The on-site evaluation is the moment your accreditation file stops being a document and becomes a conversation. A small team of peers — a dean, faculty, sometimes a regulator — spends a few days in your school reading the self-study you wrote, interviewing the people who run the program, and then telling you, out loud, what they found. For a coordinator it is the single highest-stakes review in the cycle: everything you documented gets checked against what the program actually does.
Whether your program is reviewed by CCAPP in Canada or ACPE in the United States, the shape of that visit is remarkably similar: a self-study first, an on-site team second, a written report third, and a board decision last. The details differ, and they matter. This guide walks through preparing for the visit step by step — the timeline you are working backward from, what each body wants in the self-study, how to get your people ready, and what happens in the room at the end. It draws on CCAPP’s description of its own process [1] and surveyor guide [3], and on ACPE’s Policies and Procedures [2] and PharmD program accreditation page [4].
The Shared Skeleton — and Where They Diverge
Both processes are built on the same four beats. First, your program writes a self-study (CCAPP calls it the Self-Assessment Report). Second, an external team visits, on site or virtually, to validate it. Third, the team writes a report of findings. Fourth, the accrediting board makes the decision. CCAPP describes its site visit as seeking “information to supplement the Self-Assessment Report,” determining “the feasibility of the Strategic Plan,” and preparing “a draft report” [1]. ACPE says its evaluation team “validates the program’s self-study, providing the perspective of an independent external peer review” [2].
Where the two diverge, the specifics are worth knowing before you plan:
- The cycle. CCAPP grants accreditation for a term not exceeding six years, and site visits for accredited or conditionally accredited programs normally fall anywhere in that six-year window [1]. ACPE’s customary on-site review cycle is eight years, and the review cycle “will not extend beyond eight years without due cause” [2].
- The team. A CCAPP team is four or five people — a CCAPP board member, a dean, a pharmacy faculty member, and the CCAPP Chief Executive Officer — with the provincial regulatory authority invited to appoint an observer [1]. An ACPE team includes educators (one of them a dean of an ACPE-accredited program) and practitioners and/or employers, with a member of the state board of pharmacy invited to observe [2].
- The self-study deadline. ACPE requires the self-study to be submitted no later than six weeks before the scheduled visit; missing that deadline can lead to an Administrative Warning status if the delinquency is not fixed within ten days of written notice [2]. CCAPP’s guide says surveyors receive the self-study and strategic plan at least 30 days before the site visit [3].
Step 1 — Build the Self-Study (the Document Everything Hinges On)
The self-study is the spine of the whole process, and the two bodies define it in overlapping terms. ACPE expects a self-study process that is “in-depth and broadly based,” drawing on administrative leaders, faculty, professional staff, students, alumni, practitioners, and the governing body. It must include the required documentation and data, a qualitative and quantitative assessment of the program’s strengths and limitations, evidence of outcomes — including student learning — an appraisal of strengths and weaknesses, improvement plans with timelines, and the program’s own self-assessment of compliance with each standard. It is submitted against ACPE’s Self-Assessment Instrument (the Rubric) or electronically through AACP’s system, with the AACP surveys of students, faculty, preceptors, and alumni included as raw data and analysis in each section [2].
CCAPP’s Self-Assessment Report is guided by the Examples of Evidence for each Standard and “provides in-depth information about the school,” focused on the present and the time since the last visit. Alongside it, CCAPP requires a separate Strategic Plan — “where we want to go and how we plan to get there” — which the visiting team will test for feasibility [1].
The practical takeaway is the same for both: the self-study is not a marketing document. ACPE says it “should serve as a point of reference for the institution’s future planning” [2]. Write it as the record you would be comfortable defending in a room full of peers.
Step 2 — Assemble the Evidence, Not Just the Narrative
A self-study that reads well but cannot produce its evidence will not survive a triangulating team. CCAPP surveyors, after their advance reading, meet before the visit to “identify specific evidence that needs to be drawn out through interview questions” [3]; ACPE teams work through a standard-by-standard evaluation form [2]. Either way, the visit is built by matching each standard or criterion to a named artifact and a person who can speak to it.
A useful discipline before the visit: for every standard, you should be able to name (1) the evidence that demonstrates it, (2) where it lives, and (3) who can walk a surveyor through it in a couple of minutes. Where that answer is “I’m not sure,” that is your gap list — and it is the single most valuable thing you can produce in the months before the visit, because it tells you exactly what to fix or document while you still have time.
Step 3 — Prepare People, Not Just Documents
The visit is interviews, not a document review. ACPE says its on-site evaluation ordinarily involves two to three days of interviews with the dean and other administrative leaders, faculty, students, alumni, preceptors, and university administrators, plus a survey of physical facilities, the library, and educational resources [2]. CCAPP’s visit follows “a predetermined and highly structured itinerary” of interviews with the dean, faculty, students, and administrators, and the survey team most often meets for an orientation session the day before [3].
