Approver Policies

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					       Sample Continuing Education Approver Unit Policies
                       Table of Contents

Communication with ANCC Commission on Accreditation                                     2
Maintenance of Records, Storage, Confidentiality and Retrieval                          3
Separation of Provider and Approver Unit Activities                                     5
System for Awarding Credit                                                              6
Use of ANCC Commission on Accreditation Criteria                                        8
Use of Appropriate ANCC Language                                                        11
Sponsorship and Commercial Support Guidelines                                           12
Sample Commercial/Exhibitor Support Agreement                                           18
Sample Exhibitor Agreement                                                              22
Conflict of Interest Guidelines                                                         23
Honoraria                                                                               28
Enduring Materials                                                                      31
Program Coordinator Selection Criteria and Major Responsibilities                       33
CE Review Coordinator Selection Criteria and Major Responsibilities                     34
Director of CE/Lead Nurse Peer Reviewer Selection Criteria and Major Responsibilities   36
Appeal of Peer Review Action                                                            37
Application Action Options                                                              38
Application Withdrawal                                                                  40
Monitoring of Activities                                                                41
CE Peer Review Education                                                                43
Sample Peer Reviewer Qualifications Form                                                44
Revocation of Approval Status                                                           45
Executive Director/Lead Nurse Planner Selection Criteria and Major Responsibilities     46
Nurse Peer Reviewer Selection Criteria and Major Responsibilities                       47




                                                  1
                          COMPONENT:           8.0 Continuing Education Approver Unit
                          SUBJECT:             8.1* Communication with ANCC Commission
                                               on Accreditation




POLICY:                   The CE Approver Unit will maintain timely communication with the ANCC
                          Commission on Accreditation by providing at a minimum:
                             1.  Required and/or requested reports.
                             2.  Within 30 days, information about change in
                             3.  Name, ownership, or structure of the organization,
                             4.  Change in the nurse(s) responsible for the peer review
                                 approval process, or
                              5. Change in the name of the contact person,
                          Information about termination of accredited approver activities
                          within 30 days of the decision to terminate.

                          All continuing education nurse planners, course administrators,
                          course planning committee members, course faculty, commercial
                          supporters (sponsors, grantors, and exhibitors), course
                          participants, and Approver Unit administrators are covered by this
                          policy.
EFFECTIVE DATE:           1994
REVIEWED:                 2000, June 2006, January 2010
APPROVED BY:              CE Steering Committee
RESPONSIBLE               ACTION:
PERSON(S):
Executive Director/Lead   Responds in writing to the ANCC Commission on Accreditation:
Nurse Planner               1. requests for data about the approval process.
                            2. any organizational changes affecting the Approver Unit.
                            3. regarding termination of CE approval activities.

                          Once CE approval activities are terminated, accepts no more
                          applications for approval of CE activities or for approval as a
                          provider.

                          Notifies the public of termination of CE approval status.

                          Notifies, in writing, providers of approved CE activities and
                          approved providers of the termination of approval activities, the
                          impact on their approval status, and where they might seek future
                          approval.


                                                 2
               COMPONENT:          8.0 Continuing Education Approver Unit
               SUBJECT:            8.2* Maintenance of Records, Storage, Confidentiality
                                   and Retrieval



POLICY:        Records will be maintained for six (6) years. For two (2) years, files are kept in
               storage for immediate access. After two years, files are moved to long term
               storage. After six years, files are destroyed by shredder. Confidentiality of
               records is maintained.

               All continuing education nurse planners, course administrators, course planning
               committee members, course faculty, commercial supporters (sponsors,
               grantors, and exhibitors), course participants, and Approver Unit administrators
               are covered by this policy.
EFFECTIVE      1994
DATE:
REVIEWED:      June, 2006, January 2010
APPROVED BY:   CE Steering Committee
RESPONSIBLE    ACTION:
PERSON(S):
Program        Records will be maintained for six (6) years and include the following:
Coordinator
               Planning
CE Review          Description of the target audience
Coordinator        Method and findings of the needs assessment
                   Names, titles, and expertise of the activity planners and presenters
                   Conflict of interest disclosure statements from planners and presenters,
                     as well as resolutions of conflict of interest, as appropriate
                   Learning purpose/goal, objectives, and content
                   Instructional activities, delivery methods, learner feedback mechanisms,
                     and resources to be used
                   Methods or processes used to verify participation
                   Notice to learners to identify how successful completion will be measured
                   Marketing and promotional materials
                   Division of responsibilities among Coproviders as appropriate
                   Means of ensuring content integrity with sponsorship or commercial
                     support (if applicable)
                   The written commercial support agreement as required in standards of
                     commercial support for any activity receiving commercial support
                   Signed Coprovider agreement (as appropriate)




                                              3
Implementation
    Title, location, and date of the educational activity
    All evaluation tools used, including summative evaluations
    Participant names and unique identifier information (such as an
     automatically generated number, password code, the month and date of
     birth, address, etc.)
    Sample certificate of completion
    Number of contact hours associated with official accreditation statement
     awarded to individual participants
    Documentation of verbal provision of required disclosures (if applicable)

Information concerning applicant/applications will not be shared outside of the
approval process.

Electronic files are password protected. Only employees with a specific,
assigned user ID and password may access database information.

The Program Coordinator will maintain the appropriate files in a file cabinet or in
an electronic file for the appropriate period of time.




                               4
                     COMPONENT:           8.0 Continuing Education Approver Unit
                     SUBJECT:             8.3* Separation of Accredited Provider and
                                          Approver Unit Activities



POLICY:              AzNA‘s provider and approver units maintain separate and distinct:
                       a. policies and procedures
                       b. quality improvement activities
                       c. storage of records

                     All continuing education nurse planners, course administrators,
                     course planning committee members, course faculty, commercial
                     supporters (sponsors, grantors, and exhibitors), course
                     participants, and Approver Unit administrators are covered by this
                     policy.
EFFECTIVE            1993
DATE:
REVIEWED:            2000, June 2006; January 2010
APPROVED BY:         CE Steering Committee
RESPONSIBLE          ACTION:
PERSON(S):
Executive Director   Maintains a separate policy and procedure manual for:
                         Accredited Provider Unit
                         Approver Unit
Continuing           Designs and implements approval processes and quality
Education            improvement activities solely for approver unit activities.
Steering
Committee
CE Review            Maintains separate, secure, and confidential record storage and
Coordinator          files for:
                          Accredited Provider Unit
Program                   Approver Unit
Coordinator




                                             5
               COMPONENT:          8.0 Continuing Education Approver Unit

               SUBJECT:            8.4* System for Awarding Credit




POLICY:          The ANCC Commission on Accreditation system of awarding credit will be
                 used:
                   a. The appropriate measure of credit is the 60 minute contact hour.
                   b. A contact hour is 60 minutes of an organized learning activity, which is
                       either a didactic or clinical experience or evaluating the activity.
                   c. The minimum number of contact hours to be awarded is 0.5 contact
                       hours.
                   d. After the first contact hour, fractions or portions of the 60 minute hour
                       should be calculated. For example, 150 minutes of learning experience
                       equals 2.5 contact hours.
                   e. Welcome, introductions, breaks and viewing of exhibits are not included
                       in calculation of contact hours.
                   f. Learning activities may be conducted ―asynchronously‖ or may be
                       ―bundled‖ to allow a full learning experience to take place. ‗If ―rounding‖
                       is desired in the calculation of contact hours, the activity should be
                       rounded down to the nearest 1/10th or 1/100th.
                   g. Contact hours may not be awarded retrospectively.

               All continuing education nurse planners, course administrators, course planning
               committee members, course faculty, commercial supporters (sponsors, grantors,
               and exhibitors), course participants, and Approver Unit administrators are
               covered by this policy.
EFFECTIVE      1994
DATE:
REVIEWED:      2000, June 2006; January 2010
APPROVED BY:   CE Steering Committee




                                             6
CE Review Panel   When calculating contact hours, add the total minutes of the educational
and Provider      session, then divide by 60. Instructional time, quizzes, exams, questions and
Review Panel      answer sessions, reviews and evaluation time may be included in the
members           calculation of contact hours. If break time is not specified, a 15 minute break will
                  be deducted for each 4 hour segment of CE. Do not include welcome,
                  introductions, breaks, and/or viewing of exhibits in the calculation of contact
                  hours.

