2015 ONA Provider Manual

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2015 CE Manual  (Updated 61316)

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Introduction

Statement of Philosophy on Continuing Nursing Education

Nurses must continually update their knowledge and skills to promote and improve health care. As professionals, nurses make a commitment to continuing education as a lifelong process. The Ohio Nurses Association (ONA) endorses the concept of planned continuing education for all nurses as one means by which nurses can maintain competence, meet the standards of practice developed by the profession, advance the profession of nursing and facilitate professional growth.

Quality continuing education prepares the nurse to meet the challenge of rapid changes in knowledge, technology, and societal needs. We believe the Nursing Professional Development: Scope and Standards of Practice guides the continuing education process for learners, educators and the Approver Unit.

ONA is committed to enhancing CE through accreditation as an approver by ANCC Commission on Accreditation and as an approver by the Ohio Board of Nursing. We believe as an approver unit that we must take into consideration the needs and characteristics of potential applicants.    

ONA Approver Unit’s Purposes:

  1.  To approve individual activities and provider applications according to the ANCC Commission on Accreditation criteria and the Ohio Board of Nursing rules.
  2. To set policy within the guidelines of the ANCC Commission on Accreditation, the Ohio Board of Nursing, and the Ohio Nurses Association Board of Directors.
  3. To monitor the quality and consistency of the Approver Unit program.

ONALogo
CONTINUING EDUCATION APPROVER COUNCIL

Roster 2015

(chair) Terry Pope, MS, RN

Joyce Alley, MN, WHNP-BC

Lucinda Cave, MSN, RN, BC

Stephanie Clubbs, MSN, RN-BC, CNS

Pam Dickerson, PhD, RN-BC, FAAN

Nancy McManus, MEd, BSN, RN-BC, CGRS

Diane Moyer, MS, BSN, RN

Laura Rafeld, MSN, RN

 

Zandra Ohri, MA, MS, RN, Director, Approver Unit
614-448-1027 / zohri@ohnurses.org

Sandy Swearingen, CE Specialist
614-448-1030 / sswearingen@ohnurses.org
Ohio Nurses Association

Continuing Education Department – Approver Unit
4000 East Main Street
Columbus, OH 43213
614-237-5414
www.ohnurses.org

 

Chapter 1 – Approved Provider Unit – Application Process, Definitions, Eligibility

Introduction

This manual includes information about operation of an approved provider unit for continuing nursing education. An approved provider unit has the authority to plan, implement, and evaluate its own continuing education activities during the three-year period of provider unit approval. Criteria of the American Nurses Credentialing Center’s (ANCC) Commission on Accreditation (COA) and rules of the Ohio Board of Nursing (OBN) form the basis of the manual and its associated forms. The Continuing Education Approver Council (CEAC) of the Ohio Nurses Association (ONA) is responsible for establishing processes and policies in addition to reviewing provider and individual activity applications.

Our goal is to help you be successful in completing the provider application and providing quality continuing education. Please contact the Director of the CE Approver Unit at ONA at 614-448-1027 at any time if you have questions or need further information.

Definition

Continuing nursing education (CE) is defined as “learning activities intended to build upon the educational and experiential bases of the …[nurse] for the enhancement of practice, education, administration, research, or theory development, to the end of improving the health of the public and [nurses’] pursuit of their professional career goals.”

All education that promotes nursing professional development and/or patient care is eligible for contact hours. (Classes on personal finance or personal retirement planning are not acceptable for CE by the OBN).

 ONA’s Authority as an Approver

The Commission on Accreditation accredits and the Ohio Board of Nursing approves approver units which have demonstrated the capacity to approve and monitor the educational activities of individual activity providers and provider units. The Ohio Nurses Association is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation and approved as an approver by the Ohio Board of Nursing (OBN-001-91).

CE Chart for ONA’s Approver Unit

 Chapter1Chart

Who Can Be A Provider Unit?

A.  In order to be eligible, your provider unit must:

1. Have a clearly defined unit or department administratively and operationally responsible for continuing nursing education.

2. Have Nurse Planner(s) (see Note 1 on next page) who meet(s) qualifications of:

a. Minimum of Baccalaureate in nursing

b. Hold a current active RN license

c. Knowledge of adult learning, ANCC Accreditation criteria, and OBN rules

3. Have been functioning for at least six months, using accreditation criteria and Ohio Board of Nursing rules. During that time, at least three separate activities must have been planned, approved by ONA, implemented, and evaluated with direct involvement of a qualified nurse planner. Each activity must be at least 60 minutes in length. Jointly provided activities are not acceptable. After this requirement has been completed, you may submit an “Intent to Apply/Reapply as a Provider Unit” form, presuming that all other eligibility criteria have been met. 

For those organizations approved or accredited as a provider through another OBN approver or ANCC, please contact the Director of the CE Approver Unit for a variation on this requirement.

4. Target audience:

a.  If you are based in Ohio, more than 50% of your target audience is nurses within the states of Ohio, Pennsylvania, West Virginia, Kentucky, Indiana, Illinois, Iowa, Michigan, Minnesota, Missouri, North Dakota, South Dakota and Wisconsin.

b.  If your provider unit is based outside of Ohio, more than 50% of your target audience is 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.

If your target audience is broader than the areas identified above in #4, you are not eligible to apply to be an Approved Provider Unit through ONA. Please contact the ANCC Accreditation Program to apply for accreditation as a provider unit.

5. Be separate from any commercial entity that produces, markets, re-sells or distributes a product used on or by patients.

Your organization is ineligible for approval as a provider unit if it is a commercial interest as defined in the Standards for Commercial Support in the Appendix. A “commercial interest” is any entity 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. If you are uncertain about your status, contact the Director of CE Approver Unit at 614-448-1027.

Note 1

Additional Information about Nurse Planner. The Nurse Planner must be a currently licensed registered nurse with a minimum of a baccalaureate degree in nursing. In some organizations there may be more than one Nurse Planner. One Nurse Planner should then be selected/identified as the Primary Nurse Planner (PNP). This PNP will be responsible and accountable for the provider unit.  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, Nurse Planners must maintain expertise in educational design and adult learning theories, receive orientation to, and maintain responsibility for implementing criteria and rules in their performance of the Nurse Planner role. The essence of the Nurse Planner requirement is twofold:

– To ensure that a qualified Nurse Planner is involved in the entire process of delivery – from identification of professional practice gap through planning, implementation, evaluation and follow-up – for every continuing nursing education activity offered by the provider unit; and

– To guarantee that ANCC Accreditation Program criteria and OBN rules guide the development and implementation of every continuing nursing education activity offered by a provider unit.

Other nurses may serve on an individual activity planning committee along with a Nurse Planner. These other nurses do not have the same responsibilities, accountabilities or educational requirements as the Nurse Planners and should not be referred to as Nurse Planners. They are responsible for participating in the planning of one particular educational event.

B.  Verifying Eligibility

Eligibility forms are included on the provider unit page of the ONA website – www.ohnurses .org, Education, Approval Provider. For first time provider applicants and those who are current provider units who are re-applying, review Intent to Apply/Re-Apply as a Provider Unit.  Reviewing this form will help you determine if your organization is eligible to be a provider unit. This form must be submitted to and reviewed by the Director of the CE Approver Unit prior to submitting a provider application. Please contact ONA’s Director of CE Approver Unit with any questions about this process.

Application and Related Policies and Processes

A.  Difference between Providing and Approving

ONA is authorized through both national accreditation and state approval to be an approver of continuing nursing education. Your organization, upon achieving approval as a provider unit, is authorized to assess, plan, implement, and evaluate continuing education activities according to the criteria/rules and award contact hours for those activities. 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 of your internal operating practices or in relation to any activity your provider unit plans and presents.

B. Application Process

Step 1

For individuals interested in first time approval as a provider unit:

Review the Organizational Self-Assessment Tool – Provider in Appendix A. If you are able to meet all the criteria addressed, then review the eligibility criteria as listed above. If you feel that you meet these criteria, submit the form “Intent to Apply/Re-apply as a Provider Unit” as found on the web site (www.ohnurses.org, Education, Approved Provider). Submit this form to the Director, CE Approver Unit, at ONA at least 3 months prior to when you plan to submit the provider application.

Once the Director, CE Approver Unit, notifies you that you are eligible, prepare and submit the provider application. Applications are accepted at any time of the year.

For currently Approved Provider Units through ONA:

The form “Intent to Apply/Reapply as a Provider Unit” will be sent to you six months prior to expiration of your provider unit’s approval. You can also find the “Intent to Apply/Reapply as a Provider Unit” on the website www.ohnurses.org, Education, Approved Provider.

To ensure continuity of your provider unit’s activities, submit the provider application at least three months before your current provider approval expires. All criteria must be met before approval is granted. If approval expires, your provider unit may not award contact hours.

Step 2 for all applicants:

Submit three complete typed copies of the provider unit application packet and the application fee. Each copy of the application must include a table of contents and have pages clearly numbered consistent with the table of contents. The pages need to be collated. Bind your application securely. Comb binding or spiral binding is recommended. Please do not use rubber bands, staples or clips.

To be accepted for review, all provider applications MUST be submitted on the current ONA provider application form and completed in the format defined in this manual. Applications not submitted on the correct form or in the proper format will be returned with directions about what changes are needed before the review can take place.

C.  Review Process

Step 1 

You will be notified by email that your application has been received at ONA. A preliminary review will be conducted, and you will be advised that the application is complete or that additional information is needed. If you are a first-time provider, you will be assigned a provider number. This number is very important and MUST be included on any subsequent correspondence or additional material related to your provider application. Once you have been approved as a provider, this number becomes your provider number. For currently approved providers seeking re-approval please be sure your provider number is on all correspondence or other material related to your provider application.

Step 2

Your provider application is sent to two nurse peer reviewers to assess the documentation and evidence submitted for compliance with criteria. The reviewers’ information is then sent to the Director, CE Approver Unit.

Step 3

The Director, CE Approver Unit, will notify you in writing via email if any additional documentation/evidence may be needed to complete the review of your application.. If further information is needed, a specific due date will be set for return of the information to ensure follow-up review.

Step 4

The CE Approver Unit Director will notify you of the final decision via email.

As you proceed through the application process, help is available. Phone calls or email to the ONA CE Director of the Approver Unit are encouraged. Consultation can be arranged. The goal is for you to be successful at providing quality continuing education.

D.  Types of action taken on provider applications

There are four types of action possible on an application for provider unit approval.

1. Approval with Distinction indicates exemplary performance.

2. Approval for three years occurs when your written application materials indicate that the criteria and rules are met.

3. Provisional Approval occurs when your written application materials indicate limitations in meeting criteria and rules that are expected to be resolved within six months or less. You will be required to submit a written progress report. After review of the progress report, approval can be granted for the remainder of the three year approval period or approval can be denied.

4. Denial of Approval occurs when written application materials indicate that your provider unit:

a.  Is not in adherence with the criteria of the ANCC Accreditation Program, the rules of the Ohio Board of Nursing, and/or requirements of the ONA 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 documented areas of concern on the provisional approval progress report.

E.   Receiving Approval of Individual Activities during the Initial Application Process

If a first time applicant wishes to award contact hours for an activity while the initial provider application is in process, individual CE applications must be submitted to ONA following the appropriate criteria and accompanied by the required application fee. If a currently approved provider unit allows their provider approval to expire, they would also submit individual activities for approval if they wished to award nursing contact hours.

F.  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 ONA CE Approver Unit Director in writing of the decision to withdraw the application. Fees will not be refunded if the review process has begun. If the review process has not begun, the application fee, minus an administrative fee, will be returned to the applicant.

If your organization requests to withdraw, then wishes to apply again later, the process can be resumed within six months of the original application submission. If more than six months has elapsed, you must again meet eligibility criteria as a new applicant (submit 3 activities, etc). If the fee was returned, then a new fee must accompany the request to continue with the application process.

G.   Length of Approval

The maximum approval period for provider units is three years. During the approval period, the provider unit is authorized to award contact hours for CE activities without submitting documentation forms for individual activities to ONA. However, all supporting or required documentation forms must still be completed for each CE activity provided. Documentation of meeting the criteria must be done using current ANCC criteria and OBN rules.

H.  Suspension and Revocation of Approval

Approval may be suspended and/or revoked from an approved provider unit as a result of ANY one of the following:

1. Failure to remain in adherence with relevant criteria, rules and requirements defined in this manual;

2. Investigation and verification by the CEAC of written complaints or charges by consumers or others;

3. Refusal to comply with an investigation by the CEAC;

4. Misrepresentation.

5. Failure to submit required information such as the annual survey or follow-up information.

Suspension and revocation are effective on the date the email (read and delivery requested) or 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, the provider unit may not award contact hours. All statements regarding provider unit approval status must be removed from publicity material and certificates of attendance printed and/or distributed after that date. If provider unit status is revoked, the provider unit may not award contact hours.

I.   Reconsideration and Appeal

If your organization does not agree with the CEAC decision of suspension, revocation or denial, you may appeal the decision in writing within ten business days of the date the notification is sent. Applicants may not appeal eligibility requirements, criteria or rules upon which the Approver Unit program is based.

The applicant must submit an appeal in writing within ten business days of the notification of the adverse decision being sent. The appeal must briefly state the reason(s) the applicant contests the decision. There is a nonrefundable appeal fee. For further information about the appeal process, please contact the Nurse Peer Review Leader (the Director of CE Approver Unit) at ONA.

J.  Reporting of Data

Approved Provider Units will be requested to submit a provider survey by Jan. 30 of each year.

The provider unit may also be asked to submit additional documentation to demonstrate adherence to criteria. An example of a monitoring request might be a review of an activity documentation file mid-approval cycle. Failure to respond to monitoring requests will result in suspension of approval as a provider unit.

K.  Provider Unit Changes

The Primary Nurse Planner (PNP) or designee must notify ONA in writing, within seven business days of the discovery or occurrence of the following:

  • Significant changes or events that impair their ability to meet or continue to meet Accreditation Program, OBN or ONA requirements or that make them ineligible for Approved Provider status
  • Loss of status as a state nurses association of the ANA
  • Any event that might result in adverse media coverage related to the delivery of CNE
  • Change in commercial interest status

The Primary Nurse Planner or designee must notify ONA, in writing and within 30 days, of any change within the Approved Provider organization, including but not limited to:

  • Changes that alter the information provided in the Approved Provider application, including change of address or name
  • A decision not to submit a provider application after the intent to apply is approved
  • Change in Primary Nurse Planner
  • Change in Nurse Planners
  • Suspension, lapse, revocation, or termination of the Primary Nurse Planner or any of the Nurse Planners registered nursing licenses
  • Change in ownership
  • Indication of potential instability (e.g., labor strike, reduction in force, bankruptcy) that may impact the organization’s ability to function as an Approved Provider

Other Questions or Concerns?

If other issues arise that generate questions, please contact the Nurse Peer Review Leader (ONA’s CE Approver Unit Director), 614-448-1027 (zohri@ohnurses.org) or her assistant Sandy Swearingen at 614-448-1030. (sswearingen@ohnurses.org).

Chapter 2 – Approved Providers, Roles and Responsibilities  

(Adapted with permission from the 2015 ANCC Primary Accreditation Approver Application Manual and from “Tips for Preparing the Provider Application” by Pam Dickerson, Montana Nurses Association)

This chapter outlines the application requirements for providers approved by the Ohio Nurses Association to offer CNE, including the criteria for submitting the narrative component of the application and the application process.  This chapter includes both the criteria of the ANCC Accreditation Program and the Ohio Board of Nursing rules.

The chapter is divided into several sections:

  • Introduction
  • Applicant and Approved Provider Responsibilities
  • Provider Application
  • Organizational Overview (OO)
  • Approved Provider Criterion 1: Structural Capacity (SC)
  • Approved Provider Criterion 2: Educational Design Process (EDP)
  • Approved Provider Criterion 3: Quality Outcomes (QO)
  • Attestation Statement
  • Individual Activity Files
  • Responsibilities
  • Submission of the Provider Application
  • Annual Reporting

 

Provider Unit – Comprises the members of an organization who support the delivery of continuing nursing education activities.

multi-focused organization (MFO)  – An organization that exists for other purposes in addition to providing CNE.

primary nurse planner – A registered nurse who holds a current, unencumbered nursing license and a baccalaureate degree or higher in nursing who is designated as the Primary Nurse Planner. S/he has the authority  within an Approved Provider Unit to ensure adherence to the ANCC Accredited Approver and Accreditation Program criteria and the Ohio Board of Nursing rules in the provision of CNE. This person serves as the liaison between the Ohio Nurses Association and the Approved Provider Unit.

nurse planner – A registered nurse who holds a current, unencumbered nursing license and a baccalaureate degree or higher in nursing who is designated as the Nurse Planner. The Nurse Planner is actively involved in all aspects of planning, implementation, and evaluation of each CNE activity. The Nurse Planner is responsible for ensuring that appropriate educational design principles are used and processes are consistent with the requirements of the ANCC Primary Accreditation Program and the Ohio Board of Nursing.

