization’s human research protection practices.

When you find a gap, design a policy, procedure, or practice that makes sense for your HRPP, and then use the AAHRPP Standards to refine what you have developed.

Communicate the new policy, procedure, or practice throughout your HRPP.

Construct an Element-by-Element index of your supporting documents.

For each Element, list the supporting document, assign it a number, and provide a very brief explanation.

Use page numbers, paragraph numbers, item numbers, titles, and headings to pinpoint the information. This index becomes Section C of your accreditation application.

Copy your documents.

Provide one copy of each document cited in your Element-by-Element index.

Do not include non-organizational documents.

Cross-reference and cite each document as many times as necessary but include only one copy. These copies become Section D of your accreditation application.

See Instructions for Submitting Materials in Support of Accreditation for more details about creating an Element-by-Element index.

Don’t be afraid to ask.

AAHRPP is available as a resource throughout the accreditation process. If you have questions or need help, just ask.