                                                Example:
                    9:00 am to 10:00 am Speaker A         60 mins
                    10:00 am to 10:45 am Concurrent Session: 45 mins
                                Speaker B or C
                    11:00 am to 12:30 pm Speaker D         90 mins

                    Total = 195 minutes  60 = 3.25 contact hours

                  (Note: Contact hours are based on the total minutes one participant is able to
                  attend, not the total minutes of the entire educational activity (e.g., concurrent
                  sessions‘ contact hours are not totaled.)

                  A single contact hour certificate may be given for an entire CE activity. The
                  participant must be present for the entire activity to receive a certificate. This is
                  appropriate to a CE activity design that is integrated, requiring full participation
                  to achieve the overall educational goal.

                  Contact hour certificates may also be given for portions of a CE activity. The
                  participant must be present for the entire portion of the CE activity in order to
                  receive a certificate for that portion of the CE activity. This is appropriate to a CE
                  activity design with separate portions or sessions that can stand independently.
                  Independent Learning Activity (i.e. journal article, online course)
                  Mergener Formula= 0.9 X 22.3+(0.00209xW)+(2.78xQ)+(15.5xD)] where
                  W = number of words
                  Q = number of test questions
                  D = degree of difficulty
                  For example in a learner paced course of 7,500 words and 30 test
                  questions….
                                 1.     -22.3 (negative 22.3) = (22.3)
                                 2.     # words (7,500) x (0.00209) = 15.675
                                 3.     # questions = 30 x 2.78 = 83.40
                                 4.     Difficulty Score is 5 x 15.5 = 77.5
                                 So…(22.3) + 15.765 + 83.40 + 77.5 = 154.365
                  2. Multiply 154.365 x 0.9 = 138.928 minutes
                  3. Divide 138.928 by 60 = 2.3 contact hours
CE Review         Recalculate contact hours awarded when random applications are audited.
Coordinator



                                                 7
                  COMPONENT:          8.0 Continuing Education Approver Unit
                  SUBJECT:            8.5* Use of ANCC Commission on Accreditation
                                      Criteria



POLICY:           ANCC Commission on Accreditation educational design criteria must be
                  used to plan and implement all nursing continuing education activities.

                  All continuing education nurse planners, course administrators, course
                  planning committee members, course faculty, commercial supporters
                  (sponsors, grantors, and exhibitors), course participants, and Approver Unit
                  administrators are covered by this policy.
EFFECTIVE DATE:   1992
REVIEWED:         1997, 2000, June 2006; January 2010
APPROVED BY:      CE Steering Committee
RESPONSIBLE       ACTION:
PERSON(S):




                                         8
CE Review           When an application is submitted refer to 8.16 policy Application Action
Coordinator         Options.

Peer Review Panel   Utilize checklist of acceptable ANCC criteria and appropriate application
                    (see www.aznurse.org) when reviewing applications.
Provider Review
Panel               Utilize current ANCC Manual for the Accreditation Program for clarification
                    as needed.

                    The following educational design criteria and evidence must be
                    followed/provided for each educational activity:
                     Registered nurses must be involved in the continuing education
                        planning process. This includes a minimum of the Nurse Planner from
                        the Provider Unit and at least one other individual.
                     The continuing education activity is developed in response to the
                        educational needs of the target audience.
                     A gap in knowledge is identified and the purpose/goal(s) for the activity
                        is clearly stated.
                     The measurable educational objectives define the expected outcomes
                        for the learner.
                     The content is related to and is consistent with the activity objectives.
                        Each objective has corresponding content.
                     Content specialists with knowledge and expertise in the content area are
                        utilized as needed to design the learning activity.
                     The teaching/learning resources support achievement of objectives and
                        are congruent with the overall design of the learning activity.




                                           9
   Learners are informed in advance of the activity‘s purpose/goal and
    learning objectives and the criteria to be used to determine successful
    completion of the activity.
   Designated criteria must be used to verify participation and completion
    of the learning activity.
   Contact hours are calculated in a logical and defensible manner.
   The designated evaluation process is used for each activity and
    includes the following:
        Relationship of objectives to overall purpose/goal(s) of activity
        Learner‘s achievement of each objective
        Effectiveness of teaching/learning resources
        Time required of the learner to complete the activity
   Feedback (periodic and/or final) is provided to the learner by test item
    feedback and certificates of completion.
   All communications, marketing materials, certificates, and other
    documents that refer to approval status must contain the official
    approval statement.
   Participants receive written verification of the successful completion of
    the activity.
   Appropriate commercial support, conflict of interest, and relevant
    financial interest guidelines are followed.
   Appropriate disclosures are provided to activity participants prior to
    start of the activity.
   Records are secured and maintained in a confidential manner.
   Co-provided activities follow the stated guidelines.




                       10
                  COMPONENT:        8.0 Continuing Education Approver Unit
                  SUBJECT:          8.6* Use of Appropriate ANCC Language




POLICY:           The ANCC Commission on Accreditation is recognized by the AzNA Approver
                  Unit through the required use of specific approval language.

                  Appropriate language and recognition of ANCC Commission on
                  Accreditation system must be used on all communications, marketing
                  materials, certificates of completion, and other documents that refer to the
                  Approver Unit’s ANCC-accredited status, approved CE activities, or for
                  Approved Providers must contain the official accreditation statement.
                  All continuing education nurse planners, course administrators, course planning
                  committee members, course faculty, commercial supporters (sponsors,
                  grantors, and exhibitors), course participants, and Approver Unit administrators
                  are covered by this policy.
EFFECTIVE         1992
DATE:
REVIEWED:         June 2006; January 2010
APPROVED BY:      CE Steering Committee
RESPONSIBLE       ACTION:
PERSON(S):
Director of       Assures that a section in the application form addresses the accreditation status
Continuing        of AzNA.
Education/Nurse
Peer Review       “The Arizona Nurses’ Association is accredited as an approver of continuing
Leader            nursing education by the American Nurses Credentialing Center (ANCC)
                  Commission on Accreditation.”
CE Review Panel                             For approved CE activities
members           “This continuing nursing education activity is approved by the Arizona Nurses
                  Association, an accredited approver by the American Nurses Credentialing
CE Review         Center’s Commission on Accreditation.”
Coordinator                                   For approved providers
                  “(Name of Approved Provider) is an approved provider of continuing nursing
                  education by the Arizona Nurses Association, an accredited approver by the
                  American Nurses Credentialing Center’s Commission on Accreditation.”
                  Determine that all communications, marketing materials, certificates of
                  completion, and other documentation contain correct terminology and indicate
                  on review checklist before assigning category of approval.




                                               11
               COMPONENT:          8.0 Continuing Education Approver Unit
               SUBJECT:            8.7* Sponsorship and Commercial Support Guidelines




               Accreditation refers to recognition of continuing nursing education only
POLICY:        and does not imply Commission on Accreditation approval or
               endorsement of any commercial product.


               All continuing education nurse planners, course administrators, course
               planning committee members, course faculty, commercial supporters
               (sponsors, grantors, and exhibitors), course participants, and Approver Unit
               administrators are covered by this policy.
EFFECTIVE      January 2010
DATE:
REVIEWED:
APPROVED BY:   CE Steering Committee
RESPONSIBLE    ACTION:
PERSON(S):
               For the purposes of this policy, the following definitions are provided:

               Commercial Interest—Any entity either producing, marketing, re-selling, 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, markets, re-
               sells, or distributes healthcare goods or services consumed by, or used on,
               patients. Exceptions are made for no-profit or government organizations and
               non-healthcare related companies. The definition allows an accredited provider
               to be owned by a firm that is not a commercial interest. It also allows a
               provider to have a ‗sister company‘ that is a commercial interest, as long as the
               accredited provider maintains corporate firewalls to prohibit any influence or
               control by the ‗sister company‘ over the continuing education program of the
               accredited provider. In this case, ANCC would expect that the accredited
               provider would have an adequate corporate firewall in place to prohibit any
               influence or control by the ‗sister company‘ over the continuing education
               program. ANCC does not consider providers of clinical service directly to
               patients to be commercial interests.