Introduction

Organizations interested in submitting an application as an Approved Provider must complete the eligibility verification process by submitting the Intent to Apply/Re-apply form and meet all eligibility requirements. ONA is responsible for assessing that the applicant is eligible to apply. (Note: This form is to be completed by both first time provider applicants and currently approved provider units.)

An organization interested in becoming approved as a Provider Unit (referred to after approval as an Approved Provider) must define both the structural and operational components of the Provider Unit. (Appendix A may be of assistance in assessing your structure.)

A Provider Unit is defined structurally and operationally as the members of the organization who support the delivery of CNE activities. The Provider Unit may be a single focused organization devoted to offering CNE or a separately identified unit within a larger organization. If the Provider Unit is within a larger organization, the larger organization is defined as a multi-focused organization (MFO). (For example, the Provider Unit may be placed within the Education Department of a hospital or school of nursing.)

The applicant applying for approval is the Provider Unit (PU). The MFO organization is not the applicant. Therefore, all criteria that pertain to the applicant are demonstrated by the functions of the Primary Nurse Planner (PNP) and Nurse Planners (if applicable) of the Provider Unit. Provider Units plan, implement, and evaluate CNE activities according to Ohio Nurses Association’s guidelines, which are based on ANCC accreditation criteria and Ohio Board of Nursing rules.

The Primary Nurse Planner (PNP) is responsible for establishing an infrastructure to support and guide the provider unit.  The PNP maintains the structural capacity of the provider unit, oversees the educational design process for activities, establishes and monitors quality outcome measures, and evaluates the overall effectiveness of the provider unit.

Provider Units are responsible for developing individual education activities and awarding contact hours to nurses for use in fulfilling their own goals for professional development, licensure, and certification.

Each educational activity is led by a Nurse Planner in collaboration with at least one other planner. Contact hours may not be awarded for CNE activities developed without the direct involvement of a Nurse Planner. Provider Units may jointly provide activities, but they may not approve activities.

To be eligible to apply for Approved Provider status, an organization must:

  • Be one of the following:
  1. State nurses association (C/SNA) of the ANA
  2. College or university
  3. Healthcare facility
  4. Health-related organization
  5. Multidisciplinary educational group
  6. Professional nursing education group
  7. Specialty Nursing Organization (SNO)
  • Be administratively and operationally responsible for coordinating the entire process of planning, implementing, and delivering CNE
  • Identify one Nurse Planner who will act as the Primary Nurse Planner and serve as the liaison between Ohio Nurses Association and the Approved Provider Unit.
  • Have a Primary Nurse Planner who is a registered nurse, holds a current, unencumbered nursing license. Have a PNP that has authority within the organization to ensure compliance with ONA’s guidelines in the provision of CNE.
  • Have a Primary Nurse Planner who is responsible for the orientation of all Nurse Planners in the organization to ONA’s guidelines.
  • Ensure that all other Nurse Planners in the Approved Provider Unit are registered nurses who hold current, unencumbered nursing licenses and a baccalaureate degree or higher in nursing.
  • Ensure that each CNE activity has a qualified Nurse Planner who is an active participant in the planning, implementing, and evaluation process.
  • Be operational for a minimum of six months prior to application.
  • Initial applicants must have completed the process of assessment, planning, implementation, and evaluation for at least three separate educational activities provided at separate and distinct events:
  • With the direct involvement of a Nurse Planner
  • That adhered to ONA’s guidelines
  • That were each a minimum of one hour (60 minutes) in length
  • That were not jointly provided
  • That were approved by ONA and presented
  • Not be a commercial interest as defined in the glossary and the American Nurses Credentialing Center’s Content Integrity Standards for Industry Support in Continuing Nursing Educational Activities.
  • Target the majority (>50%) of their CNE activities to nurses in a single HHS region and its contiguous states (based on the HHS regions: http://www.hhs.gov/about/agencies/regional-offices). Applicants whose target audience is in multiple regions or in states that are not confined to a single region and its contiguous states, for more than 50% of its activities may not be an Approved Provider. Instead they must apply to ANCC as an Accredited Provider through ANCC accreditation process.
  • Disclose previous denials, suspensions, and/or revocations received from other ANCC Accredited Approver Units and/or other accrediting/approving organizations.

Applicant and Approved Provider Responsibilities

  • Must be in and maintain compliance with all applicable federal, state, and local laws and regulations that affect the organization’s ability to meet ONA’s guidelines.
  • Must identify a Primary Nurse Planner who holds overall responsibility for Approved Provider Unit compliance with ANCC criteria and OBN rules
  • Must identify a Primary Nurse Planner who is responsible for orienting Nurse Planners to ONA’s guidelines if there is more than one Nurse Planner.
  • Must ensure that a Nurse Planner is an active participant in the planning, implementing, and evaluation of each educational activity.
  • Must ensure that Planning Committees have a minimum of a Nurse Planner and one other planner to plan each educational activity; the Nurse Planner is knowledgeable about the CNE process and is responsible for adherence to ONA’s guidelines; one planner needs to have appropriate subject matter expertise for the educational activity being offered. (The Nurse Planner may also be a subject matter/content expert.)
  • Must ensure that the Nurse Planner is responsible for ensuring completion and review of Conflict of Interest forms by each Planning Committee member, planner, faculty, presenter, author, and content reviewer, to ensure no conflict of interest is present, or if it is, that it is resolved prior to involvement in the activity.

Note: A content reviewer is an individual selected to evaluate an educational activity during the planning process or after it has been planned but prior to delivery to learners for quality of content, bias and any other aspects of the activity that may require evaluation.

  • Must notify ONA in writing, within seven business days of the discovery or occurrence of the following:
  • Significant changes or events that impair their ability to meet or continue to meet Accreditation Program requirements or that make them ineligible for Approved Provider status
  • Any event that might result in adverse media coverage related to the delivery of CNE
  • Change in commercial interest status
  • The Primary Nurse Planner or designee must notify ONA, in writing and within 30 days, of any change within the Approved Provider organization, including but not limited to:
  • Changes that alter the information provided in the Approved Provider application, including change of address or name
  • A decision not to submit a provider application after the intent to apply (eligibility form) is approved
  • Change in Primary Nurse Planner or suspension, lapse, revocation, or termination of the Primary Nurse Planner’s registered nursing license
  • Change in Nurse Planners or suspension, lapse, revocation, or termination of any of the Nurse Planners registered nursing licenses
  • Change in ownership
  • Indication of potential instability (e.g., labor strike, reduction in force, bankruptcy) that may impact the organization’s ability to function as an Approved Provider

Intent to Apply/Re-apply as a Provider Unit

Each organization who wishes to become an Approved Provider Unit or who wishes to apply again as a provider unit must first complete and submit an intent to apply or re-apply.  The Director of Continuing Education will review your intent form and notify you if you are eligible to apply to ONA as a Provider Unit.  Once you receive notice that you are eligible to apply, you may begin working on the provider application. The Intent to Apply or Re-apply form should be submitted at least three months prior to submitting the provider application.

PART ONE of Provider Application

Beginning the Process

First, download and review the provider application from the ONA web site. It will be helpful to read through the entire application to get a sense of the information you will need to document and the resources and information you will need to have at hand to write your responses.

Second, determine the members of the team that will be involved in completing the application. The Primary Nurse Planner (the person responsible for the provider unit) should be the leader of this team. If there are other Nurse Planners in the provider unit, they should be included. Consider others who are stakeholders in the provider unit – depending on your practice setting; these may include representatives from nursing administration, academic deans, or corporate directors. Inform these people about the provider application process and how they will be expected to assist you in completing the documentation of evidence.

The Provider Application

The following six sections are required written documentation for all Provider Unit applicants (both new and existing provider units):

  • Demographic Information
  • Organizational Overview (OO)
  • Approved Provider Criterion 1: Structural Capacity (SC)
  • Approved Provider Criterion 2: Educational Design Process (EDP)
  • Approved Provider Criterion 3: Quality Outcomes (QO)
  • Attestation Statement
  • Approved Provider Activity files

Note: All documents will be reviewed for adherence to Accreditation criteria, OBN rules and ONA’s guidelines at the time educational activities were planned, implemented, and evaluated.

Demographic Information

The Demographic Information page includes name and address of the provider unit, contact information for the Primary Nurse Planner, approval status, and location of records for the provider unit.

Approved Provider Organizational Overview

The Organizational Overview (OO) is an essential component of the application process that provides a context for understanding the Approved Provider Unit/organization. The applicant must submit the following documents and/or narratives:

Structural Capacity

OO1.   Demographics

  1. Submit a description of the features of the Provider Unit, including, but not limited to the size, geographic range, target audience(s), content areas, and the types of educational activities offered.
  2. If the Provider Unit is part of a multi-focused organization, describe the relationship of these dimensions to the total organization.

For example, how does the provider unit fit within the structure of a college of nursing or a state health department? In a hospital, how does the provider unit fit within the context of the hospital’s other departments and services? (If your provider unit is a free-standing organization – you don’t do anything else besides continuing nursing education – you can skip this item, but mark it as “not applicable” so we won’t think you just ignored it.)

OO2.   Lines of Authority and Administrative Support

  1. Submit a list of the names, credentials, positions, and titles of the Primary Nurse Planner and other Nurse Planner(s) (if any) in the Provider Unit.
  2. Submit position descriptions of the Primary Nurse Planner and Nurse Planners (if any) in the Provider Unit. Position descriptions should be specific to your role in the provider unit, not your “job description”, unless they are the same. See examples in the appendix.
  3. Submit a chart depicting the structure of the Provider Unit, including the Primary Nurse Planner and other Nurse Planner(s) (if any).
  4. If part of a larger organization, submit an organizational chart, flow sheet, or similar kind of image that depicts the organizational structure and the Provider Unit’s location within the organization.

position description – description of the functions specific to the role of Primary Nurse Planner and Nurse Planners that relate to the Provider  Unit.

Be very sure the provider unit is clearly evident. If you have a decentralized provider unit, made up of Nurse Planners from various departments, use dotted-line connections to show the provider unit in context with the other departments.

Educational Design Process

OO3.   Data Collection and Reporting

Approved Provider organizations report data, at a minimum, annually to ONA. Required submissions include all of the following:

  1. Submit a complete list of all CNE offerings provided in the past 12 months, including activity dates; titles; target audience; total number of participants; number of contact hours offered for each activity; joint provider status; and any commercial support, including monetary or in-kind amount. (Note: This is also the data that you are required to submit as part of your annual report to ONA.)
  2. New applicants: Submit a list of the CNE offerings approved by ONA and provided within the past 12 months. Include the items listed above and the assigned ONA number.

Quality Outcomes

OO4.   Evidence

A provider organization must demonstrate how its structure and processes result in positive outcomes for itself and for nurses participating in its educational activities.

  1. Submit a list of the quality outcome measures the Provider Unit has collected, monitored, and evaluated over the past 12 months specific to the Provider Unit. Outcomes must be written in measurable terms. Be as specific as possible.

Quality outcomes are those things that form the basis of your purpose as a provider unit – what do you want to accomplish as a provider unit? Consider quality outcome measures such as more diversity in types of learning activities offered, greater number of activities, more variety in learning options to address varied learning needs, cost savings for your provider unit or for your learners, number of participants in your learning activities, and operational improvements to make your provider unit more effective/efficient. This is not an exhaustive list – there may be others that are more pertinent to your provider unit.

We suggest that you select 2 or 3 quality outcome measures for your provider unit each year. Develop your provider unit’s desired outcomes around the items on this list. Then create an action plan of how you will achieve each outcome. At the end of the year, evaluate your progress in achieving these goals and decide whether new outcome measures are appropriate for the following year.

Examples of categories of outcome measures include, but are not limited, to the following:

  • Cost savings for customers
  • Cost savings for Provider Unit
  • Volume of participants in educational activities
  • Volume of educational activities provided
  • Satisfaction of staff and volunteers
  • Satisfaction of faculty
  • Change in format of CNE activities to meet the needs of learners
  • Change in operations to achieve strategic goals
  • Operational improvements
  • Quality/cost measures
  • Turnover/vacancy for Provider Unit staff and volunteers
  • Professional development opportunities for staff and volunteers

Examples of measurable outcome measures for the Provider Unit might be:

  • Increase the number of fully functioning Nurse Planners so that there is at least one Nurse Planner for each department within 12 months.
  • Develop at least one independent study pertaining to ethics for each unit by the end of the year.
  1. Submit a list of the quality outcome measures the Approved Provider Unit collected, monitored, and evaluated specific to Nursing Professional Development. Outcomes must be written in measurable terms. Be as specific as possible.

This gets at the heart of why you have a provider unit – the ongoing education of nurses to enhance their practice and their ability to provide quality care. Consider possible outcome measures related to professional practice behaviors, use of evidence-based standards, leadership skills, critical thinking/clinical judgment skills, competency, improvement in nursing practice, or improvement in patient outcomes. Including measurement standards with these outcomes, just as you did with the outcome measures for your provider unit, will help you evaluate your effectiveness in these areas. The items listed are only suggestions – there may be others that are more pertinent to your particular provider unit. Just as you did with the quality outcomes for your provider unit, select 2 or 3 outcome measures that you want to work on for the year, develop goals around these outcome measures, create an action plan, design your educational activities and provider unit processes in a way that enables you to track progress in meeting those goals, and then evaluate your progress at the end of the year. For the following year, you may want to keep or revise those quality outcome measures and related goals.

Examples of categories of outcome measures include, but are not limited to, the following:

  • Professional practice behaviors
  • Leadership skills
  • Critical thinking skills
  • Nurse accountability
  • Nurse competency
  • High-quality care based on best-available evidence
  • Improvement in nursing practice
  • Improvement in patient outcomes
  • Improvement in nursing care delivery

Examples of measurable outcome measures related to nursing professional development might be:

  • Preceptors will report that 100% of new graduates are using critical thinking skills by the end of the 8th week of employment.
  • 80% of nurse managers will present a balanced budget to the administrative team by the end of the 3rd quarter of 2016.
  • All new employees will exemplify leadership behaviors of advocacy, assertiveness, clinical judgment, and reflective practice by the end of 1 year of employment.

Note: New applicants should develop and submit with their application a list of quality outcome measures that will be collected, monitored, and evaluated.

Tips for completing the next 3 sections of the provider application:

The following sections of your application are the narrative portions – where you describe your process and give an example related to each criterion. Remember that you should be addressing the who, what, why, where, when, and how aspects of each item in order to provide a complete answer. In addition, look for key words in the heading of the section or the criterion to help you answer the question at hand. For example, SC1talks about the Primary Nurse Planner’s commitment to learner needs. The focus is on commitment to learners in the big picture of the provider unit’s operations, not on how you collect needs assessment data for a particular learning activity. We have provided “food for thought” questions to help you develop your answer. These are NOT the specific questions that need to be answered in your description. Think through each item, and talk with your team about processes and examples before you begin to write. Typically, we’re looking for about a half-page for your description and another half-page for your example. One or two sentence answers will not provide adequate descriptions or examples.

Approved Provider Criterion 1:  Structural Capacity (SC)

The capacity of an Approved Provider Unit is demonstrated by commitment to, identification of and responsiveness to learner needs, continual engagement in improving outcomes, accountability, and leadership. Applicants will write narrative statements that address each of the criteria under Commitment, Accountability, and Leadership to illustrate how structural capacity is operationalized.

  • Each narrative must include a specific example that illustrates how the criterion is operationalized within the Provider Unit.

Commitment. The Primary Nurse Planner demonstrates commitment to ensuring nurses learning needs are met by evaluating Provider Unit processes in response to data that may include, but is not limited to, aggregate individual educational activity evaluation results, stakeholder feedback (staff, volunteers), and learner/customer feedback.

Describe and, using an example, demonstrate the following:

SC 1.   The Primary Nurse Planner’s (PNP) commitment to learner needs, including how Provider Unit processes are revised based on data.

Key words: Primary Nurse Planner, commitment, learner needs (in aggregate), and revised processes.

Note: This item relates to the overall functioning of the Provider Unit and the PNP’s commitment to learner needs, not specifically to the individual activity planning.  Examples might include suggestions based from multiple requests; discussions to increase attendance opportunities at CE events – done by offering more classes convenient to the night shift; offering podcasts; getting commercial support to be able to get national speakers, etc.

