AQIP Category Five



Context for Analysis

Category Five Contents

The university has maintained its strength, and made some progress in Category 5 since its last systems portfolio, and believes that further significant improvements can be made.

USM remains strong and integrated with a clear Strategic Plan and a well-defined mission and values. The university sets directions in alignment with all three, seeking future opportunities while maintaining strong communication between the levels and units across the university and by staying focused on student learning.

Progress has been made in several areas.  With the implementation of the Collegiate Learning Assessment (CLA) and the National Survey of Student Engagement (NSSE), as well as a yearly Assessment Day, USM has strengthened its processes for addressing the needs of student stakeholders, as well as gathered data and information vital to decision making.  The addition of a Student Success Office and new Director of Human Resources will provide the university with support in aligning performance processes for results and improvements.  Finally, the upgrade and revamp of USM’s website demonstrates a commitment to high performance and further improves communications with all internal and external stakeholders.  

5P1 How, when, and by whom the organization’s mission and values are defined and reviewed

The University of Saint Mary's (USM) mission and values are defined and reviewed by all members of the university community, including the governance system. This governance system consists of Administrators and a two-tiered Board: a Board of Trustees (BOT) and a Board of Members composed of the elected leadership of the university's sponsors, the Sisters of Charity of Leavenworth (SCL). The sponsors have representatives on the board to ensure mission and open communication between the two governance bodies (See Link 5P1-1: USM Bylaws). Administratively, the University is led by the president and the four vice presidents (VP) who work as a team and comprise the Administrative Council (AC). Information and concerns flow both up and down through direct reports. Cross-functional taskforces address multi-department concerns to ensure efficient ways to address issues. Governance listings and functions are outlined in the (See Link 4P7-1: Employee Handbook).

Communication channels include:

  • Directors

  • Academic Leadership Council (ALC)

  • Faculty Senate

  • University Assembly (faculty and staff)

  • Teacher Education Committee

  • AQIP Action Project Committees

  • Student Life Staff

  • Extended Sites

  • Cross functional task forces such as Six Terms, Emergency Management Task Force, and Startup/Orientation team

Accreditation and Regulatory groups that have oversight relationship with USM include:

  • Higher Learning Commission/North Central Association (HLC/NCA)

  • Council for Higher Education Accreditation (CHEA)

  • Commission on Collegiate Nursing Education (CCNE)

  • International Assembly for Collegiate Business Education (IACBE)

  • National Council for the Accreditation of Teacher Education (NCATE)

  • Kansas State Department of Education (KSDE)

  • Kansas State Board of Education

  • Kansas Board of Nursing

  • Behavioral Sciences Regulatory Board (BSRB)

  • Commission on Accreditation in Physical Therapy Education (CAPTE)

  • Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)

The University ensures that the practices of its leadership system – at all institutional levels – are aligned by focusing on the mission, core values, and the implementation and assessment of the Strategic Plan (SP). The mission and values serve as a guiding structure from which the SP flows. USM reinforces the mission and core values through faculty/staff and new student orientation, University Days (all faculty & staff come together as a group), and through the Mission Council, whose objective is to keep the mission front and center on campus and to sponsor activities that aid the University in internalizing core values and making them operational.

USM also ensures leadership system alignment through the ongoing improvement (OGI) process, the structure of the SP; clear governance and staff reporting structures; policies and procedures; annual reports; eSpire (USM's learning management system); a newly revamped website; the Marketing bulletin board and large television monitor inside the main entrance in Mead Hall; the university catalog; handbooks; and the Global Studies Institute Starr Report.

The BOT, who participated in the process and approved the SP, receives quarterly updates. When the BOT is updated, so are faculty and staff. All new proposals outlined in the SP are presented to both faculty/staff and BOT in the form of a business plan that connects the project to the mission and Strategic Plan, provides a five year budget, market assessment, and an exit strategy.