               Commercial Support—Financial, or in-kind contributions given by a
               commercial interest, which is used to pay all or part of the costs of a continuing
                                            12
education activity.
    ANCC does not consider providers of clinical service directly to patients
      to be commercial interests. For the purposes of eligibility, ANCC
      considers the following types of organizations eligible for accreditation
      and free to control the content of continuing education:
          o Liability insurance providers
          o Health insurance providers
          o Group medical practices
          o Acute care hospitals (for-profit and not-for-profit)
          o For profit rehabilitation centers
          o For-profit nursing homes
          o Universities with nursing development and continuing nursing
             education programs
          o Specialty Nursing Organizations
          o Constituent Member Associations
          o Federal Nursing Services
          o National nurses organizations based outside the United States
          o a single-focused organization devoted to offering continuing
             education

Financial relationships—ANCC defines ―financial relationships‖ as those
relationships in which the individual benefits by receiving a salary, royalty,
intellectual property rights, consulting fee, honoraria, ownership interest (e.g.,
stocks, stock options, or other ownership interest, excluding diversified mutual
funds), or other financial benefit. Financial relationships can also include
‗contracted research‘ where the institution gets the grant and manages the
funds and the individual is the principal or named investigator on the grant.
Financial benefits are usually associated with roles such as employment,
management position, independent contractor (including contracted research),
consulting, speaking and teaching, membership in advisory committees or
review panels, board membership, and other activities from which
remuneration is received, or expected. ANCC considers relationships of the
person involved in the continuing education activity to include financial
relationships of a family member.

Relevant financial relationships—ANCC considers financial relationships in
any amount occurring within the past 12 months as ―relevant‖ in terms of
creating a conflict of interest.

Off label—Using products for a purpose other than that for which it was

                             13
approved by the Food and Drug Administration (FDA).‖

    To maintain the integrity of continuing education programs receiving
     commercial support, the Approver Unit will assure that whenever
     commercial products are displayed, the appropriate accreditation statement
     reflecting this policy must appear on all written materials.

    Accreditation refers to recognition of continuing nursing education only and
     does not imply AZNA or ANCC Commission on Accreditation approval or
    endorsement of any commercial products displayed in conjunction with an
                                       activity.

    The Approver Unit will also ensure that the following standards are met:
      The source of all support from entities with commercial interests must be
        disclosed to learners. When commercial support is other than monetary
        support, the nature of the support must be disclosed to learners.
      ‗Disclosure‘ must never include the use of a trade name or a product-
        group message.
      The Approver Unit must disclose the above information to learners prior
        to the beginning of the educational activity.
      Arrangements for commercial exhibits or advertisements cannot
        influence planning or interfere with the presentation, nor can they be a
        condition of the provision of commercial support for continuing education
        activities.
      Product-promotion material or product-specific advertisement of any
        type is prohibited in or during continuing education activities. The
        juxtaposition of editorial and advertising material on the same products
        or subjects must be avoided.
      Live (staffed exhibits, presentations) or enduring (printed or electronic
        advertisements) promotional activities must be kept separate from
        continuing education.
             Print, advertisements and promotional materials shall not be
                interleafed within the pages of the continuing education content.
                Advertisements and promotional materials may face the first or
                last pages of printed continuing education content as long as
                these materials are not related to the continuing education
                content they face and are not paid for by the entities with
                commercial interests in the continuing education activity.
             Computer-based, advertisements and promotional materials
                shall not be visible on the screen at the same time as the

                              14
        continuing education content and shall not be interleafed between
        computer ‗windows‘ or screens of the continuing education
        content
       Audio and video recording, advertisements and promotional
        materials shall not be included within the continuing education.
        There will be no ‗commercial breaks.
       Live, face-to-face continuing education, advertisements and
        promotional materials shall not be displayed or distributed in the
        educational space immediately before, during, or after a
        continuing education activity.
       The Approver Unit shall not allow representatives of an entity with
        commercial interests to engage in sales or promotional activities
        while in the space or place of the continuing education activity.
       Educational materials that are part of a continuing education
        activity, such as slides, abstracts, and handouts, shall not contain
        any advertising, trade name, or a product-group message.
       Print or electronic information distributed about the non-
        continuing education elements of a continuing education activity
        that are not directly related to the transfer of education to the
        learner, such as schedules and content descriptions, may include
        product promotion material or product-specific advertisement.
       The Approver Unit shall not use an entity with a commercial
        interest as the agent providing a continuing education activity to
        learners, e.g., distribution of self-study continuing education
        activities or arranging for electronic access to continuing
        education activities.
       The content or format of a continuing education activity or its
        related materials must promote improvements or quality in health
        care and not a specific proprietary business interest of an entity
        with a commercial interest.
       Presentations must give a balanced view of therapeutic options.
        Use of generic names will contribute to this impartiality. If the
        continuing education educational material or content includes
        trade names, when available, trade names from several
        companies should be used, not just trade names from a single
        company.
       All presenters must declare any conflict of interest or vested
        interests.
       The Approver Unit will ensure all education activities are free
        from bias.

                      15
      In the event that any form of commercial support is provided for an
       education activity, The Approver Unit will maintain control of the
       educational content and disclose to the learners all financial
       relationships or lack of, between the commercial supporter and The
       Approver Unit or presenters.
          o Learners will be made aware of the nature of all commercial
              support and any conflict of interests for all education activities.
          o Funds from a commercial source should be in the form of an
              education grant to the provider of the education activity and must
              be acknowledged in printed materials and/or brochures.
          o Education activities are distinguished as separate from
              endorsement of commercial products. When commercial
              products are displayed, participants will be advised that
              accredited status as a provider refers only to its continuing
              education activities and does not imply ANCC Commission on
              Accreditation endorsement of any commercial products.
          o Education activities that present research conducted by
              commercial companies will be designed and presented with
              scientific objectivity.
          o Learners will be informed if the presentation is about the off-label
              use of a product.

Determining Appropriate Use of Commercial Support
    The Approver Unit must make all decisions regarding the disposition
     and disbursement of commercial support.
    The Approver Unit cannot be required by an entity with a commercial
     interest to accept advice or services concerning teachers, authors, or
     other education matters, including content, from the entity as conditions
     of contributing funds or services.
    All commercial support associated with a continuing nursing education
     activity must be given with the full knowledge and approval of The
     Approver Unit.

Written Agreements Documenting Terms of Support
    The terms, conditions, and purposes of the commercial support must be
      documented in a written agreement with the entity that includes AZNA
      and its educational partner(s). The agreement must include AZNA, even
      if the support is given directly to AZNA‘s educational partner or a
      Coprovider.
    The written agreement must specify the entity that is the source of

                            16
       commercial support.
      Both the entity and AZNA must sign the written agreement regarding the
       support to be provided/accepted.

Expenditures For An Individual Providing Continuing Nursing Education
   The provider must have written policies and procedures governing
     honoraria and reimbursement of out-of-pocket expenses for planners,
     teachers, and authors.
Expenditures for Learners
   Social events or meals at continuing nursing education activities cannot
     compete with or take precedence over the educational events.
   AZNA may not use commercial support to pay for travel, lodging,
     honoraria, or personal expenses for non-teacher or non-author
     participants of a continuing nursing education activity.
   AZNA may use commercial support to pay for travel, lodging, honoraria,
     or personal expenses for bona fide employees and volunteers of AZNA,
     Coprovider, or educational partner. This element applies only to nurses
     whose official residence is in the United States.

Accountability
   AZNA must be able to produce accurate documentation detailing the
     receipt and expenditure of commercial support.

Commercial Support for the CNE Activity
   AZNA‘s acknowledgment of commercial support may state the name,
    mission, and areas of clinical involvement of the company or institution
    and may include corporate logos and slogans, if they are not product-
    promotional in nature.




