Adopted from Montana Nurses Association Accredited Approver Unit Courtesy of Pam Dickerson, PhD, RN BC, FAAN, Director of Continuing Education, MNA

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1 Adopted from Montana Nurses Association Accredited Approver Unit Courtesy of Pam Dickerson, PhD, RN BC, FAAN, Director of Continuing Education, MNA Completing the WNA Approved Provider Application Narrative Self Study There are four components to the application: the Organizational Overview (OO), Structural Capacity (SC), Educational Design Process (EDP), and Quality Outcomes (QO). The Organizational Overview provides us with data to form a big picture understanding of your provider unit. The three subsequent sections give you an opportunity to clearly describe your provider unit in detail. For each SC, EDP, and QO response, you will be asked to provide a description of your process, followed by a specific example. For the process description, think about your responses in relation to describing step by step and in detail: the who, what, when, where, why, and how components of the questions. Who s involved? What do you do? When is it done? Where do you do it, or where do you get the resources to do it? Why do you do it, and what s the desired outcome? Think about how you carry out your policies, procedures, and/or processes in order to be sure you re always adhering to criteria. Your example should be very concrete and specific (e.g. When we offered the course on Wound Care for long term care nurses was held on August 15, 2015, we identified the professional practice gap as. ) and tell us the story of how your process was used in day to day operations. Organizational Overview (OO) This section helps us understand your provider unit, and, if applicable, the organization within which the provider unit operates. Provide detailed information to address each item as follows: OO1: Demographics (Structural Capacity) 1. Submit a description of the features of the provider unit. This description should include: a. Scope of services (Do you serve one facility? If you are a multi facility system, college or government agency, how many locations do you provide CNE to? What nurses do you serve: inside your organization only? nurses from the community? Do you routinely jointly provide CNE activities?) b. Size (number of nurse planners, number of activities, number of learners served, or other aspects related to the size of your provider unit). Health or educational systems: include the number of sites for which you provide education and if there are nurse planners at those sites or if you manage the program centrally from one location. March 20,

2 c. Geographic range (your facility, your community, your state, or your region). (Please note that organizations having a target audience outside their region or contiguous states (see eligibility form for information about regions) for more than 50% of their activities are NOT eligible to be approved providers but may apply to ANCC to become accredited providers. Contact WNA if you have questions about this). d. Target audience (RNs, APRNs, RNs) What set up? What practice areas? Interprofessional groups? Others as applicable. e. Content areas (clinical, non clinical give examples of broad categories (e.g. leadership, certificate courses, nursing education curriculum, QI nursing). f. Types of educational activities offered (live, enduring material, blended learning, or other types) 2. If your provider unit is part of a larger organization, describe how your provider unit fits within that organization. Provide the geographic range, population served, and size of your larger organization. Describe how the activities of the APU fit into your organization s goals, strategic plan and educational system. 3. (If your provider unit is a free standing organization you don t do anything else besides continuing nursing education you can skip this item, but mark it as not applicable so we won t think you just ignored it.) OO2: Lines of Authority and Administrative Support (Structural Capacity) 1. Submit a list of the names, credentials, positions, and titles of the Primary Nurse Planner and any other nurse planners in your provider unit. Be sure your list includes name, credentials, positions, and titles for each person. 2. Submit position descriptions for the Primary Nurse Planner and other nurse planners listed in #1. These may or may not be the formal position descriptions that these people hold in your organization, but should reflect the qualifications and responsibilities of each person related to his/her role in the provider unit. These can be written into the application at this point or added as appendices. Be specific to the role of the PNP in managing the APU. 3. Submit a chart showing the structure of the provider unit. Be sure to include the Primary Nurse Planner and other nurse planners (if applicable). Again, this can be copied into this place in the application or added as an appendix. The relationship of members of the provider unit to the Primary Nurse Planner should be clearly evident. 4. Submit a chart showing how the provider unit fits within the larger organization, if you are part of a larger organization. Be very sure the provider unit is clearly evident. If you have a decentralized provider unit, made up of nurse planners from various departments, use dottedline connections to show the provider unit in context with the other departments. OO3: Data Collection and Reporting (Educational Design Process) 1. Submit a complete list of all continuing nursing education (CNE) activities provided in the past 12 months, including activity dates, titles, target audience, total number of participants, number of contact hours offered for each activity, joint providers (if any), and any commercial support, March 20,

