According to John C. Willis, DC, MA, DABCO, Chiropractic History editor, “The event in the last 100 years that most signified chiropractic’s entrance in the mainstream was the recognition of the Council on Chiropractic Education (CCE) in 1974. Why? No event has given us the credibility and legitimacy that true accreditation of our colleges did — not only through the eyes of the government and society, but also through our own eyes.”(1)
Dr. Willis is referring to recognition of CCE by the precursor to the U.S. Department of Education (DE), the U.S. Commissioner of Education, Department of Health, Education and Welfare, which in 1974 first awarded the Accrediting Commission of the CCE its recognition on the list of nationally recognized accrediting agencies and associations for a period of one year. He explains that doctors of chiropractic (DCs) owe much to the dedicated few visionaries who knew the necessity of playing by the same rules in education by which other professions played. He pointed out that during his last year in chiropractic college, he borrowed money through a government-backed student loan — the direct result of CCE recognition. In fact, those loans brought on a surge in student enrollment when they became available. Another aspect of recognition is that chiropractic colleges receive federal grants for research. DCs serve our armed forces and legislators in formal and well-paid positions. CCE’s importance has been multiplied by similar accrediting agencies around the world, thereby providing a sort of homogeneity. “I cannot imagine the world without the achievements brought about by CCE recognition,” according to Willis.
The purpose of CCE is to ensure the quality of chiropractic education and promote academic excellence. Craig S. Little, DC, MEd, president of CCE, states that CCE is recognized by both the U.S. DE and the Council on Higher Education Accreditation (CHEA) as the national accrediting body for doctor of chiropractic programs (DCP), single-purpose chiropractic institutions of higher education and chiropractic residencies. The goal of accreditation is to ensure that the education provided by institutions of higher learning meets acceptable levels of quality. CCE, like other accrediting agencies, develops evaluation criteria and conducts peer evaluations to assess whether or not those criteria are met. Institutions and/or programs that request an agency’s evaluation and meet an agency’s criteria are then “accredited” by that agency. (See sidebar, “Why Accreditation Matters.”)
Dr. Little points out a common misperception of CCE’s role as an accrediting body. “We don’t set scope of practice, which is for the jurisdictional bodies, and we don’t set the philosophy of the profession, which is for the trade organizations,” he explains. “What we do is certify quality. Basically the programs tell us, ‘This is what we are doing, and this is how we know how well we are doing it.’ CCE takes a look at whether they are indeed doing what they say they are doing; we send peers in who look at how they are assuring quality in what they do. CCE’s role is to set standards for educational quality.”
Raising Educational Requirements
Before students begin the journey of becoming DCs, they must gain entrance into a chiropractic college. The CCE sets the standards required by chiropractic schools for admissions. The prerequisite for admission includes 90 credit hours of undergraduate education. Also, CCE approved new academic standards effective January 2012, which raised the GPA for admission to 3.0 from 2.5 (out of a 4.0 scale), while keeping in place the requirement for 90 hours of undergraduate coursework, rather than requiring a bachelor’s degree.(2) CCE does point out that in certain states candidates must have completed a baccalaureate degree prior to entering chiropractic college, to meet licensure requirements. For example, in Ohio beginning June 30, 2010, to apply for a license to practice chiropractic, a bachelor’s degree became required.
Dr. Little explains that while the vast majority of students admitted to chiropractic programs possess a bachelor’s degree, CCE is like many health care disciplines (including medicine) and does not require the degree for admission. CCE does require that chiropractic programs review and assess the effectiveness of admissions policies, along with evidence of implementation of changes that improve their effectiveness.
CCE has in place a Standards Review Task Force working in five-year cycles to review accreditation standards. This process covers examining current literature, licensing requirements and educational best practices, including admissions standards. “Given the challenging nature of the doctor of chiropractic educational program, the DCP’s admissions policies are designed to ensure that admitted students possess the academic and personal attributes for success. This includes developing the skills, knowledge sets, attitudes and behaviors that are necessary to succeed in the program, as well as passing the exams necessary to obtain a license to practice as a knowledgeable, skillful, caring and ethical DC capable of best serving the public and the chiropractic profession.” (CCE Accreditation Standards, 2013, Page 20.)
Joseph Brimhall, DC, president of the University of Western States and a former president of CCE, says CCE standards establish the evaluation process and accreditation requirements to ensure that graduates are competent to provide high-quality, safe and effective care for their patients. “CCE’s recognition by the U.S. DE and CHEA provides assurances of the quality and integrity of CCE’s accreditation standards. The standards drive a progression of continuous improvement, verified by external peer assessment, to help ensure that chiropractic education remains credible, legitimate and innovative,” he says.