                           17
                                          SAMPLE
Commercial / Exhibitor Support Letter of Agreement and Standards of Commercial Support for
               Continuing Education Activity Between AZNA and [Grantor]

Arizona Nurses Association (AZNA) is committed to presenting continuing education activities that
promote improvements or quality in healthcare and are independent of the control of commercial
interests. As part of this commitment, AZNA has outlined in this written agreement the terms,
conditions, and purposes of commercial support for its continuing education activities. A commercial
interest is any entity producing, marketing, re-selling, or distributing health care goods or services,
consumed by, or used on, patients or an entity that is owned or controlled by a n entity that produces,
markets, re-sells, or distributes healthcare goods or services consumed by , or used on, patients.
Exceptions include non-profit or government organizations and non-health care related companies.
Providers of a clinical service directly to patients are not considered a commercial interest. Commercial
support is defined as financial, or in-kind, contributions given by a commercial interest, which is used to
pay all or part of the costs of a continuing nursing education activity.

An educational grant does not entitle a grantor to Exhibit Space at an activity.

In order to meet the ANCC accreditation standards, our files must contain a signed Letter of Agreement
(LOA) before the program actually occurs. Please mail or fax the completed form to AZNA. AZNA
Learning Solutions, LLC is the ACCREDITED PROVIDER for this program and all financial
transactions must be handled through our office. (Form must be typed or in legible print)

PROGRAM TITLE:
PROGRAM                                  PROGRAM
DATE                                     LOCATION

Grantor                                     Contact                                Telephone     Fax
Name                                        Name
TAX ID                                      EMAIL
Address                                     Address
City,                                       City,
State                                       State
Zip Code                                    Zip Code

Granting of Educational Support by Commercial / Exhibitor Source

The above named Grantor wishes to provide the following educational support of the continuing education
activity listed above: (check choices)

I. ____Unrestricted educational grant in the amount of $ _____________ for the support of
programming.
        (If exhibiting, please check the exhibit box below)
II. ___Restricted grant to reimburse expenses for:


                                                18
      A. Speaker expenses to consist of:

____ Speaker Name(s):
      _________________________________________
      __________________________________________

____ All speaker expenses
      To include  All expenses  Travel only                 Meals only            Honoraria only

___ Honoraria Amount $________________ (Indicate amount determined by the Nurse Planner.)

      B. Catering functions (specify): $__________________________________
      C. Exhibit $_____________,
      D. Other (indicate amount and purpose such as equipment loan, brochure distribution, etc.)


       Management and Conditions of Funds From Commercial / Exhibitor Sources

1.PURPOSE OF AND CONTROL OVER THE EDUCATIONAL ACTIVITY
      The activity shall be independent and non-promotional, focused on educational content, and
     free from commercial influence or bias. Information presented about commercial products shall
     be objective and based on scientific methods generally accepted in the nursing or medical
     community.
      AZNA shall maintain full control over the planning, content, topics, quality, scientific
     integrity, implementation, and evaluation of the activity, and over the selection of speakers,
     moderators, authors, or other faculty for the activity.
      [Grantor] shall not engage in scripting, targeting points for emphasis, or other actions
     designed to influence the content of the activity.
2. GRANTOR ASSISTANCE IN PLANNING, PRODUCTION, AND MARKETING OF THE
ACTIVITY
      AZNA may solicit assistance in the planning and production of the activity from [Grantor].
         That solicitation must be in writing. Acceptance by AZNA of advice or services concerning
         speakers, moderators, authors, invitees, or other educational matters, including content, shall
         not be a condition of support for this activity. [Grantor] shall not suggest speakers,
         moderators, or authors who are or were actively involved in promoting the company's
         products or who have been the subject of complaints regarding misleading or biased
         presentations.
      [Grantor] may provide services in support of the preparation of activity materials; however,
         these materials shall not, by their content or format, advance the specific proprietary interests
         of [Grantor].
      If [Grantor] offers to provide a presentation reporting results of scientific research, [Grantor]
         shall provide to AZNA a detailed outline in order to confirm the scientific integrity of the
         presentation.
      AZNA must authorize dissemination of information about this activity by or on behalf of
         [Grantor], and any information must identify the activity as produced by AZNA.


                                                19
          Invitations or mailing lists shall not be generated by the sales, marketing or other departments
           of [Grantor] and shall not be generated or procured to reflect sales or marketing goals of
           [Grantor].
         AZNA cannot use a commercial interest as the agent providing a continuing education activity
           to learners.
    DISCLOSURE
              Meaningful disclosure shall be made to the activity audience of the following:
              [Grantor's] funding of the activity, without reference to specific products.
                 i.       Any significant relationship between AZNA, authors, presenters, or moderators
                          and [Grantor].
                ii.       Any significant financial or other relationship between authors, presenters, or
                          moderators and the manufacturers of products or providers of services mentioned
                          by the author, presenter, or moderator during the activity.
               iii.       Whether any product mentioned during the activity is not labeled for the use
                          under discussion or is still investigational.
               iv.        Disclosure shall be made in writing in all instances when that is possible. Should
                          disclosure occur verbally, such disclosure must be verified by AZNA by written
                          documentation in the activity file and follow accreditation standards.
    SCOPE AND PRESENTATION OF THE ACTIVITY
           The title of the activity shall fairly and accurately represent the scope of the presentation.
           The activity shall present discussion of multiple treatment options, and shall not focus on a
          single product, except when options are so limited as to preclude meaningful discussion.
           Faculty shall be instructed to use generic names of products, or, if trade names are used, to
          use those of several companies.
           Opportunity for meaningful discussion or questioning shall be provided during a live
          activity.
    CONDUCT OF [GRANTOR] AT EDUCATIONAL PRESENTATIONS
              Exhibit placement shall not be a condition of support for the activity.
              No commercial/exhibitor promotional materials shall be displayed or distributed in the
                  same room immediately before, during, or immediately after the educational activity.
              Representatives of commercial/exhibitor supporter may not engage in sales activities while
                  in the room where the educational activity takes place.
              Information about [Grantor's] product(s) presented in the activity may only be further
                  disseminated after the initial presentation, by or at the behest of the [Grantor], in response
                  to an unsolicited request or through an independent provider outside the room where the
                  educational activity took place.
2.   SOCIAL EVENTS
          a. Social events shall not compete with, nor take precedence over, the educational activity. The
             appropriateness of the social event is at the sole discretion of AZNA, and AZNA shall have
             final authority in the scheduling and production of the social event.
          b. The cost of the social event shall be modest.
3.   STRUCTURE OF GRANT AND USE OF FUNDS
          a. The educational grant shall be made payable to AZNA. [Grantor] shall pay no other funds to
                  the director of the activity, faculty, or others involved with the activity.
          b. Grant funds shall not be used to pay travel, lodging, registration fees, honoraria, or personal
                  expenses for non-faculty attendees.

                                                   20
          c.Grant funds may be used to permit medical students, residents, or fellows to attend the
               activity, as long as the selection of students, residents, or fellows who will receive the
               funds is made either by the academic or training institution, or by AZNA with the full
               concurrence of the academic or training institution.
         d. AZNA upon request, shall furnish [Grantor] with a report concerning the expenditure of
               grant funds provided.
 4. REGULATORY AUTHORITY
       a. AZNA and [Grantor] agree to abide by all requirements of the ANCC Standards for
             Commercial Support, ACCME Standards for Commercial Support of Continuing Medical
             Education, the FDA Final Guidance on Industry-Supported Scientific and Educational
             Activities (December 1997), the AMA regulations regarding the Physician's Recognition
             Award, the AMA Opinion 8.061: Gifts to Physicians from Industry, and the AMA Opinion
             9.011: Continuing Medical Education.
5. CHOICE OF LAW
         a. Jurisdiction and venue shall be in San Diego County. The laws of the State of California
             shall govern in all matters pertaining to this Agreement. The parties understand that
             AZNA, as the Accredited Provider is an agency of the State of California and, as such, is
             prohibited from committing resources beyond a single fiscal year. Therefore, AZNA may
             terminate this agreement upon 30 days’ written notice to Grantor.