3 including monetary or in kind support. (Note that this is also the data you are required to submit as part of your annual report to the accredited approver.) a. If you are a first time applicant, submit a list of the CNE activities approved by WNA and provided within the past 12 months, including the items listed in #1 above (except joint provider relationships, which do not apply to new applicants). Please also note the activity approval number. OO4: Quality Outcomes (quality outcomes) IMPORTANT: Please see handout on writing outcome measures! 1. Submit a list of quality outcome measures you evaluated in the past year related to the operation of your provider unit. Quality outcomes are those things that form the basis of your existence as a provider unit what do you want to accomplish as a provider unit? Consider quality outcome measures such as more diversity in types of learning activities offered, greater number of activities, more variety in learning options to address varied learning needs, cost savings for your provider unit or for your learners, number of participants in your learning activities, and operational improvements to make your provider unit more effective/efficient. This is not an exhaustive list there may be others that are more pertinent to your provider unit. Be as specific as possible in providing this list, so that you will have clear evidence of what you want to evaluate to determine your success. For example, if an outcome measure is to offer more diverse learning activities, your outcome measure might be Increase the proportion of enduring materials from 10% to 30% within 12 months, including at least 3 web casts and 3 online learning modules. Use the handout for writing outcome measures. We suggest that you select 2 or 3 quality outcome measures for your provider unit each year. At least annually, evaluate your progress in achieving these outcome measures, and decide whether new or modified outcome measures are appropriate for the following year. In your narratives for QO 2, you will be expected to describe your process for evaluating your progress against those quality outcome measures for your provider unit and provide an example showing one specific instance where you ve done that. 2. Submit a list of quality outcome measures you evaluated in the past year related to the professional development of your nurse learners. This gets at the heart of why you have a provider unit the ongoing education of registered nurses to enhance their practice and their ability to provide quality care. Consider possible outcome measures related to professional practice behaviors, use of evidence based standards, leadership skills, critical thinking/clinical judgment skills, competency, improvement in nursing practice, or improvement in patient outcomes. Including measurement standards with these outcomes, just as you did with the outcome measures for your provider unit, will help you evaluate your effectiveness in these areas. The items listed are only suggestions there may be others that are more pertinent to your particular provider unit. March 20,

4 Just as you did with the quality outcomes for your provider unit, select 2 or 3 outcome measures that you want to work on for the year, design your educational activities and provider unit processes in a way that enables you to track progress in meeting those outcomes, and then evaluate your progress at the end of the year. For the following year, you may want to keep or revise those quality outcome measures and related goals. In your narrative for QO 3, you will be expected to describe your process for collecting and evaluating data to show if, or to what extent you have achieved these outcome measures, and provide a specific example demonstrating how the work of your provider unit has impacted nursing professional development and/or the nurse s ability to provide quality care. NOTE: The following three sections of your application are the narrative portions where you describe your process and give an example related to each criterion. Remember that you should be addressing the who, what, why, where, when, and how aspects of each item in order to provide a complete answer. In addition, look for key words in the heading of the section or the criterion to help you answer the question at hand. For example, SC1 talks about the Primary Nurse Planner s commitment to learner needs. The focus is on commitment to learners in the big picture of the provider unit s operations, not on how you collect needs assessment data for a particular learning activity. We have provided food for thought questions to help you develop your answer. These are NOT the specific questions that need to be answered in your description. Think through each item, and talk with your team about processes and examples before you begin to write. Remember: One or two sentence responses will not provide adequate descriptions or examples. Typically, a thorough description of an example that will lead to a passing score is several sentences long and may be one half page or longer. Do not respond, See attachment or See question X. Do not repeat the same exact example. Structural Capacity (SC) SC 1: COMMITMENT: The primary Nurse Planner s commitment to learner needs, including how approved provider unit processes are revised based on aggregate data, which may include but is not limited to individual educational activity evaluation results, stakeholder feedback, and learner/customer feedback. Key words/phrases here are commitment, learner needs, how processes are revised. Consider the following in developing your answer: 1. How does the Primary Nurse Planner use feedback to change or improve provider unit processes or learning activities? 2. How do you know what styles of learning fit your learners best or what learning modalities (live, webinars, independent study, etc.) they prefer? 3. What do you do with this information? First, describe your process, and then in the next box provide a very specific example. The process description should provide insight into your usual process for collecting, analyzing, and acting on feedback data that helps the provider unit remain responsive to changing learner needs. The beginning March 20,