The evidence provided here and in 5P2 demonstrates that we have met Core Component 1A: the institution’s mission is broadly understood within the institution and guides its operations. Although we revisit the university’s mission statement regularly – especially when we engage in developing a new strategic plan – it has remained largely intact since the university’s founding.  It was developed in concert with the university’s sponsors, the Sisters of Charity of Leavenworth, and it continues to inform our mission as a Catholic liberal arts university.  Much has changed at the university, but not its mission.  Our mission statement is prominently and proudly displayed in all of our printed and online materials.  Each of our strategic plans begins by reiterating our commitment to that mission, so as to assure that the goals set in each plan are consistent with our mission.   The Board of Trustees is charged with assuring that the university is true to its mission.  And our Mission Council offers programs and events throughout the year, making sure we never lose sight of it.

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5P2 How leaders set directions in alignment with mission, vision, values and commitment to high performance

USM sets direction in alignment with mission, vision, and values by involving the entire USM community and the Board of Trustees in its strategic planning process. The Strategic Plan (SP) drives the action and plans at USM and is now a permanent process in which all of our stakeholders are involved. The SP process analyzes the needs and trends of students and stakeholders through multiple means that include an environmental scan, a SWOT analysis (Strengths, Weaknesses, Opportunities, Threats) as well as student and alumni surveys. In establishing strategic initiatives, the SP committee uses the information generated from these collaborative forecasting activities to set direction in keeping with our core values. The model for SP development follows the USM Ongoing Improvement (OGI) model and ensures that the needs and expectations for student learning are central to decision making.

In other activities at USM, similar processes are used and model the leadership emphasis on ongoing improvement as highlighted in the following.

  • Every new initiative must have a business plan, complete with a marketing study and marketing plan, 5-year financial outlook, and a statement as to how it aligns with the mission and the SP.

  • As USM engages in ongoing improvement, the Administrative Council encourages and provides financial resources for professional development and training opportunities throughout the university. Every faculty has a professional development plan that is reviewed each year. The Faculty Senate regularly discusses issues of “teaching and learning.” Other professional staff members have professional development appropriate to their area (e.g. safety training for security officers,  Jenzabar training for the business office, updates and use of the online bookstore for faculty and staff and how to deal with clients (students) for everyone). Professional development of personnel is ultimately the responsibility of each vice president.

  • As part of the educational process, all employees are trained to model the core values when interacting with each other and with students. When students fail to act according to the core values, employees are encouraged to address the issue or send the information to student life so that it might be a “teachable moment” for the student. 

The evidence presented here and in 5P1 demonstrates that we have met Core Component 1A. (covered in 5P1)

The evidence presented in 5P2 demonstrates that we have met Core Component 2C: the governing board of the institution is sufficiently autonomous to make decisions in the best interest of the institution and to assure its integrity. USM’s Board of Trustees plays an active role in governance, but it does so in an appropriate manner.  It assures the university’s commitment to its mission and sets priorities that support that mission and serve to preserve, enhance, and advance the university.  Every major program and policy is initially reviewed and approved by the Trustees, but the BOT does not engage in any inappropriate day-to-day management, which is left to higher administration.  The Trustees support the university in many ways, none the least of which is the offering of their expertise in areas from which the university may benefit.  The Board of Trustees represents the university to all constituencies, including external individuals and organizations, while, once again, not engaging any of those constituencies in any way that would compromise the university.

The evidence presented in 5P2 demonstrates that we have met Core Component 5C: the institution engages in systematic and integrated planning. The university has developed and adheres to a carefully outlined and detailed planning process that begins at the administrative level and extends through each university program.  It involves all relevant university constituencies as well as external stakeholders and constituents, as appropriate.  This assures that resources are allocated in alignment with the university’s mission and priorities. As an examination of planning documents will show, those priorities are aligned with student learning and all other operations. That this planning process has been effective in planning for, and weathering, the inevitable fluctuations in our economic and educational environment is reflected in USM’s success in not only minimizing the impact of the vagaries and challenges of the past few years, but also in its continuing to grow, expand its resources, and improve its services.   