AGREED:                                                     AGREED:

AZNA                                                   Grantor
Signature:                                             Signature:
Print Name:                                            Print Name:
Title:                                                 Title:
Date:                                                  Date:

                           Please make checks payable to AZNA and mail to:

                                           AzNA Address here




                                                21
                                 Arizona Nurses Association
                                          Address

                                  EXHIBITOR AGREEMENT
             Regarding Terms, Conditions, and Purposes for an Exhibitor/Vendor
Title of Activity:
Location:
Date(s):
Name of Company as you would like it to appear in course materials:
Company (Company Name/Branch):
Contact Person:
Address:
City, State, Zip :
Phone:_____________________________ Fax: _______________________
Email:
Exhibit Fee: (The company listed above wishes to participate as an exhibitor for the above-named
activity. Exhibitor fees are provided in the amount of $_____________________.
Signature: (Company representative and AZNA representative to sign at bottom of page.
Conditions:
     The Exhibiter agrees to abide by the ANCC Standards and ACCME Standards for Commercial
        Support of Continuing Medical Education.
     AZNA agrees (1): to abide by the ANCC Standards and the ACCME Standards for Commercial
        Support of Continuing Medical Education; and (2) to acknowledge support from the exhibit in
        program syllabi.
     Exhibitor will display only during those hours which have been specified by the program
        coordinator or Nurse Planner. Representatives will wear program name tags (issued by AZNA) if
        they chose to attend any portion of the education session.
AGREED TO:                                         AGREED TO:

Company Representative (Print Name):            AZNA Representative (Print Name):



Title:                                          Title:
Signature:                                      Signature:

Date:                                           Date:

EXHIBITOR: Return a copy of the Exhibitor Agreement with your company name, exhibitor fee,
and authorized representative’s name, contact information, and signature to the address above.


                                             22
                  COMPONENT:          8.0 Continuing Education Approver Unit

                  SUBJECT:            8.8* Conflict of Interest Guidelines




POLICY:           All educational activities must be free of commercial bias for or against
                  any product, and educational materials may not advance the interests of
                  a financial supporter or proprietary company.


                  All continuing education nurse planners, course administrators, course
                  planning committee members, course faculty, commercial supporters
                  (sponsors, grantors, and exhibitors), course participants, and Approver Unit
                  administrators are covered by this policy.
EFFECTIVE DATE:   January 2010
REVIEWED:
APPROVED BY:      CE Steering Committee
RESPONSIBLE       ACTION:
PERSON(S):
PROCEDURE         For the purposes of this policy, the following definitions apply:

                  Conflict of Interest—A “conflict of interest‖ exists when an individual has an
                  opportunity to affect continuing education content in relation to a commercial
                  interest with which he/she has a financial relationship.
                       ANCC considers ―opportunity to affect continuing education content‖ to
                         include content about specific agents/devices, but not necessarily
                         about the class of agents/devices, and not necessarily content about
                         the whole disease class in which those agents/devices are used.
                       With respect to financial relationships with commercial interests, when
                         a person divests himself or herself of a relationship, it is immediately
                         not relevant to conflicts of interest but it must be disclosed to the
                         learners for 12 months.

                  Commercial Interest—Any entity either producing, marketing, re-selling, 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, markets, re-
                  sells, or distributes healthcare goods or services consumed by, or used on,
                  patients. Exceptions are made for non-profit or government organizations and
                  non-healthcare related companies. The definition allows an accredited
                                              23
provider to be owned by a firm that is not a commercial interest. It also allows
a provider to have a ‗sister company‘ that is a commercial interest, as long as
the accredited provider maintains corporate firewalls to prohibit any influence
or control by the ‗sister company‘ over the continuing education program of
the accredited provider. In this case, ANCC would expect that the accredited
provider would have an adequate corporate firewall in place to prohibit any
influence or control by the ‗sister company‘ over the continuing education
program. ANCC does not consider providers of clinical service directly to
patients to be commercial interests.

Commercial Support—Financial, or in-kind contributions given by a
commercial interest, which is used to pay all or part of the costs of a
continuing education activity.
    ANCC does not consider providers of clinical service directly to patients
       to be commercial interests. For the purposes of eligibility, ANCC
       considers the following types of organizations eligible for accreditation
       and free to control the content of continuing education:
           o Liability insurance providers
           o Health insurance providers
           o Group medical practices
           o Acute care hospitals (for-profit and not-for-profit)
           o For profit rehabilitation centers
           o For-profit nursing homes
           o Universities with nursing development and continuing nursing
              education programs
           o Specialty Nursing Organizations
           o Constituent Member Associations
           o Federal Nursing Services
           o National nurses organizations based outside the United States
           o a single-focused organization devoted to offering continuing
              education

Financial Relationship—those relationships in which the individual benefits
by receiving a salary, royalty, intellectual property rights, consulting fee,
honoraria, ownership interest (e.g., stocks, stock options, or other ownership
interest, excluding diversified mutual funds), or other financial benefit.
Financial relationships can also include ‗contracted research‘ where the
institution gets the grant and manages the funds and the individual is the
principal or named investigator on the grant. Financial benefits are usually
associated with roles such as employment, management position,


                           24
independent contractor (including contracted research), consulting, speaking
and teaching, membership on advisory committees or review panels, board
membership, and other activities from which remuneration is received, or
expected. ANCC considers relationships of the person involved in the
continuing education activity to include financial relationships of a
spouse/partner.
       o With respect to personal financial relationships, ‗contracted
          research‘ includes research funding where the institution gets the
          grant and manages the funds and the person is the principal or
          named investigator on the grant.
       o ANCC considers financial relationships in any amount occurring
          within the past 12 months as ―relevant‖ in terms of creating a conflict
          of interest.

Determining Independence
The Approver Unit must ensure that the following decisions are made free
   from the control of a commercial interest:
   identification of continuing education needs,
   determination of educational objectives,
   selection and presentation of content,
   selection of all persons and organizations that will be in a position to
   control the content of the CNE,
   selection of educational methods, and
   evaluation of the activity.
The Approver Unit ensures that any entity with a commercial interest cannot
   take the role of non-accredited partner in a Co-provider relationship.

A Conflict of Interest/Commercial Support Disclosure Statement must be
completed by every nurse planner, presenter, and planning committee
member prior to the beginning of the educational activity.

Resolution of Personal Conflicts of Interest
   All individuals must disclose any financial relationships with an entity
     with a commercial interest.
   Each individual who is in a position to control the content of an
     education activity has disclosed all financial relationships with any
     entity with a commercial interest in the provider. Financial relationships
     must be disclosed to the learners during the time when the relationship
     is in effect and for 12 months afterward.
   An individual who refuses to disclose financial relationships will be

                           25
       disqualified from being a planning committee member, a teacher, or an
       author of continuing education activities and cannot have control of, or
       responsibility for, the development, management, presentation, or
       evaluation of the continuing education activity.
      All conflicts of interest will be identified and resolved prior to the
       education activity being delivered to learners.
      Conflicts of interest can be resolved by:
            o Altering the financial relationship with the commercial interest
            o Altering the individual‘s control over continuing education
               content about the products or services of the commercial
               interest, and/or
            o Validating the activity content through independent peer review.
      If there is a conflict of interest that is resolved, individuals in a position
       to control the continuing education content must attest to the content‘s
       objectivity.
      If conflicts of interest cannot be resolved, the Approver Unit may:
            o Remove the individual from any position of control over the
               continuing education content
            o Withdraw the application for credit

Disclosures
The following disclosures must be made relevant to conflicts of interest and
commercial bias:
    Conflicts of interest (including any influencing financial relationship, or
       lack thereof, disclosed by planners or presenters).
    Relevant financial relationships of those with control over continuing
       education content and the mechanism to identify and resolve conflicts
       of interest
    Sponsorship or Commercial Support related to the educational activity
    Non-endorsement of products
    Off-label use (relating to any product used for a purpose other than that
       for which it was approved by the Food and Drug Administration).

Disclosure of information about provider and faculty relationships may be
disclosed verbally to participants at a continuing education activity. When such
information is disclosed verbally at a continuing education activity, AZNA must
be able to supply ANCC with written verification that appropriate verbal
disclosure occurred at the activity. With respect to this written verification:
     A representative of AZNA who was in attendance at the time of the
       verbal disclosure must attest, in writing:

                             26
          o that verbal disclosure did occur; and
          o itemize the content of the disclosed information or that there was
             nothing to disclose.
      The documentation that verifies that adequate verbal disclosure did
       occur must be completed within one month of the activity.

The Approver Unit is responsible for ensuring that learners are aware of any
relevant financial relationship(s), to include the following information:
           o The name of the individual,
           o The name of the commercial interest(s), and
           o The nature of the relationship the person has with each
              commercial interest.
     For an individual with no relevant financial relationship(s), the learners
       must be informed that no relevant financial relationship(s) exist.

