Your program makes a change — it moves to a new building, adds a degree option, brings in a new dean, or the institution that sponsors it changes ownership — and the question that keeps a coordinator up at night isn't whether the change is a good one. It's whether anyone has to be told, who exactly, by when, and what you need to have in a folder if a site visitor ever asks. In the CAAHEP system, that question has a specific name: substantive change. Getting it right is one of the quieter, higher-stakes parts of running an accredited program, because the consequence of missing it isn't a footnote — it's administrative probation and, eventually, withdrawal.
This post walks through what CAAHEP's own standards require: what counts as a substantive change, what you must report to your Committee on Accreditation (CoA) and to CAAHEP, how "when" actually works, and the documentation to keep on file. The claims below are drawn from CAAHEP's Policies and Procedures Manual and the Standards & Guidelines documents, so you can check each one against the numbered references at the end.
What "Substantive Change" Means in the CAAHEP System
Every CAAHEP profession's Standards & Guidelines carry the same base requirement, written as Standard V.E. It says the sponsor "must report substantive change(s) as described in Appendix A" to the applicable CoA "in a timely manner," and that "additional substantive changes to be reported ... within the time limits prescribed" are then listed [2]. CAAHEP's Standards and Guidelines page [5] hosts the full set of profession documents.
Two things about that structure matter for a coordinator. First, the requirement sits in two layers. The base layer — Standard V.E plus Appendix A — is common to every CAAHEP profession, because Appendix A is added by CAAHEP after it approves a set of standards, and CAAHEP's policy manual notes that Appendix A is not subject to review or revision by the CoAs [1]. Second, on top of that base, each CoA may list its own additional changes it wants reported. So the honest answer to "what counts?" is always: the base list, plus whatever your specific CoA has added.
The Base List, and the CoA-Specific List on Top of It
Appendix A — titled "Application, Maintenance, and Administration of Accreditation" — is where the base obligations live. It covers how a program applies for initial and continuing accreditation, and a section on the administrative requirements for maintaining it. But the list of what counts as a substantive change sits in Standard V.E, and it varies by CoA. Three current profession documents show the range.
Surgical technology (ARC/STSA) lists a change in facilities or the program's physical address, a change to maximum enrollment capacity, a change of ownership, the deletion or addition of distance education, the deletion or addition of a satellite program, and the deletion or addition of a consortium partnership [2]. Clinical research (CAAPCR) lists a change in the sponsoring institution's legal status or form of control, a change in its regional or national accreditation status, and a change in the degree awarded [3]. Respiratory care (the Joint Review Committee on Education in Respiratory Care) lists curriculum changes that result in a change of ten percent or more of program credits, a change in the degree awarded, and changes in the organizational structure or mission of the sponsoring institution that impact the program [4].
The pattern is the point. The same "substantive change" standard produces different checklists depending on which CoA reviews your program. If you're coordinating across professions, or if your profession's list is shorter than you'd expect, that's not a gap — it's how the system is built. Finding your CoA is the first step, because its V.E list is the one that applies to you.
What You Must Report — and Who Gets the Notice
Beyond the CoA-specific substantive changes, Appendix A's administrative section names the changes a program is required to report, and it's worth noticing who gets told. Changes in the chief executive officer, the dean of health professions or an equivalent position, and required program personnel must be reported to the CoA and CAAHEP within a reasonable period of time [2]. A change of name or a change of controlling ownership must be submitted to CAAHEP and the applicable CoA(s) [1]. And the sponsor must promptly inform both CAAHEP and the CoA of any adverse decision affecting its accreditation by a recognized institutional accrediting agency or a state agency [2].
The "report to both" detail trips people up. A change that looks like an internal human-resources event — a new dean, a new program director — is still a reportable event under the standards, and it goes to two recipients, not one. CAAHEP's policy manual [1] is explicit that failing to notify the CoA and CAAHEP of changes in program personnel or other significant changes is one of the things that can put a program on administrative probation.
"When" Is a Clock Your CoA Sets
Coordinators want a number — thirty days, sixty days — and the honest answer is that CAAHEP's standards don't give you one. The base standard says changes are reported "in a timely manner" and "within the time limits prescribed"; the administrative section says personnel changes are reported "within a reasonable period of time," as defined by the CoA and CAAHEP policies [2]. In other words, the exact window is set by your CoA's policy, and it can differ from profession to profession.
That's why the practical rule is to treat every potentially reportable change as one you should raise with your CoA early, in writing, and get the acknowledgment on record. If your CoA's policy sets a specific number of days for a given change, that number governs; if it doesn't, "timely" is the standard you're held to, and a documented, prompt notification is how you demonstrate you met it. CAAHEP's overall process is built around written submissions at every step, so a written change report fits the grain of the system.
The Big One: Transferring Sponsorship
The largest "change" a program can undergo is a transfer of sponsorship — when an accredited program moves from one educational institution to another. CAAHEP's policy manual is precise here: accreditation itself cannot be transferred from one program to another, but the sponsorship of an accredited program can move between institutions, and whether that affects accreditation status depends on whether critical factors — funding, curriculum, faculty, facilities — remain unchanged [1].
