AAOHN Individual Educational Activity. AA-IA Applicant Eligibility Verification

Transcription

1 Section 1: Eligibility AAOHN Individual Educational Activity Applicant Eligibility Verification Applicants interested in submitting an individual educational activity for approval must complete the Eligibility Verification and meet all Eligibility Requirements. Verification forms received from applicants that do not meet Eligibility Requirements will be rejected without substantive review. Johns Hopkins Education and Research Center; Bloomberg School of Public Health Name of Applicant 615 N Wolfe St Room W7517 Street Address Baltimore MD City State Zip/Postal Country Identify Organization Type: X Constituent Member Associations of ANA College or University Healthcare Facility Health - Related Organization Multidisciplinary Educational Group Professional Nursing Education Group Specialty Nursing Organization Other: Describe - Mary Doyle, MPH, RN, BSN, COHN_S/CM Primary Point of Contact: Name and Credentials Director of Continuing Education Title/Position m.doylejhsph.edu Telephone Number Address Has the applicant ever been denied accreditation by ANCC or had its accreditation status suspended or revoked? Yes X No If yes, please provide the following information: Date: Action: Denial Suspension Revocation Rev. 03/14/11 AA-IA Applicant Eligibility Verification Page 1 of 4

2 Brief description: Has the applicant ever been denied approval by or had approval suspended or revoked for an individual activity or a provider application by the AAOHN Approver Unit? Yes X No If yes, please provide the following information: Date: Action: Denial Suspension Revocation Brief description: Has the applicant ever been denied approval by or had approval suspended or revoked for an individual activity or a provider application by another ANCC Accredited Approver? Yes X No If yes, please provide the following information: Date: Action: Denial Suspension Revocation Brief description: A currently licensed registered nurse with baccalaureate degree or higher in nursing is actively involved, as the nurse planner, in the planning, implementing and evaluation process of this continuing education activity. X Yes No Please list the name and credentials of the nurse involved/responsible for this educational activity: Mary Doyle Nurse Planner's Name Credentials MPH, RN, BSN, COHN-S/CM Section 2: Commercial Interest The following section is intended to collect information about the applicant's corporate structure. Some applicant types are automatically exempt from ANCC s definition of a commercial interest, including: Blood banks, Constituent Member Associations, Diagnostic laboratories, Federal Nursing Services, For-profit and not for profit hospitals, For-profit and not for profit nursing homes, For profit and not for profit rehabilitation centers, Group medical practices, Government organizations, Health insurance providers, Liability insurance providers, National nurses organizations based outside the United States, Non-health care related companies, and Specialty Nursing Organizations A single-focused organization* devoted to offering continuing nursing education Rev. 03/14/11 AA-IA Applicant Eligibility Verification Page 2 of 4

3 (* The single-focused organization exists for the single purpose of providing CNE) NOTE: 501c applicants are not automatically exempt. The ANCC Accreditation Program requires 501c applicants to be screened for eligibility. x An "X" on this line identifies the applicant as exempt from ANCC s definition of a commercial interest. Identify the applicant's exemption type from section 2 above and enter it here: For-profit and not for profit hospital If you checked the box above, then you have completed this questionnaire, proceed to Section 5. Section 3 - Only complete this section if applicant organization is not exempt An "X" on this line identifies the applicant as not exempt from the ANCC Accreditation Program s definition of a commercial interest. The following questions must be answered, so AAOHN can assess the applicant's eligibility. Does the applicant produce, market, re-sell, or distribute health care goods or services consumed by, or used on, patients? Yes If yes, the applicant is not eligible for approval of Individual Educational Activities. No If no, complete the next bulleted question Is the applicant owned or controlled by a multi-focused organization (MFO*) that produces, markets, re-sells, or distributes health care goods or services consumed by, or used on, patients? Yes If yes, complete the next bulleted question No If no, this section of the questionnaire is complete, proceed to Section 5. Is the applicant a separate and distinct entity from the MFO*? Yes - If yes, continue to section 4 No - If no, the applicant is not a separate and distinct entity from the MFO* then the applicant is not eligible for approval of Individual Education Activities. * Multi-Focused Organization (MFO) is an organization that exists for more than providing continuing nursing education. Section 4: Commercial Interest Evaluation - Continued Does the multi-focused organization that owns the applicant have a 501-C Non-profit Status? Yes No If no, complete the next bulleted question If yes, does the company that owns the applicant advocate for a commercial interest (as defined by the ANCC Accreditation Program?) Yes If yes, or not sure, please describe the relationship the company that the applicant has with a commercial interest and the types of work the company that owns the Rev. 03/14/11 AA-IA Applicant Eligibility Verification Page 3 of 4