Timing of Disclosure
    The Approver Unit must disclose the above information to learners prior
      to or at the time of the beginning of the educational activity.




                            27
                          COMPONENT:           8.0 Continuing Education Approver Unit

                          SUBJECT:             8.9* Honoraria




                          Payment of reasonable honoraria and reimbursement of reasonable out-of-
POLICY:                   pocket expenses for faculty and others who contribute to continuing
                          education development and delivery is customary and proper.
                          The amount of the honorarium and details about allowable expenses should
                          be specified in an agreement or in correspondence with the individual who
                          will receive the honorarium and reimbursement as part of the
                          invitation/confirmation process. AZNA allows a range of honoraria to be
                          offered to or negotiated with speakers, authors, reviewers, and editors.
                          Ranges and negotiations must not be dependent on whether there is
                          external funding for the activity.
                          AZNA recognizes there may be varying levels of honoraria depending on
                          the type of activity, the number of faculty, credentials, etc. Exceptions may
                          be made when extraordinary circumstances warrant additional
                          remuneration (e.g. rush jobs, requests for additional copy/pieces/supporting
                          materials not a part of the original agreement, rewrites due to new
                          developments in the field, etc. Exceptions will not be influenced by the
                          external funding availability. Should such an exception be made, the reason
                          will be documented in the activity file, and approved by the Nurse Planner.
                          Individuals who provide services for continuing nursing education provider-
                          produced continuing education activities may not receive payments from
                          any other sources for their service(s).
                          All continuing education nurse planners, course administrators, course
                          planning committee members, course faculty, commercial supporters
                          (sponsors, grantors, and exhibitors), course participants, and Approver Unit
                          administrators are covered by this policy.
EFFECTIVE DATE:           January 2010
REVIEWED:
APPROVED BY:              CE Steering Committee
RESPONSIBLE               ACTION:
PERSON(S):
Executive Director/Lead         An honorarium is a payment for services for which fees are not legally
Nurse Planner                    required and which does not require contract agreement to be

                                                 28
    negotiated and formalized.
   Honoraria are paid to persons of scholarly or professional standing in
    conjunction with an academic activity.
   AzNA, the Coprovider, or designated educational partner must pay
    directly any teacher or author honoraria or reimbursement of out-of–
    pocket expenses in compliance with the provider‘s written policies and
    procedures.
   No other payment shall be given to the director of the activity,
    planning committee members, teachers or authors, Coprovider, or any
    others involved with the supported activity.
   If teachers or authors are listed on the agenda as facilitating or
    conducting a presentation or session, but participate in the remainder
    of an educational event as a learner, their expenses can be
    reimbursed and honoraria can be paid for their teacher or author role
    only.
   Honoraria must comply with the accreditation guidelines and not
    influence the choice of speaker or the content of the presentation.
   The Nurse Planner negotiates all honoraria fees.
   Prior to confirming any speaker for an activity the Nurse Planner
    should discuss with any presenter whether an honorarium and
    expenses are required.
   A written confirmation or agreement should follow any such
    conversation.
   The amount paid will vary depending on the activity, and the
    requirements for and expertise or the faculty, the length of the
    presentation, preparation, and travel time.
   No honoraria or reimbursements will be paid directly by the
    commercial supporter(s) to a presenter.
   Required documentation must be submitted before reimbursement. If
    original receipts are lost or unavailable, signed written documentation
    requesting exceptions may be submitted in lieu of original receipts.
    This documentation should include details of the cost and nature of
    the expense, and an explanation of why the original receipts were not
    submitted.
   Requests that fail to document acceptable expenses may be refused.
    Original receipts will not be returned. Expense reports will be
    processed in 15-20 working days.
   Following the speaker‘s presentation participant evaluation results will
    be returned to AZNA in order to evaluate the effectiveness of the
    speaker for other activities.


                     29
   Larger honoraria, especially those derived from commercial support,
    are discouraged.




                    30
                  COMPONENT:          8.0 Continuing Education Approver Unit
                  SUBJECT:            8.10* Enduring Materials




POLICY:           Enduring materials, defined as printed, recorded, or computer-assisted
                  instruction used over time at various locations and which constitute a
                  planned activity of continuing education, are subject to the same
                  accreditation requirements, policies and procedures as all other
                  educational activities. Examples of such materials include: programmed
                  texts, audio tapes, CD ROMs, videotapes, or other computer-assisted
                  materials which are used alone or in combination with written materials.
                  Not included are ―reference materials‖ such as books, journals, or
                  manuals.


                  All continuing education nurse planners, course administrators, course
                  planning committee members, course faculty, commercial supporters
                  (sponsors, grantors, and exhibitors), course participants, and Approver
                  Unit administrators are covered by this policy.
EFFECTIVE DATE:   January 2010
REVIEWED:
APPROVED BY:      AzNA Board of Directors
RESPONSIBLE       ACTION
PERSON




                                        31
   Enduring materials are planned and implemented just like any other
    approved activity.
   All information provided to participants of other types of educational
    activities will also be provided (without an opt-out option) to
    participants utilizing enduring materials including:
             Name and credentials of principle faculty/content experts
             Medium or combination of media used
             Method of participation in the learning process
             Estimated time (contact hours) to complete the educational
                activity
             Disclosure statements of anyone with a financial
                relationship
             Acknowledgement of commercial support
             Dates of original release and most recent review or update
             Termination date (date after which enduring material is no
                longer certified for credit)
   General continuing education information must be included and
    stated at the beginning of the enduring material including (i) Approval
    statement; (ii) Contact hours statement; (iii) Target audience; and (iv)
    Disclosure of financial relationships and off-label discussions.
   Enduring materials are reviewed at least once every three years or
    more frequently if indicated by new scientific developments. The
    review date must be included on the enduring material along with the
    original release date and a termination date.
   Applicants will not enlist the assistance of commercial interest to
    provide or distribute enduring materials to learners.
        When an enduring material is created from a live continuing
            education activity, two separate activities are created—one live
            activity and one enduring material activity. Both activities must
            comply with all accreditation standards, and the enduring
            material activity must also comply with policies relating to
            enduring materials.




                       32
               COMPONENT:            8.0 Continuing Education Approver Unit
               SUBJECT:              8.12*Program Coordinator Selection Criteria and Major
                                     Responsibilities




POLICY:        The Program Coordinator is selected by the Executive Director. The position is
               detail oriented and requires an individual who can prioritizes multiple projects at
               one time. The individual must have initiative, be able to make appropriate
               decisions, communicate effectively with all AzNA stakeholders and customers,
               and handle confidential information appropriately.

               All continuing education nurse planners, course administrators, course planning
               committee members, course faculty, commercial supporters (sponsors, grantors,
               and exhibitors), course participants, and Approver Unit administrators are
               covered by this policy.
EFFECTIVE      January 2010
DATE:
REVIEWED:
APPROVED BY:   CE Steering Committee
RESPONSIBLE    ACTION:
PERSON(S):
Program              Serves as staff to the Continuing Education Approval Unit, for both the
Coordinator           individual activities and provider applications
                     Records all new applications for review and processes payments for
                      review fees
                     Maintains files and correspondence for all applications in accordance with
                      ANCC criteria.
                     Coordinates the CE Review panel meetings and provider approval
                      reviews.
                     Attends Steering Committee meetings.
                     Answers questions from applicants and refers to appropriate personnel if
                      needed.




                                              33
                  SUBJECT:           8.0 Continuing Education Approver Unit
                  COMPONENT:         8.13* Continuing Education (CE) Review
                                     Coordinator Selection Criteria and Major
                                     Responsibilities


POLICY:           The CE Review Coordinator is selected by the Executive Director. The
                  position requires a registered nurse with a baccalaureate degree in
                  nursing required and a graduate degree preferred. Knowledge of the
                  American Nurses Credentialing Center's Commission on Accreditation
                  criteria is also required.