Consider:

  • How do you as the PNP use feedback from your learners to change or improve Provider Unit processes or learning activities?
  • How do you know what styles of learning fit your learners best or what learning modalities (live, webinars, independent study documents, etc.) they prefer?
  • What do you, the Primary Nurse Planner, do with this information?

First, describe your process, then in the next box provide a very specific example. The beginning of an example might look something like this: “Over the past six months, our hospital has hired a significant number of new registered nurses. Our RN demographic mix is now 36% millennial generation, 35% generation X, 25% baby boomers, and 4% traditionalists. Based on this data, we surveyed all of our RNs to determine their preferred learning styles. We had an 82% response rate to our survey, and based on this data we found that….  Therefore, I, as the Primary Nurse Planner ….”

Accountability. The Primary Nurse Planner is accountable for ensuring that all Nurse Planners in the Provider Unit adhere to the ANCC accreditation criteria [and OBN rules]

SC2.    How the Primary Nurse Planner ensures that all Nurse Planner(s) of the Provider Unit are appropriately oriented/trained to implement and adhere to the ANCC accreditation criteria.

Key words: Primary Nurse Planner, Nurse Planners, oriented/trained, implement/adhere.

Examples might include first we orient new Nurse Planners, then have them work with a preceptor, and then monitor their performance to ensure adhering to the criteria; sharing Provider Newsletters; becoming certified as a Nursing Professional Development Specialist; description of how keep up to date with the criteria and rules; etc.

Consider:

  • As the PNP, how do you orient new Nurse Planners to your Provider Unit?
  • How do you keep them updated on changes?
  • How do you monitor to be sure they are doing the right things on a consistent basis?

Leadership. The Primary Nurse Planner demonstrates leadership of the Provider Unit through direction and guidance given to individuals involved in the process of assessing, planning, implementing, and evaluating CNE activities in adherence to ANCC accreditation criteria [and OBN rules].

SC 3.   How the Primary Nurse Planner provides direction and guidance to individuals involved in planning, implementing and evaluating CNE activities in compliance with ANCC accreditation criteria.

Key words: Primary Nurse Planner, direction and guidance, compliance

Consider:

  • As the Primary Nurse Planner, how do you role-model maintenance of standards?
  • How do you make your expectations clear to other Nurse Planners and others involved with CNE activities?
  • What process do you implement to support others who participate on planning committees or engage in the work of providing CNE?
  • How do you help Nurse Planners problem-solve when challenges or questions arise?
  • What leadership skills do you use to guide Nurse Planners and others in their work?

Approved Provider Criterion 2: Educational Design Process (EDP)

The Provider Unit has a clearly defined process for assessing needs as the basis for planning, implementing, and evaluating CNE. CNE activities are designed, planned, implemented, and evaluated in accordance with adult learning principles, professional education standards, and ethics.

  • Each narrative must include a specific example that illustrates how the criterion is operationalized within the Provider Unit.

Evidence must demonstrate how the Provider Unit complies with each criterion.

TIP:  You are expected to have a clearly defined process for developing continuing nursing education activities in accordance with adult learning principles, professional education standards, and standards related to ethical practice and behavior.

If you are a returning provider, you will be including three sample activities with your provider application. If you are a new provider, you will have recently completed at least three activities that have been approved by ONA. Your examples in the EDP items may relate to these activities, but you are free to use other examples as well. If you use an example from one of your activities, you still need to provide a full description and example in this section. It is not acceptable to say, for example, “see identified gap in our activity on emergency preparedness”. Once again, remember that your response should include who, what, when, where, why, and how components to help peer reviewers get a clear picture of how your provider unit plans, implements, and evaluates learning activities.

In this section, your descriptions should clearly show the process you use to conduct each step of the activity planning and evaluation processes for any given learning activity (this section is specific to learning activities, whereas the SC and QO sections are more general). The examples should be related to how you implemented your process in one specific instance. Note that you may use different examples as you explain your processes; all of the examples do not come from one activity. Also, you are not required to use the sample activities you include with your provider application as the examples, although you may do so if you wish.

Assessment of Learning Needs. CNE activities are developed in response to, and with consideration for, the unique educational needs of the target audience.

Describe and, using an example, demonstrate the following:

EDP 1.  The process used to identify a problem in practice or an opportunity for improvement (professional practice gap).

Key words/phrases here are process, identify, problem or opportunity

A professional practice gap can be considered to be the “distance” (gap) between where a learner is now (point A) and where a learner should be (point B) in relation to a particular piece of knowledge, skill set, or ability to apply knowledge and skills in the practice setting. An educational activity is designed to move the learner from point A to point B. The activity will not be effective unless and until the professional practice gap is clearly identified, so this is a critical first step in developing an educational activity.

Consider:

  1. How do you define a professional practice gap?
  2. How do you know when one exists?
  3. How do you determine what the issue is that needs attention?
  4. What sources of data might alert you to the existence of a professional practice gap?

Your example, as with all of the examples in this section, should “paint a picture” of how you addressed this criterion for one of your planned activities. Again, remember to include who, what, why, where, when, and how components to make your response complete.\

EDP 2.  How the Nurse Planner identifies the educational needs (knowledge, skills and/or practice(s)) that contribute to the professional practice gap.

Key words/phrases here are nurse planner, identifies, educational needs, contribute to

Consider:

  1. What evidence do you use to determine why the professional practice gap exists?
  2. How does your needs assessment data support you in doing this gap analysis? Or, conversely, how does identifying the gap help you do a more targeted assessment of the needs of the learners expected to participate in this activity?
  3. What resources do you use to identify those underlying needs (example: new national standards have been issued for blood pressure monitoring or stroke care; hospital quality data shows that one department has an above-benchmark rate of infection)
  4. How do you determine whether the gap is in knowledge, skills, or application in practice?
  5. How do you use this evidence to determine whether there is an educational need at all, versus an individual compliance or competency issue?

Planning. Planning for each educational activity must be independent from the influence of Commercial Interest Organizations.

EDP 3. The process used to identify and resolve all conflicts of interest for all individuals in a position to control educational content.

Key words/phrases here: process, identify, resolve, conflicts of interest, control educational content

Consider:

  1. How do you and other Nurse Planners in your Provider Unit define “conflict of interest”? Is everyone clear on what this means?
  2. Who assesses the Nurse Planner’s conflict of interest for the activity?
  3. What happens if the Nurse Planner has a conflict of interest?
  4. What sources of evidence do you include when assessing for conflict of interest?
  5. How do you determine who has the ability to “control content” for an activity?
  6. How do you analyze data to determine whether there is a conflict of interest for anyone involved with the learning activity?
  7. What happens if someone declines to provide evidence related to conflict of interest for self or spouse?
  8. What if the person states that he/she does not have a conflict of interest, but the Nurse Planner thinks there may be one?
  9. What if the person states that he/she has a conflict of interest, but the Nurse Planner does not evaluate the situation as a conflict?
  10. NOTE: It is always required to identify presence or absence of conflicts of interest. “Not applicable” is not an acceptable response.
  11. What do you do when a conflict of interest is identified when collecting data about the person involved with the activity?
  12. What options do you consider in resolving the conflict?
  13. In the example, why did you select the option you did, and what happened as a result?
  14. If you never have had to resolve a conflict of interest, your example should be based on a situation where you reviewed the COI data and how you determined that no resolution was necessary. “Not applicable” is not an acceptable response.

Note:   Refer to the appendix on COI, the COI form and the COI decision tree.

Design Principles. The educational design process incorporates best-available evidence and appropriate teaching methods.

EDP 4. How content of the educational activity is developed based on best-available current evidence to foster achievement of desired outcomes (e.g., clinical guidelines, peer-reviewed journals, experts in the field).

Key words/phrases here: content, best available current evidence, desired outcomes

Consider:

  1. Who selects content for the activity?
  2. How does the content selected relate to the professional practice gap and evidence supporting the need for the activity (data from EDP 1 and 2)?
  3. How do you define “best available current evidence”?
  4. What are sources of evidence typically used to meet identified educational needs?
  5. How does the planning committee work with the speaker/author to assure that content and references/resources relate to closing the identified practice gap?
  6. How do you validate that the presenter/author is using best-available evidence to present the information?
  7. What would you do if you suspected that content was not based on best available evidence?
  8. Have you used content reviewers to evaluate content to be sure it is based on best available evidence?

EDP 5.  How strategies to promote learning and actively engage learners are incorporated into educational activities.

Key words/phrases here: strategies, promote learning, actively engage learners

Consider:

  1. Why is it important that learners be actively engaged?
  2. What evidence from adult learning principles and other theoretical foundations supports the importance of this approach in helping learners translate knowledge into practice?
  3. What are common strategies used in your Provider Unit to engage learners?
    How do you select which strategies to use for specific educational activities?
  4. How do you evaluate the effectiveness of learner engagement strategies in your educational activities?
  5. What if learners don’t “engage”?
  6. How do the selected teaching methods relate to the identified professional practice gap and contribute to the learners’ ability to achieve the desired outcome of the activity?

Evaluation. A clearly defined method that includes learner input is used to evaluate the effectiveness of each educational activity. Results from the activity evaluation are used to guide future activities.

EDP 6.  How summative evaluation data for an educational activity were used to guide future activities.

Key words/phrases here: summative, guide future activities

Consider:

  1. How do you collect evaluation data? (NOTE: Think carefully about what data you want to collect to assess whether a practice gap has been closed and how you want to do it for each activity.)
  2. How you do select evaluation strategies based on whether the identified gap is in knowledge, skill, or application in practice?
  3. How do you summarize evaluation data?
  4. Who is responsible for this process?
  5. How is it shared, and with whom?
  6. What is the purpose of sharing summative evaluation data?
  7. How does this data help in planning future learning activities?

EDP 7.  How the Nurse Planner measures change in knowledge, skills, and/or practices of the target audience that is expected to occur as a result of participating in the educational activity.

Key words/phrases here: measures change, result of educational activity

Consider:

  1. Given that the purpose of continuing nursing education is to enhance the professional development of the nurse and/or improve patient care, what data do you look for to indicate that your educational activity has contributed to that purpose?
  2. What evaluation data do you collect to indicate that the previously identified gap has been filled for a given learning activity?
  3. How do you measure change?
  4. When do you measure change? (Consider both short term and long-term strategies)
  5. What resources do you use to help you measure change? (Consider quality improvement, risk management, or other existing sources of evidence within your system)
  6. What evidence have you looked at to show whether or not a learning activity changed nursing practice?
  7. How do you hold learners accountable for implementing what they have learned?

Approved Provider Criterion 3: Quality Outcomes (QO)

The Provider Unit engages in an ongoing evaluation process to analyze its overall effectiveness in fulfilling its goals and operational requirements to provide quality CNE.

Provider Unit Evaluation Process. The Provider Unit must evaluate the effectiveness of its overall functioning as a Provider Unit.

Describe and, using an example, demonstrate each of the following:

 QO1.     The process utilized for evaluating effectiveness of the Provider Unit in delivering quality CNE. (Note: This is not just about evaluating your individual activities. Look at the bigger picture of the Provider Unit.)

Key words/phrases here: evaluating effectiveness, Provider Unit, delivering quality CNE

Consider:

  1. What is your evaluation plan for your Provider Unit?
  2. What does “effectiveness” include for your Provider Unit?
  3. What things, besides your individual activities, do you consider in your evaluation of the effectiveness of your Provider Unit? What about personnel, finances, material resources?
  4. How often does your Provider Unit evaluation process occur?
  5. Who engages with you in the evaluation process?
  6. Why is it important that you conduct this type of evaluation?

QO2.   How the evaluation process for the Provider Unit resulted in the development or improvement of an identified quality outcome measure for the Provider Unit. (Refer to identified quality outcomes listed in OO4a.)

Key words/phrases here: evaluation process, development/improvement of quality outcome measure

(NOTE: This criterion refers directly back to OO4a – be sure to review the quality outcome measures for your Provider Unit before addressing this criterion. Remember that QO2 relates to the effectiveness of the Provider Unit and is specific to provider unit operations – not learner outcomes.)

Consider:

  1. What outcomes measures (identified in OO4a) are you using to evaluate your Provider Unit?
  2. What data have you collected around these outcomes measures?
  3. From whom have you collected data about the effectiveness of your Provider Unit in meeting the pre-identified quality outcome measures?
  4. How do you analyze this data to determine your effectiveness?
  5. Based on that data, what changes have you made to an existing outcome measure? Why?
  6. What new outcome measures, if any, have you added? Why?
  7. What outcome measures, if any, have you deleted from your priorities? Why?

Value/Benefit to Nursing Professional Development. The Provider Unit shall evaluate data to determine how the Provider Unit, through the learning activities it has provided, has influenced the professional development of its nurse learners.

Describe and, using an example, demonstrate:

QO3.   How, over the past 12 months, the Provider Unit has enhanced nursing professional development. (Refer to identified quality outcomes list in OO4b.)

Key words/phrases here: past 12 months, enhanced nursing professional development

(NOTE: This criterion refers directly back to OO4b – be sure to review your quality outcome measures for nursing professional development before addressing this criterion. Remember that QO3 relates to how your Provider Unit has contributed to improving the practice of nursing.)

Consider:

  1. How were your learning activities designed to help nurses learn and grow?
  2. What evidence do you have that nurses were able to implement what they learned?
  3. How did what nurses learned improve their professional development or the care they provided for their patients?
  4. How do you know this?
  5. What metrics provide supporting evidence that professional growth or change in practice occurred and that professional practice gaps were closed?
  6. How do you report and/or share your quality outcomes data with others in your organization?
  7. Why does it matter? How do your outcomes benefit the organization as a whole?

 Part Two of the Provider Application: Attestation Statement

The provider application will require a signed attestation statement from the Primary Nurse Planner which addresses the following responsibilities:

I attest that I will adhere to the following criteria of ANCC and the rules of the Ohio Board of Nursing as defined in the ONA Provider Manual:

  1. Adhering to laws/rules/ethical business practices
  2. Educational requirements and responsibilities of the primary nurse planner and nurse planners
  3. Timely communication about core changes and responses to requests for information from ONA
  4. Process to ensure meeting of all criteria and rules

PART Three of the Provider Application: Individual Activity Files

As a component of the educational design process, the Approved Provider Unit applicant should select and submit CNE activity files to ONA that have been planned within 12 months of the Provider Unit application date and comply with ANCC criteria and OBN rules.

For Currently Approved Provider Units

Submit documentation for three sample activities. Each activity must be at least one hour in length. Include:

  • Documentation form with all required attachments – COI forms, marketing sample, certificate, evidence of disclosures, joint provider agreement if applicable, commercial support agreement if applicable, and reference list/bibliography
  • Summative evaluation and conclusion/final decisions about activity made by Nurse Planner
  • If the activity is an Ohio Category A activity, include the PowerPoint presentation, handout and/or module given to learners

Note: For First Time Applicants Only: If you are a first time applicant for provider status, submit:

  • Acknowledgement and approval letters from ONA for the 3 activities ONA has approved
  • A copy of the FINAL certificate that was given to learners for each of these 3 activities
  • A summative evaluation for each of these 3 activities
  • Documentation for an activity that has been planned and will be presented after provider status has been achieved. Include the provider unit activity documentation form and all required attachments – COI forms, marketing sample, certificate, evidence of disclosures to be made, commercial support agreement if applicable and reference list/bibliography. The marketing material and certificate should contain the provider statement that will be used by your organization once provider status has been achieved.
  • The provider statement that must be used is:

(Provider name) (OH-###, expiration date) is an approved provider of continuing nursing education by the Ohio Nurses Association (OBN-001-91), an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

Note: The provider number will be assigned when your provider application is received. The expiration date (e.g., 6/1/2014) will be provided once you are approved as a provider unit.

Responsibilities Each Provider Unit Must Follow:

In preparation for becoming an Approved Provider Unit and throughout your approval, you must meet each of the roles and responsibilities listed below. Each activity file will be reviewed to ensure that this is occurring.

  1. Awarding Contact Hours

Contact hours are determined in a logical and defensible manner. Contact hours are awarded to participants for those portions of the educational activity devoted to the learning experience and time spent evaluating the activity. One contact hour = 60 minutes. No fewer than 0.5 contact hours can be awarded for an educational activity. If rounding is desired in the calculation of contact hours, the provider must round down to the nearest 1/10th or 1/100th. Educational activities may also be conducted “asynchronously” and contact hours awarded at the conclusion of the activity.

Contact hours may not be awarded retroactively except in the case of a pilot study.

Participants in the pilot study assist in determining the length of time required for completing an educational activity in order to calculate the number of contact hours to award. Those participants may be awarded contact hours once the number is determined. 

  1. Approved Provider Statement

There are two places where the approved provider statement must be listed – on the certificate and in the written disclosures. Learners must be informed prior to the start of the activity that you are an Approved Provider. You may not insert any other words into this official approved provider statement.

