AQIP Category Eight



Context for Analysis

Category Eight Contents

The cornerstone for USM’s continuous improvement planning is the Strategic Plan.  In 2006, USM adopted, as a part of its strategic plan, the following Strategic Focus Statement:

“USM will realize its mission by developing a regionally recognized nursing program, building on its liberal arts foundation, with the introduction of program and strategic partnerships in allied health, and foster financial stewardship to further promote and enhance its reputation of academic excellence.”

The strategic initiatives were:

  • USM will develop allied health, starting with nursing, as a niche for which the university will be recognized.

  • USM will improve its financial stability through revenue enhancement, fund development and cost containment.

With the overall success of implementing the 2006 Strategic Plan, USM updated the Strategic Plan, building on its success, in 2011.  Accordingly, USM adopted the following Strategic Focus Statement:

“USM will advance its mission by continuing development of health science programs, improving student persistence rates, and enhancing facilities and technology infrastructure.”

The current strategic initiatives are:

  • USM will continue to develop programs in the health sciences, as a niche for which the university will be recognized.

  • USM will improve its retention and graduation rates by improving academic success, enhancing students’ sense of belonging and building a stronger student community, and improving student-athlete success by promoting a positive culture for discipline and learning.

  • USM will improve and enhance facilities and technology infrastructure to meet the changing educational needs of its diverse student body.

The following criteria informed the selection of initiatives to ensure alignment with USM goals, values, and priorities:

  • Fit with Mission

  • Fit with Mandates for Services

  • Fit with USM strengths and opportunities

  • Built on prior Strategic Plan(s)

  • Required resources available

  • Financial stability improved

To meet the strategic initiatives, action plans were developed, and responsibility assigned for completion of action plans with due dates and measurable outcomes and targets set.  Progress on action plans is updated on a regular basis and reported to USM stakeholders such as the AC, BOT and members of the USM community.

8P1 Key planning processes

A central feature of USM's strategic and systematic planning process is the Ongoing Improvement (OGI) concept, used by all departments, linking strategic initiatives and annual goals to mission, research, collaborations, actions, evaluation, and improvement. This was designed and implemented as a necessary university-wide component for the 2001 Comprehensive Curricular Initiative.

Figure 8-1 graphically depicts the centrality of mission and student learning in the OGI process which utilizes a data-based, collaborative decision making approach.

Figure 8-1: In pursuit of Excellence….Circle of On-Going Improvement

The reliance on the OGI model in priority setting and decision making, including required “after action” assessment, is evident in USM's strategic planning process, initiated in the fall of 2005 by the Administrative Council (AC) as an AQIP Action Project. The initial comprehensive Strategic Plan (SP), adopted by the BOT in October 2006, linked the mission with new strategies and action plans resulting in a clearly defined and innovative institutional vision for the next five years. The timing of this strategic plan was significant in pursuing growth opportunities as USM faced financial challenges.

The strategic planning process resulted in a blueprint to successfully bring stability to the University over the next five years. Specifically, this plan provided for the collection of data and trends in several key areas. Analysis of information informed the decision process which then led the University to pursue its vision. The Strategic Planning Committee (SPC) used this data-based process to monitor, track and evaluate the steps completed during implementation.

The SPC was formed with representative members, selected by the President from the Board of Trustees (BOT), AC, faculty, staff, and the Extended Sites (ES). The SPC met on a regular basis and engaged in every aspect of the Strategic Plan development.

The planning process used by SPC is shown in Link 8P1: Strategic Planning Process.

USM began a similar process to update the 2006 Strategic Plan in September 2010. The updated Strategic Plan built upon the lessons learned from the 2006 Strategic Plan.  The updated Strategic Plan was adopted in June 2011 and will provide the strategic direction for USM for the next three to five year period.  See the June 2011 Strategic Plan.

The Board of Trustees is updated quarterly on progress in the University’s Strategic Plan.  Also, the BOT holds an annual retreat where current issues in higher education are discussed, and longer term topics considered.