4 No applicant does for or on behalf of a commercial interest that might be considered advocacy. Is any component of the multi-focused organization an entity that produces, markets, re-sells, or distributes health care goods or services consumed by, or used on, patients? Yes If yes, please describe the health care good or service consumed by or used on patients and the role of the entity in producing, marketing, re-selling or distributing those healthcare goods or services. No If no, this section of the questionnaire is complete, proceed to Section 5. If yes, please complete and submit the Individual Activity Eligibility Commercial Interest Addendum with this Form. Section 5: Statement of Understanding On behalf of JHSPH I hereby certify that the information provided on and with this application is true, complete, and correct. I further attest, by my signature on behalf of JHSPH that JHSPH will comply with all eligibility requirements and approval criteria throughout the entire approval period, and that JHSPH will notify AAOHN promptly if, for any reason while this application is pending or during any approval period, JHSPH does not maintain compliance. I understand that any misstatement of material fact submitted on, with or in furtherance of this application for activity approval shall be sufficient cause for AAOHN to deny, suspend or terminate JHSPH approval of this individual activity and to take other appropriate action against JHSPH. (Eligibility Verification forms received without a signature incur a delay in processing which will cause a delay in the review of the individual education activity application.) An X in the box below serves as the electronic signature of the individual completing this form and attests to the accuracy of the information contained. X Electronic Signature (Required) Date _1/7/13 Mary Doyle, MPH, RN, BSN, COHN-S/CM Completed By: Name and Title Please return the completed Eligibility Verification Form and, if necessary, the Individual Activity Eligibility Commercial Interest Addendum with this Form to AAOHN at: (insert and/or address of ANCC Accredited Approver). Rev. 03/14/11 AA-IA Applicant Eligibility Verification Page 4 of 4

5 AAOHN Individual Activity Applicant Eligibility Commercial Interest Addendum Applicants should only complete this addendum if directed to do so by: the Individual Educational Activity Applicant Eligibility Verification Or By AAOHN, the Accredited Approver Name of Applicant Primary Point of Contact: Name, Degree(s) and Credentials Title/Position Telephone Number Address Please answer the following questions to assist in verifying the applicant's eligibility: 1. A re there organizational and procedural safeguards ( corporate firewalls ) in place to ensure that the applicant is separate from any commercial interest listed on the Individual Educational Activity Applicant Eligibility Form? Yes No If no, the applicant is not eligible for approval of individual education activities If yes, complete the following: Multi-Focused Organization (MFO) is an organization that exists for 2. more than providing continuing nursing education A re the applicant s offices physically separate from the MFO or component of the MFO (a Multi-Focused Organization (MFO) is an organization that exists for more than providing continuing education)? Yes No 3. Is the applicant a separate legal entity from the MFO and components of the MFO? Yes No 4. Does the applicant have a separate federal tax identification number from the MFO and components of the MFO? Yes No Deleted: Rev. 3/14/11, 01/01/13 Individual Activities Applicant Eligibility Commercial Interest Addendum Page 1 of 3

6 5. Do any members of the MFO or component of the MFO have the ability to do any of the following: A) Require or suggest information relating to the content of the applicant's CE activities; Yes No B) Review of activity content; Yes No C) Suggest faculty for an activity; Yes No D) Recommend either educational format or methods of evaluation. Yes No 6. Does the applicant share services with the MFO or component of the MFO? Yes No If yes, please list services that are shared and describe how this is accomplished. 7. Please describe any additional information that ensures the applicant is independent of a commercial interest s ownership and control. 8. A re the applicant s servers, phone and fax lines, addresses, web domains, if any, and other information technology infrastructures separated in any way from the MFO or component of the MFO? Yes No 9. Can employees of the MFO or component of the MFO access electronic information concerning the applicant's CE activities stored on the applicant s computers? Yes No If yes, please explain: 10. In connection with the applicant s finances, which of the following does the applicant do? A. Maintain own budget Yes No B. Conduct own grant reconciliation Yes No N/A C. Maintain own Profit/Loss statement(s) Yes No D. Maintain own billing, accounts receivable and payable Yes No Deleted: Rev. 3/14/11, 01/01/13 Individual Activities Applicant Eligibility Commercial Interest Addendum Page 2 of 3

7 E. Issue own W-9 forms. Yes No 10. Is the applicant the employer of record for its own employees? Yes No 11. Does the applicant have any written policies addressing its independence in the manner in which its CE activities are planned and published? Yes No 12. Does the applicant collaborate on any projects with companies that meet the ANCC Accreditation Program s definition of a commercial interest? Yes No 13. Please describe anything else that assures independence of the applicant in connection with its governance structure. Please provide a diagram showing the applicant in relation to the MFO and/or component of the MFO, as applicable. Please indicate which component of the MFO meets the definition of a commercial interest. If there are any written policies regarding assuring the independence of the applicant from the MFO or component of the MFO, please provide copies to AAOHN. Statement of Understanding: An X in the box below serves as the electronic signature of the individual completing this Individual Activity Applicant Eligibility Commercial Interest Addendum and attests to the accuracy of the information given above. Electronic Signature (Required) Completed By: Name and Title Date Please return the completed Addendum to: AAOHN, at Approver@AAOHN.org Deleted: Rev. 3/14/11, 01/01/13 Individual Activities Applicant Eligibility Commercial Interest Addendum Page 3 of 3

