Docstoc

Sample Bio Data for Nurses

Document Sample
Sample Bio Data for Nurses Powered By Docstoc
					Provider Unit Guidelines - 2010

    General Information
    Eligibility Requirements
          Intent to Apply Form
          Intent to Reapply Form
    Approval Process For Provider Unit Applications
          Submit Provider Unit Application
              First Time Provider Unit Applicant
              Reapplying Provider Unit Applicant
          Review Process
          Types of Action Taken
          Appeal Process
          Provider Unit Changes Must Be Reported
    Criteria for Approval as a Provider Unit
          Sample Completed Provider Unit Application Form
          Attestation Statement Regarding Operational Requirements
          Sample Completed Bio Data Form for Provider Unit Personnel
          Sample Completed Provider Unit Evaluation Form
    Provider Unit Application Blank Forms
          Intent to Apply Form
          Intent to Reapply Form
          Provider Unit Application Form
          Attestation Statement Regarding Operational Requirements
          Bio Data Form for Provider Unit Personnel
          Provider Unit Evaluation Form
    Frequently Asked Questions
                                                Washington State Nurses Association
                                                575 Andover Park West, Suite 101
                                                Seattle, Washington 98188
                                                206-575-7979




Continuing Education Approval                   DATE: October 2010
  and Recognition Program

          CEARP




                C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                            -1-
                        WASHINGTON STATE NURSES ASSOCIATION
                Continuing Education Approval and Recognition Program (CEARP)


                                       GENERAL INFORMATION

Approval as a Provider Unit (PU) is recognition of the applicant‘s organization, educational processes
and capacity to award contact hours for continuing nursing education (CNE) activities. The PU has the
authority to assess, plan, implement and evaluate its own CNE activities during the three-year approval
period. The approved Provider Unit may offer an unlimited number of educational activities during the
period of approval.

Approval as a Provider Unit is based on an in-depth analysis of the quality of several learning activities
to estimate the likelihood of a Provider Unit‘s ability to continue to plan and produce such activities
over a three-year period. To achieve Provider Unit approval, an applicant must meet the eligibility
requirements and develop internal processes for development and review of continuing nursing
education. After Provider Unit approval is granted, the applicant is responsible for maintaining these
internal peer review processes to assure adherence to American Nurses Credentialing Center's
Commission on Accreditation (ANCC/COA) criteria and the Washington State Nurses Association's
(WSNA) Continuing Education Approval Recognition Program (CEARP) criteria.

NOTE: PROVIDER UNITS DO NOT APPROVE ACTIVITIES. Provider Units are granted
approval to assess, plan, implement and evaluate activities (APIE) that meet ANCC/WSNA
CEARP criteria. Provider Units have the ability to award contact hours. Provider Units never
have the authority to approve their own or anyone else’s activities. The words “approved”,
“application” or “applicant” should never be used in connection with any activity planned and
presented by the provider.




                             C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                         -2-
                                  ELIGIBILITY REQUIREMENTS

A. Who can apply to become an approved Provider Unit?
   1. The Provider Unit must be administratively and operationally responsible for coordinating all
      aspects of the CNE activities provided by the organization. A Provider Unit may be either:
      a. A single-focused organization devoted to offering CNE. It exists for the single purpose of
         providing CNE; or
      b. A distinct, separately identified unit within a complex, multi-focused organization; e.g.: it
         may be a CNE division, a staff development department, or a nursing education committee
         within a larger organization. (Multi-focused organization exists for more than the purpose of
         providing CNE.) Provider Units within complex organizations must demonstrate their
         autonomy for providing CNE in the written documentation they submit.

   2. The Provider Unit must have the services of at least one Designated Nurse Planner who is
      responsible for adhering to ANCC criteria and WSNA CEARP approval criteria in the provision
      of CNE. The Designated Nurse Planner must be a registered nurse and hold a baccalaureate or
      higher degree. Either the baccalaureate or higher degree must be in nursing. Additionally, the
      Designated Nurse Planner must have education or experience in the field of education or adult
      learning. The Designated Nurse Planner must demonstrate competence in performing
      successfully at the expected level. Accepted demonstration of competence can be evaluated by
      review of the Designated Nurse Planner‘s curriculum vitae, biographical data form or
      professional portfolio. (Portfolio is a collection of documents, articles and exhibits that
      summarizes an individual‘s abilities, skills, growth, achievements and specific accomplishments
      attained over an extended period of time.)

       In some organizations there may be additional nurse planner(s). One nurse planner should be
       selected/identified as the lead nurse planner for a particular CNE activity. All nurse planners
       must meet the educational criteria of a minimum of a baccalaureate degree in nursing. Nurse
       planners may work for the Provider Unit as staff members, consultants or volunteers.

       In addition to meeting the minimum educational requirement, the Designated Nurse Planner and
       all nurse planners must maintain expertise in educational design and adult learning theories, as
       well as receive orientation to and maintain responsibility for implementing criteria in their
       performance of the nurse planner role.

       NOTE: The rationale for the nurse planner requirement is twofold:
         1. To ensure that the nurse planner is involved in the entire process of delivery—from needs
            assessment through planning, implementation, evaluation (APIE) and follow-up for every
            CNE activity offered by the Provider Unit; and
         2. To ensure that ANCC Accreditation Program and WSNA CEARP criteria guide the
            development and implementation of every CNE activity offered by the Provider Unit.

       Other nurses may serve on an individual activity planning committee along with one of the lead
       nurse planners. These other nurses do not have the same responsibilities, accountabilities or
       educational requirements as the Designated/Lead Nurse Planners. They are only responsible for
       participating in the planning of a particular educational event.
       NOTE: WSNA CEARP must always have an up-to-date list of the Designated and Lead Nurse
       Planners in approved Provider Units.



                            C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                        -3-
   3. The Provider Unit must have been operational for at least six months, using ANCC COA criteria
      and/or WSNA CEARP approval criteria. During that time, at least three separate activities must
      have been planned, implemented and evaluated with:
         a.. direct involvement of a qualified nurse planner (as specified above);
         b. each program being at least one hour (60 minutes) in length;
         c. adherence to the relevant criteria of the ANCC/WSNA CEARP or another accredited
             ANCC approver.
      NOTE: Co-provided activities may not be counted among the three completed activities.

      After this requirement has been completed, the organization/applicant may submit an ―Intent to
      Apply as a Provider Unit‖, presuming all other eligibility criteria have been met.

   4. Target audience:
      a. If you are based in Washington State, you must target more than 50% of your learning
         activities to nurses within the states of Washington, Alaska, Oregon, Idaho, Montana,
         Wyoming, Colorado, Hawaii and California. If your target audience is broader than the areas
         identified, you are NOT eligible to apply to be an approved Provider Unit through WSNA
         CEARP. You are, however, eligible to contact the ANCC Accreditation Program to apply
         for accreditation as a Provider Unit.

          NOTE: Activities offered over the internet are usually considered to be targeted to nurses in
          multiple regions covering more states than listed here.

      b. If you are based outside of Washington State, you must target more than 50% of your
         learning activities to nurses within the geographic range of your Provider Unit. Check
         www.hhs,gov/about/regionmap.html for the identification of your region plus the states
         contiguous to your region.

   5. The Provider Unit must be separate from any commercial entity that produces, markets,
      re-sells or distributes a product used on or by patients. A Provider Unit is ineligible for
      approval if it is a commercial interest as defined in the Standards for Commercial Support. A
      ‗commercial interest‘ is any entity either producing, marketing, re-selling, or distributing
      healthcare goods or services consumed by, or used on, patients or 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. This definition allows a provider to have a ‗sister company‘ that is a
      commercial interest, as long as the approved Provider Unit has in place and maintains adequate
      corporate safe guards to prohibit any influence or control by the ‗sister company‘ over the CNE
      program of the approved Provider Unit. In this instance, WSNA CEARP would expect that the
      approved Provider Unit would have adequate corporate safeguards in place to prohibit any
      influence or control by the ‗sister company‘ over the CNE.
      NOTE: Currently, approved commercial entities will retain their approved status until July 31,
      2010. They will not be eligible for re-approval. (adapted from ANCC Application Manual,
      2009)

B. Submit Intent to Apply/Re-apply

   Eligibility forms must be completed by the Designated Nurse Planner prior to submitting an
   application. For first-time Provider Unit applicants, complete the ―Intent to Apply as a Provider
   Unit—Initial application‖. For currently approved Provider Units, complete the ―Intent to Re-apply

                            C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                        -4-
as a Provider Unit‖. Reviewing the applicable form will help you determine if your organization is
eligible to be a Provider Unit. This form will be submitted to and reviewed by the Education
Program Specialist prior to submitting a Provider Unit application. Please contact WSNA‘s
Education Program Specialist with any questions about this process.

   1. For First-Time Applicants:
      Review the eligibility criteria as listed in the general information. If you feel you meet those
      criteria, submit the form ―Intent to Apply as a Provider Unit—Initial Application‖ as found
      in the CEARP Nursing Education section on the web site (www.wsna.org). Submit this form
      to the Education Program Specialist at WSNA at least three months before you plan to
      submit the provider application. Once the Education Program Specialist notifies you that you
      are eligible, the completed Provider Unit application must be submitted three months from
      the date of the approval notice.

       If an applicant wishes to offer approved CNE while the initial provider unit application is in
       process, individual faculty directed or independent study applications must be submitted to
       WSNA CEARP following the appropriate criteria and process and accompanied by the
       required application fee.

   2. For Currently-Approved Provider Units through WSNA CEARP
      Submit the form ―Intent to Reapply as a Provider Unit—Currently Approved Provider Unit‖
      which will be included with the reminder notice. The notice and form will be sent 9 months
      prior to your expiration date. The intent form is to be completed by the Designated Nurse
      Planner.




                        C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                    -5-
                                                        SAMPLE

                          WASHINGTON STATE NURSES ASSOCIATION
                  Continuing Education Approval and Recognition Program (CEARP)

                         Intent to Apply as a Provider Unit – Initial Application
                              To be completed by Designated Nurse Planner

Complete and submit this form to the Education Program Specialist at WSNA. Once you receive
confirmation that you are eligible to apply as a Provider Unit, you may submit your Provider Unit
application.

Section 1: Demographics
Date form completed: September 1, 2010
Organization name : ABC Hospital
If you were approved as a provider by WSNA CEARP at some time in the past, list old Provider Unit
number [CEARP PA-###]: N/A
Please list the three applications approved by WSNA:
   CEARP #             Name of Activity            Date Approved                              Contact Hours
1.
2.
3.

The Designated Nurse Planner must be the primary contact during the application review process.
Name and credentials: Dorothy Anderson, MN, BSN, RN.