[Name of Approved Provider Unit][Assigned Provider Number, Expiration Date] is an approved provider of continuing nursing education by the Ohio Nurses Association (OBN-001-91), an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

  1. Documentation of Completion
  2. Participants receive written verification of their successful completion of an activity, which includes, at a minimum:

–     Title and date of the educational activity

  • Name and address of provider of the educational activity (web address acceptable)
  • Number of contact hours awarded
  • Approved Provider statement
  • Participant name

Include the following if applicable:

  • Information about Category A (Ohio nursing law and rules) if the activity is about Ohio nursing law and rules (ORC or OAC 4723).
  • Information about number of pharmacotherapeutic contact hours for APRNs if the activity is about pharmacotherapeutics. 
  1. Commercial Support

Commercial support is when a commercial entity provides money or in-kind services to a provider for an activity. The Provider Unit must adhere to the American Nurses Credentialing Center’s Content Integrity Standards for Industry Support in Continuing Nursing Educational Activities at all times. These standards are listed in Appendix G.

The Provider Unit must have a signed, written agreement if commercial support is accepted.

Organizations providing commercial support may not provide or jointly provide educational activities.

  1. Conflicts of Interest

Conflict of Interest occurs when a person who has the ability to control content of a continuing nursing education activity has a financial relationship with a commercial interest organization*, the products or services of which are related to the topic of the educational activity.

The Nurse Planner is responsible for evaluating the presence or absence of conflicts of interest and resolving any identified actual or potential conflicts of interest during the planning phases of an educational activity. If the Nurse Planner has an actual or potential conflict of interest, he or she should excuse himself or herself from the role as Nurse Planner for the educational activity.

Note: Refer to Appendix F for additional information about Conflicts of Interest.

  1. Disclosure Responsibilities

Disclosures in the Planning Process:

Signed Conflict of Interest Disclosure Form. All planners, presenters, faculty, authors, and content reviewers must disclose any conflicts of interest related to planning of an educational activity. Forms must be signed and dated. Disclosure must be relative to each educational activity. If a potential or actual conflict is identified, the planning process must include a mechanism for resolution.

Disclosures provided to the Learner:

Learners must receive disclosure of required items prior to the start of an educational activity. In live activities, disclosures must be made to the learner prior to initiation of the educational content. In enduring print materials or Web-based activities, disclosures must be visible to the learner prior to the start of the educational content. Required disclosures may not occur or be located at the end of an educational activity. Evidence of the disclosures to the learner must be retained in the activity file. All disclosures must be made in writing.

Disclosures always required include:

  • Notice of requirements for successful completion of the educational activity:

Prior to the start of an educational activity, learners must be informed of the criteria used to determine successful completion, which may include but are not limited to:

  • Required attendance time at activity (e.g., 100% of activity, or miss no more than 10 minutes of activity)
  • Successful completion of post-test (i.e., attendee must score X% or higher)
  • Completed evaluation form
  • Return demonstration
  • Presence or absence of conflict of interest for planners, presenters, faculty, authors, and content reviewers. Any influencing relationships, or lack thereof, of planners, presenters, faculty, authors or content reviewers in relation to the educational activity.

If there is a COI that has been identified and resolved, you must disclose:

  • Name of individual
  • Name of commercial interest
  • Nature of the relationship the individual has with the commercial interest

Disclosures required, if applicable, include:

  • Commercial Support. Learners must be informed if a commercial interest has provided financial or in-kind support for the educational activity.
  • Joint Providership. Learners must be informed of the names of all providers involved in a joint providership.
  • Expiration of Enduring Material (Independent Study). Educational activities provided through an enduring format (e.g., print, electronic, Web-based) are required to include an expiration date documenting how long contact hours will be awarded. This date must be visible to the learner prior to the start of the educational content. The period of expiration of enduring material should be based on the content of the material but cannot exceed three years. ANCC requires review of each enduring material at least once every three years, or more frequently if indicated by new developments in the field specific to the enduring material. Upon review of enduring material for accuracy and current information, a new expiration date is established.
  1. Approved Provider Unit Recordkeeping

The Approved Provider Unit is responsible for maintaining activity file records in a retrievable file (electronic or hard copy) accessible to authorized personnel for six years. The criteria delineated under the Provider Educational Design process must be followed consistently during the period of approval, and the recordkeeping files must include evidence in the form of:

  • Activity Documentation Form with all attachments

∙     Summative evaluation (A summative evaluation is a listing of the raw data collected from the participants on the evaluation form).

∙     Joint provider agreement with signature and date (if applicable)

∙     Completed final decision about activity by the Nurse Planner.

  1. Jointly Providing Activities for Continuing Nursing Education

Jointly providing is the Provider Unit’s process for planning, developing and implementing an educational activity in collaboration with another organization(s).  (See Appendix D for more detail.)

When an activity is jointly provided, the Approved Provider is referred to as the provider of the educational activity. The other organization(s) are referred to as the joint provider(s) of the educational activity. The jointly providing organization may not be a commercial interest. The Approved Provider Unit’s Nurse Planner must be on the planning committee and is responsible for ensuring adherence to the ANCC accreditation criteria and OBN rules.

When an educational activity is jointly provided, the Provider Unit’s Nurse Planner is responsible for:

  • Signed joint provider agreement which includes:
  • The name(s) of the organizations acting as the joint provider(s)
  • Responsibilities of the Approved Provider Unit and the joint providers
    • Name and signature of the Nurse Planner of the Approved Provider Unit
    • Name and signature of the individual on behalf of the joint provider(s)
    • Date the agreement was signed
  • Ensuring that the Approved Provider Unit name is prominently displayed in all marketing material. The Approved Provider Unit’s name will be on the certificate.

In the event that two or more organizations are Approved Providers, one will act as the provider of the educational activity and the other(s) will act as the joint provider(s). If collaborating providers are all approved, one is designated to retain the provider responsibilities by mutual, written agreement. The Approved Provider Unit designated to retain these responsibilities is referred to as the provider, and the other collaborating providers are referred to as joint providers.

  1. The Nurse Planner(s) of the Approved Provider Unit plans and provides CE activities. The Approved Provider Unit may not approve its own activities or the activities planned by outside entities.
  1. Annual Reporting. Each Approved Provider Unit is required to submit an annual report by January 30. Information includes any changes, statistical data and additional information as determined by the CE Approver Council.

 Submitting the Provider Application:

  1. Before completing the provider application, be sure you have submitted your Intent to Apply/Re-apply as a Provider Unit to ONA and have received approval to continue.
  2. Complete the narrative component of the provider application.
  3. Include the attachments to the provider application as described throughout this chapter.
  4. Number all the pages sequentially (including the individual activities). Collate all pages.
  5. Include a table of content so that reviewers can easily find information.
  6. Ensure that all pages are legible and that abbreviations are explained.
  7. Bind the application securely. Comb binding or a light inexpensive binder is recommended for each copy of the complete application. Staples, rubber bands and paper clips are not acceptable.
  8. Submit a total of three copies along with the application fee to the Ohio Nurses Association. Please check the ONA website for the current application fee for Approved Provider Units. (www.ohnurses.org, Education, Approval for CE Programs, Approved Providers). Your fee is not refundable once the review process has begun. If a refund is issued prior to the start of the review, an administrative fee of $25.00 will be deducted.
  9. If you are applying again as a provider unit, be sure to submit the application by the due date (three months before expiration). Also be sure to include your provider number on all correspondence.

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Chapter 3 – Educational Design Process

 (Copied and adapted from ANCC‘s 2015 Accreditation Manual with permission from Kathy Chappell)

This chapter outlines the process of developing and/or evaluating individual educational activities according to ANCC Accreditation Program criteria, which ensure that individual education activities are effectively planned, implemented, and evaluated according to educational standards and adult learning principles.

The educational design expectations described in this chapter and applicable at the individual activity level are fundamental to high-quality continuing nursing education (CNE). Accordingly, organizations accredited as Approver Units must ensure that these expectations are met and that the ANCC criteria for accreditation are applied in such a manner as to ensure the Approved Provider and/or Individual Activity Applicant offers individual educational activities that meet these criteria.

CNE is designed to improve the professional practice of nursing and to positively impact patient, system, and/or population outcomes. CNE is defined as ““learning activities intended to build upon the educational and experiential bases of the professional RN for the enhancement of practice, education, administration, research, or theory development, to the end of improving the health of the public and RNs’ pursuit of their professional career goals.”Interprofessional continuing education (IPCE) is defined as “when members of two or more professions learn with, from, and about each other to enable effective collaboration and improve health outcomes”  (www.jointaccreditation.org).

Within an accreditation framework, the following principles of high-quality educational design are employed:

  • Addresses a professional practice gap (change in standard of care, problem in practice, or opportunity for improvement)
  • Incorporates the active involvement of a Nurse Planner in the planning process
  • Analyzes educational need(s) (knowledge, skills, and/or practices) of registered nurses and/or healthcare team members that underlie the problem or opportunity (why the problem or opportunity exists)
  • Identifies the learning outcome(s) to be achieved by learners participating in the activity
  • Uses strategies that engage the learner in the educational activity and are congruent with the educational needs and desired learning outcome(s)
  • Chooses content based on evidence-based practice or best-available evidence
  • Evaluates achievement of learning outcome(s)
  • Plans independently from the influence of commercial interest organizations

Educational Design Process

The process of planning begins with identifying when CNE, or IPCE, might be a desired intervention to address a change that has been made to a standard of care, a problem that exists in practice, or an opportunity for improvement. Once an educational intervention is determined to be appropriate, a Nurse Planner is engaged to begin the planning process.

The Nurse Planner starts by analyzing data that validate the need for the educational activity. This analysis forms the basis of a professional practice gap, or the difference between the current state of practice and the desired state of practice. It is important to note that a professional practice gap may exist for registered nurses or healthcare regardless of the practice setting. Professional practice gaps are not limited to clinical practice and may also exist in areas of professional work such as administration, education, and research.

Planning Committee:

Once the professional practice gap is identified, the Nurse Planner can begin to select individuals to assist with planning the educational activity by forming a Planning Committee, or the Nurse Planner may participate as a member of an interprofessional planning team. The Planning Committee must include at least two people: the Nurse Planner and a content expert. The Nurse Planner may function as both the Nurse Planner and the content expert; however, two people must be involved with planning each educational activity. Other individuals may be selected, as appropriate, to help plan the activity. The Nurse Planner ensures that the educational activity is developed in compliance with ANCC accreditation criteria.

Planning continues with further analysis of the professional practice gap. The Nurse Planner and Planning Committee evaluate the root cause(s) of the gap, or why the gap exists. If the gap is related to a lack of knowledge, skills, and/or practices of registered nurses, an educational intervention is appropriate. The gap may exist for other reasons, however, and alternate, non-educational strategies may need to be considered.

Underlying Educational Needs:

When the professional practice gap has been identified, the Nurse Planner and Planning Committee conduct a needs assessment to determine the underlying educational needs of registered nurses, or members of the healthcare team, that contribute to the gap. The Nurse Planner and Planning Committee evaluate what registered nurses or members of the healthcare team do not know (knowledge deficit), do not know how to do (skill deficit), or are not able to do in practice (practice deficit). A backward-planning process, as described by Moore, Green, and Gallis (2009), is a useful method for determining the educational needs and targeting the educational activity appropriately to address the gap.

Target Audience:

Once the educational need has been identified, the Nurse Planner and Planning Committee can determine the target audience for the educational activity. The target audience is defined as the specific registered nurse learners or healthcare team members the educational activity is intended to impact.

Learning Outcome(s):

The Nurse Planner and Planning Committee then develop the desired learning outcome for participants in the target audience. A learning outcome is written as a statement that reflects what the learner will be able to do as a result of participating in the educational activity. The learning outcome must be observable and measureable. The learning outcome addresses the educational needs (knowledge, skills, and/or practices) that contribute to the professional practice gap, and achieving the learning outcome results in narrowing or closing the gap. A learning outcome may be assessed short term or long term. There may be more than one learning outcome for an educational activity.

Content for Educational Activity:

Content for the educational activity may be chosen by the Nurse Planner and Planning Committee, or it may be selected by others participating in the educational activity such as individual speakers or authors. It is the responsibility of the Nurse Planner and Planning Committee to ensure that content is based on the most current evidence, which may include, but is not limited to, evidence-based practice, literature/peer-reviewed journals, clinical guidelines, best practices, and content experts/expert opinion. If there is concern that content selected is not based on best-available evidence or may be biased within the educational activity, the Nurse Planner and Planning Committee may choose to engage a content reviewer. The purpose of a content reviewer is to provide independent and expert evaluation of content to ensure best-available evidence is presented, content is balanced, and the content is not promotional or biased.

Content that has previously been developed may also be identified as appropriate to include within the educational activity. If previously developed content is incorporated, the Nurse Planner is responsible for ensuring that content meets criteria for best-available evidence and is appropriate in relation to the identified practice gap, and that permission to use the content has been obtained as applicable.

Active Learner Engagement:

As part of the design process, the Nurse Planner and Planning Committee develop ways to actively engage learners in the educational activity. Strategies to engage learners may include, but are not limited to, integrating opportunities for dialogue or question/answer, including time for self-check or reflection; analyzing case studies; and providing opportunities for problem-based learning. Active learner engagement may function as an opportunity for formative assessment during the educational activity by providing the presenter with immediate learner feedback.

Criteria for Awarding Contact Hours:

During the planning process, the Nurse Planner and Planning Committee determine the criteria that learners must meet to earn contact hours. Criteria should be based on the desired learning outcome(s). Criteria may include, but are not limited to, awarding credit commensurate with participation in the activity, requiring attendance for a specified period of time (e.g., 100% of activity, or miss no more than 10 minutes of activity), successfully completing a post-test (e.g., attendee must score X% or higher), completing an evaluation form, or successfully completing a return demonstration.

Evaluation:

The Nurse Planner and Planning Committee determine the method that will be used to evaluate the educational activity. The evaluation components and method of evaluation should be relative to the desired learning outcome(s) of the educational activity. Evaluation may be formative and integrated within the educational activity. Evaluation is also summative at the conclusion of the educational activity. Evaluation methods include assessment of change in knowledge, skills, and/or practices of the target audience. Change in knowledge, skills, and/or practices may or may not occur based on a variety of factors; however, evaluation should assess for such change. Evaluation may also include collecting data that reflect barriers to learner change.

Evaluations may include, but are not limited to, both short- and long-term methods, as illustrated in Table 4.

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Following the conclusion of the educational activity, the Nurse Planner and/or Planning Committee review the summative evaluation data to assess the impact of the educational activity and determine how results may be used to guide future educational activities, as applicable.

Independence from Commercial Interest Organizations

The educational planning process outlined in this chapter is designed to provide independent continuing education firmly rooted in the identification of professional practice gaps and learning needs of registered nurses and/or members of the healthcare team. In order to fully ensure independence of these CNE/IPCE activities and meet accreditation criteria, actions that ensure there is no commercial influence in the planning and execution of these activities is an important component of the overall process. The next section focuses on conflict of interest, commercial support, and content integrity in the presence of commercial support.

Ensuring Independence and Content Integrity

The following is an abbreviated outline of the requirements for ensuring independence and content integrity when planning educational activities. See ANCC Content Integrity Standards for Industry Support in Continuing Nursing Educational Activities available … in the Appendix of this manual for full standard requirements.

Conflict of Interest

A conflict of interest exists when an individual is in a position to control or influence the content of an educational activity and has a financial relationship with a commercial interest, the products or services of which are pertinent to the content of the educational activity. The Nurse Planner is responsible for identifying and resolving conflicts of interest during the planning and implementation phases of an educational activity.

The Nurse Planner may engage the individual with the identified conflict of interest to participate in the resolution process through actions such as having the individual sign a speaker agreement outlining expected practice or submitting/revising presentation materials, but the Nurse Planner must be actively engaged in the resolution process and is ultimately accountable for compliance. The Nurse Planner is also responsible for informing learners of the presence or absence of conflicts of interest for all individuals in a position to control content of the educational activity. If the Nurse Planner has a conflict of interest, he or she should recuse himself or herself from the role as Nurse Planner for the educational activity.

It is critical that all individuals in a position to control content of an educational activity are provided with the definition of a commercial interest organization prior to disclosing relevant relationships.

 Identification and Evaluation:

The Nurse Planner is responsible for ensuring that all individuals who have the ability to control or influence the content of an educational activity disclose all relevant relationships with any commercial interest, including, but not limited to, members of the Planning Committee, speakers, presenters, authors, and/or content reviewers. Relationships with commercial interest organizations are considered relevant if they exist within the past 12 months. Relationships of the individual’s spouse/partner may be considered relevant and must be reported, evaluated, and resolved.

