AA113-H Program Review Requirements – Academic Affairs

UT Health Science Center:

AA113-H Program Review Requirements – Academic Affairs



Approval Body: CASA

Effective Date: 07/01/2014

Category: Academic

Last Review: 08/03/2021

Next Review: 08/03/2024

Contact: MaryAnn Clark, Associate Vice Chancellor Academic Affairs

 901.448.4930



All programs offered at the University of Tennessee Health Science Center (UTHSC) are reviewed every five to seven years (in accordance with TN Higher Education Commission requirements). Such a review must include both an internal self-evaluation (focused on components outlined below) and an external peer review conducted by external consultants or trained auditors. Programs that are accredited by profession-specific accrediting agencies may use the required accreditation cycle and review procedures to satisfy this program review requirement.


According to the Tennessee Higher Education Commission (THEC) “the purpose of [an] academic program review is to ensure that standards of the discipline are being met and that adequate financial support is evident. Each program is reviewed according to accreditation review cycles or at least once every five to seven years by THEC program evaluation criteria.” Programs not eligible for accreditation are to undergo evaluation by external consultants or a trained team of auditors “to ensure that standards of the discipline are being met and that adequate financial support is evident.” Non-accredited professional degree programs may be reviewed as a part of a systematic accreditation review of another related degree, however, sufficient documentation specifically pertaining to the non-accredited program (indicative of both a self-study and a review by a team of external consultants) must be submitted in order to meet this requirement. All reviews, whether per accreditation standards or the policy outlined in this document, must begin with a program-based self-study of the program followed by an external peer review.

The primary purpose of the program self-study is to ensure the program is functioning at the highest levels of academic quality, is consistent with the mission and standards of both the college and UTHSC as well as with professional expectations and is continuing to represent a needed area of study. At a minimum, the self-study will include a program overview and evidence of a critical review of the curriculum; a summary of academic or professional standards and the means through which they are met; a description of the means through which the program is delivered; evidence of sufficient, qualified faculty and a qualified program director/coordinator; a summary of facilities and resources used to support the program; practices related to student recruitment, admissions and evaluation; a summary of alumni activities related to the program/profession; a review of the budget and finances since the last program review; and an analysis of program-based metrics and identified student learning outcomes, and actions taken as a result of a review of data gathered, since the time of the last program review. The self-study should also include a review of program strengths and weaknesses and identified recommendations for consideration.

The primary purpose of the external review is to solicit input from external experts to validate and verify information and conclusions reached in the self-study and to provide guidance to campus and college leadership regarding strategies for consideration to strengthen the program. The external review itself should mirror the issues addressed in the self-study. The external reviewers will be asked to review available information and documentation as provided through the self-study. In addition, the external review team will be asked to provide an analysis of the strengths and weaknesses of the program overall, the extent to which the program is meeting the standards as set forth for the profession or discipline, an analysis of the resources and institutional support available for the program, and recommendations for strengthening the quality of the program.


PART A: Self-Study (for non-accredited programs)

The self-study includes, but is not limited to, the following:

  • Program Overview: The first section includes the mission, goals, and objectives of the program; description of the relationship between program objectives and the mission and goals of the UTHSC and the college through which the program is offered; the current need and demand for the program; and an overview of any interdisciplinary activities or external relationships associated with the program. This first section also defines and documents the administrative responsibility and oversight for the program (including an organizational chart for program oversight and administration). Finally, this section provides a summary of recommendations from the previous external review (if applicable) as well as a listing of resultant actions taken to strengthen the program based on those recommendations. Supporting documentation for this section should include, but not be limited to, official documents/publications summarizing the objectives and focus of the program under review as well as a copy of the last program review and identified action items (if applicable).
  • Curriculum and Academic Standards: The curriculum must be adequately structured to meet the stated objectives of the program and reflect the breadth, depth, theory, and practice appropriate to the discipline and level of the degree. This section presents program objectives; degree requirements; identified student learning outcomes; course descriptions and course sequences/schemas; a curriculum map demonstrating linkages between stated objectives and the curriculum (where available); descriptions of culminating experiences; and the process and strategies used to assess mastery of the program objectives prior to graduation. In addition, the process for reviewing the curriculum on an ongoing basis is outlined and documented. This section provides a summary of academic and/or professional standards guiding the program and the means through which they are considered and met. Included in the supporting documentation is the course syllabus for each course identified in the program curriculum.
  • Curriculum Delivery Strategies: This section describes the means through which the curriculum is delivered (e.g., face-to-face, online, videoconferencing, hybrid delivery). For programs offered completely or partially through electronic means (thus through online delivery, videoconferencing, or a combination of face-to-face and online/videoconferencing), the following are addressed at a minimum:
    • Means through which the technology-based delivery strategies employed are routinely monitored and evaluated to assure appropriateness and effectiveness given the objectives of the program/course and are consistent with evolving standards and expectations within the profession or discipline;
    • Means through which enrolled students are given comparable access to fundamental academic and student support services throughout their program of study;
    • Evidence of compliance with any policies and procedures at the institution, college and/or program level governing programs delivered through electronic means; and,
    • Processes through which faculty who use electronic means to deliver all or a portion of the curriculum are uniquely qualified, routinely evaluated, and provided sufficient and appropriate training related to best practices in curriculum delivery through electronic means.
  • Faculty: Information provided demonstrates there is a sufficient number of faculty members who are appropriately qualified to deliver the program curriculum. This section includes a table with all faculty members actively engaged in the delivery of the curriculum, complete with all information used to credential the faculty (per SACSCOC standards; i.e., academic credentials and how these relate to courses taught, additional information on licensure or other means of demonstrating qualifications to address the identified course objectives). Information provided describes the standards used for credentialing faculty for delivery of the curriculum (including the credentials required for individuals mentoring students in either practice settings or research laboratories as applicable). In addition, this section includes summary data for faculty involved in the delivery of the program, including but not limited to the percent of full-time/part- time/volunteer faculty; percent of the faculty by rank and tenure status; and demographic information for the faculty. At a minimum, this section includes an up-to- date CV (as of the current calendar year within which the self-study is being submitted) for each faculty member along with any additional documents explaining the process whereby they were credentialed (e.g., transcripts, up-to-date licensure or certifications) based on documents provided as part of the official faculty file delivered to the UTHSC Office of Faculty Affairs.
  • Program Director/Coordinator: This section focuses on the individual(s) responsible for program oversight, direction and coordination. Information provided summarizes the process and criteria used by the college to assign responsibility for program coordination along with the credentials/qualifications for the individual(s) currently assigned to serve this function. Individuals in such positions are expected to be academically qualified in the discipline/profession itself as well as qualified to serve in a leadership capacity to direct and oversee the design, delivery and routine assessment of the program. Finally, information provided summarizes the process for routine evaluation of the individual(s) responsible for program coordination and includes documentation of prior reviews of the person currently serving in this capacity.
  • Students and Alumni: All student admissions, recruitment, enrollment, and evaluation practices are presented (with sufficient documentation demonstrating that the standards used are publicly available) and shown to be consistent with academic standards and expectations of the college, UTHSC, and the profession/discipline. This section includes student data since the time of the last evaluation (or covering the last 5 years for a first time program evaluation), e.g., information as to the number of applications along with admissions, enrollment, retention, and graduation rates by sex and ethnicity as well as information on financial support provided to enrolled students where applicable (e.g., the percentage of students on assistantships and/or receiving financial aid by year by race/ethnicity and sex since the last evaluation – or for the last 5 years for the first program review). Student support services are clearly outlined and documented (including information on access to financial aid and financial counseling, student advising and counseling resources). Information provided summarizes graduate placement since the last evaluation (or for the prior five years for first time program evaluations). Finally, information secured from alumni regarding professional experience and perceptions of the program and their professional preparation is included as evidence of the effectiveness of the program.
  • Assessment and Evaluation: The program demonstrates and documents that careful and systematic evaluation of the program occurs on a routine basis with sufficient consideration and utilization of the information gathered to maintain or improve the quality of the program. Information provided includes the schedule for program assessments or evaluations, the kinds of data gathered and used during the evaluation, the results from such assessments since the time of the last review (or the prior 5 years for first time program reviews), examples of actions taken as a result of the data gathered during this period of time, and the office or individuals responsible for overseeing the systematic review of the program. Both identified student learning outcomes (SLOs) and program-specific outcomes are included along with reports prepared specifically related to the attainment of the SLOs since the time of the last review (or for the prior 5 years for first-time program evaluations). For programs offered at the baccalaureate level, a portion of this section is devoted to outlining the process and tools used to evaluate attainment of the identified general education competencies and results of this assessment since the time of the last review (or the prior 5 years for new program reviews).
  • Facilities and Resources: This section focuses on summarizing the facilities and resources available to support the program and related academic activities (i.e., practice sites, research facilities, laboratories) and demonstrating such are sufficient to meet the stated objectives of the program based on current and projected enrollment. At a minimum, information provided demonstrates that the available space (classrooms,laboratories, study space), library resources, mentoring sites (e.g., laboratories, practice sites) and other support resources (e.g., clerical support, scientific equipment), areadequate to support a high quality program given the current and projected enrollment.
  • Budget and Financial Support: Summary of the program budget, sources of funds (both internal and external to UTHSC), and expenditures for the preceding five years (or since the time of the last evaluation) are included to demonstrate sufficient financial resources to support and sustain a high quality program. Any anticipated expenditures to support projected programmatic growth or expansion are included as well.
  • Strengths and Weaknesses of the Program and Recommendations for Consideration: The final section includes a summary of identified strengths and weaknesses of the program and recommendations for potential action as a result of the self-study.