5 of an example might look something like this: Over the past six months, our hospital has hired a significant number of new registered nurses. Our RN demographic mix is now 53% millennial generation, 35% generation X, and 12% baby boomers. Based on this data, we surveyed all of our RNs to determine their preferred learning styles. We had an 82% response rate to our survey, and based on this data we found that. Therefore we. Provide a description of your process, and then include a specific example. SC 2: ACCOUTABILITY: How the Primary Nurse Planner ensures that all Nurse Planners in the provider unit are appropriately oriented/trained to implement and adhere to the ANCC Accreditation Criteria. Key words/phrases here are primary nurse planner, nurse planners, oriented/trained, implement, and adhere. Questions you might want to consider in developing your response include: 1. How do you orient new nurse planners to your provider unit? 2. How do you keep them updated on changes? 3. How do you monitor to be sure they are doing the right things on a consistent basis? Provide a description of your process, and then include a specific example. SC 3: LEADERSHIP: How the Primary Nurse Planner provides direction and guidance to individuals involved in planning, implementing, and evaluating continuing nursing education (CNE) activities in compliance with Accreditation criteria. Key words/phrases here are Primary Nurse Planner, direction and guidance, compliance Think about these things: 1. As the primary nurse planner, how do you role model maintenance of standards? 2. How do you make your expectations clear to other nurse planners and others involved with CNE activities? 3. What process do you implement to support others who participate on planning committees or engage in the work of providing CNE? 4. How do you help nurse planners problem solve when challenges or questions arise? 5. What leadership skills do you use to guide nurse planners and others in their work? Provide a description of your process and include a specific example. Educational Design Process (EDP) You are expected to have a clearly defined process for developing continuing nursing education activities in accordance with adult learning principles, professional education standards, and standards related to ethical practice and behavior. In this section, your descriptions should clearly show the process you use to conduct each step of the activity planning and evaluation processes for any given learning activity (this section is specific to learning activities, whereas the SC and QO sections are more general). The examples should be related March 20,

6 to how you implemented your process in one specific instance. Note that you may use different examples as you explain your processes; all of the examples do not come from one activity. EDP 1: ASSESSMENT: The process used to identify a problem in practice or an opportunity for improvement (professional practice gap). Key words/phrases here are process, identify, problem or opportunity A professional practice gap can be considered to be the distance (gap) between where a learner is now (point A) and where a leaner should be (point B) in relation to a particular piece of knowledge, skill set, or ability to apply knowledge and skills in the practice setting. An educational activity is designed to move the learner from point A to point B. The activity will not be effective unless and until the professional practice gap is clearly identified, so this is a critical first step in developing an educational activity. 1. How do you define a professional practice gap? 2. How do you know when one exists? 3. How do you determine what the issue is that needs attention? 4. What sources of data might alert you to the existence of a professional practice gap? Provide a description of your process, and then include a specific example. EDP 2: ASSESSMENT: How the nurse planner identifies the educational needs (knowledge, skills, and/or practices) that contribute to the professional practice gap. Key words/phrases here are nurse planner, identifies, educational needs, contribute to 1. What evidence do you use to determine why the professional practice gap exists? 2. How does your needs assessment data support you in doing this gap analysis? Or, conversely, how does identifying the gap help you do a more targeted assessment of the needs of the learners expected to participate in this activity? 3. What resources do you use to identify those underlying needs (example: new national standards; hospital quality data nurse input shows that one department has an abovebenchmark rate of infection) 4. How do you determine whether the gap is in knowledge, skills, or application in practice? 5. How do you use this evidence to determine whether there is an educational need at all, versus an individual compliance or competency issue? Provide a description of your process, and then include a specific example. EDP 3: PLANNING: The process used to identify and resolve all conflicts of interest for all individuals in a position to control educational content. Key words/phrases here: process, identify, resolve, conflicts of interest, control educational content March 20,