  • Employees of commercial interest organizations are not permitted to serve as planners, speakers, presenters, authors, and/or content reviewers if the content of the educational activity is related to the products or services of the commercial interest organization.
  • Employees of commercial interest organizations are permitted to serve as planners, speakers, presenters, authors, and/or content reviewers if the content of the educational activity is NOT related to the products of the commercial interest organization.
  • Individuals who have nonemployee relationships with commercial interest organizations are permitted to serve as planners, speakers, presenters, authors, and/or content reviewers as long as the Provider has implemented a mechanism to identify, resolve, and disclose the relationship as outlined in these standards.

 Resolution:

When an individual has a relevant relationship with a commercial interest organization, the Nurse Planner must implement a process to resolve the conflict of interest. Actions taken to resolve conflicts of interest must demonstrate resolution of the identified conflicts of interest prior to presenting/providing the educational activity to learners. Such actions must be documented in the activity file, and documentation must demonstrate (1) the identified conflict and (2) how the conflict was resolved.

Resolution processes may include, but are not limited to

  • Removing the individual with a conflict of interest from participating in all parts of the educational activity;
  • Revising the role of the individual with a conflict of interest so that the relationship is no longer relevant to the educational activity;
  • Not awarding continuing education contact hours for a portion or all of the educational activity;
  • Undertaking review of the educational activity by the Nurse Planner and/or member of the Planning Committee to evaluate for potential bias, balance in presentation, evidence-based content or other indicator of integrity, and absence of bias, AND monitoring the educational activity to evaluate for commercial bias in the presentation;
  • Undertaking review of the educational activity by the Nurse Planner and/or member of the Planning Committee to evaluate for potential bias, balance in presentation, evidence-based content or other indicator of integrity, and absence of bias, AND reviewing participant feedback to evaluate for commercial bias in the activity;
  • Undertaking review of the educational activity by a Content Reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicator of integrity, and absence of bias, AND monitoring the educational activity to evaluate for commercial bias in the presentation; and
  • Undertaking review of the educational activity by a Content Reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicator of integrity, and absence of bias, AND reviewing participant feedback to evaluate for commercial bias in the activity.

 Commercial Support:

Commercial Interest Organizations may provide monetary funding or other support (Commercial Support) for continuing nursing educational activities in accordance with the following fundamental principles:

  1. Commercial Support must not influence the planning, development, content, implementation, or evaluation of an educational activity; AND
  2. Receipt of Commercial Support must be disclosed to learners.

Commercial Support may be used to pay for all or part of an educational activity and for expenses directly related to the educational activity, including, but not limited to, travel, honoraria, food, support for learner attendance, and location expenses. Commercial Support may be used to support more than one educational activity at the same time or multiple activities over a period of time.

Commercial Support is:

  • Financial Support – money supplied by a Commercial Interest Organization to be used by a Provider for expenses related to the educational activity. Financial support may be provided as an unrestricted grant, educational grant, donation, or scholarship.
  • “In-Kind” Support – materials, space, or other nonmonetary resources or services used by a Provider to conduct an educational activity, which may include, but are not limited to, human resources, marketing services, physical space, equipment such as audiovisual materials, and teaching tools (for example, anatomic models).

 Ensuring Content Integrity of an Educational Activity in the Presence of Commercial Support:

Commercial Interest Organizations providing commercial support for continuing educational activities may not influence or participate in the planning, implementation, or evaluation of an educational activity. All of the following requirements to ensure content integrity must be satisfied by the Provider when commercial support is accepted.

  1. The commercial interest organization and … [approved] provider must have a written agreement setting forth the terms of the relationship and the support that will be provided. The written agreement will also reflect the requirements set forth in items 2-4, below.
  • payments for expenses related to the educational activity must be made by the Provider. The Provider must keep a record of all payments made using Commercial Support funding. Commercial Support funds may only be used to support expenses directly related to the educational activity.
  1. The Provider is responsible for maintaining an accounting of expenses related to Commercial Support.
  2. A Commercial Interest Organization may not jointly provide educational activities.

Educational Activity Characteristics

Types of activities:

There are … [two] primary types of educational activities that may be delivered live or via an enduring format.  (The following definitions are adapted to ONA’s types of activities.)

  • [Faculty Directed]…: The Provider controls all aspects of the learning activity. The Provider determines the desired learning outcome based on a needs assessment and gap analysis, selects content based on best-available evidence, chooses strategies to facilitate learning, and identifies methods for collecting and analyzing evaluation data. (Examples include live activities and live webinars.)
  • [Independent Study]…: The Provider determines the desired learning outcome based on a needs assessment and gap analysis, selects content based on best-available evidence, chooses strategies to facilitate learning, and identifies methods for collecting and analyzing evaluation data. The learner determines the pace at which he/she engages in the learning activity. (Examples include print articles, online courses, e-books, and self-learning modules/independent studies.)

Considerations for Live and Enduring Formats:

Live educational activities, whether in person or web-based, are … [Faculty Directed] activities. There is no expiration date for a live activity; however, the Provider is expected to evaluate repeated activities as needed to determine that the practice gap still exists, that the underlying educational needs are still relevant for the target audience, and that content is still based on current evidence. Live activities, or portions of live activities, may be repurposed for enduring materials. If repurposed, an expiration date is assigned to the enduring activity.

Enduring activities are… [Independent Study] activities. Enduring materials have an expiration date, after which no contact hours may be awarded. The period of expiration of enduring material should be based on the content of the material. Providers must review content of enduring materials at least once every 3 years, or more frequently if indicated by new developments in the field specific to the enduring material. Review of enduring material content should be conducted for 

  • Accuracy of content,
  • Current application to practice, and
  • Evidence-based practice.

Upon completion of the enduring material review, a new expiration date should be established.

 Joint Providership:

Approved Providers and Individual Activity Applicants may jointly provide educational activities with other organizations. The jointly providing organization cannot be a commercial interest. The Approved Provider or Individual Activity Applicant is referred to as the Provider of the educational activity; the other(s) is referred to as the Joint Provider(s). In the event that two or more organizations are approved, one will assume responsibility for adherence to the ANCC criteria and is the Provider; the other(s) is referred to as the Joint Provider(s). Materials associated with the educational activity, such as marketing materials, advertising, agendas, and certificates of completion, must clearly indicate the approved organization (Provider) awarding contact hours and responsible for adherence to ANCC criteria.

 Awarding Contact Hours:

Contact hours are determined in a logical and defensible manner. Contact hours are awarded to participants for those portions of the educational activity devoted to the learning experience and time spent evaluating the activity. One contact hour = 60 minutes. If rounding is desired in the calculation of contact hours, the Provider must round down to the nearest 1/10th or 1/100th (e.g., 2.758 should be 2.75 or 2.7, not 2.8). Educational activities may also be conducted asynchronously and contact hours awarded at the conclusion of the activities.

Time frames must match and support the contact hour calculation for live activities. Evidence may include, but is not limited to, agenda for the activity, outline of content to be delivered in the activity, and/or other marketing materials. Time for breaks and meals should be clearly delineated and not included in total contact hours awarded. For enduring materials such as print, electronic, web-based, etc., the method for calculating the contact hours must be identified. The method may include, but is not limited to, a pilot study, historical data, or complexity of content.

Contact hours may not be awarded retroactively except in the case of a pilot study. Participants in a pilot study assist in determining the length of time required for completing an educational activity in order to calculate the number of contact hours to award. Those participants may be awarded contact hours once the number is determined.

 Approved Provider Statement:

Approved Providers are required to provide the official Approved Providers statement to learners prior to the start of each educational activity and on each certificate of completion. The official Approved Provider statement must be displayed clearly to the learner and worded according to the most current Accreditation Manual. When referring to contact hours, the term “accredited contact hours” should never be used—contact hours are awarded.

The official ANCC approval statement must be written as follows, based on the Provider of the educational activity: {The statement below has been adapted to fit OBN requirements in addition to ANCC’s requirements.)

Name of Approved Provider [OH-###, expiration date] is an approved provider of continuing nursing education by the Ohio Nurses Association (OBN-001-91), an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

Certificate or Documentation of Completion:

A certificate or documentation of completion is awarded to a participant who successfully completes the requirements for the individual education activity.

The certificate or document must include:

  • Title and date of the educational activity;
  • Name and address of the provider of the educational activity (web address acceptable);
  • Number of contact hours awarded;
  • Approved provider statement; and
  • Participant name.
  • Plus additional requirements listed regarding Category A and Pharmacology, if applicable.

Required Information Provided to the Learner:

Learners must receive required information prior to the start of an educational activity. In live activities, required information must be provided to the learner prior to initiation of the educational content. In enduring materials (print, electronic, or web-based activities), required information must be visible to the learner prior to the start of the educational content. Required information may not occur or be located at the end of an educational activity.

Required information for learners includes:

  • Approval statement of provider responsible for educational activity
  • Notice of requirements to receive contact hours: Learners are informed of the criteria that will be used to award contact hours, which may include, but are not limited to:
    • Actual time spent in the educational activity
    • Required attendance time at activity (e.g., 100% of activity, or miss no more than 10 minutes of activity)
    • Successful completion of post-test (e.g., attendee must score X% or higher)
    • Completed evaluation form
    • Return demonstration
  • Presence or absence of conflicts of interest for all individuals in a position to control content of the educational activity.
    • For individuals in a position to control content who have a relevant relationship with a commercial interest organization (conflict of interest is present), the following required information must be provided to learners:
      • Name of individual
      • Name of commercial interest
      • Nature of the relationship the individual has with the commercial interest
    • For individuals in a position to control content who do not have a relevant relationship with a commercial interest organization, the activity Provider must inform learners that no conflict of interest exists.
  • Additional required information, if applicable, includes:
    • Commercial support: Learners must be informed if a commercial interest organization has provided financial or in-kind support for the educational activity.
    • Expiration of enduring materials [independent studies]: Educational activities provided through an enduring format (e.g., print, electronic, web-based) are required to include an expiration date documenting how long contact hours will be awarded.
    • Joint Providership: Learners must be informed of the Provider of the educational activity and all other organizations that participated in jointly planning the activity.

 

Chapter 4 – Educational Activities for Approved Provider Units

This chapter has been developed to guide you in completing the Documentation Form for your faculty directed, independent study, and blended activities. More detailed information about different components of planning an activity can be found in Chapter 3.

A faculty directed CE activity involves participant attendance. It is distinguishable by the fact that the pace of the activity is determined by the provider who plans and schedules the activity. Contact hour credit awarded is based on the time allocated for the activity. Examples of faculty directed CE activities include but are not limited to conventions, courses, seminars, workshops, lecture series, and distance learning activities such as teleconferences and audio conferences. Knowledge and use of adult learning principles should be reflected in all aspects of the educational design, i.e. learning outcomes, content, learner engagement strategies, etc.

A faculty directed activity may be repeated as often as desired so long as the Nurse Planner determines it is still current.

An independent study CE activity is designed for completion by learners, independently, at the learner’s own pace and at a time of the learner’s choice. The provider designs the educational activity and determines the amount of credit to be awarded. Examples of independent study activities include but are not limited to viewing videotapes or listening to audio tapes and completing post test questions; accessing on-line activities; reading selected article(s) and completing post-test questions; and learning and practicing skills independently in the activity and seeking an instructor to evaluate a return demonstration. Knowledge and use of adult learning principles should be reflected in all aspects of the educational design, i.e. learning outcomes, content, etc. Periodic review of evaluation feedback from learners is an important aspect of ongoing monitoring of effectiveness of the activity.

An independent study activity may be made available to learners as long as the Nurse Planner deems it is still current.

A blended learning activity is a combination of both independent study and faculty directed processes. For example, the learner needs to review articles online prior to the program to learn principles about a topic and then come to class to actually apply the information.

Faculty directed to independent study activity: The activity documentation form is also used when the live presentation is presented (faculty directed) and then turned into an independent study. (Only one form is needed, but all questions need to be answered to address both methods of presentation.)

Activities are analyzed by the Nurse Planner in relation to the summative evaluation data from both the learner and the Nurse Planner regarding continuation of the activity or if revisions are needed.

Documentation Form

The documentation form has items that are numbered from 1 through 19. The following is a description of these items.

  1. List the title of the activity. This title needs to appear the same throughout the documentation form and all attachments such as the certificate, advertising, etc.
  1. List the number of contact hours you wish to provide for your activity. 
  1. Select the type of activity and insert dates as appropriate. Options include Faculty Directed; Independent Study, Blended activity, and an activity that is done live first and then turned into an independent study.

The date of the event is the date that you will provide the faculty directed presentation in the future or start and ending date of the independent study. If you are uncertain about the date, you can state “To be scheduled.” Note: Contact hours may never be given retroactively. The documentation form must be completed before the start of the event.

In the blended learning activity there are also questions to answer regarding whether the learner  always has to do all parts of the activity or  if they can do one part or another.         

  1. List the name and contact information for the Nurse Planner in the provider unit.
  1. Check whether or not you are planning a CE activity for Ohio licensed nurses and/or other Ohio Board of Nursing (OBN) certificate holders that are specifically related to Ohio nursing law and rules. If you are planning to do a Category A activity, you must do the following:
  • The content for Category A must address current Ohio nursing law and rules specifically. For example, information might include the function and composition of the OBN, disciplinary process, standards (related to rules chapter 4), delegation (related to rules chapter 13), etc. Information about incident reports, legal cases such as malpractice, etc., are probably, in general, not related to 4723 Ohio Administrative Code (OAC) or Ohio Revised Code (ORC).
  • If you are a provider unit based outside of Ohio, you must get approval for Category A activities through an OBN approver such as ONA.
  • You must include the handouts, slides, etc. that the learner will receive for review.
  • The certificate must include the words “Category A” with the amount of contact hours related to it.
  • Category A content must be evaluated annually to ensure that it is still current.
  1. Planning Committee and Faculty/Presenter/Author

A.   For the documentation form, list the name and credentials of each person on the planning committee and the faculty in the chart. Include their completed COI forms with the documentation form. DO NOT include resumes or CVs in the provider application.

There must be a planning committee for the activity. The planning committee must, at the minimum, consist of two people. Areas that must be represented on the planning committee include:

1. One provider unit Nurse Planner responsible for the activity (currently licensed RN who has at least a baccalaureate or higher degree in nursing, and who is responsible for adherence to CE criteria, rules and requirements); and

2. One person who has relevant content expertise.

As long as there are at least two people on the planning committee, one person can fill one or more of the required roles listed in items 1 and 2 above.

3. In Ohio, one LPN if LPNs are expected in the target audience (For OBN system, 4723-14, OAC).

4. If the activity is designed specifically for an APRN with prescriptive authority, then an APRN must be included on the planning committee.

5. In some instances the planning committee may ask an expert in the content to review the speaker(s) slides, references and handouts to insure that there is no bias, that there is content integrity, and that the information is the best available evidence at the time of the presentation. This content reviewer will need to provide a COI form and to be evaluated for conflict of interest prior to engaging in the review of the content. The content reviewer is NOT a member of the planning committee.

6. For independent studies: Feedback Personnel: Identify the person(s) providing feedback to the learner. (4723-14, OAC)

Note: The Nurse Planner is responsible for evaluating the presence or absence of conflicts of interest and resolving any identified actual or potential conflicts of interest during the planning and implementation phases of an educational activity. If the Nurse Planner has an actual or potential conflict of interest, he or she should excuse himself or herself from the role as Nurse Planner for the educational activity.

B.   Faculty/presenters/authors.

While there is no documentation requirement regarding Faculty/Presenters/Authors’ expertise and qualifications, they should be able to address the content area they are presenting. Expertise in subject matter can be evaluated based on education, professional achievements and credentials, work experience, honors, awards, professional publications, etc. All presenters do not have to be nurses, but nurses should address nursing care and nursing implications. It is the Nurse Planner’s responsibility to ensure that they are qualified. Include current COI forms for each person.

The conflict of interest forms must be updated with each newly planned activity.

Directions: In addition to listing names, credentials and roles of planning committee members and faculty/author/content reviewer/feedback personnel in the activity in the chart, identify if the person has a financial relationship with a commercial entity (list name of entity) and the nature of the relationship (own stock, on speakers bureau, received a research grant, is an employee, etc.). If s/he does not have a financial relationship, state None.

C.  Non-Clinical topics and COI forms. If the topic to be presented is in no way related to clinical issues and there is absolutely no possibility of a conflict of interest occurring, then you do not need to collect completed COI forms from the planning committee and faculty/presenters/authors. It is the responsibility of the Nurse Planner to ensure that this is a non-clinical topic. Examples of a non-clinical topic might be leadership, communication styles, precepting, etc.