8 AAOHN Individual Educational Activity Application Applicants interested in submitting an individual educational activity for approval by AAOHN must complete the following: 1. Individual Activity Applicant Eligibility Verification Form 2. Individual Educational Activity Application (THIS FORM) 3. Individual Activity Applicant Eligibility Commercial Interest Addendum (if applicable) Applicant's Name: Johns Hopkins Education and Research Center, CE Program; Bloomberg School of Public Health Does your activity meet the definition of continuing education? (answer questions below) o Does the content of the educational activity enable the learner to acquire or improve knowledge or skills beyond basic knowledge? X Yes No o Does the content of the educational activity enhance the professional development or performance of the nurse? X Yes No o Is the content of the educational activity generalizable regardless of the employer? X Yes No (note: facility-specific in-service training i.e. policies, procedures, annual competency evaluation, equipment competency or similar are not eligible for awarding continuing education credit) Is the activity eligible for continuing education? X Yes No If no indicated to any question above, the activity is not eligible for approval. Demographic Data: Title of Activity: Navigating Workplace Change Number of contact hours requested: 1.0 Activity Type: X Live - Activity Date(s): 3/13/13 Enduring Material/Web-Based Start Date for Enduring Material/Web-Based Activity: Expiration Date for Enduring Material/Web-Based Activity: Other: Describe: Nurse Planner contact information for this activity Name, Degree(s) & Credentials: Mary Doyle, MPH, RN, BSN, COHN-S/CM Contact Information: 615 N. Wolfe St Room W7517 Baltimore, MD work mdoyle@jhsph.edu Key Element 1: Assessment of Learner Needs - used to identify a gap in knowledge, skills, and/or practice A. Type of needs assessment method used to plan this event (check all that apply): written needs assessment or survey X learners and/or management provided input or requested topic(s) reviewed quality studies and/or performance improvement activities X_ reviewed evaluations of previous educational activities reviewed trends in literature, law and/or healthcare other: describe B. Identify the target audience expected to attend: X RNs in occupational health and safety 03/24/11 revised 01/01/13 Accredited Approver-Individual Activity Application Page 1 of 8

9 all RNs nurse practitioners/arnps LPNs X multidisciplinary: describe industrial hygienists, safety professionals other: describe C. Describe the source of the supporting evidence for the needs assessment and target audience identification (check all that apply and attach supporting evidence marked below): annual member survey data literature review outcome data periodic surveys of stakeholders or learners quality data X requests (e.g., via phone, in person or by ) X written evaluation summary requests other: describe D. Describe how objectives, content and teaching methods reflect the needs assessment (check all that apply): X Nurse Planner and planning committee reviewed needs assessment data X Nurse Planner and planning committee formulated the objectives based on the data X Faculty/presenters/authors worked with Nurse Planner and planning committee to develop objectives, content and teaching methods Other: describe Key Element 2: Qualified Planners and Faculty/Presenters/Authors/Subject Matter Experts: Please complete the table below for each person on the planning committee and include name, educational degree(s), credentials, and role on the planning committee. Planning committees must have a minimum of a Nurse Planner and one other planner to plan each educational activity. The Nurse Planner must be a currently licensed registered nurse with a baccalaureate degree or higher in nursing, be knowledgeable of the CNE process and responsible for adherence to the ANCC criteria. One planner needs to have appropriate subject matter expertise for the educational activity being offered. A. Planning Committee: Committee Member Name Academic Degree(s) Credentials Role on Committee Mary Doyle MPH, BSN, RN COHN-S/CM Nurse Planner (required) Pat Bertsche MPH, BSN, RN COHN-S, FAAOHN Subject Matter Expert (required) 03/24/11 revised 01/01/13 Accredited Approver-Individual Activity Application Page 2 of 8

10 1. The Nurse Planner X_holds a baccalaureate degree in nursing (BSN) and is current on CE criteria through (check all that apply): X reviewed the most current ANCC criteria as provided by the AAOHN in the Instructions for Individual Educational Activity Application for Approval (2013) X_ participated in the AAOHN webinar on the application process date of webinar_1/22/13 other: describe X biographical/conflict of interest (Bio/COI) forms for the Nurse Planner, Subject Matter Expert and any other Planning Committee members including conflict of interest/conflict resolution for is attached. B. Presenters must have documented qualifications that demonstrate their education and/or experience in the content area they are presenting. o Expertise in subject matter can be evaluated based on education, professional achievements and credentials, work experience, honors, awards, professional publications, etc. o The qualifications must address how the individual is knowledgeable about the topic and how expertise has been gained. o Presenters do not have to be nurses, but nurses should address nursing care and nursing implications, as applicable. o The Bio/COI Form must contain information specific to this activity. Faculty/Presenter/Author/Subject Matter Expert Name John Smith Jane Doe MS MS Academic Degree(s) LCPC Credentials LCSW, CEAP, CADC X Biographical/COI Form for each faculty, presenter, or author is attached. C. Describe how the needed qualifications of faculty/presenters/authors are identified (check all that apply): X content expertise demonstrated comfort with teaching methodology (e.g., web-based, etc.) X presentation skills X familiarity with target audience other: describe D. Planning committee assures the qualifications of the faculty/presenters/authors are appropriate and adequate by (check all that apply): X review of resume/cv of faculty/presenter/author X recommendation by colleagues review of literature written by faculty/presenter/author X observation of previous presentation by faculty/presenter/author new faculty/presenter/author being mentored by: other: describe Key Element 3: Effective Design Principles incorporates measurable educational objectives, best-available evidence, and appropriate teaching methods. A. X_Complete and submit the Educational Planning Table which includes identified gaps, purpose and educational objectives (use either the appropriate planning table - Live or Enduring Materials version) 03/24/11 revised 01/01/13 Accredited Approver-Individual Activity Application Page 3 of 8