                  All continuing education nurse planners, course administrators, course
                  planning committee members, course faculty, commercial supporters
                  (sponsors, grantors, and exhibitors), course participants, and Approver
                  Unit administrators are covered by this policy.
EFFECTIVE DATE:   January 2010
REVIEWED:
APPROVED BY:      CE Steering Committee
RESPONSIBLE       ACTION:
PERSON(S):




                                        34
CE Review Coordinator      Serves as staff advisor to the Continuing Education Approval Unit,
                            for both the individual activities and provider applications.
                           Ensures continuing education approval programs meet the
                            American Nurses Credentialing Center (ANCC) Commission on
                            Accreditation criteria.
                           Assists, develops, and maintains policies for the Continuing
                            Education Approval Unit in coordination with the Continuing
                            Education Steering Committee.
                           Assists, develops, and maintains applications materials and
                            checklists for the Continuing Education Approval Unit in
                            coordination with the Continuing Education Steering Committee.
                           Assists in the preparation and maintenance of application
                            materials for the CE Approver Unit for reaccreditation periods.
                            Participates in site survey and interview process during
                            reaccreditation.
                           Communicates with and assists customers of the Continuing
                            Education Approval Unit by:
                                o Providing information or clarification of procedures to be
                                   followed for the application process.
                                o Assisting in the approval process.
                                o Ensuring applications are processed in a timely manner.
                           Markets the approval program to potential customers.
                           Coordinates with the CE Steering Committee for appointment of
                            members to review panels.
                           Serves as a resource to the Continuing Education Approval
                            Unit/Nurse Peer Review panels.
                           Attends CE Steering Committee meetings.




                                           35
                  COMPONENT:         8.0 Continuing Education Approver Unit

                  SUBJECT:           8.14 Director of Continuing Education/Nurse Peer
                                     Review Leader
                                     Selection Criteria and Major Responsibilities


POLICY:           The Director of Continuing Education/Nurse Peer Review Leader is elected by
                  the AzNA membership.

                  All continuing education nurse planners, course administrators, course planning
                  committee members, course faculty, commercial supporters (sponsors,
                  grantors, and exhibitors), course participants, and Approver Unit administrators
                  are covered by this policy.
EFFECTIVE         1994
DATE:
REVIEWED:         June 2006; January 2010
APPROVED BY:      CE Steering Committee
RESPONSIBLE       ACTION:
PERSON(S):
Nominating        The nominating committee selects eligible individuals for Director of Continuing
Committee         Education/Nurse Peer Review Leader based on the following qualifications:
                      RN with masters degree and at least one degree which must be in
                        nursing from an accredited College/University,
                      current valid license to practice as a registered nurse in the state of
                        Arizona,
                      experienced in conducting and/or managing Continuing Education in
                        nursing and
                      a current member of the Arizona Nurses Association.
AzNA Membership   The AzNA membership elects one candidate for the Director of Continuing
                  Education.
Director of           Chairs the CE Steering Committee.
Continuing            Presents changes in fees, organizational structure, and policies and
Education               procedures for continuing education to board for approval.
                      Maintains AzNA accreditation as an approver and provider.
                      Monitors Provider Unit and Approver Unit continuing education activities.




                                               36
                        COMPONENT:        8.0 Continuing Education Approver Unit
                        SUBJECT:          8.15 Appeal of Peer Review Action




POLICY:                 There is an appeal process for applications that have been denied by
                        the panel reviewers.

                        When applicant‘s request for approval of a continuing education activity
                        is denied, the applicant may appeal the adverse decision by notifying (in
                        writing) the CE Review Coordinator.

                        All continuing education nurse planners, course administrators, course
                        planning committee members, course faculty, commercial supporters
                        (sponsors, grantors, and exhibitors), course participants, and Approver
                        Unit administrators are covered by this policy.
EFFECTIVE DATE:         1991
REVIEWED:               1997, 2000, June 2006, January 2010
APPROVED BY:            CE Steering Committee
RESPONSIBLE             ACTION:
PERSON(S):
Applicant               FIRST APPEAL
                        Submit appeal in writing to the relevant CE Review Coordinator within
                        fourteen (14) days of notification of adverse decision.
CE Review Coordinator   Presents the appeal to the CE Steering Committee for reconsideration.

CE Steering Committee   Reconsiders application and renders decision regarding approval
                        category.
                            If application is given approval, appeal is ended and applicant is
                              notified within seven (7) working days.
                            If approval is deferred, applicant will be contacted within seven
                              (7) working days and asked to submit deficient materials.
                            If approval is denied, applicant will be notified of denial within
                              seven (7) working days.




                                             37
                        COMPONENT:           8.0 Continuing Education Approver Unit
                        SUBJECT:             8.16 Application Action Options




POLICY:                 Three types of actions (approval, deferred, denial) may be taken on
                        applications for approval of a continuing education activity and for
                        approval of providers. The three actions will be based on the extent to
                        which ANCC criteria are met or not met within each application. Approval
                        for individual activities is for a two-year period. Approval for provider
                        status is for a three-year period.

                        All continuing education nurse planners, course administrators, course
                        planning committee members, course faculty, commercial supporters
                        (sponsors, grantors, and exhibitors), course participants, and Approver
                        Unit administrators are covered by this policy.
EFFECTIVE DATE:         1991
REVIEWED:               1997, 2000 June 2006, January 2010
APPROVED BY:            CE Steering Committee
RESPONSIBLE             ACTION:
PERSON(S):
CE Review Panel (for    Upon receipt of application, it is submitted to appropriate peer review
Individual Activity     panel or approved provider reviewer.
Applications)
                        Using checklist summarizing ANCC criteria, applications are given one
CE Review Coordinator   category of approval. Deficiencies of criteria are noted. All panel
                        members must concur with any decision to deny an application.

                        Applicant is notified of decision in writing. Deficiencies are communicated
                        and must be corrected before the application can be reviewed again and
                        assigned a different action.

                        Approved CE applications for individual activities are assigned an ID
                        number.




                                               38
CE Provider Review      Adheres to the following guidelines for duration of provider approval:
Panel(for Provider
Applications)              1. The approval period begins on the day of the month in which
                              approval was granted.
CE Review Coordinator      2. Provider approval shall expire on the day of the month, three
                              years after the approval was granted (i.e., provider approval
                              granted in May 14, 2000 will expire May 13, 2003).
                           3. Three (3) months prior to expiration of provider approval, a
                              provider will be notified in writing. However, the provider is
                              ultimately responsible for tracking their approval period and
                              submitting their application in a timely manner.
                           4. Only one (1) courtesy notification of pending expiration of
                              provider status will be furnished.
                           5. Notification will request that the application for renewal of
                              approved provider status be submitted prior to the expiration of
                              the current approval period.
                           6. Extension of provider approval for no longer than three (3)
                              months may be considered upon presentation in writing of a
                              request for extension that contains sufficient and justifiable
                              rationale as judged by the Provider Approval Panel. An example
                              of sufficient and justifiable rationale is the employment of a new
                              provider unit administrator no more than 60 days prior to
                              expiration of AzNA provider approval.
                           7. Applicant is notified of decision in writing. Deficiencies are
                              communicated and must be corrected before the application can
                              be reviewed again and assigned a different action.

                        Requests for Retroactive Approval

                        No contact hours are awarded for a CE activity if the application is
                        received after the CE activity has been completed.




                                              39
                      COMPONENT:         8.0 Continuing Education Approver Unit
                      SUBJECT:           8.17 Application Withdrawal




POLICY:               Applications may be withdrawn without prejudice prior to review by
                      appropriate panel.

                      All continuing education nurse planners, course administrators, course
                      planning committee members, course faculty, commercial supporters
                      (sponsors, grantors, and exhibitors), course participants, and Approver
                      Unit administrators are covered by this policy.
EFFECTIVE DATE:       1994
REVIEWED:             2000, June 2006, January 2010
APPROVED BY:          CE Steering Committee
RESPONSIBLE           ACTION:
PERSON(S):
Program Coordinator   Receives requests for withdrawal of an application before review; this

AzNA Staff            must be a written request for withdrawal.


                      If request to withdraw application occurs after application has been
                          reviewed by CE Review Panel, the full application fee is retained.
                      If request to withdraw application occurs before application has been
                          reviewed by CE Review Panel, a $10 service fee is retained.




                                           40
                         COMPONENT:         8.0 Continuing Education Approver Unit
                           SUBJECT:         8.18 Monitoring of Activities




POLICY:                 The quality of activities awarded approval are monitored.