The procedure runs in three steps. The outgoing institution's chief executive officer (or designee) gives written notice of intent to transfer to the CoA and CAAHEP. The new sponsor's chief executive officer completes and submits a CAAHEP Request for Accreditation Services form requesting the transfer. Then the new sponsor submits a defined set of documentation to the CoA: a summary of the basis for the relocation, an organization chart identifying key personnel, institutional accreditation and state authorization, the degree or certificate evidence, and exhibits showing it can continue to meet the Standards — including a specific budgetary commitment, faculty curricula vitae, a curriculum outline, and the list of clinical affiliate facilities with their affiliation agreements. The CoA acknowledges receipt; if everything documents compliance it recommends approval to CAAHEP, and if not it can ask for more information, require a self-study, require a site visit, or recommend denial [1]. Applying doesn't guarantee the transfer is granted; the respiratory care standards say so explicitly [4].
What to Keep on File
The standards don't just tell you what to report; they tell you to file your reports. Appendix A requires the sponsor to file all reports in a timely manner — self-study reports, progress reports, probation reports, annual reports, and the like [2]. Layer that on top of the change-specific documentation and you get a concrete record-keeping list. For every reportable event, keep the written notification you sent, to whom it went (CoA and CAAHEP), when it was sent, and the CoA's acknowledgment. For a transfer of sponsorship, keep the full exhibit package and the CoA's decision. For a voluntary withdrawal or a request for inactive status, keep the form submission and the records-retention location you committed to.
This is where the institutional-knowledge argument earns its keep. A coordinator who leaves with her program's change history in her head — which changes were reported, what the CoA said, where the student records now live — leaves a gap the next coordinator has to reconstruct under time pressure. A standing folder, or a connected evidence map, that ties each change to its notification and its response is the difference between a clean handoff and an archaeology project.
What Happens If You Miss It
The consequence ladder is spelled out in both the standards and the policy manual. A program can be placed on administrative probation — a public status whose notification comes from CAAHEP — generally as a result of non-payment of fees, failure to submit an annual or progress report, or failure to notify the CoA and CAAHEP of personnel changes or other significant changes [1]. Before recommending it, the CoA must give the program two notices, the second warning that probation is coming if the requirements aren't met. If the cited concerns aren't resolved in a reasonable time, a recommendation to withdraw accreditation can go to the CAAHEP Board of Directors [1]. And the flip side is worth knowing: the policy manual defines administrative probation as a temporary status imposed when a program has not complied with administrative requirements, and in the example of unpaid fees, notice of removal is sent once the fee is paid [1]. The path back out is there — it's just one you'd rather not need.
A Checklist Before You Make the Change
Before you execute a change that might be reportable, run it through five questions. Does it touch anything in your profession's Standard V.E list or in Appendix A? Is it on your CoA's additional substantive-changes list? Who exactly gets notified — and is it both the CoA and CAAHEP? What does your CoA's policy say the clock is? And what do you document, and where does it go so the next coordinator can find it? If the answer to any of those is "I'd have to check," that's your cue to write to your CoA now, not after the fact.
MapOutcomes is built for exactly this kind of obligation. It gives your program a connected evidence map where each reportable change, its notification, and its response live in one place with the documents attached — so "what did we report, and what did the CoA say" becomes a question you can answer in seconds instead of an afternoon of digging through inboxes and folders.
References
- Commission on Accreditation of Allied Health Education Programs (CAAHEP), "Policies and Procedures Manual (updated September 24, 2025)," caahep.org, 2025. [Online]. Available: https://cdn.prod.website-files.com/5f466098a462432df91fef63/69d9100d5b695d405ad33b60_CAAHEP%20Policies%20and%20Procedures_July_2025_updated9242025.pdf
- CAAHEP and ARC/STSA, "Surgical Technology Essentials/Standards and Guidelines (Appendix A)," caahep.org, 2025. [Online]. Available: https://cdn.prod.website-files.com/5f466098572bfe97f28d59df/67a10dcfea191396b6f4012f_STStandardsApproved6-15-23_Update1-16-25.pdf
- CAAHEP and CAAPCR, "Clinical Research Standards and Guidelines," caahep.org, 2026. [Online]. Available: https://cdn.prod.website-files.com/5f466098572bfe97f28d59df/6aa837c99c5c84e14ba4502b_ClinicalResearchStandardsApproved8-20-26.pdf
- CAAHEP and JRCRC, "Respiratory Care Essentials/Standards and Guidelines," caahep.org, 2025. [Online]. Available: https://cdn.prod.website-files.com/5f466098572bfe97f28d59df/67a10d55f57c59254c43ff7a_RCStandardsApproved1-20-22_update1-27-25.pdf
- CAAHEP, "Standards and Guidelines," caahep.org. [Online]. Available: https://www.caahep.org/program-directors/standards-and-guidelines
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