The actual planning process is spelled out in detail in Category 5P1.  The process is commonplace and follows best practices, but it also includes an Ongoing Improvement Model, which the university developed several years ago.  This model has been widely recognized and applauded by HLC and CHEA as advancing the university’s commitment to continuous quality improvement.  The university also employs a Data Based Decision Making Process, developed through an HLC AQIP Action Project, and incorporates data gathered from various sources, both internal and external (e.g. KICA, CIC, CLA and NSSE). 

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5P3 How these directions take into account the needs and expectations of current and potential students and key stakeholder groups

The University of Saint Mary core values are community, respect, justice, and excellence. USM's mission and sponsorship of the Sisters of Charity of Leavenworth make evident within the culture of USM the pervading commitment to these values, to “service to one's neighbor,” and to ethical dimensions of decision making and action. Expectations for living out the values are communicated in policy and exemplified in practice. Examples of these expectations include the following.

  • Expectations of faculty and staff are outlined in contractual or letter of agreement compliances: “Faculty/staff member agrees to perform duties to the best of his/her ability, to conduct himself/herself in a professional manner, to support and further the objectives and mission of the university, and to assist and cooperate with the University in the administration of its policies.”

  • The faculty/staff handbook includes ethical statements regarding academic honesty and professional behavior in all areas, ways to address grievances, regulatory financial controls, EOE statements, distinctive values of service and social responsibility in mission.

  • The Student Handbook describes the student code of conduct that flows from the University mission. New students are oriented to the expectations outlined in the handbook (see Link 5P3: Student Handbook).

The Mission Council helps to permeate the culture with the mission and core values with activities throughout the year. Workshops, orientation, University Day, and Faculty Institutes are often focused on such expectations. USM also uses EAP (employee assistance program) to provide training to supervisors.

The evidence presented here and in 5P8 demonstrates that we have met Core Component 1B: the mission is articulated publicly. As noted above, USM’s mission is clearly and publicly stated in all of its literature, as are its values, vision, goals, etc. All such statements are current and help inform the university’s more specific policies and programs, so as to better and more accurately inform its various stakeholders, constituencies, and the general public.  Examples of exactly where USM’s mission is articulated are included in 5P3, as well as how the mission is made clear and advanced by offices such as the Mission Council. 

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5P4 How leaders guide the organization in seeking future opportunities while enhancing a strong focus on student learning

USM leaders guide the institution in seeking future opportunities and building and sustaining a learning environment through the SP. Academic program Annual Reports require growth plans congruent with the university’s mission and Strategic Plan. The Extended Sites strategic plan for growth is in place, and three academic programs have formal growth plans regarding enrollment that are reported to the BOT annually.  Five year program reviews are in place for all graduate programs and are in the process of being implemented for all undergraduate programs, all of which will have growth plans, as well.

Faculty and staff are encouraged to surface new ideas or opportunities. The university tracks key indicators to continually assess or monitor the university's learning environment, such as how ULOs are measured (see Categories 1 & 7), faculty evaluations, and the entire academic picture. The OGI model (as described in Category 8) encourages ongoing improvement through reflection on past actions and through professional development of faculty/staff who then can bring new insights and knowledge to the university community. For example, the Chair of Nursing attends state and national conferences on partnering between universities and health care systems. She brings back strategies and shares recommendations. The Director of Online Learning has done the same with online learning.

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5P5 How we make and carry out decisions

USM involves representatives from all campus constituencies through cross-functional teams, task forces, and committees as possible and necessary for informed decision making. In other words, “who needs to be at the table?” All decisions aim to be framed by mission and in response to the SP. A component of USM's ongoing improvement process includes an OGI after action assessment, which resides at the level of which the project is executed. This is how the university improves its processes.

USM practices the principle of subsidiary: problems are analyzed and solutions discovered at the level where activities are implemented. The New Student Orientation is an example of how this process leads to ongoing improvement. Better communication through cross-functional input resulted in improving the experience and led to USM's most successful orientation to date in August 2011. Nevertheless, the process of continual improvement is ongoing.