                        All continuing education nurse planners, course administrators, course
                        planning committee members, course faculty, commercial supporters
                        (sponsors, grantors, and exhibitors), course participants, and Approver
                        Unit administrators are covered by this policy.
EFFECTIVE DATE:         1994
REVIEWED:               2000, June 2006, January 2010
APPROVED BY:            CE Steering Committee
RESPONSIBLE             ACTION
PERSON
CE Review Coordinator   Individual Activities
                        Assures that continuing education monitoring is accomplished by
                        reviewing every application that has been reviewed by the Review
                        Panels.
                        Approved Providers
                        At least once during their approval period, conduct a random sampling of
                        approved provider activities and a quality improvement review relative to
                        their unit.
                        Monitoring includes a review of the following:
                            1. Education design (via a review of the activities and course
                                documentation forms)
                            2. Management of commercial support (via a review of policies or
                                commercial support documents)
                            3. Provision of appropriate disclosures to learners (via review of
                                promotional materials, course materials, etc.)
                            4. Assurance that all required items are kept on file (via review of a
                                checklist or similar tool)
                            5. Review of their quality assurance activities (via review of activity-
                                related documents such as evaluation forms, etc.).
                         If during this monitoring process, issues are discovered relative to any of
                         the items above, a written response is provided to the provider and
                         follow-up monitoring will occur within the next 12 months.




                                               41
               COMPONENT:            8.0 Continuing Education Approver Unit
               SUBJECT:              8.19 CE Peer Review Education




POLICY:        Volunteer peer reviewers are utilized to provide the initial review of all activity
               and provider applications. Each peer reviewer has demonstrated and
               documented expertise in education, staff development, and accreditation
               standards.

               All continuing education nurse planners, course administrators, course planning
               committee members, course faculty, commercial supporters (sponsors, grantors,
               and exhibitors), course participants, and Provider Unit administrators are covered
               by this policy.
EFFECTIVE      January 2010
DATE:
REVIEWED:
APPROVED BY:   CE Steering Committee
RESPONSIBLE    ACTION:
PERSON(S):
Peer Review    1.    Peer reviewers are educated about accreditation criteria, expectations of
member           ANCC relative to the responsibilities of their position, and the Approver Unit‘s
                 peer review processes in a variety of ways including but not limited to:
                         o AzNA annual education sessions related to accreditation changes
                            and updates
                         o ANCC webinars
                         o One-on-one education sessions with the Continuing Education
                            (CE) Review Coordinator
                         o AzNA Newsletter
                         o Emails to peer reviewers as needed
                2. The applicant completes an annual update to the CE Review process.
                3. Peer review training information will be maintained on all Peer Reviewers.




                                               42
                                PEER REVIEWER QUALIFICATIONS FORM
                    Date: ________________________________________
              Please do not attach any additional material. Use this form exclusively.

Name
Highest degree, license,
certificate, etc.:
Degrees held*
*A nursing degree at the level of baccalaureate or higher is required.
Licenses and certifications
Mailing address preferred
City, State, Zip Code
Employer name,
department, address (if
applicable):

                                  Home:                              Fax:
Telephone, etc.
                                  Work:                              E-mail:

                                  Cell Phone
Title, description of present
position (if employed)
Source of knowledge of continuing nursing education:
   academic training       experience          orientation   other
Please explain/describe the above:



Source of knowledge of ANCC Accreditation criteria:
   academic training       experience          orientation   other
Please explain/describe the above:



Source of knowledge of approver unit processes:
   experience       orientation      other
Please explain/describe the above:




                                                      43
                         COMPONENT:         8.0 Continuing Education Approver Unit
                           SUBJECT:         8.20 Revocation of Approval Status




POLICY:                 There is a procedure to revoke approval status from an approved
                        individual application or an approved provider.

                        When a variance is brought to the attention of AzNA (either through audit
                        or consumer complaint) that shows an individual approved activity or an
                        approved provider is not meeting the ANCC guidelines, AzNA institutes a
                        probationary revocation process.

                        All continuing education nurse planners, course administrators, course
                        planning committee members, course faculty, commercial supporters
                        (sponsors, grantors, and exhibitors), course participants, and Approver
                        Unit administrators are covered by this policy.
EFFECTIVE DATE:         April, 2007
REVIEWED:               January 2010
APPROVED BY:            CE Steering Committee
RESPONSIBLE             ACTION:
PERSON(S):
CE Review Coordinator   After learning of the variance the CE Coordinator will notify the approved
                        applicant or approved provider. They will then have ten (10) business
                        days to provide documentation showing corrective action regarding the
                        variance.
Program Coordinator     If the approved applicant or approved provider fails to correct the
                        variance a Notice of Revocation will be sent to them by Certified Mail
AzNA Staff              and they will have a ten-day probationary period to respond to the
                        Notice of Revocation.
                        If no action is taken after ten (10) days, the status of the individual
                        program or provider will be revoked.




                                              44
                      COMPONENT:         8.0 Continuing Education Approver Unit
                      SUBJECT:           8.11* Executive Director/Lead Nurse Planner
                                          Selection Criteria and Major Responsibilities




POLICY:               The Executive Director is the Nurse Planner and is accountable to the
                      AzNA President and Board of Directors. A baccalaureate degree in
                      nursing and a master‘s degree in nursing or related field from an
                      accredited college or university are required. Knowledge of the American
                      Nurses Credentialing Center (ANCC) Commission on Accreditation criteria
                      is also required.

                      All continuing education nurse planners, course administrators, course
                      planning committee members, course faculty, commercial supporters
                      (sponsors, grantors, and exhibitors), course participants, and Provider Unit
                      administrators are covered by this policy.
EFFECTIVE DATE:       January 2010
REVIEWED:
APPROVED BY:          AzNA Board of Directors
RESPONSIBLE           ACTION
PERSON
Executive Director/   The Executive Director/Lead Nurse Planner provides the following:
Nurse Planner             Oversight, compiling documentation, and ensuring compliance with
                            accreditation agencies in all aspects of the review process
                          Development, implementation, and evaluation of policies and
                            procedures for the Approval Unit
                          Management and direction of the activities of the support staff
                          Maintenance of appropriate preparation, orientation, and training in
                            ANCC accreditation standards to function effectively in the role




                                             45
                COMPONENT:            8.0 Continuing Education Approver Unit
                SUBJECT:              8.21* Nurse Peer Reviewer
                                      Selection Criteria and Major Responsibilities




POLICY:         Peer reviewers are selected by the Director of Continuing Education/Nurse Peer
                Review Leader, the CE Review Coordinator, or other designated individual. Peer
                reviewers must have at least a Bachelor of Science Degree in Nursing. Additional
                experience in education is recommended.

                All continuing education nurse planners, course administrators, course planning
                committee members, course faculty, commercial supporters (sponsors, grantors,
                and exhibitors), course participants, and Approver Unit administrators are covered
                by this policy.
EFFECTIVE       2010
DATE:
REVIEWED:       April 2010
APPROVED        CE Steering Committee
BY:
RESPONSIBLE     ACTION:
PERSON(S):
Director of      1. The Peer Review applicant downloads, completes and submits appropriate
CE/Nurse Peer      Peer Reviewer Qualification Form from the AzNA web site or is sent a Form via
Review Leader      email or regular mail.
                 2. The applicant is screened by either the Director of CE/Nurse Peer Review
CE Review          Leader, the CE Review Coordinator, or other designated individual.
Coordinator      3. The individual is ―approved‖ by either the Director of CE/Nurse Peer Review
                   Leader, the CE Review Coordinator, or other designated individual.
CE Approval      4. The applicant completes an orientation to the CE Review Panel process
Panel              within 90 days of approval.
                 5. The applicant completes an annual update to the CE Review process.
Peer Review      6. Peer review training information will be maintained on all Peer Reviewers.
member           7. To assure the appropriate review of nursing continuing education programs,
                   Peer Reviewers must
Staff               assure that individual continuing education activities and provider
                       applications meet the American Nurses Credentialing Center (ANCC)
                       Commission on Accreditation criteria for review and approval of continuing
                       education.
                    Communicate with the CE Review Coordinator and Nurse Peer Review
                       Leader as needed
                    Ensure applications are processed in a timely manner.



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