11 B. Learner Feedback: Check the best description or describe how learners will be provided feedback. X question/answer session return pre/post-test questions with answers engage learners in dialogue follow-up communication following the activity role play return demonstration other - describe: C. Successful Completion: Consistent with the purpose, objectives and teaching/learning strategies 1. Criteria for successful completion for live and enduring material/web-based activities include: (check all that apply) x attendance at entire event or session attendance for at least % of event attendance at 1 or more sessions X completion/submission of evaluation form achieving passing score on post-test. (passing score is: %) return demonstration other - describe: 2. Rationale for method selected above to determine successful completion: (check all that apply) X purpose of event indicated what was needed to successfully complete the activity category of evaluation selected importance of content knowledge importance of content application other - describe: 3. Partial Credit Awarded for Participation X no partial credit is awarded contact hours awarded based on # of minutes attended contact hours awarded for half day (1/2 of total eligible contact hours) contact hours awarded based on # of sessions attended D. Verify Participation Recordkeeping requires a method to collect both the participant s name and a unique identifier X attendance/participation will be verified through sign in sheets/registration form. signed attestation statement by participant verifying completion of entire activity collection of participation verification via computer log other - describe: Key Element 4: Awarding Contact Hours one contact hour = 60 minutes. Activities must be a minimum of 30 minutes (0.5 contact hours). The contact hour may be taken to the hundredths but may not be rounded up (e.g should be 2.75 or 2.7, not 2.8). A. Live Events: If the activity is 3 hours or less, the time frames including evaluation can be placed on Educational Planning Table. Clearly state time spent on welcome, introductions, pre/posttests, presentation, hands-on or clinical experience, breaks and evaluation. If the activity is more than 3 hours, include 3 hours of content on the Educational Planning Table plus an agenda or schedule and advertising for the entire event. The time frames must match and must support the contact hour calculation. B. Enduring materials (print, CD,web-based, etc.): submit completed Educational Planning Table for Enduring Materials. 03/24/11 revised 01/01/13 Accredited Approver-Individual Activity Application Page 4 of 8

12 Key Element 5: Evaluation a clearly defined method to evaluate the effectiveness of educational activity which must include learner input A. Check or describe the methods of evaluation to be used: (check all that apply) X evaluation form (REQUIRED: evaluates each objective and each faculty/presenter/author - attach copy) pre and/or post-test (attach a copy if testing is to be used) return demonstration case study analysis role play other - describe: (attach a copy) Key Element 6: Approval Statement for Individual CNE Activities all communications, marketing materials, certifications, and other documents that refer to awarding contact hours or continuing education credit for an individual educational activity must include the approval statement of the accredited organization (AAOHN). The approval statement must be displayed clearly to the learner, stand alone on its own line of text, and be written exactly as indicated by the Accredited Approver. A. Type of advertising to be used: check all that apply X flyer/brochure memo/letter meeting notice web site social media other - describe: B. Submit a copy of the advertising material including relevant pages of the web site (if applicable). The approval statement must stand alone on its own line of text and be worded as noted below. If advertising is released prior to approval AND after an application has been submitted, the following statements may be used: This activity has been submitted to AAOHN for approval to award contact hours. AAOHN is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. For more information regarding contact hours, please contact AAOHN at or approver@aaohn.org If the advertising is to be released after approval is received, then use the following statement: This continuing nursing education activity was approved by the AAOHN, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. Key Element 7: Documentation of Completion - Learners must receive documentation of successful completion of the educational activity. Document/certificate awarded to each participant must be attached and include: Title and date of the educational activity Contact information of provider of educational activity (name, address, telephone number, , web address) Number of contact hours awarded Official approval statement from AAOHN Name of participant Key Element 8: Commercial Support and Sponsorship 03/24/11 revised 01/01/13 Accredited Approver-Individual Activity Application Page 5 of 8