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8P2 Selecting short- and long-term strategies

To assist in selecting strategies using the OGI model, SPC did the information gathering, stepped through an environmental scan, and undertook a SWOT analysis. They used internal and external factors of the scan in determining the mandates for USM's services. They reviewed demographic indicators for both traditional and nontraditional students, identifying probable majors and degrees earned both nationwide and at USM. SPC studied factors impacting the changing work place, including occupations with the largest anticipated job growth over the next several years. Internally, several student surveys found why freshmen attend college, the importance of attaining learning outcomes, and what attracted students to USM. The SWOT analysis identified the strengths and weaknesses, and examined the opportunities and threats facing USM. By looking at USM and its competitors, USM crafted a strategy to help compete successfully in the regional market.

The Committee spent a great deal of time and effort on Internal Collaborative Processes, the next step in USM's OGI process. The SCP sought to have an informed, data based process. Given current challenges for higher education, it was incumbent upon USM to engage the University community in defining initiatives that reflect the changing needs of constituencies, while maintaining fidelity to the mission and values in providing a quality education. For each strategic plan, faculty and staff were engaged in several steps of developing and updating the strategic plan. A recurring theme was the need for USM to develop and maintain a focus for distinctive priorities. The SPC decided to narrow the strategic issues down to two key issues, which were refined in the strategic plan update.

Moving into the Action & Implementation, the SPC focused on two critical points. First, USM lacked focus. The Committee decided USM should define an academic niche. The second critical strategic issue was that USM is challenged by limited resources. The Committee decided USM must increase financial stability. Consequently, the strategic initiatives and the Vision for the first five years were identified (Context for Analysis).  In the 2011 strategic plan update, that focus was refined with three specific foci (Context for Analysis).  Both strategic plans contain long-term strategies, i.e. building an academic niche, and short-term strategies, i.e. improving fiscal stability.

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8P3 Developing action plans to support organizational strategies

Developing, implementing, tracking, and evaluating action plans occur during two steps in the OGI process, AI and Ongoing Evaluation (OGE ). The Strategic Plan and USM's action projects follow this model with these steps:

  • Objectives target a desired initiative

  • Metrics are identified to determine success

  • Activities, responsibilities and timelines are established

  • Resources required are estimated

  • Progress is discussed at University Assemblies

  • Results are analyzed

  • Findings are examined with internal and external stakeholders

  • Conclusions lead to revised or new OGI Goals

Subcommittees, with oversight by the AC, are tasked with following through on these action plans.

Exemplifying these action plans, the SPC formed subcommittees to formulate action steps necessary to implement the strategic initiatives for both plans.  Within the context of both external and internal realities, the action plans include program and operations analyses which drive data based decision making. This comprehensive approach balances an awareness of resources and trends with curricular, cultural, and mission related considerations.

The final action plans, with specific steps, are reviewed by the SPC, AC and the BOT, and are made a part of the adopted strategic plan document.

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8P4 Aligning planning processes, organizational strategies, and action plans

To align processes, strategies, and action plans, USM recognized that a systems approach was essential for collecting, sharing, and using information to drive effective decision making. Beginning in January 2006, USM undertook a two-part AQIP Action Project to develop a comprehensive management information system for institutional decision making that would be accessible, reliable, and systemic. (See AQIP Action Project #1 and and AQIP Action Project #5).  The vision, while still being implemented, is a closed loop OGI model highlighting input by internal and external stakeholders, a focus on programs and initiatives, a systematic process for assessing progress, and an analysis of data to make informed decisions which are reviewed by stakeholders leading to renewed objectives. With oversight by AC, the transparency of this process attempts to make information accessible and aligns efforts across the University.

As noted above (8P3) specific action plans for the strategic plan are developed with the involvement of departmental faculty and staff and specific responsibility to complete the action plan is assigned.  In other words, planning, strategies, and action plans are developed, completed, and implemented by USM faculty and staff throughout the organization.  Regular updates are made on the progress in completing each action step and reported to the AC and to the USM community during University Assemblies throughout the year.  The BOT is updated on the progress of the strategic plan at each BOT meeting. 