Title/Position within organization: Director of Continuing Education

Phone Number including area code: 206-575-1908 Fax Number:

Email Address: Danderson@abchospital.org

Address: ABC Hospital, One Main Street, Anywhere, WA

My organization is a:
    Hospital                                               Long term care facility
    School/college of nursing                              Government agency
    Professional association                               Continuing education company
    Home health agency                                     Health care office or practice
    Business providing services to the healthcare industry
    Business providing products used on or by patients
    Other (describe)

Have you ever been denied approval by or had approval revoked for an individual activity or a Provider
Unit application by WSNA CEARP? Yes           No
       If yes, please explain what happened.



                            C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                        -6-
Have you ever been denied approval by or had approval revoked for an individual activity or a Provider
Unit application by another approver (state or national)? Yes     No
       If yes, please explain what happened.

Section 2: Provider Unit
A. My Provider Unit is:
       A free standing continuing education organization
       Part of an organization that does other things besides continuing nursing education

B. If your organization does other things besides continuing nursing education, is there a separate,
   clearly defined Provider Unit which is administratively and operationally responsible for planning,
   implementing, and evaluating continuing nursing education?
       Yes        No (if no,        here and contact the WSNA Education Program Specialist)
Section 3: Nurse Planners: Designated/Lead Nurse Planners are (1) actively involved in planning all
activities from start to finish; (2) knowledgeable about the CNE process; and (3) meet the qualifications
to hold this position.
A. How many Lead Nurse Planners (excluding Designated Nurse Planner) are part of your Provider
    Unit? 2
B. Are all your Lead Nurse Planners RNs?
      Yes          No (If no,       here and contact the Education Program Specialist at WSNA)
C. Do your Designated/Lead Nurse Planners have at least a baccalaureate degree in nursing?
      Yes         No (If no,       here and contact the Education Program Specialist at WSNA)
D. Do your Designated/Lead Nurse Planners have an understanding of the WSNA CEARP guidelines
   and forms reflecting ANCC COA and WSNA CEARP criteria for continuing nursing education?
      Yes           No (If no,     here and contact the Education Program Specialist at WSNA)

E. Please list names and credentials of all current Lead Nurse Planners here: Barbara Peterson, BSN,
   RN and Susan Little, MN, RN
Section 4: Regional Target Market
A. Think about where the people who participate in your learning activities live. During the past year,
   did you market more than half of your learning activities to nurses within the state of Washington?
       Yes (go to section 5)    No (answer next question in this section)
B. During the past year, did you market more than half of your learning activities to nurses within the
   states of Washington, Alaska, Idaho, Oregon, (Region X, HHS), Montana, Wyoming, Utah, Nevada,
   California and Hawaii?
       Yes (go to section 5)     No (answer next question in this section)
C. If you answered no to the above question, is it correct that, during the past year, you marketed more
   than half of your learning activities to nurses in more states than listed above or internationally?
   (internet learning usually fits this category)
       Yes        No (If no,         here and contact the Education Program Specialist at WSNA)

Section 5: Commercial Entities
A. Is your Provider Unit part of a company that produces, markets, re-sells or distributes a product that
   is used on or by patients?
       Yes          No



                             C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                         -7-
B. Is your Provider Unit‘s organization owned or controlled by a company that produces, markets, re-
   sells or distributes a product that is used on or by patients?
       Yes            No

   If you answered ―no‖ to both of these two questions, you have completed this form. Please return it
   to the Education Program Specialist at WSNA. You will be contacted to confirm your eligibility.

   If you answered ―yes‖ to either of the above questions, please continue with the items below.

C. Your organization is part of a company or system that produces, markets, re-sells or distributes a
   product that is used on or by patients. It is important that your Provider Unit is separate from any
   commercial interest to avoid the perception of bias in your continuing nursing education activities.
   Your answers to items 1 and 2 below will help WSNA CEARP assess the degree of separation.

1. Please describe the safeguards (sometimes called firewalls) in place to ensure that your Provider
   Unit is separate from commercial activities of the company.

2. Please provide to WSNA CEARP an organizational chart showing how the Provider Unit fits within
   the total organization and how separation is maintained between the Provider Unit and the
   commercial entity. (attach copy)


Thank you for completing this form. Please return it to:

                                     Education Program Specialist
                                  Washington State Nurses Association
                                   575 Andover Park West Suite 101
                                          Seattle WA 98188
                                          FAX 206-575-1908
                                           hfaber@wsna.org


You will be contacted to confirm your eligibility.


Office Use Only:

Date received documentation: ___________________________________

Eligible to apply as a first time Provider Unit?         Yes         No

If no, why not: _______________________________________________________________________


Date notified applicant: _________________________________________

Reviewer Signature: ____________________________________

   The Washington State Nurses Association is an accredited approver of continuing nursing education by the
                       American Nurses Credentialing Center’s Commission on Accreditation


                             C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                         -8-
                                                    SAMPLE

                       WASHINGTON STATE NURSES ASSOCIATION
               Continuing Education Approval and Recognition Program (CEARP)

             Intent to Reapply as a Provider Unit – Currently Approved Provider Unit
                              To be completed by Designated Nurse Planner

You have received this form with your reminder notice indicating that your Provider Unit approval will
expire in nine months. Complete and submit this form within four (4) weeks of receiving it.

Section 1: Demographics
Date form completed: September 1, 2010
Organization name and provider number (CEARP PA-###): ABC Hospital-PA-22/Nov/09
The Designated Nurse Planner must be the primary contact during the application review process.
Name and credentials: Dorothy Anderson, MN, BSN, RN.

Title/Position within organization: Director of Continuing Education

Phone Number including area code: 206-575-1908 Fax Number:

Email Address: Danderson@abchospital.org

Address: ABC Hospital, One Main Street, Anywhere, WA
My organization is a:
  Hospital                                                                     Long term care facility
  School/college of nursing                                                    Government agency
  Professional Association                                                     Continuing education company
  Home health agency                                                           Health care office or practice
  Business providing services to the healthcare industry
  Business providing products used on or by patients
  Other (describe)

We have complied with all requests from WSNA CEARP for monitoring or other information during the
past three years of provider approval.
    Yes
    No
Section 2: Provider Unit
A. My Provider Unit is:
        A free standing continuing education organization
        Part of an organization that does other things besides continuing nursing education
B. If your organization does other things besides continuing nursing education, is there a separate,
   clearly defined Provider Unit which is administratively and operationally responsible for planning,
   implementing, and evaluating continuing nursing education?
         Yes
         No (if no,        here and contact the Education Program Specialist at WSNA)


                            C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                        -9-
Section 3: Nurse Planners: Designated/Lead Nurse Planners are (1) actively involved in planning all
activities from start to finish; (2) knowledgeable about the nursing CNE process; and (3) meet the
qualifications to hold this position.

A. How many Lead Nurse Planners (excluding Designated Nurse Planner) are part of your Provider
   Unit? 2

B. Are all your Lead Nurse Planners RNs?
        Yes      No (If no,         here and contact the Education Program Specialist at WSNA)

C. Do your Designated/Lead Nurse Planners have at least a baccalaureate degree in nursing?
        Yes       No (If no,       here and contact the Education Program Specialist at WSNA)
D. Do your Designated/Lead Nurse Planners have an understanding of the WSNA CEARP guidelines
   and forms reflecting ANCC COA and WSNA CEARP criteria for continuing nursing education?
        Yes           No (If no,    here and contact the Education Program Specialist at WSNA)

E. Please list names and credentials of all current Lead nurse planners here: Barbara Peterson, BSN,
   RN and Susan Little, MN, RN

Section 4: Regional Target Market
A. Think about where the people who participate in your learning activities live. During the past year, did
   you market more than half of your learning activities to nurses within the state of Washington?
       Yes (go to section 5)
       No (answer next question in this section)

B. During the past year, did you market more than half of your learning activities to nurses within the
   states of Washington, Alaska, Idaho, Oregon (HHS, Region X), Montana, Wyoming, Utah,
   California and Hawaii?
       Yes (go to section 5)
       No (answer next question in this section)

C. If you answered no to the above question, is it correct that, during the past year, you marketed more
   than half of your learning activities to nurses in more states than listed above or internationally?
   (internet learning usually fits this category)
         Yes           No (If, no,          here and contact the Education Program Specialist at WSNA.

Section 5: Commercial Entities
A. Is your Provider Unit part of a company that produces, markets, re-sells or distributes a product that
   is used on or by patients?
       Yes
       No

B. Is your Provider Unit‘s organization owned or controlled by a company that produces, markets, re-
   sells or distributes a product that is used on or by patients?
       Yes
       No

   If you answered ―no‖ to both of these two questions, you have completed this form. Please return it
   to the address below. You will be contacted to confirm your eligibility.


                             C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                        - 10 -
   If you answered ―yes‖ to either of the above questions, please continue with the items below.

C. Your organization is part of a company or system that produces or sells a product that is used on or
   by patients. It is important that your Provider Unit is separate from any commercial interest to avoid
   the perception of bias in your continuing nursing education activities. Your answers to items 1 and 2
   below will help WSNA CEARP assess the degree of separation.

   1. Please describe the safeguards (sometimes called firewalls) in place to ensure that your Provider
      Unit is separate from commercial activities of the company.

   2. Please provide to WSNA CEARP an organizational chart showing how the Provider Unit fits
      within the total organization and how separation is maintained between the Provider Unit and the
      commercial entity. (attach copy)


Thank you for completing this form. Please return it to:

                                     Education Program Specialist
                                  Washington State Nurses Association
                                   575 Andover Park West Suite 101
                                          Seattle WA 98188

                                               FAX 206-575-1908

                                                hfaber@wsna.org



You will be contacted to confirm your eligibility.




Office Use Only:

Date received documentation: _______________________-

Eligible to apply as a Provider Unit (current provider)?             Yes         No

If no, why not:

Date notified applicant: _______________________

Reviewer Signature: _____________________________________________________
   The Washington State Nurses Association is an accredited approver of continuing nursing education by the
                       American Nurses Credentialing Center’s Commission on Accreditation




                             C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                        - 11 -
               APPROVAL PROCESS FOR PROVIDER UNIT APPLICATIONS

The Washington State Nurses Association Continuing Education Approval and Recognition Program
(WSNA CEARP) is accredited as an approver of CNE by the American Nurses Credentialing Center‘s
Commission on Accreditation (ANCC-COA). The ANCC-COA accredits approver units which have
demonstrated the capacity to approve and monitor the educational activities of individual activity
providers and Provider Units. Accreditation is national in scope.

A. Application Process
       Upon receipt of notification that you are approved to apply/re-apply, complete the form labeled
       ―Application for Provider Unit Approval.‖ Be sure to completely fill in all information
       requested at the top of the form. This application must be completed by the Designated Nurse
       Planner. Attach completed bio data forms for all the nurse planners. Do not send CVs or
       resumes.
      Note: The Designated Nurse Planner must be the primary contact person during the application
      review process.
       Submit three complete typed copies (one original and two single-sided copies) of the Provider
       Unit application packet with the $900 application fee. Each copy of the application must
       include a table of contents and have pages clearly numbered consistent with the table of contents.
       Assure documents are secured. Binder clips are recommended. (Do not use three-ring binders,
       comb binding, rubber bands or staples.)