13 A. X This activity has no commercial support or sponsorship. B. Commercial support/sponsorship has been provided by the following: List name of organization(s) providing commercial support or sponsorship: C. Content integrity has been/will be maintained by: (check all that apply) the commercial support/sponsorship policy/procedure has been discussed with those providing commercial support or sponsorship the commercial support/sponsorship policy/procedure has been shared in writing with those providing commercial support/sponsorship X faculty/presenters/authors have been informed of the policy/procedure re: commercial support and sponsorship and agree to not promote the products or entity providing the financial or in-kind services. X in conjunction with above, the session will be monitored and violators of policy will not be asked to present again. other: describe D. The following precautions have been taken to prevent bias in the educational content: (check all that apply) X commercial support/sponsorship and bias has been discussed with each presenter X X each faculty/presenter/author has signed a statement that says she/he will present information fairly and without bias in conjunction with the above, the session will be monitored and violators of policy will not be asked to present again other - describe E. Attach completed and signed copy of commercial support or sponsor agreement. Key Element 9: Conflict of Interest the potential for conflicts of interest exists when an individual has the ability to control or influence content of an educational activity AND has a financial relationship with a commercial interest A. In reviewing the biographical forms, did the Nurse Planner and/or planning committee suspect that there might be a conflict of interest and/or bias for the Nurse Planner, any planning committee member and/or faculty/presenters/authors not self-reported on the COI form? Yes X No If yes, what was the concern? What was done to resolve it? B. Procedures used to resolve conflict of interest or potential bias if applicable for this activity: (check all that apply) X not applicable since no conflict of interest the Nurse Planner has discussed the conflict with individual (planner, presenter, or author) who is now aware of and agrees to the commercial support/sponsorship policy/procedure. presenter has signed a statement that says she/he will present information fairly and without bias in conjunction with the presenter agreeing with the commercial support/sponsorship policy/procedure and signing a statement, the nurse planner or designee will monitor the session to ensure conflict does not arise other (i.e. remove individual from participating in all parts of the activity; revising the role of the individual; or not awarding contact hours for a portion or all of activity): describe Key Element 10: Written Disclosures Provided to Participants learners must receive disclosure of required items prior to the start of an educational activity. A. Successful Completion of Activity: Must include the purpose and/or objectives plus criteria for successful completion (i.e. required attendance, post-test, completed evaluation form, return demonstration) NOTE: not applicable or n/a is not an acceptable response below. information on advertising material (attach copy) 03/24/11 revised 01/01/13 Accredited Approver-Individual Activity Application Page 6 of 8

14 written information on handouts for activities/directions (attach copy) verbal statement and someone in the audience will witness and document the verbal disclosure (Reminder: place a signed notation in the file to describe the verbal disclosure) X other : describe slide prior to activity (attach copy) B. Absence or Presence of Conflict of Interest for the Nurse Planner, planning committee members, and faculty/presenters/authors, including financial relationships: (check all that apply) X planners disclose no conflict of interest relative to this educational activity X faculty/presenters/authors disclose no conflict of interest relative to this educational activity** ** Lack of conflict of interest disclosed to learners by: information provided in advertising (attach copy) information provided on handouts (attach copy) information provided in print at the start of the non-live activity (attach copy) verbal statement and someone in the audience will document the verbal disclosure (Reminder: place a signed notation in the file to describe the verbal disclosure) X other: describe slide (attach copy) planners disclose a conflict of interest relative to this educational activity [list name(s): and complete 'C' below] faculty/presenters/authors disclose a conflict of interest relative to this educational activity [list name(s): and complete 'C' below] ** Presence of conflict of interest disclosed to learners by: information provided in advertising (attach copy) information provided on handouts (attach copy) information provided in print at the start of the non-live activity (attach copy) verbal statement and someone in the audience will document the verbal disclosure (Reminder: place a signed notation in the file to describe the verbal disclosure) other: describe (attach copy) If there is no conflict of interest disclosed by planners and faculty/presenter/author, skip C. C. Disclosure of Resolution to Learners: Conflicts of interest and resolution for planners and faculty/presenters/authors, including financial relationships, and resolution of such must be disclosed to the learners prior to the educational activity: (check all that apply) ** Conflict of Interest resolution disclosed to learners by: information provided in advertising (attach copy) information provided on handouts (attach copy) information provided in print at the start of the non-live activity (attach copy) verbal statement and someone in the audience will document the verbal disclosure (Reminder: place a signed notation in the file to describe the verbal disclosure) other: describe (attach copy) D. Commercial support/sponsorship or lack thereof : X not applicable information provided in advertising (attach copy) information provided in handouts (attach copy) information provided in print at the start of the non-live activity (attach copy) verbal statement and someone in the audience will document the verbal disclosure (Reminder: place a signed notation in the file to describe the verbal disclosure) other: describe (attach copy) E. Non-endorsement of products displayed in conjunction with this activity: X no products are being displayed (no statement needed) 03/24/11 revised 01/01/13 Accredited Approver-Individual Activity Application Page 7 of 8