In addition, during the annual budget process, priority for additional resources is provided to action plans slated to be completed in the coming fiscal year.  This is accomplished by a process of separately identifying necessary supplemental funds needed to accomplish the action plan.  These budget requests are identified as Supplemental Requests and are reviewed individually and approved by the AC upon a priority and available financial resources basis.

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8P5 Selecting and setting measures and performance targets for organizational strategies and action plans

USM uses the OGI model to select measures and set performance targets for strategic initiatives and action plans. At various points throughout the process—Information Gathering (IG), Internal Collaborative Process (ICP), and Ongoing Evaluations (OGE)—faculty, staff, and committees:

  • Analyze information, data-based results, and external and internal trends which lead to new objectives for action plans

  • Define benchmarks for effective achievement of objectives based upon this systematic review of results

  • Select metrics and define targets for performance targets

  • Finalize action steps and implementation procedures, aligning activities with anticipated goals and outcomes

The action plans proceed through the governance structure for review and approval by AC, and when appropriate, to the BOT. Since the OGI model is cyclical, the analysis of results leads to new goals and objectives, that when studied (IG) and discussed (ICP), yield new performance measures and benchmarks for the next improvement cycle.

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8P6 Linking strategies and action plans to resources and future needs

For recent fiscal years, USM has had fiscal and human resources sufficient to support its current, on-going operations.  USM has experienced significant growth in the recent past.  Enrollments have increased, a new residence hall was opened in the fall of 2009 on the main campus, a new Doctorate of Physical Therapy (DPT) program enrolled its first class of students in the summer of 2012, a multi-million dollar renovation of a former residence hall into a health science building is nearly complete, and University finances have improved, despite recent economic activity.  The University’s recent financial statements demonstrate that improvement (See Link 8P6-1: USM audited financial statements) as evidenced by the HLC Financial Ratios for USM. (see 8R4)

USM identifies resource needs for strategic initiatives and action plans during the AI step of OGI. Committees conduct a thorough review of human and financial resources needed for each action plan determining what is essential for effective implementation. If the action plan can be supported within existing budgets, the department chair and/or appropriate vice president allocate the resources.

If the plan requires additional funding, the budget preparation process allows for the request of supplemental funds which are subject to a separate review and approval process from ongoing budget funding.  If the action plan is significant or material in scope, for example a strategic initiative, USM has established a program to fund new programs.  The Project Initiation Fund (PIF) is a fund separate and apart from USM operating and endowment funds and is funded by bequests received by USM.  PIF funds used to begin a new program are then returned once the program is stable and producing a surplus.  PIF was utilized to successfully develop and implement the DPT program. 

AC either approves resources or modifies the scope or timeline of the action plan based on budget realities, including supplemental budget requests or the use of PIF funds.  AC uses a strategic planning and return on investment (ROI) approach to determine priorities and allocations. During the OGE step, ROI is a factor in judging effectiveness and ongoing support.  The proposed budget is then presented to the BOT for approval and interim budget summaries are provided to AC and presented to the BOT on a monthly basis.

The evidence provided here demonstrates that we have met Core Component 5A: the institution’s resource base supports its current educational programs and its plans for maintaining and strengthening their quality in the future. With each approved application to HLC and other accreditors for new programs, reaccreditation, and reaffirmation submitted over the past four years (since our last portfolio review), USM has demonstrated that it has the fiscal and human resources, as well as the physical and technological infrastructure, sufficient to support its current and expanded operations (e.g. implementation of a Doctorate in Physical Therapy and multi-million dollar renovation of Berchmans Hall – formerly a residence hall -- as a health science building).  As demonstrated in this section, USM’s resource allocation process ensures that its educational purposes are protected from adverse circumstances, as much as is humanly possible.  The process whereby resource planning is implemented, including its effective use of the OGI model, strategic planning linked to resources, use of our Project Initiation Fund, and so on, clearly demonstrates that the process is deliberate and carefully considered, resulting in goals that are well planned and realistic, as well as consistent with the University’s mission.