Dr. Brimhall points out that while CCE increased the minimum GPA to 3.0, it also eliminated some of the prerequisite requirements for applicants, especially in the sciences. “The increased GPA is consistent with higher academic expectations, and many have observed that this has driven more students to seek admission in chiropractic programs because of the expected increased rigor and scope of education,” he says. But Dr. Brimhall notes that at the same time, some chiropractic institutions have chosen to admit individuals with less science preparation than previously required. “Those students are being carefully monitored with regular reports to CCE to determine how they will perform,” he says. “I don’t believe the full impact of that change in the accreditation requirements has yet been realized.”
“The chiropractic programs’ enrollment has been fairly consistent since the new academic standards have been in place,” says David S. O’Bryon, president of the Association of Chiropractic Colleges, which represents all the accredited United States chiropractic programs, plus several international institutions. “Overall enrollment in the health professions has been very competitive, with the advent of new programs across the board.”
DCs as Primary Care Physicians
CCE’s accreditation standards specifically state that a chiropractic degree program prepares its graduates to practice as “primary care physicians,” while also using the term “portal-of-entry provider.” Dr. Little points out that both definitions speak to a level of student learning outcomes that prepares DCP graduates to serve as competent, caring, patient-centered and ethical primary health care professionals. “The CCE does not dictate or establish chiropractic program curricula, as CCE values educational freedom and institutional autonomy,” he says. “Each institution creates and offers a curriculum of its own accord that supports and fulfills its unique educational mission, philosophies and programmatic goals.” Whether a program chooses to focus on graduating solo practitioners or practitioners who work in an integrative health care environment or some point in between, the standards encourage that self-determinism.
“The term ‘primary care physician’ means that the graduate of a CCE-accredited educational program is competent to assess, diagnose, manage and document a patient’s health needs as a whole person,” says Dr. Brimhall. “While ‘portal of entry’ is part of primary care and implies that the patient is seen without a referral from another health care provider, the duty of primary care exceeds portal-of-entry designation.”
Residency Program Accreditation
In January 2014, CCE released its voluntary standards on residency program accreditation, and according to Dr. Little, the CCE Residency Program Accreditation Standards were developed to benefit the public, protect the interests of residents and improve the quality of teaching, learning, research and professional practice through residency training. The purpose of the accreditation of doctor of chiropractic residency programs (DCRPs) is to ensure the quality of training though chiropractic residencies. Governmental (Veterans Administration) and nongovernmental (DCP residency) programs now have access to a recognized accrediting process that ensures educational quality and integrity to governments, jurisdictional licensing and regulatory bodies, institutions, professional organizations, residents, other accrediting agencies and the public at large.
“As the profession begins to develop postdoctoral residency training programs, it is critical to substantiate the quality and integrity of those programs,” says Dr. Brimhall. “Accreditation standards for residency programs from a credible and reliable agency like CCE provide such assurances.”
Student Loans and Debt
What determines the ability of the student to get federal financial aid (including grants and loans) is the fact that the students’ program or college/university is accredited, according to Dr. Little. Much change is anticipated on the subject of student loans and debt relief. “The DE is putting pressure on the accreditors to make sure that programs report their graduation rates, and there are student success measures in place,” he explains. “For example, if the student wants to know about chiropractic programs, visit CCE’s website (www.cce-usa.org/Accredited_Doctor_Chiro.html), and all of the accredited programs are there – you can click on any program and come up with the school’s national board scores.”
CCE requires chiropractic college programs to maintain active links so success rates are visible to the public at all times. There are benchmarks that show graduation completion rates and pass rates on national boards. “We get a lot of influence from U.S. DE and CHEA to make sure that there is transparency,” says Dr. Little. “That information does not directly translate into student loan interest rates, but programs do keep track, and it’s part of their semiannual reporting to CCE. Many outcomes are monitored for each program, and a lot of work goes into it.”
CCE looks at a program’s audited financial statements and makes a detailed analysis to assure that if a student comes into a program, and if the institution experiences financial challenges, it has the resources to make sure the student will be able to graduate within the specified time interval. CCE accreditation standards address an institution’s financial ability to support its chiropractic program. “So if CCE finds a program that is on shaky financial ground, it would be reported to U.S. DE. If the situation is not rectified, that would potentially affect its ability to use federal financial aid to secure future student grants or loans,” Dr. Little says.
Looking ahead, student loans are a big issue looming on the horizon. According to Dr. Little, the U.S. DE and Congress are interested in solid student outcomes, at a lower cost to the student. “There is a lot of pressure to do more with less,” he says. “We are asking them to do more. Account for student success outcomes, with pressure to not raise their tuition rates, because students are coming out with unacceptable levels of debt – it is a hard thing to do.”
According to O’Bryon, chiropractic institutions are very concerned about student debt, and there are financial advisors on campus to help students understand it. “The cost of our programs is very competitive compared to other health professions,” he says. “There are some new federal programs that the ACC supports that include loan forgiveness and payment based on income. The Bureau of Labor Statistics indicates that there is a growing need for doctors of chiropractic. Salary.com, which monitors salaries, also indicates a robust return on investment in the profession.”