       To be accepted for review, all applications MUST be submitted on current WSNA CEARP
       forms obtained from the WSNA Education website and completed in the format defined in these
       Guidelines. Applications not submitted on correct forms or in the proper format will be returned
       with directions about what changes are needed before the review can take place.
       Note: These guidelines/forms will be periodically updated, therefore, check that you are using
       the most current Guidelines located on the WSNA website: www.wsna.org.

          First-Time Provider Unit Applicants Must Submit:
             a. A composite list of all completed activities, which includes:
                 1. titles of activities that have been approved by WSNA CEARP or other ANCC
                    Approver during the past 24 months;
                 2. date approved;
                 3. date(s) presented;
                 4. assigned WSNA CEARP number (if applicable); and
                 5. number of contact hours approved.

              b. In addition submit:
                  Acknowledgement and approval letters from WSNA CEARP for the 3 activities
                     WSNA CEARP has approved
                  A summative evaluation for each of these 3 activities
                  Documentation for an activity that has been planned and will be reviewed and
                     presented after Provider Unit status has been achieved. Include all required
                     attachments: bio data forms, objectives, evaluation tool, marketing sample,
                     certificate, evidence of disclosures to be made, commercial support/sponsorship
                     agreement if applicable, post-activity QI tool. The marketing material and


                            C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                       - 12 -
                     certificate should contain the required Provider statement that will be used by
                     your organization once Provider Unit status has been achieved.
                    The sample certificate that you will use once you become an approved Provider
                     Unit. The Provider Unit statement must be included on the certificate. (Key
                     Element 7).

         Reapplying Provider Unit Applicants Must Submit:
                A composite list of all completed CNE activities with titles, dates presented and
                  contact hours provided in the past three (3) years.
                A complete file for one CNE activity implemented during the prior three-year
                  approval period, including completed application, objectives, signed bio data
                  forms, advertising materials, review check lists, post activity QI form, evaluation
                  summaries and changes made as a result of evaluations must also be included.
                Upon receipt of the application, the CEARP Reviewer will select a minimum of
                  two completed CNE activities from the composite list and request submission of
                  the completed files for the two completed CNE activities selected.

B. Review Process
  A preliminary quantitative review for completeness of the application is conducted by WSNA staff.
  You will be notified that the application is complete or additional information is needed. If you are a
  first-time applicant, you will be assigned a provider number. This provider number is very
  important and MUST be included on any subsequent correspondence or additional material related
  to your provider application. For currently approved Provider Units seeking re-approval, be sure
  your provider number is on all correspondence or other material related to your provider application.

  Applications are reviewed by members of the WSNA CEARP Committee. You will be notified by
  email of the name of the reviewer within five (5) working days after it is assigned and then
  contacted by the reviewer within 30 days after receipt of your application. The review process can
  take as long as three months depending on the completeness of the application and need for any
  additional supplemental information from the applicant. The goal of WSNA CEARP is to for you to
  be successful in providing quality CNE.

  You will be officially notified in writing regarding the final action on your application.

  One copy of your entire application, all correspondence to and from you related to the application,
  the CEARP review forms, and action on your application are kept on file at WSNA for six years.
  Only authorized personnel have access to the files. Accreditation and regulatory bodies such as the
  ANCC Accreditation program may review files.

C. Types of Action Taken by WSNA CEARP

  There are three types of action possible on an application for Provider Unit approval:

     1. Approval for three years occurs when your written application materials indicate that the
        criteria are met. During the approval period, the Provider Unit can award contact hours for
        CNE activities without submitting documentation to WSNA CEARP. However, the
        ANCC/WSNA CEARP criteria must be met by the Provider Unit for each individual CNE
        activity.


                           C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                      - 13 -
     2. Conditional Approval occurs when your written application materials indicate limitations in
        meeting criteria that can be resolved within twelve months or less. During this Conditional
        Approval time period, no contact hours can be granted by the Provider Unit applicant
        without prior approval of each proposed individual CNE activity by the assigned WSNA
        CEARP Reviewer. This will require submission of a complete faculty directed or
        independent study application, with payment of the usual fees for such activities, at least 45-
        days in advance of the scheduled date for the activity. Advertising and certificate approval
        wording must reflect activity approval by WSNA CEARP (not the approved provider
        language). Your Provider Unit will be listed on the WSNA website as having ―conditional
        approval‖. After additional review of the requested materials is reviewed and found to
        comply with ANCC/WSNA CEARP criteria, WSNA CEARP will confer full approval for
        the remainder of the three year approval period or deny approval.

     3. Denial occurs when written application materials indicate that your Provider Unit:
        a. Is not in adherence with the criteria of the ANCC COA and/or the requirements of the
           WSNA CEARP approval process and will not be able to adhere within an identified
           period of time; or
        b. Has not demonstrated adherence to or improvement in relation to WSNA CEARP
           documented areas of concern during the conditional approval process.

D. Appeal Process
  A Provider Unit will receive information regarding the appeal process at the time they are notified of
  the Conditional Approval or Denial action. To file an appeal, the applicant must submit its written
  argument to WSNA CEARP Committee .within 30 days following notification of the approval
  decision. Applicants considering whether to appeal a decision, or to request a reconsideration of a
  decision, should contact the WSNA CEARP Education Specialist.

E. Withdrawal and Resubmission of an Application
  A Provider Unit applicant has the right to withdraw an application at any time prior to completion of
  the approval process without prejudice to any future applications. The Provider Unit applicant must
  notify the WSNA CEARP in writing of the decision to withdraw the application. One complete
  application and a copy of all correspondence will be kept on file in the WSNA office for six years.
  Fees will not be refunded if the review process has begun. If the review process has not begun, the
  application fee, minus a $100 administrative fee will be returned to the applicant.

  If the applicant chooses to resubmit, the applicant has up to six months from initial submission to
  resume the approval process. After six months have passed, all eligibility criteria must be met again,
  and a new application including the required fee must be submitted.

F. Suspensions and Revocations

  Approval may be suspended and/or revoked from an approved Provider Unit (PU) as a result of
  ANY of the following:
     1. Unable to satisfactorily confirm that the PU adheres to criteria and requirements defined by
        ANCC criteria and/or WSNA CEARP Guidelines;
     2. Pay accreditation fees promptly;
     3. Investigation and verification of written complaints or charges;

                           C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                      - 14 -
     4. Refusal to fully comply with all requests for information; or
     5. Misrepresentation of ANCC and/or WSNA CEARP criteria, requirements, values or goals.

  Suspended Provider Units must immediately cease (a) offering or approving WSNA CEARP
  approved contact hours, and (b) referring to itself in any way as an approved Provider Unit by
  WSNA CEARP. Suspended units may, within 120 days of the suspension date, apply for
  reinstatement. Reinstatement may be granted if the suspended Provider Unit adequately
  demonstrates that it intends to fully adhere to the ANCC and WSNA CEARP approval criteria.

  Suspension and revocation are effective on the date the certified letter of notification is received by
  the organization. In cases of suspension, the Provider Unit may not award contact hours until all
  conditions relative to the suspension have been met. In cases of revocation, all statements regarding
  Provider Unit approval status must be removed from publicity material and certificates of
  completion printed and/or distributed after that date. If Provider Unit status is revoked, the Provider
  Unit may not award contact hours.

  Suspension and revocation decisions are open to appeal. The appeal, along with an appeal
  processing fee, must be submitted in writing to WSNA CEARP within 30 business days after
  receiving written notification of the suspension or revocation decision. Provider Units considering
  an appeal should contact the WSNA CEARP office for more information.

G. Recordkeeping
  Documentation of meeting these criteria must be completed on the CNE activity documentation
  forms for each activity and maintained in a secure file for six years. The Provider Unit is
  responsible for maintaining these internal processes to assure adherence to ANCC and WSNA
  CEARP criteria during the three-year approval period.

H. Reporting of Data
  Approved Provider Units will be asked to submit annual survey data and periodic requests for
  information in order to help evaluate and monitor the WSNA CEARP approval system and meet
  ANCC COA requirements. Failure to respond to monitoring requests will result in suspension
  of approval as a Provider Unit.

I. Provider Unit Changes
  The approved Provider Unit must maintain communications with WSNA CEARP during the
  approval period. At a minimum, the following must be reported in writing:
     1. Reports of data requested by WSNA CEARP within the time frame specified when the data
         is requested;
     2. Within 30 days, information about change in:
         a) name, ownership or structure of the organization, or
         b) the nurse planner(s), or
         c) the name of the contact person, or
         d) voluntary termination of Provider Unit status.




                           C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                      - 15 -
Provider Units that decide to cease the CNE services for which they are approved, must notify
WSNA CEARP how they will continue to make activity participation records available to learners.
Once approval is terminated, the Provider Unit may no longer use statements concerning approved-
Provider Unit status on publicity material or certificates of completion and may not award contact
hours.




                        C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                   - 16 -
                   CRITERIA FOR APPROVAL AS A PROVIDER UNIT - 2010

The following criteria, key elements (which clarify the major aspects of each criterion) and required
evidence is required to qualify for approval as a Provider Unit.

CRITERION 1: MISSION STATEMENT

The documented beliefs/philosophy and goals of the Provider Unit reflect the importance of
continuing nursing education and the needs and characteristics of the Provider Unit’s potential
learners. In a multi-focused organization, the Provider Unit: is clearly defined, accurately,
clearly, and consistently named, and, supported by the administrative structure.

Key Elements:

1. Beliefs and Goals (often referred to as mission statement) are relevant and appropriate to
   prospective learners.

               Required Evidence:
                Submit the beliefs and goals of the Provider Unit. If the Provider Unit is part of a
                  multi-focused organization, describe how the beliefs and goals of the Provider Unit
                  link with the goals, mission and functions of the total organization. Incorporate goals,
                  beliefs, scope, target audience, and types of education activities offered. This should
                  also include expected outcomes (e.g., changes in participants’ knowledge,
                  competency, behavior or patient outcomes) and how the Provider Unit anticipates
                  measuring those changes and outcomes.
                Describe features of the Provider Unit that characterize its scope such as its size,
                  geographical range, target audience(s), content areas and the type of educational
                  activities it offers. If the Provider Unit is part of a multi-focused organization,
                  describe the relationship of these scope dimensions in the total organization.

2. Scope and Administrative Support. Organizational structures and lines of authority support
   the operation of the Provider Unit.