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8P7 Addressing risk in the planning process

USM has an active risk management plan in place.  The various components of the risk management plan can be summarized by the following graphic.

The components of risk management are integrated throughout the operations of USM and are regularly considered and reviewed by the AC.  Regular reports on risk management topics are also presented to the BOT.

As appropriate, all of the above components of risk management are considered throughout the planning process.  For example, a business plan is required of all new programs which includes a five year financial forecast, detailing start-up and operational capital needs, human resource needs, technology requirements, legal requirements, and other key information critical to the proposed programs’ success.

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8P8 Developing faculty, staff, and administrator capabilities to meet changing requirements arising from strategies and action plans

USM provides opportunities to develop the capabilities of faculty, staff, and administrators to meet strategic goals. Supervisors determine needs through professional development reports, stakeholder and employee surveys, and training consultants. At times, action plans may include recommended training.  For example, in the 2011 Strategic Plan, to address the strategic initiative of improving and enhancing the technology infrastructure to meet changing educational needs, one action plan step is to develop effective technology training programs for students and faculty. Based on the review of this information along with current strategic initiatives, and action plans, AC sets priorities for capacity building.

An individual faculty member, staff member, or department can initiate professional development activities to build capabilities. This includes sabbatical leaves for one or two semesters, which USM grants in order to provide opportunities for faculty to develop professionally through research or study, and thereby enrich his or her teaching. AC designates annual budget allocations for professional development and training and these funds are requested through the appropriate vice president. In the request, the individual or department identifies how participation in the proposed activity will advance their professional skills and USM priorities.  Further, the newly created position of Director of Human Resources (HR) is charged with developing appropriate training programs, including professional development training.  HR will implement the program and track employee training participation.

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8R1 Measures of planning process effectiveness

Effectiveness measures for USM’s planning processes are collaboratively determined as a part of the OGI process. Individuals, departments, and committees work together to define measures and assess progress based on USM goals and priorities. Administrative heads determine progress toward objectives and mission-related goals by analyzing the Annual OGI Reports that faculty and staff submit describing their individual growth and their program's improvement. Administrative vice presidents report to the President summarizing accomplishments and improvement needs. The criteria for judging effectiveness focuses on the steps of the OGI template as well as on the measurable results of the targeted action plan.

Examples of measures include:

  • Student recruitment, financial aid, enrollment and retention statistics

  • Interim and annual financial reports and statistics

  • Student assessment data (NSSE, CLA)

  • Strategic Plan action steps’ outcomes

  • AQIP Action Projects and related updates

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8R2 Results for accomplishing organizational strategies and action plans

Current status on achieving the action plan results for the 2011 Strategic Plan is summarized in the following Table 8-1.

Table 8-1: 2011 Strategic Plan Progress Results

Develop Health Sciences Programs

Action Plans

Fall 2012 Progress Results

Develop a Degree in Health Information Management

In process, CAHIIM accreditation with first students enrolled in Fall 2012

Develop an online Master of Science in Nursing (MSN) Program

In process, awaiting approval from HLC

Explore and Develop an Accelerated Bachelor of Science in Nursing Program

Completed with first enrolled class in Summer 2012

Complete Implementation of Doctor of Physical Therapy Program

Completed with first enrolled class in Summer 2012

Explore Other Health Science Programs

Ongoing with a search for a Physician Assistant Program Director in progress



Improving Retention and Graduation Rates

Action Plans

Fall 2012 Progress Results

Improving Academic Success
(See Categories 1 & 3)

Improved identifying factors for at-risk students

Improved academic profile of incoming Freshman (See Link 8R2-1: Freshman Academic Profile)

Designed a system for advising and mentoring enhancing student learning and retention

Implemented Collegiate Learning Assessment (CLA)
Developed an Honors Program

Enhance Student Sense of Belonging and Build Stronger Student Community

Increased residential retention from 54% to 61% from Fall 2011 to Fall 2012

Administered National Survey of Student Engagement (NSSE)

Improve Student-Athlete Academic Success
(See Category 3)