Part B: External Review (for non-accredited programs)

The external peer review consists of an off-site review of the documentation provided (i.e., the self-study and all accompanying documentation) and a subsequent on-site visit designed to verify the information provided and to gather additional information to be included in the review team’s final report. The review team should be comprised of a minimum of two experts (3 preferred) who meet the following criteria:

  • The peer evaluator is a faculty member and/or program director at an institution with a comparable program;
  • The peer evaluator has not been a collaborator nor mentor of any current program faculty members;
  • The peer evaluator has no apparent conflict of interest or vested interest in the outcome of the review.

The program director submits a list of proposed peer evaluators to the dean for final approval. The approved list of evaluators is forwarded to the Vice Chancellor for Academic, Faculty and Student Affairs (VC AFSA) as a point of information.

The review team is directed to do each of the following:

  • verify that the self-study conveys a realistic assessment of the program and that the standards of the discipline are being met;
  • confirm (or contest) that adequate resources and institutional support are evident for continued support of the program;
  • provide identified strengths and weaknesses of the program; and,
  • provide recommendations for strengthening the program.

The review team may also be charged with evaluating additional identified areas of concern and/or related data at the request of the chancellor, the chief academic officer, or the dean.

Components of the final external peer review report include, but are not limited to, the following:

  • Confirmation of the information provided for each of the criteria presented above;
  • Observed strengths and potential weaknesses for each of the areas (criteria) presented above;
  • Overall strengths and potential weaknesses of the program under review;
  • A statement of confirmation or concern regarding whether or not the program meets the standards of the discipline and has access to sufficient resources and institutional support to maintain a high quality program; and
  • Recommendations to the dean of the college regarding ways to strengthen the quality of the program.

PROCEDURES FOR ALL PROGRAM REVIEWS (for both accredited and non- accredited programs)

The following steps are to be followed to review and complete the program review:

  1. No later than one year prior to an anticipated program review (either of an accredited or non-accredited program) the dean of the college submits in writing to the VC AFSA notification of an upcoming program review. The notification should include the anticipated delivery date of the self-study to the accrediting body or external review team (as appropriate) and the anticipated on-campus site visit time period (tentative month or quarter of the year at a minimum as feasible).
  2. All self-studies are to be reviewed and approved in accordance with existing college guidelines and expectations, including review by the dean, prior to submission.
  3. Following college and dean review, a draft of the self-study is provided to the Office of the VC AFSA a minimum of four weeks prior to anticipated submission to the external review team or accreditor.
  4. A final official copy of the self-study is submitted electronically (including all supporting documents) by the dean on behalf of the program to the Office of the VC AFSA at the point at which it is submitted to the external review team/accrediting agency.
  5. For non-accredited programs, the dean of the college (on behalf of the program) will work in collaboration with the program director to identify potential suitable site visitors for the program review. Official invitations to the site visitors are extended by the dean of the college on behalf of the program. For accredited programs, program reviews will follow the procedures required by the appropriate accrediting agency.
  6. It is the expectation that the dean, chief academic officer for the institution and the chancellor will be involved to some extent in all program reviews. At a minimum, both the VC AFSA and the chancellor are invited to the exit interview with the review team (unless accrediting agency rules strictly prohibit such).
  7. A copy of the final report from the site review team is submitted to the Office of the VC AFSA within two weeks of receipt by the program.
  8. Within 3 months of receipt of the formal recommendations from the external review panel, the dean of the college must submit a Program Review Action Plan to the VC AFSA. The Program Review Action Plan should include, but is not limited to, the following components:
    1. A summary of recommendations provided by the site review team;
    2. Anticipated or proposed responses or courses of actions to be undertaken by college/program leadership and faculty in response to the recommendations;
    3. Anticipated reallocation of funds or redistribution of effort required to undertake the proposed actions;
    4. Identified outcomes based on the proposed actions; and,
    5. Metrics by which progress in achieving the identified outcomes will be measured.

      The Program Review Action Plan must be signed by the program director, dean, and VC AFSA indicating a mutually understood and agreed upon course of action to address the deficits and/or recommendations indicated.
  9. At the conclusion of each academic year, a Program Review Action Plan Progress Report is submitted by the dean to the VC AFSA, summarizing actions undertaken over the course of the year and progress made in achieving the identified outcomes based on the metrics employed.


Effective: July 1, 2014

Reviewed: May 15, 2018, Committee on Academic and Student Affairs (CASA) Chancellor Approved: May 23, 2018

Reviewed: August 3, 2021, CASA

Approved: October 11, Chief Academic Officer

AA113-H Program Review Requirements – Academic Affairs
Version: // Effective: 07/01/2014
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