7 NOTE: It is always required to identify presence or absence of conflicts of interest. Not applicable is not an acceptable response. 1. How do you and other nurse planners in your provider unit define conflict of interest? 2. Who assesses the nurse planner s conflict of interest for the activity? 3. What happens if the nurse planner has a conflict of interest? 4. What sources of evidence do you include when assessing for conflict of interest? 5. How do you determine who has the ability to control content for an activity? 6. How do you analyze data to determine whether there is a conflict of interest for anyone involved with the learning activity? 7. What happens if someone declines to provide evidence related to conflict of interest for self or spouse? 8. What if the person states that he/she does not have a conflict of interest, but the nurse planner thinks there may be one? 9. What if the person states that he/she has a conflict of interest? What does the nurse planner do to assess if there really is a conflict? 10. What do you do when a conflict of interest is identified when collecting data about the person involved with the activity? 11. What options do you consider in resolving the conflict? 12. In the example, why did you select the option you did, and what happened as a result? 13. If you never have had to resolve a conflict of interest, your example should be based on a situation where you reviewed the COI data and how you determined that no resolution was necessary. Not applicable is not an acceptable response. Provide a description of your process, and then include a specific example. EDP 4: DESIGN PRINCIPLES: How content of educational activities is developed based on best available current evidence to foster achievement of desired outcomes (e.g. clinical guidelines, peer-reviewed journals, experts in the field). Key words/phrases here: content, best available current evidence, desired outcomes 1. Who selects content for the activity? 2. How does the content selected relate to the professional practice gap and evidence supporting the need for the activity (data from EDP 1 and 2)? 3. How do you define best available current evidence? 4. What are sources of evidence typically used to meet identified educational needs? 5. How does the planning committee work with the speaker/author to assure that content and references/resources relate to closing the identified practice gap? 6. How do you validate that the presenter/author is using best available evidence to present the information? 7. What would you do if you suspected that content was not based on best available evidence? 8. Have you used content reviewers to evaluate content to be sure it is based on best available evidence? Provide a description of your process, and then include a specific example. March 20,

8 EDP 5: DESIGN PRINCIPLES: How strategies to promote learning and actively engage learners are incorporated into educational activities. Key words/phrases here: strategies, promote learning, actively engage learners 1. Why is it important that learners be actively engaged? 2. What are common strategies used in your provider unit to engage learners? How do you select which strategies to use for specific educational activities? 3. How do you evaluate the effectiveness of learner engagement strategies in your educational activities? 4. What if learners don t engage? 5. How do the selected teaching methods relate to the identified professional practice gap and contribute to the learners ability to achieve the desired outcome of the activity? Provide a description of your process, then include a specific example. EDP 6: EVALUATION: How summative evaluation data for an educational activity are used to guide future activities. Key words/phrases here: summative, guide future activities 1. How do you collect evaluation data? (NOTE: You are NOT required to have an evaluation form; you are required to have an evaluation process. Think carefully about what data you want to collect to assess whether a practice gap has been closed and how you want to do it for each activity.) 2. How you do select evaluation strategies based on whether the identified gap is in knowledge, skill, or application in practice? 3. How do you summarize evaluation data? 4. Who is responsible for this process? 5. How is it shared, and with whom? 6. What is the purpose of sharing summative evaluation data? 7. How does this data help in planning future learning activities? Provide a description of your process and then include a specific example. EDP 7: EVALUATION: How the Nurse Planner measures change in knowledge, skills, and/or practices of the target audience that are expected to occur as a result of participating in the educational activity. Key words/phrases here: measures change, result of educational activity 1. Given that the purpose of continuing nursing education is to enhance the professional development of the registered nurse and/or improve patient care, what data do you look for to indicate that your educational activity has contributed to that purpose? March 20,

9 2. What evaluation data do you collect to indicate that the previously identified gap has been filled for a given learning activity? 3. How do you measure change? 4. When do you measure change? (Consider both short term and long term strategies) 5. What resources do you use to help you measure change? (Consider quality improvement, risk management, or other existing sources of evidence within your system) 6. What evidence do you look at to show whether or not a learning activity changed nursing practice? 7. How do you hold learners accountable for implementing what they have learned? Provide a description of your process, then include a specific example. Quality Outcomes (QO) The Approved Provider Unit engages in an ongoing evaluation process to analyze its effectiveness and its contributions to improving nursing professional development. QO 1: EVALUATION PROCESS: The process utilized for evaluating effectiveness of the Approved Provider Unit in delivering quality CNE. Key words/phrases here: evaluating effectiveness, delivering quality CNE 1. What is your evaluation plan for your provider unit? 2. What does effectiveness mean for your provider unit? How do you know you are effective? 3. What things, besides your individual activities, do you consider in your evaluation of the effectiveness of your provider unit? What about organization strategic plan, mission, stake holder input, customer satisfaction, opportunities for improvement, and or human and financial resources? 4. How often does your provider unit evaluation process occur? 5. Who engages with you in the evaluation process? 6. Why is it important that you conduct this type of evaluation? Provide a description of your process and then include a specific example. An example would ideally include the results of your most recent approval. QO2: EVALUATION PROCESS: How the evaluation process for the Approved Provider Unit resulted in the development or improvement of an identified quality outcome measure (from OO4a). Key words/phrases here: evaluation process, development/improvement of quality outcome measure (NOTE: This criterion refers directly back to OO4a be sure to review the quality outcome measures for your provider unit before addressing this criterion. Remember that QO2 relates to the effectiveness of the provider unit and is specific to provider unit operations not learner outcomes.) 1. What outcomes measures (identified in OO4a) are you using to evaluate your provider unit? 2. What data have you collected around these outcomes measures? March 20,