Increase student-athlete academic success (See Table 3P1-1: GPAs of Student-Athletes)

Implemented positive culture changes through character education programing

Improved freshman student-athlete retention rate from 53% to 65% from Fall 2011 to Fall 2012


Improve and Enhance Facilities Infrastructure

Renovate Berchmans Hall

Completed renovation of Ground and 1st floors in May 2012 to provide space for the DPT program
Completed renovation of 2nd and 3rd floors in September 2012 to provide additional space and relocate Nursing Program
Prepared 4th floor (top floor) for future renovation

Determine Need to Improve and/or Expand Athletic Facilities

Determined need to improve football and soccer game fields; plans now underway

Develop a Deferred Maintenance Plan

Completed inventory of deferred maintenance projects

Budgeted $276,000 for FYE 2013 deferred maintenance projects compared to $95,000 in deferred maintenance expenses in FYE 2012



Improve and Enhance Technology Infrastructure

Assess Academic Technology Needs

Assessed technology needs of each academic department

Phased completion of classroom technology upgrades

Assessed technology needs of students

Improved wireless access across campus

Explored the use of collaborative technology and computer labs

System for Ongoing assessment of faculty staff and student technology needs

Determine Viability of Cloud Computing

Moved student email accounts to the Cloud in October 2012
Plans to move employee email accounts to the Cloud by December 2012

Develop a Life Cycle Management Plan

Completed inventory of technology equipment
Prepared multi-year replacement/upgrade of hardware schedule

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8R3 Performance Projections and Targets for 2013-2015

In Table 8-2 Administrative Council projects performance goals for 2013-2015 which are aligned with USM's strategic initiatives.

Table 8-2: Performance Goals

Develop Health Sciences Programs

Action Plans

Performance Goals

Develop a Degree in Health Information Management

Candidacy received from CAHIIM. Obtain full CAHIIM accreditation by May 2014

First students successfully completing accreditation exams for RHIA by May 2014

Develop an online Master of Science in Nursing (MSN) Program

Obtain HLC approval by February 2013

Begin marketing program for Fall 2013

Complete Implementation of Doctor of Physical Therapy Program

Complete faculty hiring by Summer 2014

Obtain full CAPTE accreditation by March 2015

Graduate 1st class of DPT students in May 2015

Explore and Possibly Build Physical Therapy Assistant Program

Complete initial study in March 2014


Improving Retention and Graduation Rates

Action Plans

Performance Goals

Improving Academic Success

Improve academic profile of incoming Freshman:
    Fall 2010 baseline:  ACT 20.4   GPA 3.2
   Target for Fall 2015:  ACT 22.5   GPA 3.25
Feasibility of Summer Bridge Program to become AQIP Project with completion in 2013

Identify at-risk students with 65% accuracy
45% of students have internship or practicum by Spring 2014
Graduating seniors will have internships or practicums by Spring 2015

Enhance Student Sense of Belonging and Build Stronger Student Community

Data collected only for residence life programs. Established benchmarks for all campus programs

Improve and Enhance Facilities Infrastructure

Action Plans

Performance Goals

Complete a Master Campus Building Plan

Completed Master Plan by June 2014

Determine Optimal Residential Living Options

Completed study in June 2011. Determined housing not needed until 2015

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8R4 Comparing results for planning continuous improvement

In some instances, comparing performance projections for action plans and strategies with others is a challenge due to the nature of the initiatives.  For example, the planning for building a health science niche and its results doesn’t lend itself to comparison with other institutions.  However in some cases, comparing results for our process for planning continuous improvement occurs in two ways. First, the environmental scan that is regularly updated at USM provides a comparative picture of strategic priorities in relation to changing needs and market demands. Increasing retention, shifting demands for student life quality, and allied health professions are top priorities in the trends literature based on demographic shifts, educational trends, and workforce realities now and in the future.