The Six Terms Special Task Force is another example of a cross functional group finding solutions at the level they are implemented. This task force involves personnel from the business office, registrar's office, admissions, extended sites, and online programs, all of whom were affected by increasing the number of session starts. They identify problems within procedures and software programs that make their processing of enrollment inefficient. Through communication and analysis of procedures, changes are made that garnered the support of all offices and increased efficiency and responsiveness.

In USM academic governance, the decision-making process originates in various committees – standing or ad hoc. Standing committees serve as policy committees, curriculum committees, and advisory committees. Ad hoc committees are short in existence and are created by the Vice President for Academic Affairs to serve a specific urgent function. When a decision needs to be made about curriculum or policy at the committee level, majority approval is required within the committee before the proposal, policy change, or idea is presented to the Academic Affairs Committee, the Graduate Council, the Faculty Senate, and the Vice President for Academic Affairs (VPAA) for approval. If approved by the Academic Affairs Committee, the request is then presented to the Faculty Senate twice – the first time for discussion of the request and the second time for a motion and vote for acceptance or rejection of the motion. Motions made by the Graduate Council go directly to the Faculty Senate. If approved by the Faculty Senate, the request is then forwarded by the VPAA to the President and BOT for their approval. Upon approval of the BOT, the requested change is enacted. Other committees, such as the Academic Leadership Council (ALC), Rank and Tenure, and Teacher Education, serve advisory functions to the VPAA. Requests and recommendations come from these committees to the VPAA who then makes the formal request for approval to the Faculty Senate or President or BOT. If the decision requires curricular policy change, the decision goes through the Faculty Senate. If the decision requires approval regarding issues of rank and tenure, the VPAA communicates the recommendations of the Rank and Tenure Committee to the President and to the BOT for approval.

Figure 5P5-1 Academic Governance Decision Tree

The evidence presented here and in 5P9 demonstrates that we have met Core Component 5B: the institution’s governance and administrative structures promote effective leadership and support collaborative processes that enable the institution to fulfill its mission. USM employs policies and procedures that engage its internal constituencies in governance, each according to the areas in which they are best prepared to contribute.  In Section 5P5, we provide a detailed explanation of our planning process that involves cross-functional teams, task forces, and numerous committees.  As we put it, in our planning we always ask, “Who needs to be at the table?”  We employ our Ongoing Improvement Model (see 5P2) so as to assure continuous quality improvement.  We practice the process of subsidiary by which we mean that problems are best analyzed and solved at the level where the related activity is being implemented.  Some examples of how these processes are used are included, as well as a step-by-step explanation of how decisions are made, who is involved, and what the process of approvals entails, depending on the nature of the issue.

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5P6 Use of data, information and performance results in the decision-making process

Leadership decisions are framed by the mission, directed by the Strategic Plan, and informed by key indicators. The key indicators also serve as touchstones of progress. Key indicators include data and information such as tuition, demographics, discounts, academic measures such as CLA and cultural measures such as NSSE, with particular attention to those that are highlighted by the Strategic Plan which focuses on academics and finances. The Administrative Council (AC) regularly monitors data reports designed to measure key indicators. VPs and the AC review the data reports at various intervals as appropriate: weekly (e.g. admissions, cash flow), quarterly/semester (e.g. investments, enrollment, retention, and faculty evaluations), yearly (e.g. growth plans, cost of programs, cost of recruitment, service learning courses).

Another important source of information that the AC uses is environmental key indicators. Financial and enrollment data are shared among the presidents of the Kansas Independent College Association (KICA). Comparative data are also provided through CIC Tool Kits. These external data points are used to provide perspective of the competition and set appropriate goals.

The addition of the CLA and NSSE has been a significant step forward in USM's decision-making process.

The evidence presented here and in 5P2 demonstrates that we have met Core Component 5C. (covered in 5P2)

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5P7 How communication occurs between and among the levels and units of the organization

USM's structure is designed to provide for vertical communication through line groups and for cross communication among departments and across the USM community. The AC serves as the integrating factor for the vertical lines of communication. Cross communication happens regularly through task forces established to address challenges and opportunities that cross group lines. Community-wide events such as University Days and University Assemblies allow everyone to receive the same information and hear each other's questions. Gathering all personnel together also builds community so that cross functional team members already know one another.