               Required Evidence:
                Submit an organizational chart, flow sheet or similar kind of image that depicts the
                  organizational structure of the Provider Unit.
                Provide the name and credentials of the individual in each position identified on the
                  organizational chart.
                If the Provider Unit is part of a multi-focused organization, submit an additional
                  depiction that identifies the Provider Unit’s lines of authority and structural location
                  within the total organization.

   Be as clear as possible in describing the Provider Unit. This will help you if a question arises in the
   future and will help the CEARP Committee understand the scope of the Provider Unit. Questions to
   consider include the composition of your Provider Unit, the structure of the Provider Unit, etc.
   (examples: all departments within the hospital; all nursing departments within a 6-hospital system,
   the CNE department of a university, etc.)



                             C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                        - 17 -
CRITERION 2: EDUCATIONAL DESIGN

The Provider Unit has a clearly defined process for assessing need, planning, implementing and
evaluating (APIE) continuing nursing education (CNE) in accordance with adult learning
principles and professional education standards and ethics. The educational design process
includes procedures for protecting educational content from bias, providing learners appropriate
information and documentation related to their participation, and maintaining records in a secure
and confidential manner.

              Required Evidence for First-time Applicants:
              If you are a first-time applicant for Provider Unit status, submit:
                   Acknowledgement and approval letters from WSNA CEARP for the 3 activities
                      WSNA CEARP has approved
                   A summative evaluation for each of these 3 activities
                   Documentation for an activity that has been planned and will be reviewed and
                      presented after Provider Unit status has been achieved. Include all required
                      attachments: bio data forms, objectives, evaluation tool, marketing sample,
                      certificate, evidence of disclosures to be made, commercial support/sponsorship
                      agreement if applicable, post-activity QI tool. The marketing material and
                      certificate should contain the required Provider statement that will be used by
                      your organization once Provider Unit status has been achieved.
                   The sample certificate that you will use once you become an approved Provider
                      Unit. The Provider Unit statement must be included on the certificate. (Key
                      Element 7).

              Required Evidence for Reapplying Approved Provider Unit Applicants:
                  A composite list of all completed CNE activities with titles, dates presented and
                    contact hours provided in the past three (3) years.
                  A complete file for one CNE activity implemented during the prior three-year
                    approval period, including completed application, objectives, signed bio data
                    forms, advertising materials, review check lists, post activity QI form, evaluation
                    summaries and changes made as a result of evaluations must also be included.
                  Upon receipt of the application, the CEARP Reviewer will select a minimum of
                    two completed CNE activities from the composite list and request submission of
                    three copies of the completed files for the two completed CNE activities selected.
                    These must be received in the WSNA office within one week of contact by the
                    reviewer.

Key Elements:

1. Assessment of Learner Needs. CNE activities are developed in response to and with
   consideration for the unique educational needs of the Provider Unit’s target audience (as
   associated with the Mission Statement).

              Required Evidence:
              Describe the process of activity planning, including the
               needs assessment
               determination of target audience


                           C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                      - 18 -
                 development of objectives, content and teaching-learning strategies in response to the
                  needs assessment .

2. Qualified Planners and Faculty. Each educational activity is planned collaboratively by at
   least one Designated/Lead Nurse Planner and one other planner. The Provider Unit’s
   Designated/Lead Nurse Planner(s) must be a registered nurse and hold a baccalaureate or
   higher degree in nursing. Additionally, the Designated/Lead Nurse Planner must have
   education or experience in the field of education or adult learning. Each member of the
   planning group should represent at least one of the following areas: the relevant content
   expertise; the target audience; responsibility for adherence to ANCC accreditation criteria.
   Each planning committee must have representation of all these three areas. Nurse planners
   contribute oversight and must be actively involved in both the planning and the analysis of
   evaluation data for the educational activity. The planning committee assures the qualifications
   of the faculty member(s) are appropriate and adequate.

              Required Evidence:
              Identify Designated/Lead Nurse Planner(s) and all other person(s) who participated in
              the planning process. Document the content expertise of the collaborating planner(s) who
              represents this area (required), and of the activity presenters as appropriate.
               Describe the role(s) played by the Provider Unit’s Designated/Lead Nurse
                  Planner(s) and any additional key personnel or groups involved in the process of
                  ensuring the quality of educational activities. If the Unit relies on the services of
                  multiple and/or ad hoc Nurse Planners, describe how all nurse planners are kept up-
                  to-date on the requirements for adhering to ANCC accreditation standards and
                  WSNA CEARP approver standards. Also, describe how the Provider Unit ensures the
                  performance of each Lead Nurse Planner meets both the requirements of the Provider
                  Unit and the expectations of ANCC and WSNA CEARP.
               Submit a description of the manner in which the needed qualifications of faculty are
                  identified.
               Submit a description of how the planning committee ensures that the selected faculty
                  meets the needed qualifications.

3. Effective Design Principles. Each educational activity is developed with:
      a. an identified learning goal (purpose) and explicit educational objectives for the learner;
      b. identified gaps in knowledge, skills, practice identified (based on the needs assessment)
          which the activity is designed to address;
      c. content congruent with the activity’s learning goal and educational objectives;
      d. teaching and learning strategies congruent with the activity’s objectives and content;
      e. criteria for judging successful completion of an activity that are consistent with the
          learning goal, objectives, teaching and learning strategies as listed above; and
      f. a method determined for verifying participation in an activity.

              Required Evidence:
              Submit a description of the activity:
               purpose, learner objectives and related content;
               identified gaps(based on the needs assessment);
               teaching-learning strategies used, including resources, materials, delivery methods
                 and learner feedback mechanisms;
               rationale and criteria selected for judging successful completion, and


                           C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                      - 19 -
                 method selected for verifying participation.

4. Awarding Contact Hours. Contact hours associated with the official accreditation statement
   are awarded to participants for those portions of the educational activity devoted to didactic or
   clinical experience or to evaluating the activity. Contact hours are calculated in a logical and
   defensible manner. One contact hour = 60 minutes. A provider of an educational activity may
   award no fewer than 0.5 contact hours for an educational activity. 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 provider is to round down to the
   nearest 1/100th. Contact hours may not be awarded retrospectively.

              Required Evidence:
              Identify and provide supporting documentation of how the number and calculation of
              contact hours are awarded for the activity.

5. Activity Evaluation. A clearly defined method, which includes learner input, is used to
   evaluate the effectiveness of each educational activity.

              Required Evidence:
               Describe the method used to evaluate the activities
               Identify the category of evaluation i.e. learner satisfaction, knowledge enhancement,
                 skill and attitude change, change in practice/performance, relationship of the
                 practice change to quality of service. It is strongly recommended that at least a
                 portion of the activities provided be evaluated at one of the higher levels of
                 evaluation.
               Include supporting documentation for the descriptions above.

6. Approval Statements. The approval statement is a mark of the status of the Provider Unit. All
   communications, marketing materials, certificates and other documents that refer to the status
   of approval by an ANCC-accredited approver must contain the official approval statement:

          (Insert Name of approved Provider Unit) is an approved provider of continuing nursing
          education by the Washington State Nurses Association, an accredited approver by the
          American Nurses Credentialing Center’s Commission on Accreditation.

   The approval statement must start and end on a line separate from other text. It must stand alone.

              Required Evidence:
              Submit samples of promotional materials developed for an activity.

7. Documentation of Completion. Participants receive written verification of their successful
   completion of an activity, which includes at a minimum:
      a. the name of the participant learner
      b. the name and address of the Provider Unit
      c. the title and date of the educational activity
      d. the official accreditation statement, and
      e. the number of contact hours awarded.




                            C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                       - 20 -
              Required Evidence:
               Submit a sample copy of the certificate awarded to participants upon completion of
                 the educational activity.
               First-time applicants: Include sample certificate of completion as it would appear
                 following accreditation and containing the appropriate accreditation statement once
                 approved as a Provider Unit.

8. Sponsorship and Commercial Support Guidelines. Education must be kept separate from
   promotional activities. Commercial support, exhibits or the presentation of research
   conducted by a commercial company shall not influence the design and scientific objectivity of
   any educational activity. Commercially-supplied funds for an educational activity that are
   given in the form of an educational grant or in-kind assistance shall be acknowledged in the
   brochures and/or printed materials or electronic promotion for the continuing nursing
   education activity. (Refer to Standards for Disclosure and Commercial Support, Appendix J.)

              Required Evidence:
              Submit a description of:
               Any sponsorship or commercial support related to the educational activity;
               How content integrity is maintained for education activities that receive sponsorship
                 or commercial support, if any, including, but not limited to the policy and associated
                 procedures for resolving conflicts;
               What/how precautions are taken to prevent bias in the educational content;
               A template of the written agreement used in the presence of sponsorship or
                 commercial support.

9. Conflict of Interest Guidelines. Conflict of interest disclosure statements shall be obtained
   from all activity planners and presenters to identify the presence or absence of any potentially
   biasing relationship of a financial, professional or personal nature on the part of those who
   have an impact on the content of an educational activity. Planners and presenters must
   disclose the presence or absence of conflict of interest relative to each activity. All potential
   conflicts shall be resolved prior to the planning, implementation or evaluation of the CNE
   activity. (Refer to the conflict of interest discussion in Appendix I.)

       Note: ANCC defines a ―conflict of interest‖ as when an individual has an opportunity to affect
       CNE content with products or services from a commercial interest with which he/she has a
       financial relationship. ANCC considers ―opportunity to affect CNE 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.

              Required Evidence:
               Submit documentation of the conflict of interest disclosures(or disclosures of absence
                 of conflict of interest) relative to a specific activity;
               Describe procedures followed to resolve any real or potential bias or conflict of
                 interest is resolved.

10. Disclosures Provided to Activity Participants. Participants shall receive the following
    information regarding each and every activity in advance of, or at the time of the event. If the
    disclosure is provided verbally, there will be documentation provided by a designated person
    in the audience of the activity that the disclosure was appropriately made. See Standard 6A


                           C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                      - 21 -
   and 6B of the Standards for Disclosure & Commercial Support (in Appendix J) for further
   guidance.

      a. Notice of requirements for successful completion: Learners are informed in advance of the
         learning goals, objectives of the educational activity, and the criteria to be used to determine
         successful completion of an educational activity.
      b. Conflicts of Interest: Activity participants are informed of any influencing financial
         relationships or lack thereof disclosed by planners or presenters. (Refer to Appendix I for
         further instruction.)
      c. Disclosure of Relevant Financial relationships and Mechanism to Identify And Resolve
         conflicts of Interest. (See further instruction, Appendix J, Standards for Disclosure &
         Commercial Support).
      d. Sponsorship or Commercial support: Activity participants are made fully aware of the
         nature of any commercial support related to an educational activity. (Refer to Appendix J,
         Standards for Disclosure & Commercial Support.)
      e. Non-endorsement of products: Activity participants are advised that approved status does
         not imply endorsement by the provider, ANCC and WSNA CEARP of any commercial
         products displayed in conjunction with an activity.
      f. Off-label use: Learners are notified when an educational activity relates to any product use
         for a purpose other than that for which it was approved by the Food and Drug
         Administration.
      g. Expiration Date for Awarding Contact Hours: Endurable educational documents must
         include a statement that explains how long contact hours will be awarded for an independent
         study activity. This statement must appear on all marketing materials and on the educational
         materials.

