The ANCC Commission on Pathway to Excellence® (“COPE”) ensures that applicants seeking ANCC Pathway to Excellence® designation or re-designation have the opportunity to appeal an adverse decision.
The ANCC Commission on Pathway to Excellence (“COPE”) ensures that applicants seeking ANCC Pathway to Excellence (PTE) designation or re-designation have the opportunity to appeal an adverse decision rendered by the PTE Program. Adverse decisions include a denial of designation or re-designation, probation, suspension, or revocation of designation. Please note a denial of threshold eligibility at the initial phase of document review is not appealable.
Except for in the case of adverse decisions resulting from initial designation or re-designation, prior to issuing an adverse decision, the PTE Program will conduct an informal investigation. The PTE Program will notify the target organization of the issue, identify the standards or requirements that have allegedly been violated or not met, and provide the organization with 20 days from the date of notice to respond. The PTE Program Office will consider all relevant information uncovered in the investigation. The information that an organization provides in response to this investigation and prior to the PTE Program’s decision, may be considered during any subsequent appeal; new information that was not provided during this initial review will not be permitted for consideration during the appeal process.
At the conclusion of its investigation or review, the PTE Program shall issue a written response notifying the organization of the conclusion of its investigation and any adverse outcome. If an adverse decision is issued, the notice shall also list key findings supporting the decision and highlight the right to appeal.
1. Types of Appealable Issues: While threshold eligibility determinations are not appealable, determinations regarding other phases of the application (initial or renewal) process may be appealed (“Application-Based Appeals”). In addition, post-designation, non-application adverse decisions may be appealed (“Conduct-Based Appeals”). Appeals of Conduct-Based determinations include such matters as a failure of continued compliance with standards, or a failure of continued compliance with laws that directly bear upon the organization’s eligibility requirements to continue as a PTE designated organization.
2. Scope of Appealable Issues: Appealable issues are limited to factual (e.g., the initial adverse decision was based on an erroneous understanding of the facts) or procedural issues (e.g., the PTE Program’s failure to follow its processes). Organizations may not appeal eligibility requirements, standards upon which the PTE Program is based, or the setting of passing scores.
PROCEDURE FOR APPEALING AN ADVERSE DECISION:
1. Upon receiving notice of an adverse decision, an applicant has 20 business days to notify the PTE Program Office in writing of their intent to appeal such decision. Notice of intent to appeal may be issued via email sent to the attention of the Director of Pathway to Excellence, American Nurses Credentialing Center, 8515 Georgia Ave., Suite 400, Silver Spring, MD 20910 or email with read receipt. The notice of appeal must be signed by the chief nursing officer or program director; it must include a clear indication that the organization intends to appeal, and specify the adverse decision which it is appealing. Further, the notice of appeal must include the following information:
a. The basis for the appeal, e.g. the procedural or factual mistake justifying appeal; and
b. Any documentation supporting the appeal.
Except where the Pathway Program has granted in writing a request for an extension of time made prior to the end of the response period, an organization who fails to provide its notice within the time and manner specified in this policy, will lose its right to appeal and the adverse decision will be final.
2. Once the PTE Program Office receives the applicant’s initial notice of appeal, the PTE Program Director or the Director’s designee will convene an appeal panel within a reasonable time. For conduct-based appeals, the appeal panel will be made up of three (3) members of the COPE who do not have a conflict of interest in the matter. For application-based appeals the panel shall be convened of one (1) designee of the COPE and two (2) experienced appraisers, appointed by the PTE Program Office. The designee of the COPE Executive Committee serves as the chair of the panel and shall be a voting member of the appeal panel. The two (2) appraisers are chosen from the pool of current Pathway to Excellence appraisers who have previously served as a Team Leader. Neither of the appraisers will have participated in the initial review of the appellant’s application and all individuals considering the appeal will be impartial, without any ties to the applicant organization.
3. The supportive information submitted by the applicant will be forwarded by the PTE Program Office to the appeal panel along with any relevant materials considered by the PTE Program when making the initial decision from which the appeal arises. During the appeals process, all substantive correspondence to the appellant will be in writing from the PTE Program Director and addressed to the point of contact provided by the applicant. The appeal panel may at its discretion conduct further investigation into the issues raised in the notice of appeal and may seek additional information from the PTE Program Office, appraisers included in the original application team and appellant.
4. An appeal conference call will be scheduled once the appeal panel has reviewed all appeal- related materials. The appeal panel will consider the issues raised by the appellant and will determine whether the initial decision will be affirmed or reversed. The appellant will be permitted, but is not required, to address the appeal panel directly during a specified conference call for the purpose of providing clarification only. New evidence may not be presented. The appellant’s presentation will be limited to 10 minutes. For application-based appeals, the appeal panel may ask questions of the appraisers assigned to this organization.
5. The appellant shall be notified of the decision by a telephone call and email with a read receipt by the PTE Program Director. For application-based appeals, if the appellant is notified of a decision to reverse the initial adverse decision, the PTE Program staff will prepare the applicant for Nurse Survey. (In order for a decision not to proceed to a Nurse Survey to be reversed, every failed Practice Standard must be overturned, because all six standards must be met to achieve or retain PTE Program designation.)
6. If the initial decision is affirmed by the appeal panel, the appellant may submit a second appeal to the Executive Committee of the COPE. Only procedural errors in the initial appeal process may be raised on the second appeal, which shall be final. The appellant must request a second appeal within 10 business days from the date upon which it received the appeal panel decision (as indicated by the read receipt). The request for a second appeal must be in writing directed to the Chairperson of the COPE, must delineate the nature of each alleged procedural error, including procedural errors in the initial appeal process, must specifically allege the prejudice to the outcome which each such error caused, (i.e., the alleged error must not be harmless error).
Upon receiving a request for a second appeal, the matter will be referred to the Executive Committee of the COPE. The COPE may investigate the basis for the second appeal with the PTE Program staff and, for application-based appeals, the appraisal team leader, and/or appraisal team member(s). If the COPE determines that the issues on appeal have no merit, the appeal will be denied. If the COPE determines that the issues presented in the second appeal have merit, it may reverse the decision with directions regarding reasonable action to correct the error(s); however, while a determination that the issues on appeal have merit may require reversal of the initial adverse decision, this will not always be the case. The appellant will be notified of the second appeal decision in writing.
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