10 3. From whom have you collected data about the effectiveness of your provider unit in meeting the pre identified quality outcome measures? 4. How do you analyze this data to determine your effectiveness? 5. Based on that data, what changes have you made to an existing outcome measure? Why? 6. What new outcome measures, if any, have you added? Why? 7. What outcome measures, if any, have you deleted from your priorities? Why? Provide a description of your process, then include a specific example. QO 3: VALUE/BENEFIT TO NURSING PROFESSIONAL DEVELOPMENT: How, over the past 12 months, the Approved Provider Unit has enhanced nursing professional development (refer to identified quality outcomes listed in OO4b). Key words/phrases here: past 12 months, enhanced nursing professional development (NOTE: This criterion refers directly back to OO4b be sure to review your quality outcome measures for nursing professional development before addressing this criteria. Remember that QO3 relates to how your provider unit has contributed to improving the practice of nursing.) 1. How were your learning activities designed to help nurses learn and grow? 2. What evidence do you have that nurses were able to implement what they learned? 3. How did what nurses learned improve their professional development or the care they provided for their patients? 4. How do you know this? 5. What metrics provide supporting evidence that professional growth or change in practice occurred and that professional practice gaps were closed? 6. How do you report and/or share your quality outcomes data with others in your organization? 7. Why does it matter? How do your outcomes benefit the organization as a whole? Provide a description of your process, then include a specific example. Submitting the Self Study Application NEW APPROVED PROVIDER APPLICANTS Your application package to WNA will consist of: 1. The provider application and all required attachments, such as position descriptions and organizational charts. 2. Composite list of all activities that have been approved in the past year. 3. Copies of the actual certificates given to learners for three activities that were approved by WNA. 4. Copies of the summative evaluations for these three activities. March 20,

11 RETURNING APPROVED PROVIDERS Your application package to WNA will consist of: 1. The provider application and all required attachments, such as position descriptions and organizational charts 2. Composite list of all activities that have been planned and implemented in the past year 3. Three complete activity files. Files should be for activities completed within the past year, unless you have had an activity with commercial support and/or sponsorship in the preceding 2 years (see explanation with EDP 10 above). If you conduct activities with commercial support, include one of those activities. If you jointly provide CNE, include a jointly provided activity. If you do blended or an on line learning, provide an example of this as one of your activities. Thank you for your efforts in completing this application and for your commitment to quality continuing education for Registered Nurses. March 20,

12 DEFINITIONS Content Expert: An individual with documented qualifications demonstrating education and/or experience in a particular subject matter. Content Reviewer: An individual selected to evaluate an educational activity during the planning process or after it has been planned but prior to delivery to learners for quality of content, potential bias, and any other aspects of the activity that may require evaluation. You may have someone on your planning committee review the activity content, or you may have a Content Reviewer, who is independent from the planning committee, fulfill this task. Nurse Peer Reviewer: A currently licensed RN with a baccalaureate or higher degree in nursing who is validated as having competence in evaluation of criteria and is actively involved in evaluation of approved provider and/or individual activity applications in relation to ANCC accreditation criteria as a member of an accredited approver unit. Nurse Planner: A currently licensed RN with a baccalaureate degree or higher in nursing who is actively involved in planning, implementation, and evaluation of continuing nursing education activities within the provider unit in adherence with ANCC accreditation criteria. This person is accountable to the primary nurse planner. (Note: there may be additional nurses who serve on a planning committee, but the nurse planner is the person with knowledge of accreditation criteria who is part of the approved provider unit and is accountable for maintaining adherence to criteria in the planning, implementation, and evaluation of the learning activity.) Planning Committee: At least two individuals responsible for planning each educational activity; one individual must be a nurse planner and one individual must have appropriate subject matter expertise Primary Nurse Planner: A currently licensed RN with a baccalaureate degree or higher in nursing who is designated as the Primary Nurse Planner and serves as the liaison between the ANCC Accredited Approver and the approved provider. This person is accountable for all operations of the approved provider unit. RESOURCES American Nurses Association and Association for Nurses in Professional Development (2010). Nursing Professional Development Scope and Standards of Practice. Silver Spring, MD; Author. American Nurses Credentialing Center (2015) ANCC Primary Accreditation Approver Application Manual. Silver Spring, MD., author. CONTACT INFORMATION Mary Kay Scheller, RN, BSN, MS, CHCP, Nurse Peer Review Leader, , wna nprl@metastar.com March 20,