             Required Evidence:
             Describe the methods used to inform activity participants of the above information.
              Requirements for successful completion.
              Conflict of Interest documents
              Disclosure statements
              Sponsorship/Commercial Support
              Non-endorsement of products
              Off-label use
              Expiration date for awarding contact hours

11. Recordkeeping. For each provided educational activity, the following documentation is kept in
    a secure, confidential and a retrievable manner for six years:
        a. Planning:
                description of the target audience
                the 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 and
                   resolutions of conflict of interest, as appropriate
                purpose, objectives and content
                instructional strategies, delivery methods, learner feedback mechanisms and
                   resources to be used
                method or process used to verify participation
                notice to learners identifying how successful completion will be measured


                           C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                      - 22 -
               marketing and promotional materials
               division of responsibilities among co-providers, if any, and
               means of ensuring content integrity with sponsorship or commercial support, if
                any; and
              the written commercial support agreement as required in the Standards of
                Commercial Support for any activity receiving commercial support.
       b. Implementation:
              title, location and date of educational activity
              all evaluation tools used, including a summative evaluation
              participant names and unique identifier information (e.g.: an automatically
                generated number, a password code, the month and date of birth, an address,
                etc.)
              sample certificate of completion
              number of contact hours associated with official accreditation statement
                awarded to individual participants
              documentation of the verbal provision of required disclosures (see Standard 6A,
                B of the Standards for Commercial Support for further guidance, refer to
                Appendix J.)

              Required Evidence:
              Describe the Provider Unit’s recordkeeping system, including:
               how activity records are consistently collected, and
               how records are stored and secured in a consistent, logical, safe and confidential
                 manner.

12. Co-Provided Activities. When educational activities are co-provided, the approved Provider
    Unit is responsible for ensuring adherence to all ANCC criteria. The approved Provider Unit
    retains the following responsibilities:
        a. determination of the educational objectives and content;
        b. selection of the content specialist planners and activity presenters;
        c. the awarding of contact hours, as appropriate, to the individual educational Activity;
        d. recordkeeping procedures;
        e. evaluation methods and categories and
        f. management of any sponsorship or commercial support.

   If collaborating providers are all ANCC accredited, one is designated to retain the provider
   responsibilities by mutual, written agreement. The unit designated to retain these
   responsibilities is referred to as the provider and the other collaborating providers are
   referred to as co-providers. (Refer to Appendix H for more information.)

              Required Evidence:
              Submit a description of how responsibilities are assigned and maintained for co-provided
              activities, if any. (The co-provider agreement must be signed by each party involved in
              the provision of the activity and must identify the responsibilities of each party.)

CRITERION 3: UNIT OPERATIONS

The Provider Unit ensures the quality of continuing nursing education (CNE) through an
established process involving a qualified nurse planner for developing, delivering and evaluating


                           C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                      - 23 -
the effectiveness of the educational activities it offers. Adequate resources are provided to support
the Provider Unit’s full range of functions.

Key Elements:

1. Designated Nurse Planner.
   At least one nurse carries out the role of the Designated Nurse Planner with responsibility for
   assessing needs, planning, implementing and evaluating CNE activities. The Designated Nurse
   Planner is responsible for assuring that all Nurse Planners are appropriately prepared, oriented and
   trained to use the same approach and policies established by the Provider Unit. The Designated
   Nurse Planner must be a registered nurse with a baccalaureate or higher degree in nursing.
   Additionally, the Designated Nurse Planner must have education or experience in the field of
   education or adult learning.

               Required Evidence:
                Submit a position description for the Designated Nurse Planner reflecting
                  qualifications and job functions; and
                Submit a description of the activities of the Designated Nurse Planner in assuring
                  other Nurse Planners are appropriately prepared, oriented and trained to function in
                  that role. Provide accompanying evidence.

2. Resources. Sufficient human, material and financial resources are available to carry out the
   administrative, educational and supportive functions of the Provider Unit.

              Required Evidence:
               For Designated Nurse Planners, nurse planners, and other key personnel (individuals
                 as defined by the applicant organization) involved in providing CNE or the overall
                 administration of the Provider Unit, submit position descriptions that clearly identify
                 job functions and biographical data summaries that demonstrate the qualifications of
                 current incumbents. The position descriptions must reflect qualification requirements
                 for the Nurse Planner(s) and roles relative to CNE that are consistent with those of
                 the ANCC Accreditation Program.
               Submit a description of the material resources that support the functions of the
                 Provider Unit.
               Submit a brief description of the Provider Unit’s current sources of financial support
                 and how financial support will be sustained throughout the approval period. Do not
                 submit detailed budget reports.
               Submit a report identifying the amount and frequency with which commercial support
                 for educational activities is received.

3. Business Practices. The Provider Unit must adhere to all regional, state and national laws and
   regulations and operate the business and management policies and procedures of its CNE
   program (as they relate to human resources, financial affairs and legal obligations) so that its
   obligations and commitments are met. The Provider Unit must adhere to all reasonable
   ethical expectations in its provision of CNE and its business practices.

               Required Evidence:
               Submit the signed Attestation Statement that the approved Provider Unit complies with
               all applicable local, regional, state or national laws and regulations and operates its


                            C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                       - 24 -
               business in an ethical manner. This attestation is to be signed by the leader(s) of the
               approved Provider Unit.

CRITERION 4: PROVIDER UNIT EVALUATION

The Provider Unit engages in an ongoing evaluation process to analyze its overall effectiveness in
fulfilling its beliefs, goals and functions, and in providing quality CNE. Plans and goals for the
Provider Unit’s future development in CNE are identified and re-evaluated on a regular basis.

Documentation Requirements:
Required evidence for this criterion should include a written plan for evaluation of the Provider Unit
indicating what is evaluated, when it is evaluated, who participates and findings of most recent
evaluation and date that was done. This plan should include those items stated in Criterion 4, Key
Element 1, (i.e., the process used and what was identified as needing change). Examples of the
evaluation data that are collected with an explanation as to how they have been used to increase the
effectiveness of the Provider Unit should also be included.

NOTE: First-time applicants are expected to have implemented their Provider Unit performance
improvement plan throughout the six months of operational status that is required for application
eligibility. Data examples should be selected that are representative of that period. New goals for the
Provider Unit should be described under Key Element 4.

Key Elements:

1. Provider Unit Evaluation Process. The Provider Unit must have a plan in place to evaluate
   the effectiveness of its overall CNE Program.
       a. administrative and operational procedures
       b. array of educational offerings, including those offered on a repeated basis for which
           participant input and evaluation data can be collected and analyzed over time
       c. outcomes and results, and
       d. progress toward goals for improvement.

               Required Evidence:
               Document what process was used, what was identified as needing change (or not).
               Submit the plan for implementing the Provider Unit’s overall evaluation process for the
               next three years. This plan should address, at a minimum, items 1.a through 1.d listed
               above. (Refer to sample Provider Unit Evaluation Plan.)

2. Provider Unit Evaluation Participants. The Designated Nurse Planner shall participate in the
   unit evaluation. The Provider Unit shall identify other participants to be included in the
   evaluation process.
              Required Evidence:
             Identify appropriate stakeholders that are involved in the evaluation of the Provider Unit.
             (This may differ based upon the type of provider’s organization.)




                             C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                        - 25 -
3. Provider Unit Evaluation Results. Evaluation data are used to confirm, expand or change the
   operations of the Provider Unit.

             Required Evidence:
             Describe how results of the overall program evaluation process have been used to
             confirm, expand and improve the Provider Unit’s operations.

4. Provider Unit Goals for Improvement. Efforts toward improvement include addressing issues,
   identifying strategies for working on targeted goals, evaluating progress toward goals and
   revising or establishing new goals.

             Required Evidence:
             Submit a description of how:
              The Provider Unit’s goals for improvement during the approval period have been
                addressed;
              What changes and progress have been made toward meeting those goal;
              What new goals for improvement have been identified, and
              Operational plans for implementation associated with the goals identified above.




                          C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                     - 26 -
                                                 SAMPLE
                              (This is not intended to be a complete example)

                          WASHINGTON STATE NURSES ASSOCIATION
                   Continuing Education Approval & Recognition Program (CEARP)

                                Application for Provider Unit Approval – 2010


DIRECTIONS: Please review the Provider Unit Guidelines
                                                                               For office use only
for additional information to complete this Provider Unit       Date Received: _______________________
application. Some of the information can be typed directly on
this form, some can be attached. If more space is needed        Amount received: ____________________
than provided on this form in any section, clearly identify     Check number: _______________________
where to find the continuation. Attached information must be
labeled and titled in accordance with the outline, divided      Credit Card (check if yes): _________________
clearly and numbered in sequence.                               Provider #: _____________________________
Each copy of the application must:
   Have a table of contents;
   Pages numbered consistent with the table of contents;
   Application bound securely. Binder clips are recommended. Do not use comb binding, three ring
      binders, staples or rubber bands.
  Submit three complete, collated, typed, single-sided copies of the application packet with the $900
  application fee.
   NOTE: These guidelines/forms will be periodically updated, therefore, check that you are using the
   most current Guidelines located on the WSNA website: www.wsna.org.

Demographic Data
 Date of this application: September 3, 2010
 Name of Provider Unit (as appears in advertising materials): ABC Hospital
 Name of organization (if different):
 For reapplying Provider Units: CEARP-PA # N/A
 Address: One Main Street, Anywhere, WA
 Phone number including area code:

The Designated Nurse Planner must be the primary contact during the application review process.
 Name: Barbara Peterson, BSN, RN
 Phone Number including area code: 206-575-1908 Fax Number: 206-575-9801
 Email Address: bpeterson@ABChospital.org

Does your Provider Unit have a website that offers any information about the Provider Unit/CNE
Activities? Intranet___ Internet_____    Yes      No
 If yes, the address is:

 Check which types of activities you plan to or do offer:    Faculty Directed       Independent Study
 For computer-based programs, list the web site address for the activities provided:

 For First-Time Provider Unit Applicant:
 A. Date of first activity approved by WSNA CEARP: February 2010
 B. Date first implemented ANCC COA and/or WSNA CEARP criteria: February 2010

                               C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                          - 27 -
C. Attach a composite list of all activities provided since date first implemented ANCC/WSNA CEARP
   criteria including title, date(s) presented, contact hours awarded for each activity. Found on page:
   xx

For Reapplying Provider Unit Applicant:
A. Please answer the following questions regarding your last three approval years:
   1. Describe how all Nurse Planners and Reviewers are kept current on ANCC, WSNA CEARP
       requirements/ application changes:

   2. Please check if one or more of your Nurse Planners or reviewers read or attended the following:
         Provider email Updates
         HIGHLIGHTS newsletter
         Attended WSNA CEARP Provider Update Conference; Date Sept. 1, 2010
         Other: (Describe:)

   3. Based on your organization‘s experience these past three years, identify two trends in nursing
      practice that have implications for CNE?
      a)
      b)

   4. Attach a composite list of all CNE activities provided during the three year approval period
      including: title, date(s) delivered, contact hours awarded. Found on page

   5. Upon receipt of the application, the CEARP Reviewer will select a minimum of two completed
      CNE activities for review from the composite list. Submit the two requested files to the WSNA
      office within a week of notification by the Reviewer.