15 information provided in advertising (attach copy) information provided in handouts (attach copy) information provided in print at the start of the non-live activity (attach copy) other: describe (attach copy) F. Discussion of off-label use: X faculty/presenters/authors have attested that they will not discuss off-label usage of products. (no statement needs to be made) information will be provided in hardcopy or via electronic media (attach copy) other: describe (attach copy) G. Expiration date for awarding contact hours for enduring materials: X not applicable - not enduring material learners notified how long contact hours will be awarded for the activity on advertising (attach copy) learners notified how long contact hours will be awarded for the activity on directions page(attach copy) Key Element 11: Recordkeeping activity file records must be maintained in a retrievable file (electronic or hard copy) accessible to authorized personnel for 6 years A. Activity File to be stored at (list location): 615 N. Wolfe St. Room W7517, Baltimore, MD Key Element 12: Co-Providership you may co-provide an educational activity with other organizations. The coprovider may not be a commercial interest or sponsor. A. X This activity will not be co-provided. B. This activity is co-provided the signed, written co-provider agreement is attached. Statement of Understanding An X in the box below serves as the electronic signature of the person completing this Individual Educational Activity Application and attests to the accuracy of the information given above. Electronic Signature (Required) Completed By: (Name and Credentials) Date Individual Activity Applicant Nurse Planner Signature: An X in the box below serves as the electronic signature of the Nurse Planner participating in the planning of this educational activity. X Electronic Signature (Required) Mary Doyle,MPH,BSN,RN,COHNS/CM 1/07/13 Completed By: Name and Credentials Date Reference: American Nurses Credentialing Center. (2011). Educational design process ANCC Primary Accreditation Application Manual for Providers and Approvers, chapter 3, /24/11 revised 01/01/13 Accredited Approver-Individual Activity Application Page 8 of 8

16 AAOHN Educational Planning Table Live CNE Activity (2013 criteria) Note: Time spent for questions/answers and evaluating the learning activity may be included in the total time when calculating contact hours. Rev. 06/12/12 Effective 01/01/13 Individual Activity Applicant Educational Planning Table Live

17 Title of Activity: Navigating Workplace Change AAOHN Educational Planning Table Live CNE Activity (2013 criteria) Identified Gap(s): _OHN s need to understand and accept the constant of change in the workplace. Description of current state: OHN s are impacted by change on a daily basis in today s work environment and do not feel equipped to handle this change. Description of desired/achievable state: OHN s have the knowledge to understand and manage change in an effective manner in the workplace. Gap to be addressed by this activity (what is missing that identifies the need for this activity/content list any identified gap based on the needs assessment. More than one may apply): X Knowledge Skills Practice Other: Describe Purpose: (write as an outcome statement, e.g. "The purpose of this activity is to enable the learner to Maximize the effectiveness of the occupational health professional in managing workplace change OBJECTIVES List learner s objectives in behavioral terms. 1. List the principles of workplace change 2.Describe strategies to build resilience and pace yourself to avoid burnout. CONTENT (Topics) Provide an outline of the content for each objective. It must be more than a restatement of the objective. Introduction of the principles behind the concept of workplace change from globalization to new processes and technology Understand and accept the constant of change Steps to be successful and build resilience by developing new skills to evolve with an everchanging environment TIME FRAME State the time frame for each objective 10 minutes 10:15 10:25 am CST 40 minutes 10:25 11:05 am CST PRESENTER List the Faculty for each objective. John Smith, MS, LCPC John Smith, MS, LCPC TEACHING METHODS Describe the teaching methods, strategies, materials & resources for each objective Lecture PowerPoint Q & A Lecture PowerPoint Q & A Lecture 3.Outline steps to support your Outline steps to thrive 10 minutes Jane Doe, LSCW, CEAP, organization s goals through through change instead of 11:05 11:15 CADA times of change. working against it: am CST PowerPoint 1. revisit goals and embrace new opportunites Q & A 2. learn to work and communicate with changing teams Rev. 06/12/12 Effective 01/01/13 Individual Activity Applicant Educational Planning Table Live

18 AAOHN Educational Planning Table Live CNE Activity (2013 criteria) Outline sources for support, example: Employee Assistance Programs (EAP) List the evidence-based references used for developing this educational activity (e.g. evidence-based practice, literature/peer-reviewed journals, clinical guidelines, best practices or content experts/expert opinion): Total Minutes 60 divided by 60 = 1.0 contact hour(s) Mary L. Doyle, MPH, RN, BSN, COHN-S/CM 1/07/13 Completed By: Name, Degree(s) and Credentials Date r Rev. 06/12/12 Effective 01/01/13 Individual Activity Applicant Educational Planning Table Live

19 AAOHN Educational Planning Table - Enduring Material (2013 Criteria) Title of Activity: Identified Gap(s): Description of current state: Description of desired/achievable state: Gap to be addressed by this activity: Knowledge Skills Practice Other: Describe Purpose: (write as an outcome statement, e.g. "The purpose of this activity is to enable the learner to.. ) 1. OBJECTIVES List learner s objectives in behavioral terms CONTENT (Topics) Provide an outline of the content for each objective. It must be more than a restatement of the objective. AUTHOR List the author for each for each objective List the evidence-based references used for developing this educational activity: Method of calculating contact hours: Pilot Study Historical Data Complexity of Content Other: Describe Estimated Number of Contact Hours to be awarded: Completed By: Name and Credentials Date Rev. 06/12/12 Individual Activity Applicant Educational Planning Table Enduring Material Page 1 of 1