One example of how cross-communication occurs in University Assembly highlights the discussion of whether the University should perform background checks on prospective employees. Research on best practices and cost was presented for feedback at one meeting. Follow-up feedback was asked to be sent to the president's office. The feedback was compiled and presented at the next University Assembly and the decision was made that the AC would move forward with background checks for full time employees.

Other examples of how information is shared across USM include: USM's public relations specialist sends all news releases out to faculty, staff and SCLs via email before they are sent to the media. A large TV monitor in the Mead Hall entryway highlights activities, accomplishments, and visiting prospective students. This is an effective and very popular communication tool for faculty, staff, and students.

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5P8 How leaders communicate a shared mission, vision and values

USM communicates mission, vision, values, strategic planning goals, and high performance expectations through several means as highlighted below.

  • The faculty and staff were directly involved in reviewing the mission, vision, and values, and creating the SP which has increased ownership of shared values, vision and expectations.

  • The SP and updates are accessible through the University's shared network drive.

  • All new employees are required to read the faculty/staff handbooks that include the mission and values. New employee orientation includes a segment dedicated to USM heritage and mission and values. All new Board of Trustees members go through orientation that discusses mission and values and the SP. The university has an online orientation for faculty who teach online, which also includes discussion of the SP, mission and values.

  • At Fall Convocation, students, faculty, and staff renew their commitment to the mission and core values.

  • An annual fall “assessment day” has been added to the calendar for assessment of data and information on student learning, engagement, and success collected the previous year.

The mission and core values are displayed in the main hallway in Mead Hall. A Mission table sits inside the main entrance that features a display that reflects the core values of the university, and highlights the core value theme each year.

  • USM communicates expectations for faculty and staff through the Employee Handbook and letter of hire.

  • Student expectations are addressed in the Student Handbook and Work-Study policies.

  • The Sullivan Award for Teaching Excellence is awarded annually to a faculty member; the Ancilla Award for Service is presented to a student who has demonstrated concern and commitment of time and effort in service to others in the local community, and especially to the poor; and the University's highest award, Caritas, honors selfless dedication and outstanding contributions.

The evidence presented here and in 5P3 demonstrates that we have met Core Component 1B. (covered in 5P3)

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5P9 How leadership abilities are encouraged, developed and strengthened among faculty, staff and administrators; how leadership knowledge, skills and best practices are communicated throughout the organization

USM is committed to providing faculty and staff opportunities to develop leadership abilities. The university offers tuition remission for employees seeking undergraduate or graduate degrees. Individual departments receive budget allocations for professional development through workshops, conferences, webinars, sabbaticals, Council of Independent Colleges (CIC) awards, and association memberships.

University-wide involvement in the strategic planning process and AQIP Action Projects also creates opportunities for development of leadership skills.

USM regularly collects and analyzes several measures of leading and communicating. The AC uses reports designated as Key Indicators that support the SP to determine if progress has been made on initiatives. While this is an indirect measure of leadership effectiveness, it does signal that USM work groups tasked to implement objectives are working productively to accomplish them. More direct measures which the AC uses to determine the climate for leadership and communication effectiveness are listed in Table 5P9-1.

Table 5P9-1 Measures of Leading and Communicating Effectiveness



Graduate Survey

To evaluate satisfaction with USM programs; suggestions for improvements

VP Board Reports

To report qualitative results of internal collaborative relationships and to establish ongoing improvement goals

Strategic Plan Updates- Key Indicators

To show progress toward reaching the SP goals and objectives

Course Evaluations

To evaluate effectiveness in teaching and learning; used in annual evaluations of non-tenured faculty, for Rank and Tenure reviews, for individual professional development plans and annual reports, for accreditation reports

Program Reviews

To analyze results of OGI objectives for direction setting, improvement efforts, communicating

PR Tracking

To show effectiveness in communicating with external stakeholders

The evidence presented here and in 5P5 demonstrates that we have met Core Component 5B. (covered in 5P5)

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5P10 How leaders and board members ensure the organization maintains and preserves its mission, vision, values and commitment to high performance during leadership succession

The Board of Trustees insures that strategic planning and all decisions are consistent with the university’s mission.  Further, USM has a Director of Mission whose focus is to educate all employees and students to the mission. As a sponsored work of the Sisters of Charity of Leavenworth, it is of high value to pass on the educational heritage of the Sisters to the next generation.