CRITERION 1: MISSION STATEMENT

The documented beliefs and goals of the Provider Unit reflect the importance of CNE and the needs and
characteristics of the Provider Unit‘s potential learners. The Provider Unit is clearly defined and, in
multi-focused organizations, supported by the administrative structure.

Key Element 1: Beliefs and goals of the Provider Unit are relevant and appropriate to prospective
learners.

A. Our Provider Unit‘s prospective learners are:
      Employees of our organization
      Nurses in our community
      Other: describe

B. To meet the needs of our prospective learners, our Provider Unit believes that: See ABC Hospital
   Philosophy/mission statement on p. xx; and overall Purpose/Goals of ABC Hospital Education Dept.
   on p. xx

C. The current goals of our Provider Unit for the new approval period are to: See pages xx

D. The outcomes we hope to achieve with our CNE activities are:
      Learner satisfaction
      Change in participants‘ knowledge

                            C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                       - 28 -
       Change in participants‘ practice
       Change in patient outcomes
       Other: describe       :

E. We measure achievement of these outcomes by:
     Learner satisfaction surveys
     Testing
     Return demonstrations
     Performance and/or process improvement initiatives
     Follow-up surveys of previous participants
      Other:

F. Our Provider Unit is:
      A free-standing organization (omit the next question)
      Part of a larger organization: the organization does more than provide continuing education
      (answer the next question)

G. The beliefs and goals of our Provider Unit link with the mission, goals, and purpose of the larger
   organization by: ABC Provider Unit is integrated into the Education Dept of ABC Hospital. The
   Education Dept reports to the ABC Hospital Chief Nursing Officer who approves the Education
   Dept. budget and monitors its activities via regular report to the Designated Nurse Planner. See
   ABC Hospital Purpose, Vision, Mission & Goals on pp. xx and the ABC Hospital Staff Org. Chart
   on pp. xx.

H. 1. If based in Washington State, the geographic range of our Provider Unit is (where we target
      more than 50% of our marketing):
          Our facility
          Our city
          Our county
          Our state
          Our region (Washington, Alaska, Oregon, Idaho, Montana, Wyoming, Utah, Nevada,
          California and Hawaii.)

   2. If based outside of Washington State, the geographic range more than 50% of our Provider Unit
      marketing is targeted to the Washington State region (Washington, Alaska, Oregon, Idaho,
      Montana, Wyoming, Utah, Nevada, California and Hawaii.)
          Yes
          No

   NOTE: If you target the marketing for more than 50% of your learning activities to people outside
   our region, you are NOT eligible to apply as a provider. Please contact the WSNA Education
   Program Specialist for additional information.

I. Our usual target audience includes:
       RNs
       Advanced Practice RNs
       Multidisciplinary participants
       Other: describe




                            C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                       - 29 -
J. Our usual content areas are:
       Clinical topics: describe safe lifting, nurse sensitive outcome indicators, safety precautions;
       infection control, etc.
       Nonclinical topics: describe
       Other: describe

K. The types of educational activities we typically offer include:
       Face-to-face / real-time learning (conferences, workshops, webinars, etc.)
       Independent studies

Key Element 2: Scope & Administrative Support.
Organizational structures and lines of authority support the operation of the Provider Unit.

A. An organizational chart for the Provider Unit is on page xx. This chart shows both:
       The organizational structure of the Provider Unit
       Names and credentials of the people in each position

B. If our Provider Unit is part of a larger organization, an organizational chart of the whole
   organization, showing how the Provider Unit links with the rest of the system, is on page xx.

CRITERION 2: EDUCATIONAL DESIGN

The Provider Unit has a clearly defined process for assessing need, planning, implementing, and
evaluating CNE. Adult learning principles, professional education standards, and ethical considerations
guide the way educational activities are conducted. There are procedures for protecting educational
content from bias, providing learners appropriate information and documentation related to their
participation, and maintaining records in a secure and confidential manner.

In accordance with WSNA CEARP, each educational activity undergoes an internal review prior to its
initial use in order to verify that all criteria and rules have been addressed. Subsequently, the Designated
Nurse Planner monitors each learning activity on a regular basis to ascertain that all components of the
activity remain relevant and appropriate. This is a quality assurance process, not an approval process.
The Provider Unit does not approve activities. The Provider Unit must not use the words ―approval,
applicant, or application‖.

Key Elements 1-10: Learning Activity Development, Implementation, and Evaluation (APIE) as
evidenced by completed CNE activities

NOTE FOR FIRST-TIME APPLICANTS                          NOTE FOR RENEWING APPLICANTS
ONLY: If you are a first-time applicant for             ONLY: Submit documentation for one
Provider Unit status, submit:                           completed activity which must be at least one
                                                        hour in length.
   Acknowledgement and approval letters                  The documentation form with all required
    from WSNA CEARP for the 3 activities                    attachments including: bio data forms,
    WSNA CEARP or other ANCC accredited                     objectives, summative evaluation,
    approver has approved.                                  marketing sample, certificate, evidence of
                                                            disclosures, co-provider agreement if
                                                            applicable, commercial
                                                            support/sponsorship agreement if
                                                            applicable (refer to 1-10 key elements)

                             C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                        - 30 -
   A summative evaluation for each of these 3               Completed reviewer(s) form(s)
    activities

   Documentation for an activity that has been              Summative evaluation
    planned and will be reviewed and presented
    after Provider Unit status has been
    achieved. Include all required attachments:
    bio data forms, objectives, evaluation tool,
    marketing sample, certificate, evidence of
    disclosures to be made, commercial
    support/sponsorship agreement if
    applicable, post-activity QI tool. The
    marketing material and certificate should
    contain the Provider statement that will be
    used by your organization once Provider
    Unit status has been achieved.

   The sample certificate that you will use                 Designated Nurse Planner‘s Quality
    once you become an approved Provider                      Improvement (QI) form
    Unit. The Provider Unit statement must be
    included on the certificate. (Key Element 7)


Assessment, Planning, Implementation and Evaluation (APIE) PROCESS: Describe (or attach a
page) the process of assessment, planning, implementation and evaluation that you use in planning,
providing, and evaluating each submitted CNE activity. see page xx

A. Internal Review Process
   1. Each activity is reviewed by (number) RN reviewers prior to the initial learning activity being
      offered.

    2. Reviewers receive information about how to conduct reviews by: (check all that apply)
          Information provided by the Designated Nurse Planner
          Periodic educational sessions
          Feedback from the Designated Nurse Planner
          Inter-rater reliability exercises
          Other: describe Currently three qualified PU staff: The Designated Planner and two Lead
          Planners who alternate the planner/reviewer roles, when one is the Planner, the other is the
          Reviewer.

    3. Describe your internal peer review process: On Page xx.

    4      Completed review forms are included with each individual activity documentation form
        submitted with the Provider Unit application.




                             C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                        - 31 -
B. Post Activity Quality Improvement Evaluation
   The Designated and/or Lead Nurse Planner(s) conduct quality improvement reviews following
   presentations of a learning activity.
       QI evidence is included with each individual activity documentation form. (Refer to Appendix E-
       2 for Sample Post Activity QI form.)

Key Element 11: Recordkeeping: Documentation for each educational activity, as noted in the
Provider Unit Guidelines, is kept in a secure, confidential, and retrievable manner for six years.

A. We assure the consistent collection of all required documents and information by using the forms
   provided by WSNA CEARP and following the directions to include additional required information
   in the files.
       Yes
       No

B. We assure maintenance of all required documentation for six years through:
     File checklist
     Regular file audits
     Other: describe

C. Security of files is maintained by:
      Locked file cabinets
      Locked offices
      Restricted access
      Computer passwords
      Other: describe

D. Confidentiality of files is maintained by:
      Access only by (describe who) PU Staff
      Following facility policy Refer to policy on pp. xx
      Other: describe:

E. Files can be retrieved by:
       Request of Nurse Planner
       Other (describe)

F. The physical address where files are maintained is: ABC Hospital, One Main Street, Anywhere, WA

Key Element 12: Co-provided Activities: Are conducted with the approved Provider Unit maintaining
responsibility for the following required elements:
     Determination of educational objectives and content
     Selection of content specialist planners & activity presenter(s)
     Awarding of contact hours
     Recordkeeping procedures
     Evaluation methods and categories
     Management of sponsorship and/or commercial support

A. Our Provider Unit co-provides CNE activities. (See Appendix H for details)
        No
        Yes

                             C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                        - 32 -
B. We maintain responsibility for the above activities by:
       Standard co-provider agreement signed by all parties which identifies responsibilities of each
       party (required) See Appendix H-1 for Sample Agreement
       Additional actions, if any:

CRITERION 3: UNIT OPERATIONS

The Provider Unit ensures the quality of CNE by following an established process involving a qualified
Nurse Planner for developing, delivering, and evaluating the effectiveness of the educational activities it
offers. Adequate resources are provided and utilized to support the Provider Unit‘s full range of
functions.

Key Element 1: Nurse Planner
A. Our Designated Nurse Planner is: (name and credentials) Dorothy Anderson, MN, BSN, RN

B. The qualifications of our Designated Nurse Planner include:
        BSN (required if no higher degree in nursing)
        Graduate degree in nursing
        Higher degree in another field
        Certification in nursing professional development
        Other: describe

C. The functions of the Designated Nurse Planner are to:
        Assess, plan, implement, and evaluate continuing nursing education activities
        Oversee the work of other Nurse Planners
        Coordinate evaluation of the Provider Unit (required)
        Manage the continuing education office/department
        Other: describe

D. The Designated Nurse Planner maintains awareness of current criteria/rules through:
        Attending provider update workshops
        Reading provider newsletters
        Participating in internal educational activities related to the planning and review processes.
        Other: describe Participate on a provider list serve to discuss issues, best practices, get updates
        from other Provider Unit personnel in other states.