20 AAOHN Biographical and Conflict of Interest Form Title of Educational Activity: Navigating Workplace Change Education Activity Date: 3/13/13 Role in Educational Activity: (Check all that apply) X Nurse Planner Content Reviewer/Expert Planning Committee Member Speaker/Presenter/Author Other Describe: Section 1: Demographic Data Name with Credentials: _Mary Doyle, MPH, RN, BSN, COHN-S/CM If RN, Nursing Degree(s): AD Diploma X BSN Masters Doctorate If non-rn, Degree(s): Bachelors Masters Doctorate Address: 615 N. Wolfe St Room W7517 Baltimore, MD Phone Number: Address: mdoyle@jhsph.edu Current Employer and Position/Title: _Director of Continuing Education, Johns Hopkins Bloomberg School of Public Health Section 2: Expertise Please describe expertise, other credentials and years of training specific to the educational activity listed above. (If the description of expertise does not provide adequate information, the AAOHN may request additional documentation.) _29 years experience as an occupational health nurse; 14 as a clinical occupational health nurse, 5 as a consultant and 10 years as director of professional continuing education for occupational health and safety at a NIOSH sponsored university program. Section 3: Conflict of Interest The potential for conflicts of interest exists when an individual has the ability to control or influence the content of an educational activity and has a financial relationship with a commercial interest, the products or services of which are pertinent to the content of the educational activity. * *A commercial interest, as defined by ANCC, is any entity producing, marketing, reselling, or distributing healthcare goods or services consumed by or used on patients, or an entity that is owned or controlled by an entity that produces, Individual Activity BIO/COI Form, 2013 criteria, 01/01/13

21 markets, resells, or distributes healthcare goods or services consumed by or used on patients. Nonprofit or governmental organizations, non-healthcare-related companies, and healthcare facilities are not considered commercial interests. Based on the definition of commercial interest above, is there an actual, potential or perceived conflict of interest for yourself or spouse/partner? Yes X No If yes, complete the table below for all actual, potential or perceived conflicts of interest: Check all that apply Category Description Salary Royalty Stock Speakers Bureau Consultant Other Section 4: Conflict Resolution - All conflicts of interest, including potential ones, must be resolved prior to the planning, implementation, or evaluation of the CNE educational activity by the Nurse Planner** ** if this form is for the Nurse Planner, an individual other than the Nurse Planner (i.e. Planning Committee) must review and sign Procedures used to resolve conflict(s ) of interest or potential bias if applicable for this activity: Check all that apply X Not applicable since no conflict of interest. Removed individual, with conflict of interest, from participating in all parts of the educational activity. Revised the role of the individual with conflict of interest so that the financial relationship is no longer relevant to the educational activity. Not awarding contact hours for a portion or all of the educational activity. Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicators of integrity, and absence of bias, AND monitoring the educational activity to evaluate for commercial bias in the presentation. Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicators of integrity, and absence of bias, AND reviewing participant feedback to evaluate for commercial bias in the activity. Other - Describe: Section 5: Statement of Understanding An X in the box below serves as the electronic signature of the individual completing this Biographical/Conflict of Interest Form and attests to the accuracy of the information given above. X Electronic Signature (required) Mary Doyle, MPH, RN, BSN, COHN-S/CM 1/7/13 Completed By: Name, Degree(s), Credentials Date Individual Activity BIO/COI Form, 2013 criteria, 01/01/13

22 An X in the box below serves as the electronic signature of the Nurse Planner or other person** reviewing the content of this Biographical/Conflict of Interest Form. X Electronic Signature (required) Patricia Bertsche, MPH, RN, BSN, COHN-S, FAAOHN 1/7/13 Completed by: Name, Degree(s), Credentials Date Individual Activity BIO/COI Form, 2013 criteria, 01/01/13

23 Individual Activity Applicant Co-Provider Agreement Individual Activity Applicants may co-provide educational activities with other organizations. The coproviding organization may or may not be an ANCC accredited or approved organization. The coproviding organization may not be a commercial interest or sponsor. The Individual Activity Applicant s Nurse Planner must be on the planning committee and is responsible for ensuring adherence to the ANCC accreditation criteria. The Individual Activity Applicant is referred to as the provider of the educational activity. The other organization(s) are referred to as the co-provider(s) of the educational activity. In the event that two or more organizations are ANCC accredited or approved, one will act as the provider of the educational activity and the other(s) will act as the co-provider(s). A qualified Nurse Planner from the Individual Activity Applicant organization must be involved in planning, implementing and evaluating the educational activity to include: developing objectives and content, selecting planners, presenters, faculty, authors and/or content reviewers, awarding contact hours, recordkeeping procedures, developing evaluation methods and managing commercial support and/or sponsorship. Decision-making responsibility may be shared collaboratively between the Individual Activity Applicant and the co-providing organization(s), however final responsibility rests with the Individual Activity Applicant when awarding ANCC contact hours. The Individual Activity Applicant acting as the provider of the educational activity is responsible for obtaining a written co-provider agreement signed by an authorized representative of the co-provider that includes the following: Name of Individual Activity Applicant acting as the provider The name(s) of the organization(s) acting as the co-provider(s) Statement of responsibility of the provider, including the provider s responsibility for: o Determining educational objectives and content o Selecting planners, presenters, faculty, authors and/or content reviewers o Awarding of contact hours o Recordkeeping procedures o Evaluation methods o Management of commercial support or sponsorship Name and signature of the individual legally authorized to enter into contracts on behalf of the Individual Activity Applicant Name and signature of the individual legally authorized to enter into contracts on behalf of the co-provider(s) Date the agreement was signed Co-Provider Agreement - Individual Activity Applicant, 01/01/13 Page 1 of 3