As noted in 4P5, due to USM’s small size and its “lean” staffing, succession planning is limited.  The need for faculty and administrators is determined by the process just noted and hired through a national search.  USM does offer considerable professional development which allows for some lateral, as well as upward, movement, mostly within staff support offices.

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5R1 Collecting and analyzing performance measures of leading and communicating

Results for leading and communicating processes and systems include leadership effectiveness in addressing issues related to SP goals and objectives, leadership communication effectiveness identified in AQIP Strategy Forums with faculty and staff, and satisfaction levels as shown in the Faculty/Staff cultural surveys.

USM has made progress on accomplishing SP goals and objectives. Enrollment and retention have increased, and new programs and partnerships have been established for healthcare and online education (e.g. Accelerated BSN in Nursing, Doctor of Physical Therapy, online RN to BSN, a Risk Management Concentration added to the MBA, and Health Information Management.

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5R2 Results for leading and communicating processes and systems

Effective leadership and communication have enabled USM to favorably compete with other institutions, both locally and nationally, as shown in the following recognitions.

For the eighth consecutive year, The Princeton Review has named USM a “Best Midwestern College” based on its meeting the review's standards for academic excellence in the region and survey feedback from students and parents. USM was one of 153 schools in the Midwest region receiving the designation. The University was the only school in the metropolitan area named two years in a row one of America 's “Best Value Colleges” for academic excellence, generous financial aid packages, and relatively low costs.

The USM Master of Arts in Teaching program was awarded the 2007 Council for Higher Education Accreditation (CHEA) Award for Institutional Progress in Student Learning Outcomes. The award is given to colleges and universities that demonstrate outstanding achievement in promoting student success, based on overall learning outcomes. University of Saint Mary was one of five institutions picked from a nationwide pool of 31 to receive this honor.

USM was a founding member of Kansas Campus Compact, which is part of a growing national coalition of college and university presidents established to encourage and support campus engagement in the community. In October 2006, USM made the first-ever President's Higher Education Community Service Honor Roll, a program that identifies and promotes community service model programs and practices in higher education, for "Distinction for General Community Service." More than 500 schools applied and only 141 institutions were named to the honor roll.

The university’s recently revamped website has also garnered much recent praise from alumni, students, and faculty.

USM realizes that these anecdotal indicators, while positive, provide little by way of benchmark comparisons to other institutions and that it has no formal process for measuring effectiveness in leading and communicating at this time. With the recent hiring of a Director of Human Resources, the university looks forward to improving this process.

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5I1 Recent improvements made in this category; how systemic and comprehensive are processes and performance results for Leading and Communicating

USM improves processes for leading and communicating by using data to assess performance and respond to need. The following have been added to our process:

  • CLA (Collegiate Learning Assessment)

  • NSSE (National Survey of Student Engagement)

Other improvements include:

  • Established a Student Success Office, charged with ongoing student success and retention.

  • Hired a Director of Human Resources, charged with creating common processes of assessment in leading and communicating.

  • Updated and revamped the university’s website with an update schedule/process for the future.

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5I2 How our culture and infrastructure help us select specific processes to improve and to set targets for improved performance results in Leading and Communicating

USM improvement targets are driven by the goals in the SP. The OGI model guides processes and principles for continuous quality improvement in these targets.  AQIP Action Projects are a direct result of this process as well as individual improvements faculty, staff and administrators make day to day and year to year in their programs and offices. 

University improvement projects are calendared with targets and timelines and employees in each department are held accountable for both. For example, a current AQIP Action Project is underway to address residential student retention, which will result in targets and timelines. (See Link 5I2: Action Project #11)

USM realizes that while there are principles and guidelines in place for continuous quality improvement, it would benefit from formalizing this process.

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