Check the attestation statement if this is applicable.

  1. Assessment of Learner Needs and Target Audience.

A.  The professional practice gap (e.g. change in practice, problem in practice, or opportunity for improvement).

1. Describe the learner’s current state. Describe what the problem is.

2. Describe the learner’s desired state. Describe what/how the nurse should know, know how to do or practice differently.

This criterion addresses WHAT. What is the issue that has created the stimulus for the request for the educational activity? There might be a problem in practice – the nurse is not doing something that s/he should be doing, or perhaps is doing something that should not be done. There might be a new opportunity for professional development – a national organization has issues new guidelines and nurses are not familiar with them.

One strategy to identify the professional practice gap is to ask “what is the current state” – where is the learner now – and “what is the desired state” – where should the learner be in relation to the issue at hand. While differentiating the current and desired states is not required in order to identify a professional practice gap, many Nurse Planners find it helpful. A gap analysis worksheet [see Appendix] is one resource that might be used to critically analyze a professional practice gap.

Identification of a professional practice gap is a critical first step in developing an educational activity, though it historically has been overlooked. Nurse Planners often receive a request for an activity and immediately jump into planning logistics – when the class will be held, who will be the speaker, and what content will be covered. This can lead to wasted time, energy, and money on the part of both the activity planners and the learners, because the educational activity is often not targeted specifically to address the problem at hand – therefore, no change or improvement in practice occurs.

A.  Evidence to validate the professional practice gap.

1. Check all methods /types of data sources that apply that validate the gap.
2. Provide a brief summary of data gathered that validates the need for this activity. Describe why this problem exists.

This criterion addresses WHY. Why does the gap exist between where the learner is now and where s/he should be in relation to the issue? What factors are contributing to this gap? Are there knowledge deficits? Skills deficits? Difficulty in transferring what the nurse knows and is able to do into the practice setting?

Once the professional practice gap has been identified, the nurse planner, often in conjunction with the planning committee, completes a needs assessment to determine the cause for the disconnect between where the learner is and where s/he should be. This process may involve such things as observing practice behaviors, collecting data from risk managers, reviewing the literature for evidence of best practices, or doing pre-tests. Collecting and analyzing data helps to identify whether the immediate need for the learner is knowledge (gaining new knowledge or perhaps letting go of knowledge that is no longer current), skills (improving the ability to demonstrate competent performance), or application in practice. This critical step helps to assure that the educational intervention is targeted at the appropriate level to address the gap and therefore improve practice.

Failure to complete this step often results in implementation of inappropriate educational activities for two reasons. Picture this scenario: A critical care manager tells the educator that nurses are having difficulty with 12-leads. A class is held to teach 12-lead interpretation to experienced critical care nurses, only to find the nurses frustrated because they already knew this information – the problem they were having was related to communicating need for change in plans of care to other members of the healthcare team based on their findings. The educational need contributing to the practice gap was not technical knowledge, it was about communication. Properly addressing the “why” question helps to target the intervention at the appropriate level.

The other issue is that the needs assessment may show that the issue is not educational at all – it’s related to a policy and procedure that needs to be changed, equipment that is not available or not in working order, or staffing issues that preclude carrying out desired plans. Determining this as part of the needs assessment process again saves educators, learners and organizations time and money.

B.  Check the educational need(s) that underlies the professional practice gap – knowledge, skill and/or practice. A gap in knowledge involves not knowing something. A gap in skill consists of having knowledge, but not knowing how to do something. A gap in practice involves having knowledge and the skill, but the inability to put it into actual practice.

C.  Identify who the potential target audience is for this activity by checking all that apply.

Specialized CE for certain Ohio groups:

– If the content is designed specifically for non-certified Clinical Nurse Specialists (CNS) licensed in Ohio, then a non-certified CNS should be included in the planning committee. In addition, the content must be at the graduate level and related to the CNS’s role.

– If the content is designed specifically for Ohio advanced practice registered nurses (APRNs) with prescriptive authority, then an APRN with prescriptive authority should be included on the planning committee. In addition, the content must be at the graduate level and related to the APRN’s prescriptive authority role.

– If the content is designed specifically for Ohio certified dialysis technicians, then it is suggested (but not required) that a certified dialysis technician be included on the planning committee. The content must be relevant to the CE requirements for the dialysis technicians. (4723-23, OAC)

D.  Identify what learning outcome you want the learner to achieve based on the information in items A 1 and 2 above. What will the learner know, show how to do, or plan to implement in practice as a result of participating in the educational activity? (Note: This outcome does not refer to what the provider will do to the learner, but what the learner can do at the end of the activity.) Be sure to write this outcome in measurable terms.

E.  Check whether this activity applies to or is related to nursing professional development or a patient outcome or both.

  1. Content. Provide an abstract describing the content that will be presented in this activity.

The content needs to be developed based on the gap identified. The content must be reflective of continuing education principles, practice and needs of the target audience.

Category A: If presenting content related to Category A (Ohio nursing law and rules), the numeric citation of the appropriate law and/or rules must be cited with the content. A copy of the handouts and/or slides to be used for this topic must be included in the documentation file.

Pharmacology hours: If presenting content related to pharmacotherapeutics for APRNs, identify this specific content as well as the time allotted for it.

A.  Provide an abstract describing the content that will be presented if this is a faculty directed activity.

B.  Provide an abstract describing the content that will be presented if this is an independent study. In addition, include the following:

– A description of what is included in the independent study package which includes an outline of all activities of the learner, materials needed to complete the study, and how the learner will get assistance with resources or interact with the provider of the independent study. (OAC 4723-14)

– A description of how the effectiveness of the study was assessed prior to its use by learners, the results of that assessment, and the changes made based on the assessment prior to making the study available to learners (OAC 4723-14).

Note: If the independent study expires and it is being reviewed again for another period, the people who have completed the study during the past period become the pilot group. You need to describe how many took the study during the past period, what comments/suggestions they had, what problems they had with the post-test (if applicable), how long it took them to complete the study, and how you have changed the independent study based on the findings. It is not appropriate to use the initial pilot information for the sections on effectiveness of the study and rationale for contact hours in this documentation form.

Copyright. If using material developed by others, it is the responsibility of the author(s) and Nurse Planner to ensure s/he has copyright permission to use the material.

  1. Contact Hours: The appropriate measure of credit is the 60 minute contact hour.

Pharmacology Hours: If the activity is being planned specifically for APRNs with prescriptive authority and the content specifically addresses pharmacotherapeutics, the Nurse Planner needs to delineate the exact amount of time that is devoted to pharmacotherapeutics. This will allow the number of contact hours related to pharmacotherapeutics to be calculated correctly. The certificate would then include the number of contact hours to be awarded AND the number of Pharm hours. (e.g., 6 contact hours including 2 Pharm contact hours)

Category A Hours. If the activity or any portion of the activity is designed specifically to address Ohio nursing law and rules, then clearly identify how much time will be spent on this topic so that the appropriate number of Category A contact hours can be awarded.

Faculty Directed activity:

– Include the amount of time spent on introduction/welcome, content, testing/return demonstration, and evaluation in Section 9 of the documentation form if the activity is two hours or less.

– Include the agenda/schedule including evaluation time if the activity is more than two hours long.

Agenda/schedule and contact hours.  Contact hours are awarded to participants for those portions of the educational activity devoted to didactic or clinical experience and to evaluating the activity.

An agenda or schedule is needed if an activity is more than two hours long in order to determine the number of contact hours to be awarded to learners. The time spent on welcome, introductions of people vs. introduction to the topic, pre/post tests, breaks, and evaluation need to be clearly and separately stated. Welcomes, introductions to people and space, breaks and exhibits are not included in the calculation of contact hours. The topic, pre/post-tests, demonstration/return demonstration, and evaluation are included in the calculation of contact hours. Evaluation is considered part of the learning activity and needs to be included in the calculation of contact hours.

If the CE activity is two hours or less, a separate schedule does not need to be included.

The appropriate measure of credit is the 60 minute contact hour. A contact hour is 60 minutes of an organized learning activity, which is either a didactic or clinical experience. The minimum number of contact hours to be awarded is 0.5 (30 minutes). Contact hours may be calculated to the hundredths (i.e. 1.45, 0.91, etc.). They may not be rounded up! (e.g., 4.59 = 4.5 or 4.59, not 4.6)

A sample schedule might look like this:

Chapter4Chart

Independent Study Contact Hour Calculation

Contact hours are determined in a logical and defensible manner, consistent with the objectives, content, teaching/learning strategies, and target audience. The rationale used to determine the number of contact hours to be awarded needs to be described. For example: Was a pilot study done? Was the determination made based on historical data? (For example, has an independent study of the same length and complexity been included in each monthly newsletter and it consistently takes learners “x” amount of time to complete it?) Is complexity of the content and data determined? If yes, how? Was a recognized formula such as the Mergener Formula used for written materials?

Participants in the pilot study may receive contact hours for their participation once the pilot study is completed and the appropriate number of contact hours to be awarded has been determined.

Describe the method for calculating the contact hours and show evidence of how contact hours were calculated.  

  1. References/Resources. Content should be selected based on the most current available evidence. Documentation should support quality of evidence chosen for content. Examples include but are not limited to evidence-based practice, literature/peer-reviewed journals, clinical guidelines, best practices, and content expert/expert opinion.

The planning committee may provide the speaker/author with reference(s) about which they want the speaker/author to address in the content. For example, if the organization is seeking accreditation or certification in a particular area, the planning committee may share the standard(s)/criteria related to this process. The speaker(s) may also provide a list of references (bibliography) used in the preparation of the presentation so that the Nurse Planner and/or content reviewer can evaluate if the content is based on best available evidence.

Check all types of references used and list the sources of those references in the documentation form. You can add a separate sheet to list the references if they do not fit into the documentation form. Each citation should include title of article/book/video, author(s), date of publication, etc. If information is found on reputable websites, include the website address, what was reviewed on the website along with the date of the download. References should be within the past 5-7 years unless the reference is a classic that is still relevant or you are addressing a historical topic.

  1. Learner Engagement Strategies. Identify the strategies that will be used during the activity that will get the participant actively involved in learning. Check all that apply on the documentation form. Note: There may be other strategies that would be appropriate that can be included under Other.
  1. Criteria for Successful Completion: Check the criterion or criteria for successful completion that the learner must meet in order to get a certificate. These criteria must be consistent with the outcome, content and learner engagement strategies.

Notes: If an activity is only 30 minutes and attendance is required, then the person must attend the entire 30 minutes in order to get the certificate. If it is a Category A activity, then the learner would need to attend the full 60 minutes in order to get a one contact hour certificate.

  1. Evaluation: Check the method(s) of evaluation for this activity.

It is an expectation that learners provide input into evaluation of each activity. The form of evaluation may vary depending upon the outcome expected, the content and learning engagement strategies. ANCC requires the evaluation be conducted at the level of identified educational need (knowledge, skill or application in practice). The Ohio Board of Nursing requires that there be a method of evaluation that addresses achievement of the outcome and the teaching effectiveness of each speaker. The planning committee may also decide to evaluate whether the participant gained knowledge at the conclusion of the activity through testing, a question (s) on the evaluation form, etc. The learner may also need to return demonstrate knowledge or skills such as in Fetal Monitoring or Basic EKG courses.

The planning committee must provide a copy of the evaluation methods.

Short term options of evaluation: Check all options that might be used for short term evaluation. This type of evaluation occurs during or at the very end of the program.

Long term options of evaluation. The Nurse Planner needs to decide if this activity’s outcome will be evaluated in the long-term, e.g. 3-6 months after the event. The key is looking to see if there is a change in nursing practice or nursing professional development. Check the option(s) that you intend to use if this is one of the outcomes for which you will conduct long term evaluation.

  1. Commercial Support

A.  Check if you did not or will not get commercial support.

B. If you are seeking support, you need to list the name of the commercial entity and provide a copy of the signed written agreement.

– A commercial interest is defined by ANCC as any entity either producing, marketing, re-selling, or distributing healthcare goods or services consumed by, or used on , patients or an entity that is owned or controlled by an entity that produces, markets, re-sells or distributes healthcare goods or services consumed by, or used on, patients. Exceptions are made for non-profit or government organizations and non-healthcare related companies.

– Commercial Support is financial or in-kind contributions given by a commercial interest that are used to pay for all or part of the costs of a CNE activity.

– A provider of commercial support may not be on an educational planning committee, be a joint provider of the activity, or the provider of the activity.

– If commercial support is provided for a CE activity, an employee from the organization providing commercial support may not be a speaker.

– There must be a signed, written agreement if commercial support is accepted between the commercial entity and the provider unit.

– Note: You are not required to have a commercial support agreement for those who are only exhibiting at the event.

The Approved Provider Unit must adhere to the American Nurses Credentialing Center’s Content Integrity Standards for Industry Support in Continuing Nursing Educational Activities at all times. These standards are listed in the appendices.

15.  Joint providership:

A. Check if you are or are not jointly providing this activity.

B.  If you are, list who your joint provider is.

C.  Check that you will maintain the overall responsibility for the activity.

D. Ensure your name is prominent on the advertising along with the joint providers.’

E. Attach the signed joint provider agreement.

When an activity is jointly provided, the Approved Provider Unit is referred to as the provider of the educational activity. The other organization(s) are referred to as the joint provider(s) of the educational activity. The jointly providing organization may not be a commercial interest. The Approved Provider Unit’s Nurse Planner must be on the planning committee and is responsible for ensuring adherence to ANCC criteria and the OBN rules.

When an educational activity is jointly provided, the Nurse Planner is responsible for:

  • The signed joint provider agreement (OBN requirement – OAC 4723-14)
  • Ensuring that the Approved Provider Unit’s name is prominently displayed in all marketing material
  • The name(s) of the organizations acting as the joint provider(s)
  • Statement that the Nurse Planner will maintain responsibility for adherence to the criteria and rules
  • The certificate is issued in the name of the Approved Provider Unit
  • Name and signature of the individual on behalf of the Approved Provider Unit
  • Name and signature of the individual on behalf of the joint provider(s)
  • Date the agreement was signed
  1. Advertising Material

Include a copy of the advertising material(s).

Advertising material includes any method of announcing an educational activity. This may include a brochure, flyer, bulletin board announcement, newsletter, memo, e-mail, web site or other form of electronic method. The advertising material must be included with the documentation form.  The advertising material may be the completed copy of a mock-up or the final material. If a mock-up of the advertising was used, the final copy of the advertising must be included in the file as soon as it is printed.

Sample of how the status of contact hours can be included on the advertising:

Participants, who successfully complete the entire activity, receive at least 75 % on the post-test and complete an evaluation form will earn 1 contact hour.   OR

This activity will provide 1 contact hour.

 Provider Name (OH-###, expiration date) is an approved provider of continuing nursing education by the Ohio Nurses Association (OBN-001-91), an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

 An Approved Provider Unit may not state that an application has been submitted or is pending or use the word “approved.” This indicates an approval process which is not permitted in a provider unit.

  1. Disclosures: Check how disclosures will be made to the learner and include a copy of these written disclosures that are given to the learners.

Disclosures provided to the Learner:

Learners must receive disclosure of required items prior to the start of an educational activity. In faculty directed activities, disclosures must be made to the learner prior to initiation of the educational content. In enduring print materials or web-based activities, disclosures must be visible to the learner prior to the start of the educational content. Required disclosures may not occur or be located at the end of an educational activity. Evidence of the disclosures to the learner must be retained in the activity file.

Disclosures always required include:

A.  Notice of requirements for successful completion of the educational activity:

Prior to the start of an educational activity, learners must be informed of the criteria used to determine successful completion.

B. Presence or absence of conflict of interest for planners, presenters, faculty, authors, and content reviewers. Any influencing relationships, or lack thereof, of planners, presenters, faculty, authors, or content reviewers in relation to the educational activity. If anyone has a COI, the following information must be disclosed to the learner:

Name of individual

Name of commercial interest

Nature of the relationship the individual has with the commercial interest.

C.  Notice of approved provider statement. Prior to the start of the event, the learner must be informed that your provider unit is approved as a provider unit. Use the provider statement as written above.

Disclosures required, if applicable, include:

D.  Commercial Support. Learners must be informed if a commercial interest has provided financial or in-kind support for the educational activity.

E.  Joint Providers. In addition to the provider unit, all joint providers must be disclosed to the learners.

F. Expiration date. Learners must be informed how long the independent study/enduring material is available to be completed. The period of expiration of enduring material should be based on the content of the material but cannot exceed three years. ANCC requires review of the content of each enduring material at least once every three years, or more frequently if indicated by new developments in the field specific to the enduring material. Upon review of enduring material for accuracy and current information, a new expiration date is established.