E. A copy of the position description for the Designated Nurse Planner is on page xx (see Appendix G
   for sample position description) or listed here

F. There are additional Nurse Planners in our Provider Unit.
        No (go to key element 2)
        Yes (answer next question before proceeding to key element 2)

G. The Designated Nurse Planner assures that all Lead Nurse Planners are prepared, oriented, and
   updated to function in the Lead Nurse Planner role by:
        Sharing information from provider update workshops
        Encouraging participation of other Nurse Planners in provider updates
        Sharing provider newsletters
        Conducting regular internal workshops

                             C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                        - 33 -
         Doing inter-rater reliability analyses
         Other: describe

Key Element 2: Resources
A. The position description, including qualifications, for the Lead Nurse Planner role (in addition to
   Designated Nurse Planner already addressed in key element 1, if applicable) is on page
   (See Appendix G)

B. Names and credentials for other Lead Nurse Planners are: Barbara Peterson, BSN, RN & Susan
   Little, MN, RN

C. Biographical Data forms for the Designated Nurse Planner and the current Lead Nurse Planners are
   on pages xx. (Use attached form)

D. Names and credentials for reviewers are: Dorothy Anderson, MN, BSN, RN; Barbara Peterson,
   BSN, RN; Susan Little, MN, RN (when one is a planner, the other is a reviewer.)

E. The position description, including qualifications, for the reviewer role is on page xx.

F. Biographical forms for current reviewers are on pages xx. (Use attached form)

G. Other key personnel in our Provider Unit include:
      Administrative assistant
      Other: describe

H. Names of these other key personnel (excluding reviewers) are Janice Conners, Administrative Asst.

I. Position descriptions for other key personnel are on pages xx.

J. Biographical form for other key personnel are on pages xx.

K. Material resources that support the Provider Unit include:
      Computers and other technology support
      Adequate office space
      Conference / meeting rooms
      Other: describe

L. Sources of financial support include:
      Registration fees from learners
      Internal department funding
      Funding from larger organization
      Commercial support and/or sponsorship
      Other: describe

M. We anticipate that financial support for the Provider Unit will be sustained throughout the period of
   approval by:
      Continuation of above source(s) of funding
      Other: describe




                             C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                        - 34 -
N. Our organization receives commercial support from companies producing or selling products that are
   used in patient care.
      No (proceed to key element 3)
      Yes (answer the following questions before proceeding to key element 3)

O. The amount of commercial support that has been received during the current Provider Unit approval
   period is approximately $500

P. The frequency with which commercial support has been received is:
      Less than 10% of our learning activities
      10-25% of our learning activities
      26-50% of our learning activities
      51-75% of our learning activities
      76-100% of our learning activities

Key Element 3: Business Practices

A. Our Provider Unit complies with all applicable local, regional, state, and national laws and
   regulations and operates its business in an ethical manner. Dorothy Anderson, MN, BSN, RN
                                                                    Signature of Admin.

B. Our Provider Unit complies with all ANCC Commission on Accreditation and WSNA CEARP
   criteria as specified in the current Provider Guidelines. Dorothy Anderson, MN, BSN, RN
                                                                    Signature of DNP

Other signatures appropriate to Provider Unit (if any): None

CRITERION 4: PROVIDER UNIT EVALUATION

The Provider Unit engages in an ongoing evaluation process to analyze its overall effectiveness in
fulfilling its beliefs, goals, and functions, and in providing quality continuing nursing education. Plans
and goals for the Provider Unit‘s future development in continuing nursing education are identified and
re-evaluated on a regular basis.

Key Element 1: Provider Unit Evaluation Process
Our 4-column evaluation plan below includes:
    What is evaluated
    When evaluation occurs
    Who participates
    Findings (results) of most recent evaluation, including what needed changed. If no changes were
       needed, the rationale is stated.
    The date of the most recent evaluation.

                PROVIDER UNIT EVALUATION PLAN (see Appendix F for form)

  WHAT IS            WHEN IT IS            WHO                       FINDINGS OF MOST RECENT
  EVALUATED          EVALUATED             PARTICIPATES              EVALUATION & DATE DONE




                             C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                        - 35 -
Key Element 2: Provider Unit Evaluation Participants
People who participate in evaluation of our Provider Unit include:
   Designated Nurse Planner (required)
   Lead Nurse Planners including other Nurse Planners
   Reviewers
   Other organizational representatives (identify)
   Learners
   Faculty / content experts
   Others (describe)

Key Element 3: Provider Unit Evaluation Results
Describe how the information in column 4 of your evaluation form (findings/results) has been used to
confirm, expand, and improve the operations of your Provider Unit. (What changes have you made
based on these findings?) If no changes were made, explain why not. see page xx
NOTE: Address goals in Key Element 4.

Key Element 4: Provider Unit Goals for Improvement
A. The Provider Unit‘s goals for improvement over the past three years (or 6 months for first time
   applicants) have been addressed by:
      Regular meetings of Provider Unit staff
      Performance improvement / process improvement initiatives
      Changes in learning activities
      Changes in Provider Unit personnel and/or roles
      Other (describe)

B. We have made the following progress in achieving these goals: Refer to Provider Unit Self
   Assessment Summary on p ___.

C. We have identified new goals for improvement. These are: Page xx

D. Plans to achieve these new goals are: Page xx

Summary: Attach the following to the application:
   Organizational chart for the Provider Unit with names and credentials;
   Organizational chart for the larger organization, showing ―fit‖ of Provider Unit (if applicable);
   Description of internal review process;
   Description of APIE process;
   Bio data forms for Provider Unit personnel;
   For first time applicants:
    1. A composite list of all completed activities during the past six months.
    2. In addition submit:
         Acknowledgement and approval letters from WSNA CEARP for the 3 activities WSNA
            CEARP has approved
         A summative evaluation for each of these 3 activities
         Documentation for an activity that has been planned and will be reviewed and presented
            after Provider Unit status has been achieved. Include all required attachments: bio data
            forms, objectives, evaluation tool, marketing sample, certificate, evidence of disclosures
            to be made, commercial support/sponsorship agreement if applicable, post-activity QI
            tool. The marketing material and certificate should contain the required Provider


                            C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                       - 36 -
              statement that will be used by your organization once Provider Unit status has been
              achieved.
           The sample certificate that you will use once you become an approved Provider Unit. The
              Provider Unit statement must be included on the certificate. (Key Element 7).
      For reapplying applicants:
           A composite list of all completed CNE activities with titles, dates presented and contact
              hours provided in the past three (3) years.
           A complete file for one CNE activity implemented during the prior three-year approval
              period, including completed application, objectives, signed bio data forms, advertising
              materials, review check lists, post activity QI form, evaluation summaries and changes
              made as a result of evaluations must also be included.
           .Upon receipt of the application, the CEARP Reviewer will select a minimum of two
              completed CNE activities from the composite list and request submission of the
              completed files for the two completed CNE activities selected.
      Application Fee of $900.

Thank you for completing this application for Provider Unit approval. Submit three copies of your
completed application to:

                                 Washington State Nurses Association
                                              CEARP
                                  575 Andover Park West, Suite 101
                                         Seattle, WA 98188

You will receive confirmation that your materials have been received at WSNA and will be notified if
any additional information is needed before review by the CEARP Review Team. You will be
contacted by your reviewer within 30 days of receipt and informed of the status of your application. See
the Provider Unit Guidelines, for a more detailed explanation of this process.




                            C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                       - 37 -
                          WASHINGTON STATE NURSES ASSOCIATION
                  Continuing Education Approval and Recognition Program (CEARP)

                 ATTESTATION STATEMENT REGARDING OPERATIONAL REQUIREMENTS

Operational requirements must be implemented by an approved Provider Unit throughout the period of approval. Adherence
to the operational requirements is assessed through the application.

Approved Provider Units will:

    1.   Use ANCC Commission on Accreditation educational design criterion as provided by WSNA CEARP to assess,
         plan, implement and evaluate all continuing nursing education (CNE) activities.
    2.   Maintain responsibility for the following when / if activities are co-provided:
             a. Determination of objectives and content
             b. Selection of presenters / content experts
             c. Awarding of contact hours
             d. Record keeping
             e. Evaluation
    3.   Maintain records for each activity for six years in a secure and confidential manner and include the following
         essential information:
             a. For each individual activity:
                      i.     Title of the educational activity
                      ii.    Number of contact hours awarded
                      iii.   Names, titles, and expertise of persons responsible for planning the educational activity and
                             presenters / content experts
                      iv.    Description of the needs assessment
                      v.     Description of the target audience
                      vi.    Location(s) and date(s) of the activity
                      vii.   Names and unique identifier of participants
                      viii. Purpose
                      ix.    Objectives, content outline and time frame
                      x.     Teaching / learning strategies, including resources, materials, delivery methods, and learner
                             feedback.
                      xi.    Process to verify completion of the educational activity, the requirements for successful
                             completion, and how learners were informed of these requirements prior to the start of the
                             activity.
                      xii.   Sample of the certificate awarded to participants.
                      xiii. Copy of the evaluation tool(s), including a summative evaluation
                      xiv. Copy of the marketing materials
                      xv.    If applicable, documentation of how co-providership responsibilities were maintained
                      xvi. Declaration of vested interest of faculty
                      xvii. If applicable, documentation of how program integrity was maintained for educational activity
                             receiving commercial support.
                      xviii. Post Activity QI Report.
             b. All Provider Unit applications and correspondence with WSNA CEARP.
             c. Any reportable changes made during the provider's approval period.

    4.   Verify participation and requirements for successful completion of all educational activities, and identify how
         learners are informed of these expectations prior to the activity.

    5.   Provide participants who successfully complete an educational activity with written verification of completion
         which includes the following:
             a. Name of the learner
             b. Number of contact hours awarded
             c. Name and address of the provider of the educational activity
             d. The title and date of the educational activity
             e. Official approval statement and assigned provider number:




                                  C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                             - 38 -
                  Name of Approved Provider Unit is an approved provider of continuing nursing education by the
                  Washington State Nurses Association, an accredited approver by the American Nurses Credentialing
                  Center's Commission on Accreditation.

    6.   Maintain timely communication with WSNA CEARP by providing at a minimum:
            a. Reports of data requested by WSNA CEARP.
            b. Within 30 days, information about change in (1) name, ownership, or structure of the organization,
                 or (2) change in the Designated Nurse Planner and/or Lead Nurse Planners, or (3) change in the
                 name of the contact person. A new bio data form will be submitted with each new person. Any
                 new Designated Nurse Planner must sign this attestation statement.
            c. Information about termination of approved Provider Unit‘s activities, within 30 days of the decision to
                 terminate.

    7.   Use appropriate language for the activity approval on all communications, marketing materials, and certificates of
         attendance. (See 5.e. above).