Second, translating these trends into performance projections, USM uses its peer institutions for comparisons by using several sources including the Council of Independent Colleges (CIC) Key Indicators Tool reports, the Kansas Independent College Association (KICA) Benchmark Summary, and HLC financial ratios. A summary of some key indicators that are tracked are listed in Table 8-3.

Table 8-3: Results Comparisons



USM 2010

USM 2011


Admission Yield Rate (Admitted/Enrollment)





Admission Yield Rate (Admitted/Enrollment)





Retention Rate Fall-to-Fall Freshmen*





Grad Rate-6yr*






*Based on cohort group


HLC Financial Ratio

USM 2010

USM 2011

Desired Range

Equity Ratio



50% to 85%

Primary Reserve Ratio



40% to 100%

Net Income Ratio




Composite Score



1.5 to 3.0

First-tme Full-time Freshmen Rentention: Fall to Fall

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8R5 Evidence of system effectiveness for planning continuous improvement

The evidence that USM's OGI process is effective can be found in how changes are made and how they align with intended goals.  In broad terms, the recent implementation of several health science programs (DPT, HIM, Accelerated BSN) together with the existing nursing program shows evidence that USM efforts to plan were effective and successful.  More specific evidence for effective planning can be found in comparative benchmarks measuring statistical outcomes.  Student recruitment and retention rates, financial results, and student assessment results are ways to measure the impact and success of the planning process.

Further evidence can be found in the HLC’s Reaffirmation of Accreditation Recommendation for USM, dated July 16, 2012, states in part:  “The Reaffirmation Panel notes that the institution has been responsive to feedback and counsel received through its Systems Appraisal and Quality Checkup visit, demonstrating the institution’s commitment to continuous quality improvement.  Emphasis has been given to strategic planning and data-driven decision making as evidenced through its Action Projects.  The institution is well positioned to make more rapid progress in meeting its goals and objectives by aligning new Action Projects with its Strategic Plan.  The Panel commends the institution in its efforts to move continuous improvement to the next level.”

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8I1 Improvements in planning for continuous improvement

In the schemas depicting ongoing improvement (8P1) and alignment of planning, strategies and action plans (8P4), steps are clearly delineated for ongoing evaluation and informed decision making.  During these steps two levels of examination simultaneously occur:

  • assessing and revising targeted objectives

  • reflecting critically on the improvement process itself

Consequently, at the level of an individual, a committee, or AC, deliberations take place regarding the effectiveness of the system. In this way, those closest to relevant decisions have input not only on desired results but on the means for continuous improvement.

Arising from that process, recent improvements in planning have included the training of AC and several directors in process improvement (i.e. Lean Thinking), and the formation of a process improvement team, which meets weekly, with representatives from several administrative departments. After action debriefings are a standard process for campus events. Further improvements include the addition of a Data Analyst position for institutional research purposes, further integration of continuous improvement planning, including the consideration of the recommendations of the AQIP Quality Checkup Report (February 2012), and regular reporting to USM stakeholders on continuous improvement projects.

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8I2 Impact of culture and infrastructure on planning continuous improvement

The development, implementation, and success of the 2006 Strategic Plan is well known throughout the USM community.  In fact, the entire USM community participated in the planning process.  Concurrently, USM made the decision to join the AQIP process.  Recognition of the benefits from both of these efforts led to the development of the 2011 Strategic Plan. USM has also experienced varying degrees of success from the AQIP projects and have learned what works and doesn’t work as potential action projects are determined and defined. The USM community was also involved in the recent AQIP Quality Checkup review.  Accordingly, planning continuous improvement is understood by the USM community and is becoming more and more embedded as a part of the USM culture and organizational infrastructure.

From that understanding, ongoing planning for continuous improvement occurs at all levels at USM and ranges from short ad hoc discussions to university-wide strategic plans.  Specific processes to improve are determined by considering the opportunity to improve, reasonableness for success (scope and resources), potential benefits, and fit with current priorities (e.g. strategic plan).  To the extent possible, measureable results, both baseline and outcomes, are reviewed to set appropriate targets for improved performance results.  More significant continuous improvement projects are summarized and reported throughout the USM organization up to and including the BOT.

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