Note: If the independent study is a Category A program, then the author and Nurse Planner should review it annually to ensure that the OBN rules have not changed. If they have, then the independent study needs to be revised.

19.  Documentation of Completion/Certificate

A copy of the completed certificate or documentation of completion to be given to the learner must be included with the documentation form. It must include the following information:

Name of learner

Name and address of approved provider unit of the educational activity (web address acceptable)

Title & date of completion of educational activity

Number of contact hours awarded

Official approved provider statement

Provider Name  (OH-###, expiration date) is an approved provider of continuing nursing education by the Ohio Nurses Association (OBN-001-91), an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

  • If the activity is designed for APRNs with prescriptive authority and provides content related to pharmacology and prescribing, then the number of pharmacology hours needs to be designated. (e.g., 6.0 contact hours including 3.0 Pharm hours.)
  • If the activity is or includes information about Category A (Ohio nursing law and rules), add the words “Category A” on the certificate and indicate how many contact hours are related to Category A. (e.g., 5 contact hours including 1 contact hour of Category A.)

 

APPENDICES – Introduction

The following appendices are included for general information about the continuing education process and to provide assistance in meeting the criteria and rules in Chapters 2 and 3 and on the provider application and the individual activity documentation form. These have been divided into sections related to the approved provider unit functioning and the individual activities planned and presented.

 Approved Provider Unit:

  • Appendix A includes an Organizational Self-Assessment Tool for the provider unit. This document can be used if an organization wants to become an approved provider unit or if a new Primary Nurse Planner starts in an existing provider unit and wants to evaluate the structure of the provider unit.
  • Appendix B includes a sample organizational chart for the provider unit.
  • Appendix C includes sample position descriptions for the Primary Nurse Planner and Nurse Planners.

Appendices related specifically to educational activities:

  • Appendix D discusses joint providership and provides an algorithm that could be used by the provider unit and a sample agreement.
  • Appendix E is sample disclosure statements.
  • Appendix F is Conflict of Interest and Resolution.
  • Appendix G includes ANCC’s content integrity standards for industry support in continuing nursing educational activities
  • Appendix H is a sample summative evaluation and Nurse Planner’s concluding notes.
  • Appendix I are guidelines for Pharmacotherapeutic guidelines from ANCC.
  • Appendix J is a sample gap analysis sheet for activities, for the provider unit and an example.

Please note:     The samples included in this manual are meant to be examples only.

References & Resources:

  1. 2015 Primary Accreditation – Approver Application Manual, American Nurses Credentialing Center’s Commission on Accreditation, Silver Spring, MD, 2015- 2016.
  1. Rules promulgated from the Ohio Law Regulating the Practice of Nursing, (Chapter 14), February 1, 2015.
  1. Ohio Board of Nursing, nursing.ohio.gov
  1. Nursing Professional Development: Scope and Standards of Practice. American Nurses Association #NPD-20, Silver Spring, MD, 2010.

Updated 6/13/16

APPENDIX A – Organizational Self-Assessment Tool – Provider

Adapted from ANCC Primary Accreditation Organizational Self-Assessment Tool – Provider

The first step in pursuing approved as a Provider Unit is an organizational self-assessment. The self-assessment process is used to evaluate organizational readiness to meet approval criteria of ANCC and Ohio Board of Nursing (OBN) rules, and to identify potential gaps that may need to be addressed within the organization.

Click here to download the self-assessment tool >>

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ONALogo

Ohio Nurses Association, 4000 East Main Street, Columbus, Ohio 43213 \ 614-448-1027 \ www.ohnurses.org    (Revised 12/2015)

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Appendix C – Position/Role Descriptions – SAMPLE

Some provider units may have Nurse Planners who are paid staff, volunteers or consultants or who are in a position other than continuing education/staff development. In these situations, there may be no job description or the person’s job description may not describe his/her role in the provider unit. The position description for the Nurse Planners and other key people in the provider unit must relate specifically to the person’s role in the provider unit, not the job description. Below are samples of a Primary Nurse Planner’s and a Nurse Planner’s position/role description in such an organization as described above. Note: These position/role descriptions are only one example of meeting the criteria.

Position Description for Primary Nurse Planner

Qualifications:

  1. A minimum of a baccalaureate degree in nursing.
  2. Hold a current, valid license as a registered nurse.
  3. Experience with the assessment, planning, implementation and evaluation of continuing education activities.
  4. Knowledge of and experience with adult learning principles.

Responsibilities:

  1. Recruit and select Nurse Planners. Ensure that they have a minimum of a BSN and have unencumbered RN licenses in the state in which they function.
  2. Orient new Nurse Planners.
  3. Keep Nurse Planners up to date with criteria including sharing Provider Newsletters.
  4. Encourage Nurse Planners and self to attend the Provider Updates, webinars, etc. provided by ONA to remain up to date with criteria and implementation of such.
  5. Monitor Nurse Planners functioning on planning committees.
  6. Work with Nurse Planners re: establishing outcomes and measuring the outcomes.
  7. Work with Nurse Planners who are having difficulty implementing the CE criteria. Releasing Nurse Planners who are unable to function as a Nurse Planner.
  8. Ensuring that there is an infrastructure from which the Nurse Planners can function. This includes having administrative support, financial resources, material resources, etc.
  9. Working with the Nurse Planners to develop and implement an evaluation process to determine the effectiveness of the provider unit as a whole. (This includes evaluating achievement of provider unit goals, material resources, financial resources, human resources, processes, educational activities, quality outcome measures, etc.)
  10. Working with the Nurse Planners to develop, collect data, evaluate and monitor quality outcome measures for the provider unit and for enhancing nursing professional development.
  11. Write and submit the provider application with input from the Nurse Planners and others as appropriate.
  12. Oversee the functioning of the provider unit.
  13. Interact with management and advocate for the provider unit.
  14. Be the contact person between the provider unit and the CE Director of the Approver Unit at Ohio Nurses Association (The Nurse Peer Review Leader – NPRL).
  15. Communicate with the NPRL regarding any changes in the provider unit and as issues arise.

Position Description for Nurse Planners

Qualifications:

  1. A minimum of a baccalaureate degree in nursing.
  2. Hold a current, valid license as a registered nurse.
  3. Experience with the assessment, planning, implementation and evaluation of continuing education activities.
  4. Knowledge of and experience with adult learning principles. 

Responsibilities:

  1. Assess professional practice gaps, identify needs that can be addressed through education, create a planning committee, develop a program(s) based on best available evidence, implement it, and evaluate it.
  2. Identify and resolve conflicts of interest, maintain content integrity, and promote learning and actively engage learners.
  3. Create outcomes related to activities, measure change in knowledge, skill, and/or practice at the time of the program and long term (for some activities).
  4. Use summative evaluation data to guide future activities.
  5. Participate in the evaluation process for the provider unit.
  6. Participate in the evaluation process for nursing professional development.
  7. Function as a content expert as appropriate.
  8. Function as the expert in the CE criteria for planning committees.

 Updated 6/13/16

Appendix D – Joint Providership For Approved Providers

Definition

To jointly provide is the Provider Unit’s process for planning, developing and implementing an educational activity in collaboration with another organization.  These organizations may be:

  • Other Provider Units
  • Health care organizations
  • Non health care organizations
  • Individuals

 When an activity is jointly provided, the Provider Unit is referred to as the provider of the educational activity and the other organization(s) are referred to as the joint provider(s) of the educational activity. The joint providing organization cannot be a commercial interest entity. The Provider Unit’s Nurse Planner must be on the planning committee and is responsible for ensuring adherence to the CE criteria and OBN rules.

When an educational activity is jointly provided, the Provider Unit’s Nurse Planner is responsible for:

  • Ensuring all OBN/ANCC/ONA continuing education criteria are met
  • Securing a signed and dated joint provider agreement with organizations acting as joint provider(s). (OBN OAC 4723-14).

When jointly providing an educational activity, tasks involved in planning, implementing, and evaluating the activity may be shared; however, the final responsibility and accountability to insure that the criteria are met remain with the designated Provider Unit. A signed written joint provider agreement confirms these arrangements.

Approval vs. Jointly providing

Jointly providing continuing education is not to be confused with approval of continuing education for another organization – which is only allowed by a recognized approver unit. If your Provider Unit Nurse Planner is not actively involved in the planning of the event, you may not provide or jointly provide that activity – which means you cannot award contact hours for the activity.

Advertising: Any advertising should include both the names of the Provider Unit and the joint provider(s). Your Provider Unit’s name must also be prominently mentioned in the advertising.

Frequent Situations:

A. There are several instances when a Provider Unit is asked to jointly provide an activity and it is not appropriate to do so. For example, when an employee is also involved in an outside organization and wants the Provider Unit to give the contact hours for an education activity being planned; when an outside organization asks for contact hours for an event they planned, etc.

Questions to be considered are:

1. Is the organization/individual asking to jointly provide an activity along with your Provider Unit?

2. Has or will one of your Nurse Planners been actively involved in planning since the beginning?

3. Will the Provider Unit’s name be prominently featured in the advertising? Will your Provider Unit’s name appear prominently on the CE certificate?

If your answer is no to one or more of the above questions, this activity does not meet the criteria to be jointly provided.

As a Provider Unit, one of your Nurse Planners must be involved in planning each educational event.  Only then can your Provider Unit award contact hours for the activity.

B. If an employee of your organization is working with a group outside of the work setting, the employee must involve a Nurse Planner to see if it would be beneficial or appropriate for your Provider Unit to jointly provide with this outside group. If the answer is yes, then the Nurse Planner will develop the joint provider agreement with the group, facilitate the planning process and proceed with the development of the jointly provided event. The Provider Unit’s name must be included as one of the event providers on the advertising material, not just in the provider statement. If the joint provider relationship is not desired or appropriate, the Nurse Planner may refer the employee and group to an approver.

C. If one of your employees participates in a local chapter of a professional nursing organization and that organization wants to offer contact hours, the employee should contact the Nurse Planner to see if it would be beneficial and feasible to develop a joint provider arrangement with said professional nursing organization. The Nurse Planner would be in contact with the other agency/organization to plan and implement the jointly provided activity. The Provider Unit’s name must be prominently included on the advertising material. If the joint provider relationship is not desired or appropriate, the Nurse Planner may refer the employee and group to an approver.

D. If the Nurse Planner is approached by an entity that has planned and developed a CE activity and is seeking a contact hour approval process, the Nurse Planner must refer this entity to an approver. In this instance, the Nurse Planner has not been involved in the planning process and, therefore, cannot jointly provide nor award contact hours for this activity.

In any or all situations, a Provider Unit has the right to say “no, we do not want to jointly provide an activity.”

See the algorithm for a diagrammed copy of the above content on the next page.

Commercial Support: Commercial interests (entities) may not jointly provide. Commercial support, however, may be obtained for an event. This might include financial or in-kind contributions. Commercial supporters are not part of the assessment, planning, implementation, and evaluation process for the activity, so they are not joint providers. However, be sure you follow the appropriate requirements regarding use of commercial support and how learners are informed.

Fees for jointly providing: There are no ANCC/ONA/OBN rules that prevent you from charging a fee for your time, expertise and resources to participate in planning an event, issuing certificates, keeping records, etc. However, be very careful that it is clear to all parties that the fee covers your involvement, not your “approval” of another organization’s activity.

Repetition of a Learning Activity by a Joint provider If the Provider Unit has a joint provider agreement with an organization for an education activity, the joint provider cannot independently offer the previously jointly provided activity in another venue without the Provider Unit.   The Provider Unit may not approve the activity for the organization that was previously a joint provider for that activity, nor may the Provider Unit allow the outside entity to use the Provider Unit’s contact hours for repetition of the activity.  That organization will need to submit an application to get approval to offer contact hours for the activity from an approver unit such as ONA. Example, School of Nursing X has a Provider Unit. An outside company or a specialty nursing organization wants to plan a CE activity with this school.  School X’s Provider Unit can plan and implement the activity with active involvement of the Nurse Planner and a representative of the outside group. However, if the joint provider wishes to repeat this activity in various locations, having no direct relationship with School X’s Provider Unit, it must submit an application to an approver such as ONA.

SAMPLE JOINT PROVIDER AGREEMENT

(Provider Unit name) and (joint provider’s name) agree to plan and present a CE activity entitled _________________ on ___________ at ________________.

The Nurse Planner for the Provider Unit will maintain responsibility for ensuring that all ANCC, OBN and ONA criteria and rules are met.

(Joint provider name) will assist by providing…… (list what is being provided).

The advertising will state that this event is presented by (Provider Unit name) and (joint provider’s name).

Provider Unit Nurse Planner’s Signature & Date: _______________________________________________ Joint provider’s Signature & Date: ___________________________________________________________ 

Appendix  E – Disclosure Statements – SAMPLES

The following are brief examples of how disclosures might be made prior to the start of the event. These disclosures can be made on the advertising, the confirmation letter, the agenda on top of the handouts received on the day of the event, etc. They could also be disclosed in multiple ways – e.g., criteria for successful completion on advertising, and then the remainder on the agenda received on the day of the event.                          

Conflict of Interest

  • The planners and faculty have declared no conflict of interest.
  • The planners and all but one faculty have declared no conflict of interest. Janet Smith has a conflict of interest. She received a research grant on this topic from ABC Pharmaceutical Company.

Criteria for Successful Completion

  • Criteria for successful completion include attendance at the entire event and submission of a completed evaluation form.
  • Criteria for successful completion include attendance at one or more sessions.

Approved Provider Statement

Provider Name is an approved provider of continuing nursing education by the Ohio Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. (OBN-001-91). (OH-###, expiration date).

If applicable:

Commercial Support

  • ABC Health Products Company provided an unrestricted grant for this activity.
  • Thanks to ABC Health Products Company for providing a grant for this activity.

Joint providership

  • The University School of Nursing and The Greatest Medical Center present….

Expiration date if independent study

  • This independent study will be available for completion until 12/31/16.

 Revised 6/13/16

Appendix F – Conflict of Interest Decision Tree

Conflict of Interest occurs when a person who has the ability to control content of a continuing nursing education activity has a financial relationship with a commercial interest organization*, the products or services of which are related to the topic of the educational activity. Conflict of interest applies to the individual involved with the activity AND his/her spouse or significant other. A relationship is considered to be relevant if it is current or has existed within the past 12 months.

The nurse planner is accountable to assess for conflict of interest, and, if present, resolve the conflict as noted below. The nurse planner is also accountable for disclosing to learners that:

  1. There is no conflict of interest for any person with the ability to control content of the educational activity OR
  1. If anyone does have a conflict of interest, the disclosure must include the name of the person, the nature of the relationship, and the name of the commercial interest (Sharon Martin is on the speakers’ bureau for XYZ Pharmaceutical Company).

NOTE: Employees of commercial interest organizations are NOT permitted to serve as planners, presenters, authors, content reviewers, or in any other role in an educational activity if the content of the activity is related to the products or services of the commercial interest organization.

The first step in the process is for the nurse planner to determine whether the content of the educational activity is clinical in nature and whether there is any potential for content to include information about products and/or services from a commercial interest organization. If not, there is no possibility of anyone having a COI and individual COI forms are not required. The nurse planner checks the appropriate line in Item 6 on the activity documentation form. Disclosure of no COI must be provided to learners.

If there is a possibility that someone may have a COI, the nurse planner must first have another person evaluate his/her status to assure that there is no conflict. Once that has been determined, the nurse planner then follows the Step 2 process as outlined on the decision tree to determine whether anyone has a COI, and if so, how the conflict should be resolved to preserve the integrity of the activity.

Resolutions may include, but are not limited to the following:

  • Removing individual with conflict of interest from participating in all parts of the educational activity
  • Revising the role of the individual with conflict of interest so the financial relationship is no longer relevant
  • Not awarding contact hours for a portion or all of the educational activity
  • Content of the educational activity evaluated by the nurse planner and/or planning committee for bias, balance in the presentation, and use of evidence-based content, and activity monitored to evaluate for commercial bias
  • Content of educational activity evaluated by the nurse planner and/or planning committee for bias, balance in the presentation, and use of evidence-based content, and participant feedback reviewed for commercial bias
  • Content of educational activity evaluated by an independent content reviewer for bias, balance in the presentation, and use of evidence-based content, and activity monitored to evaluate for commercial bias.