    8.   Implement the ANCC Commission on Accreditation system of awarding credit:
             a. The appropriate measure of credit is the 60-minute contact hour.
             b. A contact hour is 60 minutes of organized learning activity, which is either a didactic or clinical experience.
             c. The minimum number of contact hours to be awarded is 0.5.
             d. After the first contact hour, fractions or portions of the 60-minute hour may be calculated up to 1/100th of
                the hour. For example, 90 minutes of learning experience equals 1.5 contact hours.
             e. Welcome, introductions, breaks, and viewing of exhibits are not included in the calculation of contact
                hours.

    9.   Provide but not approve activities. Provider Units can only provide activities in which the Provider Unit Nurse
         Planner(s) assume(s) an active role in the entire process, from planning through evaluation. Provider Units can
         never approve activities.

    10. Ensure that all continuing nursing education activities are free from bias by having all presenters declare any vested
        interests.

    11. In the event that any form of commercial support or sponsorship is provided for an educational activity, maintain
        control of the educational content and disclose to the learners all financial relationships or lack of, between the
        commercial supporter and the Provider Unit or presenters. (Refer to Appendix J for complete information).
             a. Funds from a commercial source or sponsor should be in the form of an educational grant to the provider of
                 the educational activity and must be acknowledged in printed material, brochures and electronic
                 promotions
             b. Arrangements for commercial exhibits will not influence the planning of or interfere with the presentation
                 of educational activities.
             c. Learners will be made aware of the nature of all commercial support or sponsorships of all educational
                 activities.
             d. Educational activities are distinguished as separate from endorsement of commercial products. When
                 commercial products are displayed, participants will be advised that approved status refers only to its
                 continuing education activities and does not imply ANCC Commission on Accreditation and WSNA
                 endorsement of any commercial product.
             e. Educational activities that present research conducted by commercial companies will be designed and
                 presented with scientific objectivity.
             f. Learners will be informed of any off label use of a commercial product that is presented in educational
                 activities.

I agree to adhere to these operational requirements for continuing nursing education.

Name Provider Unit: __ _________________________

Name Designated Nurse Planner: _____________________________________ Date: ________
                                 (Electronic Signature permissible)




                                  C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                             - 39 -
                                                     SAMPLE

                                                ABC HOSPITAL

                       Biographical Data Form for Provider Unit Personnel - 2010

Instructions: Complete this form for all personnel involved in the Provider Unit – Nurse Planners,
Reviewers, and others. Copy as needed. This form is only used with the provider application. This form
is not to be used for individual activities. Use the full biographical data form for individual activities.

Date: September 3, 2010

Name, Degrees & Credentials: Dorothy Anderson, MN, BSN, RN

Day Telephone: 206-575-7979 Email Address: danderson@abchospital.org

Name of Provider Unit: ABC Hospital

Present Position (Title) & Employer: Director, Education Dept.

My role in the Provider Unit is as:
  Designated Nurse Planner
  Lead Nurse Planner
  Nurse Reviewer
  Administrator
  Administrative Assistant
  Other: (Describe)

Educational Preparation:
Nursing degree(s):                      Non Nursing Degree(s):
  Associate                               BA
  Diploma                                 Bachelor in
  Baccalaureate                           Masters in
  Masters                                 Post graduate
  Doctorate                               Doctorate in


My responsibilities/expertise for the Provider Unit include: Provide leadership for the design and
development of educational programs, topics and content including identification of and communication
with potential speakers; make arranges for educational venues with support from office administrative
assistant staff; work closely with Lead Planners in the APIE process. Provide updates to PU staff re
ANCC CNE criteria.


Describe your education, experience, and any certification related to providing CNE.

Note: ANCC requires that the Designated and Lead Nurse Planners must have education or experience
(in planning, implementation, or analysis of evaluations) in the field of education or adult learning.




                             C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                        - 40 -
                                                  Sample
                                            ABC HOSPITAL

                                            Provider Unit
                                           Evaluation Plan


      What Is              When It Is              Who Participates                         Finding of Most Recent
     Evaluated             Evaluated                                                       Evaluation and Date Done
1. ABC Hospital PU       Annually              PU professional staff               Philosophy, goals updated and
   vision, mission,                                                                approved by Hospital Administration
   goals and                                                                       7/2008
   organizational
   structure reflect
   educational needs
   of nursing staff.

2. CNE programs          Ongoing after         PU professional staff               List of CNE activities held from 2006-
   provided by           each activity                                             2010 attached with completed Post
   ABC….                 presented.                                                Activity QI reports.

3. Implementation
   of ABC PU CNE
   programs in
   accordance with
   ANCC COA and
   WSNA CEARP
   provider unit
   criteria including:
   a. qualifications     a. Ongoing as         PU professional staff               Completed October , 2007
        of PU staff;        staff
                            changes
                            made;

    b. APIE              b. QI review of       PU professional staff               QI form revised to better document
       process;             each activity                                          outcomes and ways to improve
                            after it is                                            activities in May, 2008
                            completed.

    c. internal          Ongoing               PU professional staff               Checklist of required documentation for
       review                                                                      each activity revised June 2008 with
       process to                                                                  improved filing system
       assure
       documentatio
       n of each
       activity.

    d. records           Annually              PU Professional staff               Reviewed/no changes required: Jan
       maintained                                                                  2007, 2008, 2009




                         C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                    - 41 -
4. Evaluate internal    Ongoing               All PU staff                        Revised and updated bio data forms and
   policies/procedur                                                              vested interest as required by ANCC
   es to assure                                                                   and WSNA CEARP. Jan, 2007
   efficient and
   reliable APIE for                                                              Reviewed computer hardware and
   all educational                                                                software, storage capacity for
   activities.                                                                    confidentiality of records and supplies
                                                                                  for daily office function; instituted
                                                                                  related changes as needed: 2007, 2008,
                                                                                  2009.

                                                                                  Income and expenses reviewed with
                                                                                  appropriate modifications as needed:
                                                                                  May, 2007, 2008, 2009.

5. Assess               Ongoing               PU professional staff               Attendance sign-in sheets evaluated for
   attendance for                                                                 each CNE activity; recommendations
   each activity to                                                               made to nurse planners for
   monitor staff                                                                  continuation/discontinuation or
   involvement and                                                                reformatting for future.
   relevance to staff




                        C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                   - 42 -
                             FREQUENTLY ASKED QUESTIONS
A. Can Contact Hours be awarded to Faculty?
   In activities with multiple topics and presenters, the faculty may be awarded contact hours for the
   parts of the program presented by others and in which they participate as learners.

B. What if there are major changes in Learning Activities?
   If a learning activity has met the criteria and there is a significant change in the content, then another
   planning documentation form must be completed and reviewed by the approved Provider Unit. For
   example, significant change could be substituting a new one hour segment for one that previously
   met criteria, changing objectives and content, etc.

   If the speaker changes, but the new speaker will continue to present the same content and use the
   same objectives and time frames, place a memo in the activity file regarding this change and include
   the bio data form including conflict of interest statement for the new speaker. Feel free to contact
   the WSNA Education Program Specialist with any questions regarding the need for another planning
   documentation form or just a memo.

C. What if portions of classes are being repeated?
   If during the planning process, it is identified that certain session(s) out of a larger presentation may
   potentially be repeated separately, the Provider Unit should:
   1. Identify each section of the larger presentation as a potential, separate session (e.g. Session 1:
       Acute Respiratory Distress; Session 2: Chronic Respirator distress, etc.)
   2. Identify in Key Element 3, item F-1 of the CNE form that learners may attend one or more
       sessions. (Just as a note: you might also wish to include the information on the advertising
       material.)
   3. On the certificate, identify the sessions the learner attended, the date and the contact hours
       awarded for those sessions (e.g., ―Learner name successfully completed (name of session 1)…..
                              Session 4……Session 7….. on date.‖ )

D. What about courses addressing Complementary or Alternative (Therapeutic) Modalities?
   The American Holistic Nurses Association developed the following requirements regarding
   therapeutic modalities (complementary or alternative modalities) (2005). The WSNA CEARP
   recommends that Provider Units follow these guidelines.
   1. Therapeutic modality is clearly supported by theory or research published in professional
       literature in the last five years if there is research available. The research must be made available
       to the nurse planner/planning committee upon request. This would be required if the modality is
       in question by staff, nurse planners, reviewers or CEARP members.
   2. The learning activity clearly discriminates between use of the modality for self-care or personal
       development as opposed to appropriate use of the modality with a client population.
   3. The learning activity defines and assures a recognized minimum of training when modalities
       taught are intended for professional use with a client population.
   4. The learning activity is consistent with the standards of the appropriate professional association
       related to the topic. For example, the AHNA has the Holistic Nurses Association Standards of
       Holistic Nursing Practice that address holistic nursing can be found on their website
       www.ahna.org.
   5. Presenter has the appropriate credentials and experience to provide the learning activity.
   6. NOTE: The provision of contact hours by the Provider Unit is based on an assessment of the
       educational design criteria for the learning activity and does not constitute endorsement of the

                             C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                        - 43 -
       use of a specific modality in the care of clients. (Some organizations chose to include this
       statement on advertising or the handouts.)

E. How do I handle a request to repeat a learning activity by a Co-Provider?
   If an approved Provider Unit and an outside entity (individual, company, etc.) plan a CNE Activity
   together (co-provide), the approved Provider Unit should process the Planning Documentation form
   within their internal peer review system with one of its Designated Nurse Planners as part of the
   planning process. If the co-provider then wishes to repeat the CNE activity separately from the
   approved Provider Unit, the co-provider must submit an application through an approver such as
   WSNA CEARP. The approved Provider Unit may not approve the activity for the organization that
   was previously a co-provider for that activity, nor may the approved provider allow the outside
   entity to use the Provider Unit‘s contact hours for repetition of the activity.

F. How can I keep up to date?
   It is the responsibility of the nurse planners and peer reviewers to stay up to date with the most
   current ANCC COA and WSNA CEARP CNE criteria. This can be accomplished by:
   1. Attending the annual Provider Update Conference presented by WSNA CEARP (starting in
        September, 2010);
   2. Reviewing the Provider newsletters (HIGHLIGHTS sent electronically two times per year);
   3. Reviewing the most current Provider Guidelines;
   4. Contacting the Education Program Specialist with any questions.

G. Other Questions/Concerns?
   If other issues arise that generate questions, please contact Hilke Faber, Education Program
   Specialist at WSNA, hfaber@wsna.org , 206-575-7979 ext. 3005 or Kathryn MacLeod,
   Communications Processor at kmacleod@wsna.org or 206-575-7979 ext. 3011.




                             C:\Docstoc\Working\pdf\bba71c88-550d-41b5-bf2d-cefcad482444.doc
                                                        - 44 -

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:615
posted:7/28/2011
language:English
pages:45
Description: Sample Bio Data for Nurses document sample