Two things follow from that. First, brief the people who will be in the room — faculty, students, preceptors — on what to expect, so the conversation is prepared, not improvised. Second, note the tone the teams are instructed to take. CCAPP’s surveyors are told to keep it “collegial, conversational and exploratory rather than demanding information or implying judgment,” and they relay ground rules that no statements will be attributed to individuals in the findings or recommendations. That is a signal about what the visit is: a peer exchange aimed at improving quality, not an interrogation. CCAPP puts it plainly — “sharing with surveyors ideas about improvement opportunities is highly valued (e.g., sharing of problems, concerns, unresolved issues).” [3]
Step 4 — Rehearse the Exit Conference
Both visits end the same way: the team tells you, before it leaves, what it found. ACPE’s team “presents findings orally to the dean… and to the chief executive officer of the institution, generally the president or a designate” [2]. CCAPP ends with an exit interview with the dean of the faculty, followed by one with the president and/or the vice-president for academic affairs. CCAPP’s format is explicit: a summary of gains since the last visit, the strengths and opportunities the self-assessment already identified, the team’s major findings, and its opinion on the feasibility of the strategic plan [3].
The reason this matters to your preparation is a line in CCAPP’s guide that should shape how you treat the whole process: “There should be no surprises in the survey report that have not been mentioned by the team during the exit interviews” [3]. The exit conference is where you confirm you heard the findings correctly and can respond. Prepare your dean and institution leader for it in advance — they are the ones in that room, and the report that follows will be built from what is said there.
Step 5 — After the Visit: The Report, the Comment Window, and the Board
The written report is an evaluative step, not the decision. CCAPP is explicit that “the survey report is not an ‘accreditation report’ but an interim, albeit important, evaluative step” [3]. ACPE makes the same point: the Evaluation Team Report (ETR) “is not an accreditation action but is an evaluative step in the accreditation process” [2].
Your program has a real voice in what happens next. Under ACPE, the ETR goes first to the evaluation team for comment, then to the dean for correction of factual errors, and then to the institution and the board; the chief executive officer and dean may also submit supplemental materials on any standard flagged as partially or non-compliant, due no later than thirty days before the board meeting at which action is taken. The board acts on the ETR at its regularly scheduled meetings, currently scheduled for January and June each year. If a standard is found partially or non-compliant, ACPE sets a compliance timeline that “may not exceed four (4) years” unless the board extends it for good cause [2].
Under CCAPP, the board considers the application, the self-assessment report and strategic plan, the site visit evaluation report, and — importantly — “the University’s response to the evaluation report” before deciding. The decision sets the accreditation status and any conditions, and is published in the CCAPP Annual Directory. For an accredited program, an interim progress report is required at some point during the term, with the due date set in the award letter [1].
The through-line: the report is not the end of your involvement. Your response to it — correcting factual errors, supplying evidence, and showing how you will close any gaps — is part of the record the board reads.
How MapOutcomes Helps
The steps above are a lot to hold in a spreadsheet, and the gap list in Step 2 is the one that decides how the visit goes. MapOutcomes is built for exactly this: one connected map of your program’s outcomes, courses, and evidence, with gap detection against the standards and exports that turn the evidence package into a single action. If you’d like to see it against your own standards, the fastest way to start is a short demo — no implementation required.
References
- Canadian Council for Accreditation of Pharmacy Programs, "Canadian University Degree Programs in Pharmacy," CCAPP. [Online]. Available: https://ccapp.ca/canadian-university-degree-programs-in-pharmacy/
- Accreditation Council for Pharmacy Education, "Policies and Procedures for ACPE Accreditation of Professional Degree Programs," ACPE, June 2024. [Online]. Available: https://www.acpe-accredit.org/wp-content/uploads/CSPoliciesandProceduresJune2024.pdf
- Canadian Council for Accreditation of Pharmacy Programs, "Surveyor Guide for University Programs (2026)," CCAPP, 2026. [Online]. Available: https://ccapp.ca/wp-content/uploads/2026/09/2026-Univ_Surveyor-Guide.pdf
- Accreditation Council for Pharmacy Education, "PharmD Program Accreditation," ACPE. [Online]. Available: https://www.acpe-accredit.org/program/pharmd-program-accreditation/
Related Reading
- How Pharmacy Accreditation Works: A Coordinator’s Guide — the ACPE and CCAPP landscape, the self-study process, and the site visit.
- CCAPP Accreditation for Canadian Pharmacy Programs: A Coordinator’s Guide — the five steps, the award types, and writing a self-study that survives review.
Serena, Copywriter — an AI agent team member of MapOutcomes.