24 AGREEMENT FOR COPROVIDING A CONTINUING EDUCATION ACTIVITY This educational activity is being co-provided by Johns Hopkins Education and Research Center; Bloomberg School of Public Health and Abbott Labs Global Occupational Health Services. Title of Activity: Navigating Workplace Change Date(s) if live presentation: 3/13/13 Date to begin if enduring material: Total number of Contact Hours: 1.0 Individual Activity Applicant Nurse Planner's Name: Mary L. Doyle, MPH, RN, BSN, COHN-S/CM Each item must be checked to reflect the appropriate responsibility. Those items indicated as Required are the responsibility of the Individual Activity Applicant. Responsibilities Determining educational objectives and content Selecting planners, presenters, faculty, authors and/or content reviewers Determining appropriate number of and awarding ANCC contact hours Recordkeeping procedures Evaluation method Management of commercial support or sponsorship Other items (suggestions only): Marketing Printing Registration Supplies: List: Physical location Audio-visual supplies Food Other: Other: Individual Activity Applicant Johns Hopkins ERC Johns Hopkins ERC Johns Hopkins ERC Johns Hopkins ERC Johns Hopkins ERC Johns Hopkins ERC Co-Provider Name Abbott Labs Abbott Labs Abbott Labs Abbott labs Co-Provider Agreement - Individual Activity Applicant, 01/01/13 Page 2 of 3

25 Other: Other: Financial considerations are often not part of the co-provider agreement. However, there may be decisions related to costs or revenue and those can be included below. If exchange of money is included as part of the agreement, it is recommended that the financial arrangements be stipulated in the coprovider agreement. Co-providing an educational activity is a collaborative venture that requires the direct involvement of the Nurse Planner. Contact Hours may not be purchased. FINANCIAL AGREEMENT The following is a description of financial responsibilities of the Individual Activity Applicant and the co-provider(s): 1. Abbott Labs Global Occupational Health Services will register participants. There is no registration fee for this event, thus no revenue is generated or shared. 2. Johns Hopkins ERC will pay all CNE approval/application fees to AOAHN. 3. Abbott Labs Global Occupational Health Service will reimburse the Johns Hopkins ERC for the all approval/application fees. 4. Individual Activity Applicant Representative, Name and official title: Mary Doyle, Director of Continuing Education Signature of Individual Activity Applicant Representative: Mary Doyle Name of Individual Activity Applicant organization: Johns Hopkins Education and Research Center Bloomberg School of Public Health Co-Provider Representative Name and official title: _Ellen White Senior Occupational Health Specialist Signature of Co-Provider Representative: Ellen White Co-Provider Name/Agency: Abbott Labs, Global Occupational Health Services Address:1700 Green Drive, Baltimore, MD Phone: address_ellen.white@abbott.com Co-Provider Agreement - Individual Activity Applicant, 01/01/13 Page 3 of 3

26 ACTIVITY EVALUATION FORM To assist in evaluating the effectiveness of this activity, complete this tool by marking the appropriate rating. Return the completed form as instructed to receive your contact hour certificate. Title of Activity: Navigating Workplace Change Date: 3/13/13 Please use this scale to evaluate the activity using the key below: 4 - To a GREAT extent 3 - To SOME extent 2 - To LITTLE extent 1 - To NO extent I. General Evaluation A. Objectives (List each objective from Documentation Form) GREAT SOME LITTLE NO 1. List the principles of workplace change 2. Describe the strategies to build resilience and pace yourself to avoid burnout Outline steps to support your organization s goals through times of change B. The objectives were relevant to the overall purpose(s). (List all purposes) Maximize the effectiveness of the occupational health professional in managing workplace change. C. The teaching strategies were appropriate for the Objectives and content II. Faculty Evaluation Faculty expertise enhanced the presentation (List each faculty/presenter) John Smith Jane Doe Was there any obvious influence toward a commercial product or service? How does this educational activity link to your practice? Comments: AAOHN EFFECTIVE 01/04/10

27 Sample Disclosure Statement The planners and faculty members for this offering present no conflicts of interest affecting this continuing education activity. There is no commercial support involved in this activity. Participants must attend the entire offering to receive the full continuing education contact hour. A course evaluation must be completed before the participant will receive their continuing education certificate. (Individualize statements to your activity)

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