*Commercial interest organization: any entity producing, marketing, reselling, or distributing healthcare goods or services consumed by or used on patients or an entity that is owned or controlled by an entity that produces, markets, resells, or distributes healthcare goods or services consumed by or used on patients. (ANCC, 2015)

Conflict of Interest Decision Tree

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Click here to download the below Terms and Conditions for Speakers and Authors

AppendixFChart2

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APPENDIX G  –  American Nurses Credentialing Center’s Content Integrity Standards For Industry Support in Continuing Nursing Educational Activities

(Effective date: 1/1/2013)

(Updated: 5/1/2013)

(Updated: 8/8/2014)

 

A.  Introductions

The American Nurses Credentialing Center’s Content Integrity Standards for Industry Support in Continuing Nursing Educational Activities serves as a resource for Providers* to plan, implement and evaluate quality continuing nursing educational activities with integrity, free from the  undue influence of commercial interest organizations. Federal law, core values for the Accreditation Program (2009 and 2013 Application Manuals, Accreditation Program) and the Code of Ethics for Nurses with Interpretive Statements (ANA, 2001) create the foundation for these standards, which are designed to help Providers comply with Food and Drug Administration Guidance on Industry-Supported Scientific and Educational Activities.

*”Provider” refers to an ANCC Accredited Provider or an organization or individual

approved by an ANCC Accredited Approver (Approved Provider or Individual Activity Applicant).

B.  Definition of a Commercial Interest Organization

The American Nurses Credentialing Center (ANCC) defines an organization as having a commercial interest (“Commercial Interest Organization”)* if it:

  • Produces, markets, sells or distributes health care goods or services consumed by or used on patients;
  • Is owned or operated, in whole or in part, by an organization that produces, markets, sells or distributes health care goods or services consumed by or used on patients; or
  • Advocates for use of the products or services of commercial interest

(*Reference:  Accreditation Council for Continuing Medical Education (ACCME) Standards of Commercial Support, August 2007 (www.accme.org) – ANCC’s definition is intended to ensure compliance with Food and Drug Administration Guidance on Industry-Supported Scientific and Educational Activities and consistency with the ACCME definition)

Commercial Interest Organizations are ineligible for accreditation.

An organization is NOT a Commercial Interest Organization* if it is:

  • A government entity;
  • A non-profit (503(c)) organization;
  • A provider of clinical services directly to patients, including but not limited to hospitals, health care agencies and independent health care practitioners;
  • An entity the sole purpose of which is to improve or support the delivery of health care to patients, including but not limited to providers or developers of electronic health information systems, database systems, and quality improvement systems;
  • A non-healthcare related entity whose primary mission is not producing, marketing or selling or distributing health care goods or services consumed by or used on
  • Liability insurance providers
  • Health insurance providers
  • Group medical practices
  • Acute care hospitals (for profit and not for profit)
  • Rehabilitation centers (for profit and not for profit)
  • Nursing homes (for profit and not for profit)
  • Blood banks
  • Diagnostic laboratories

(*Reference:  Accreditation Council for Continuing Medical Education (ACCME) Standards of Commercial Support, August 2007 (www.accme.org) – ANCC’s definition is intended to ensure compliance with Food and Drug Administration Guidance on Industry-Supported Scientific and Educational Activities and consistency with the ACCME definition)

C.  Related Organizations

  • Parent Organization – An organization that owns one or more subsidiary A parent organization that is a Commercial Interest Organization is not eligible for accreditation.
  • Subsidiary Organization – An organization that is owned by a parent A subsidiary of a Commercial Interest Organization is not eligible for accreditation.
  • Sister Organizations – Two organizations that share a common parent owner are “sister ” An organization may be eligible for accreditation if it establishes and maintains an adequate corporate firewall to shield it from the influence of a sister organization that is a Commercial Interest Organization.

Adequacy of a corporate firewall will be evaluated by examining evidence demonstrating independence, based on the following factors:

  1. The commercial interest organization and its non-commercial interest sister organization (the “educational organization”) have separate federal tax ID numbers;
  2. The commercial interest organization and the educational organization are separate legal entities;
  3. The operational structure of the commercial interest organization and the educational organization are separate and distinct, including but not limited to:
    • Phone, fax and email communication;
    • Web sites/links to web sites;
    • Electronic and hard copy documents;
    • Written policies and procedures that may impact the delivery of continuing education;
    • Separate governance structures and personnel; and
    • Independence in decision making;
  4. Educational content for activities is planned, developed, implemented and controlled exclusively by the educational organization. The commercial interest organization may have no influence over content of the educational activity.

D.  Types of Commercial Support for Continuing Nursing Educational Activities

Commercial Interest Organizations may provide monetary funding or other support (“Commercial Support”) for continuing nursing educational activities in accordance with the following fundamental principles:

(1)  Commercial Support must not influence the planning, development, content, implementation or evaluation of an educational activity; AND

(2) Receipt of Commercial Support must be disclosed to

Commercial Support may be used to pay for all or part of an educational activity and for expenses directly related to the educational activity, including but not limited to: travel, honoraria, food, support for learner attendance and location expenses. Commercial Support may be used to support more than one educational activity at the same time or multiple activities over a period of time.

Commercial Support is:

  1. Financial Support – money supplied by a Commercial Interest Organization to be used by a Provider for expenses related to the educational Financial support may be provided as an unrestricted grant, educational grant, donation or scholarship.
  1. “In-Kind” Support – materials, space or other non-monetary resources or services used by a Provider to conduct an educational activity; which may include and is not limited to human resources, marketing services, physical space, equipment such as audio-visual materials and teaching tools (for example, anatomic models). In-kind donations may not bear the trade names, logos or other identifying insignia of the Commercial Interest In-kind support may not include promotion of goods or services of the Commercial Interest Organization. In the event that the trade name, logo or other identifying insignia cannot be removed (i.e. embedded in the piece of equipment), the Provider must ensure that learners are aware of similar products produced by other companies.  In addition, disclosure of the in-kind donation must be provided to learners.

E.  Ensuring Content Integrity of an Educational Activity in the Presence of Commercial Support

 Commercial Interest Organizations providing Commercial Support for continuing educational activities may not influence the planning, implementation or evaluation of an educational activity. The following requirements to ensure content integrity must be satisfied by the Provider when Commercial Support is accepted:

  1. Written Agreement. There must be a written agreement between a Commercial Interest Organization providing Commercial Support and the Provider utilizing Commercial Support. The written agreement must include the following:

a.  Name of the Commercial Interest Organization;

b.  Name of the Provider;

c.  Complete description of all Commercial Support provided, including both financial and in-kind support;

d.  Statement that the Commercial Interest Organization will not participate in planning, developing, implementing or evaluating the educational activity;

e.  Statement that the Commercial Interest Organization will not recruit learners from the educational activity for any purpose;

f.  Description of how Commercial Support must be used by the Provider

i.  Unrestricted Use: Commercial Support given freely and without constraint by the Commercial Interest Organization and the Provider  has sole discretion to administer Commercial Support as appropriate for planning, developing, implementing or evaluating the educational activity;

ii.  Restricted Use: Commercial Support given to support a specific aspect of an educational activity such as meals, breakout sessions or speaker honoraria

g.  Signature of a duly authorized representative of the Commercial Interest Organization with authority to enter into binding contracts on behalf of the Commercial Interest Organization;

h.  Signature of a duly authorized representative of the Provider with authority to enter into binding contracts on behalf of the Provider; and

i. Date on which the written agreement was signed.

  1. All payments for expenses related to the educational activity must be made by the Provider.  The Provider must keep a record of all payments made using Commercial Support funding. Commercial Support funds may only be used to support expenses directly related to the educational activity.
  1. Unused The Commercial Interest Organization may request the return of unused Commercial Support funds.
  2. Accounting of The Commercial Interest Organization may request that the Provider submit a record of how Commercial Support funding was spent.
  1. Joint In the event that more than two organizations will be providing an educational activity receiving Commercial Support (jointly providing), the organization identified as the “Provider” of the activity is responsible for managing Commercial Support funds in adherence with the ANCC Accreditation criteria. A Commercial Interest Organization may not jointly provide educational activities.

F.  Conflicts of Interest Evaluation and Resolution

 The potential for conflicts of interest exists when an individual has the ability to control or influence the content of an educational activity and has a financial relationship with a commercial interest,* the products or services of which are pertinent to the content of the educational activity. The Nurse Planner is responsible for evaluating the presence or absence of conflicts of interest and resolving any identified actual or potential conflicts of interest during the planning and implementation phases of an educational activity. If the Nurse Planner has an actual or potential conflict of interest, he or she should recuse himself or herself from the role as Nurse Planner for the educational activity.

*Commercial interest, as defined by ANCC, is any entity producing, marketing, reselling, or distributing healthcare goods or services consumed by or used on patients, or an entity that is owned or controlled by an entity that produces, markets, resells, or distributes healthcare goods or services consumed by or used on patients. Nonprofit or government organizations, non- healthcare-related companies, and healthcare facilities are not considered commercial interests.

  • Employees of commercial interest organizations are not permitted to serve as planners, speakers, presenters, authors and/or content reviewers if the content of the educational activity is related to the products or services of the commercial interest
  • Employees of commercial interest organizations are permitted to serve as planners, speakers, presenters, authors and/or content reviewers if the content of the educational activity is NOT related to the products of the commercial interest
  • Individuals who have non-employee relationships with commercial interest organizations (see bullet 2 below) are permitted to serve as planners, speakers, presenters, authors and/or content reviewers as long as the Provider has implemented a mechanism to identify, resolve and disclose the relationship as outlined in these

The Nurse Planner is responsible for ensuring that all individuals who have the ability to control or influence the content of an educational activity disclose all relationships with any commercial interest, including but not limited to members of the Planning Committee, speakers, presenters, authors, and/or content reviewers. Relevant relationships** must be disclosed to the learners during the time when the relationship is in effect and for 12 months afterward. All information disclosed must be shared with the participants/learners prior to the start of the educational activity.

**Relevant relationships, as defined by ANCC, are relationships with a commercial interest if the products or services of the commercial interest are related to the content of the educational activity.

  • Relationships with any commercial interest of the individual’s spouse/partner may be relevant relationships and must be reported, evaluated, and
  • Evidence of a relevant relationship with a commercial interest may include but is not limited to receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (stock and stock options, excluding diversified mutual funds), grants, contracts, or other financial benefit directly or indirectly from the commercial interest.
  • Financial benefits may be associated with employment, management positions, independent contractor relationships, other contractual relationships, consulting, speaking, teaching, membership on an advisory committee or review panel, board membership, and other activities from which remuneration is received or expected from the commercial interest.

Evaluation

 The Nurse Planner is responsible for evaluating whether any relationship with a commercial interest is considered relevant to the content of the educational activity. Disclosures may be categorized in the following ways:

  • No relationship with a commercial interest No resolution required.
  • Relationship with a commercial interest The relationship with the commercial interest is evaluated by the Nurse Planner and determined not to be relevant to the content of the educational activity. No resolution required.
  • Relevant relationship with a commercial interest The relevant relationship is evaluated by the Nurse Planner and determined to be pertinent to the content of the educational activity. Resolution is required.

Resolution and Activity Assessment

 Actions taken to resolve conflicts of interest must demonstrate resolution of the identified conflicts of interest prior to presenting/providing the educational activity to learners. Such actions must be documented and the documentation must demonstrate (1) the identified conflict, and (2) how the conflict was resolved. Actions may include but are not limited to the following:

  • Removing the individual with conflicts of interest from participating in all parts of the educational
  • Revising the role of the individual with conflicts of interest so that the relationship is no longer relevant to the educational
  • Not awarding continuing education contact hours for a portion or all of the educational
  • Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicator of integrity, and absence of bias, AND monitoring the educational activity to evaluate for commercial bias in the
  • Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicator of integrity, and absence of bias, AND reviewing participant feedback to evaluate for commercial bias in the

Disclosure

Individuals refusing to disclose relationships with Commercial Interest Organizations may not participate in any part of the educational activity.

G.    Additional Criteria for Ensuring Content Integrity

  1.  A Commercial Interest Organization may not promote its goods or services in relation to the content of an educational activity at any time during which the educational activity takes place including the introduction and conclusion of the activity, regardless of the format of the educational activity.
  1. Advertisements for the Commercial Interest Advertisements promoting the products or services of a Commercial Interest Organization in relation to the content of an educational activity must be physically separated from the educational activity, regardless of the format of the educational activity.
  1. A Commercial Interest Organization\may not recruit learners from an audience for any reason.
  1. Providers may not share contact information related to learners without written permission from the learner.
  1. Advertising an Educational A Commercial Interest Organization may advertise an educational activity for which it has given Commercial Support. Examples of advertising may include but are not limited to: Save the Date cards, flyers and emails.
  1. Acknowledgement of Commercial Providers may acknowledge Commercial Support provided by a Commercial Interest Organization on marketing materials for the educational activity.
  1. Distribution of the Educational A Commercial Interest Organization may not distribute educational activities directly to learners.
  1. Content of the Educational Content is the responsibility of the Provider of the educational activity. All materials used for the educational activity must be free from commercial bias. To guard against the presence of commercial bias, the Provider is responsible for ensuring the following:

a.  Slides, handouts or other materials presented to the learner related to the educational activity do not display any logos or other trademarks of a Commercial Interest Organization;

b.  Live (in-person) educational activities are presented without reference to a Commercial Interest Organization; acknowledgement of commercial support is limited to the name of the entity providing support

c.  Enduring materials do not include logos, trademarks or other insignia of, or references to, a Commercial Interest Organization; acknowledgement of commercial support is limited to the name of the entity providing support

d.  Web-based materials do not include logos, other trademarks or other insignia of, or reference to, a Commercial Interest Organization; acknowledgement of commercial support is limited to the name of the entity providing support

e.  Evaluations of the educational activity make no reference to a Commercial Interest Organization or its products or services; and 

f.  Learners are not recruited for any purpose during the activity or evaluation.

H.     Exhibits, Promotions and Sales

Commercial Interest Organizations may not exhibit, promote or sell products or services during the introduction of an educational activity, while the educational activity takes place or at the conclusion of an educational activity, regardless of the format of the educational activity. Exhibits, promotion and sales must be separated from the educational activity. The following standards apply to exhibiting, promoting and selling products or services:

  • Exhibiting, promoting and selling products may not take place during an educational activity;
  • Marketing or advertising for exhibits, promotions or sales may not be included within educational activity content (e.g., slides, handouts, enduring materials).
  • Marketing or advertisement for exhibits, promotions or sales must take place in a location that is physically separated from the area where educational content is delivered.

I.  Giveaways

Commercial Interest Organizations may provide giveaways for learners, as long as there is physical separation between accessing the giveaway and learner engagement in the educational activity. Educational materials for an activity may not be packaged in items bearing logos, trademarks of a Commercial Interest Organization.

 J.  Failure to Comply

Failure to comply with the American Nurses Credentialing Center’s Content Integrity Standards for Industry Support in Continuing Nursing Educational Activities may result in suspension or revocation of accreditation or approval.

K.  Complaints

All complaints related to a Provider’s compliance with the American Nurses Credentialing Center’s Content Integrity Standards for Industry Support in Continuing Nursing Educational Activities will be investigated by the ANCC Accreditation Program Office.

Reprinted with permission from ANCC Accreditation Program.

American Nurses Credentialing Center, 8515 Georgia Ave., Suite 400, Silver Spring, MD 20910 / 1-800-284-2378 / nursecredentialing.org

AppendixGChart1AppendixGChart2AppendixGChart3AppendixGChart4

 

APPENDIX H – Sample of Summative Evaluation 

Click here to download the below example.

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APPENDIX I – Guidelines for Pharmacotherapeutic hours for APRNs (adapted from ANCC FAQs 8/21/15)

  1. It is ONA’s expectation that you will include an APRN on your planning committee when designing CE specific to APRNs.

  2. If a provider is developing content to meet the ANCC pharmacotherapeutic hour requirement, content must specifically address pharmacotherapeutics.

  3. Pharmacotherapeutic content does not need to be presented by a nurse… however the presenter must have content expertise in pharmacology.

  4. When developing the content for an educational activity, it is recommended that the provider delineate the number of pharmacotherapeutic contact hours.

  5. Existing continuing education courses/programs that include pharmacotherapeutic content may be reviewed to calculate the appropriate number of pharmacotherapeutic contact hours.

  6. When a speaker develops content for an educational activity, it would be advised that pharmacotherapeutic contact hours contained within the presentation [be clearly delineated and] be calculated at that time.

**Pharmacotherapeutic content may include but is not limited to drug specific information, safe prescribing practices, safe medication administration, prescribing methodologies, new regulations or similar content.

 

Appendix J – Gap Analysis Worksheets

Click here to download the below worksheets.

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Ohio Nurses Association, 4000 East Main Street, Columbus, Ohio 43213 \ 614-448-1027 \ www.ohnurses.org    (Revised 12/2015)

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Ohio Nurses Association, 4000 East Main Street, Columbus, Ohio 43213 \ 614-448-1027 \ www.ohnurses.org    (Revised 12/2015)