Change Is Coming
The CCE desires feedback from chiropractic physicians and the public as it seeks to improve its agency processes and outcomes. The CCE conducts a comprehensive review of its standards every five years. As part of this review, in May 2014, a survey of the community of interest was conducted regarding the current standards. The CCE Standards Review Task Force (SRTF) has prepared several draft revisions of the standards for review by the CCE. Draft two was accepted last July to be distributed for comment. This draft of the revised CCE Accreditation Standards has been placed on the CCE website (www. cce-usa.org) for public comment. [To view the revised document and the link to a survey, please click on the “Call for Comments” notice in the Announcement section of the home page. See sidebar, “CCE Clinical Education Meta-Competencies.”] CCE is also engaging in a strategic planning process to set priorities, strengthen operations, ensure that the council, employees and stakeholders are working toward common goals and assess and adjust CCE direction in response to changing health care and educational environments. Strategic planning is crucial for guiding CCE decisions, evaluating progress and changing approaches when moving forward. To maximize the strategic planning process, CCE must give careful thought to strategic objectives, realistic goals and quantifiable benchmarks for evaluating results. The metrics will be important to the agency and the council, directly affecting future decision-making.
Moving forward, CCE values the role of accreditation in higher education. Accreditation in the United States is undergoing a major change as governmental regulatory authority to judge quality expands, eclipsing accreditation’s collegial model of quality review, points out Dr. Little. According to the CHEA, accreditation must be more directly engaged in protecting students and serving the public interest. “As the country’s primary means of assuring and improving academic quality, accreditation is called upon to tackle two of the biggest concerns facing higher education: doing more to assure graduation and other forms of student success and doing more to help students avoid harmful debt and default,” Dr. Little points out. “The understanding of the community of practicing doctors of chiropractic, as CCE complies with expectations of the federal government, is necessary and appreciated.”
What Event in the Past 100 Years Signified Chiropractic’s Entrance into Mainstream Health Care? Recognition of the Council on Chiropractic Education. www.acatoday.org/content_css.cfm?CID=823. Accessed Aug. 31, 2015.
- CCE Residency Program Accreditation Standards – Principles, Processes & Requirements for Accreditation, implemented Jan. 2014. www.cce-usa.org.
Craig Little, DC, CCE president, served as a practicing doctor of chiropractic for more than 30 years. Dr. Little has a Bachelor of Science in biology, a Doctor of Chiropractic Degree from the Southern California University of Health Sciences and a Master’s degree in Educational Leadership from Chapman University. Dr. Little is completing a Doctorate of Education in interdisciplinary leadership at Creighton University. He is board-certified by the American Board of Chiropractic Orthopedists and is a fellow of the American College of Chiropractic Orthopedics. Dr. Little’s professional experience includes prior leadership roles with CCE as its chair, executive committee member and councilor. He served the chiropractic profession as president of the California Chiropractic Association, as a board member of the Congress of Chiropractic State Associations and in multiple roles with state, as well as national, chiropractic organizations.
WHY ACCREDITATION MATTERS
Accreditation is important to the chiropractic profession as it:
VERIFIES that an institution or program meets established standards;
ASSISTS prospective students in identifying acceptable institutions;
ASSISTS institutions in determining the acceptability of transfer credits;
HELPS to identify institutions and programs for the investment of public and private funds;
PROTECTS an institution against harmful internal and external pressure;
PROMOTES self-improvement of weaker programs and stimulates a general raising of standards among educational institutions;
PROMOTES faculty and staff involvement in institutional evaluation and planning;
CONTRIBUTES to professional certification and licensure; and
- PROVIDES one of several considerations used as a basis for determining eligibility for federal assistance.
(Source: United States Department of Education)
CCE CLINICAL EDUCATION META-COMPETENCIES
The Council on Chiropractic Education is asking for comments through the end of November 2015 on its draft accreditation standards, which include nine clinical education meta-competencies.
Accrediting bodies ensure a level of quality and integrity by evaluating educational practices and associated outcomes in accordance with best practices. “The attributes of the professional, in our case the doctor of chiropractic, are measured in the attainment of competencies,” says CCE President Craig Little, DC. “The CCE meta-competencies have been written as outcome statements to be measured by the DC programs – measurements that require sound methods, thresholds and analyses by the DCP to determine competency of the graduate and effectiveness of the program. The emphasis has changed from simply counting clinical encounters as measures of quality (i.e., number of adjustments and lab interpretations) to measuring the actual learning that takes place in those encounters.”
The meta-competencies paint a picture of the DC that the programs should be trying to produce. “Anyone can say that we want a graduating chiropractor to be competent, ethical and to practice in a certain manner, but these are the attributes that define what that is. Each program has the flexibility to develop its own curriculum to ensure those student learning outcomes, and by graduation the program has to document and assure that all of these meta-competencies are obtained,” says Dr. Little.
To comment, go to www.cce-usa.org. To view the revised document and link to a survey, please click on the “Call for Comments” notice in the Announcement section of the home page. (To view the section on meta-competencies, scroll to Pages 29-34.)