Nurse Peer Review Form

NURSE PEER REVIEW FORM

APPROVED PROVIDER (AP) APPLICATION – 2015 CRITERIA

REVIEW OF SAMPLE ACTIVITY RECORD FORMS

(NEW “Form 24”)

Directions: Click on a box to ‘check’ – click again to ‘un-check’. Type comments directly into table. Save completed form on your computer under a new name.

Applicant Organization:
Sample Activity requirements: Check box if requirement is met, or mark as not applicable: (contact Applicant for resubmission if requirement(s) are not met)
☐ Three activities were submitted for review with Provider Application (Renewing Providers) OR ☐ Three approval letters were submitted (New Applicants)
☐ All activities were implemented within one year of application (or previous calendar year) and were documented on appropriate Activity Record Form.
☐ N/A ☐ Provider Unit offers both ‘Live Event’ and ‘Enduring Material’ activities – one sample of each type of activity is submitted.
☐ N/A ☐ Provider Unit accepts Commercial Support – at least one sample of an activity receiving Commercial Support was submitted.
Date applicant notified for corrections to any of the above and notes:
Date of NPR Activity Record Form Review Completion: / If applicable - Date application sent to NPRL for remediation:
Note: DO NOT CONTACT APPLICANT FOR REVISIONS – JUST SCORE APPLICATION and RECORD SCORING AT THE END OF EACH SECTION AFTER NPR CONSENSUS
Review Team Leader - Name and Credentials: / Date:
Review Team Member - Name and Credentials: / Date:
Nurse Peer Review Leader / Date:
ACTIVITY RECORD #1 of 3 / Title:
☒ Live Event - Initial date(s): / ☐ Enduring Material - Start date:
QUALITATIVE REVIEW CONSENSUS / FINAL CRITERIA DETERMINATON
Activity file documentation of compliance with WNA CEAP criterion / Present / Incomplete / Not Submitted / Issue and feedback for applicant letter / Not Applicable / Met / Not Met
JOINT-PROVIDERSHIP
1. / If jointly-provided: signed Agreement submitted for each organization, identifying division of responsibilities / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
2 / If jointly provided: provider’s name is prominently displayed on all marketing materials / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
ASSESSMENT OF LEARNER NEEDS / P / I / NS / N/A / Met / Not
3. / Target audience identified / ☐ / ☐ / ☐ / ☐ / ☐
4. / Method of the needs assessment identified / ☐ / ☐ / ☐ / ☐ / ☐
5. / Source(s) of supporting evidence for needs assessment identified / ☐ / ☐ / ☐ / ☐ / ☐
6. / Supporting evidence for needs assessment data attached / ☐ / ☐ / ☐ / ☐ / ☐
7 / Problem in practice or improvement need identified / ☐ / ☐ / ☐ / ☐ / ☐
8. / Gap in knowledge, skills or practice for target audience identified / ☐ / ☐ / ☐ / ☐ / ☐
9. / Purpose of learning activity identified
- written as a learner outcome statement
- identical purpose statement used throughout activity documents / ☐ / ☐ / ☐ / ☐ / ☐
QUALIFIED PLANNERS AND FACULTY / P / I / NS / N/A / Met / Not
10. / Names, credentials listed for each planner / ☐ / ☐ / ☐ / ☐ / ☐
11. / Nurse Planner and at least one content expert identified on planning committee / ☐ / ☐ / ☐ / ☐ / ☐
12. / Approved Provider CNE Nurse Planner BD form attached
- documents required RN qualifications
- documents knowledge of NP role / ☐ / ☐ / ☐ / ☐ / ☐
13. / Approved Provider CNE Nurse Planner COI form attached
- documents qualifications if also a ‘content expert’ or presenter/author for activity
- reviewed by PNP or another planner / ☐ / ☐ / ☐ / ☐ / ☐
14. / Planner/Faculty BD/COI for each additional planner attached
- documents planning experience
- documents content expertise (if planner designated as a ‘content expert’) / ☐ / ☐ / ☐ / ☐ / ☐
15. / Attributes considered essential in selecting presenters/authors identified / ☐ / ☐ / ☐ / ☐ / ☐
16. / Process for ensuring qualifications of presenters/authors identified / ☐ / ☐ / ☐ / ☐ / ☐
17. / Names and credentials of all presenters/authors listed / ☐ / ☐ / ☐ / ☐ / ☐
18. / Planner/Faculty BD/COI for each presenter/author attached
- documents appropriate experience and content expertise for role
- reveiwed by Nurse Planner / ☐ / ☐ / ☐ / ☐ / ☐
19. / If Content Reviewers utilized, names and credentials are listed / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
20. / If Content Reviewers utilized, Planner/Faculty BD/COI for each attached - documents content expertise / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
21. / Nurse Planner review box completed on each Planner/Faculty BD/COI form
- notes absence/presence of ‘relevant relationships’
- signed/dated by Nurse Planner / ☐ / ☐ / ☐ / ☐ / ☐
22. / If COI was identified for planner, presenter, author or content reviewer: strategies to resolve COI are documented on the Planner/Faculty BD/COI form
- if ‘other procedure to resolve COI’ used, it was discussed with WNA CEAP first / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
EFFECTIVE DESIGN PRINCIPLES / P / I / NS / N/A / Met / Not
23. / Education Planning Table(s) (EPT) submitted for entire activity (or for 3 hours of a longer activity) / ☐ / ☐ / ☐ / ☐ / ☐
24. / Educational objectives describe learner-oriented outcomes; stated in measurable terms; relate to activity purpose / ☐ / ☐ / ☐ / ☐ / ☐
25. / Content provided to address each objective; enough detail to determine adequacy in addressing objective / ☐ / ☐ / ☐ / ☐ / ☐
26. / If Live Event: adequate time frames for each objective; consistant with total minutes for session listed on EPT / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
27. / If Live Event: presenters listed for each objective/content area / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
28. / Teaching methods listed for each objective; congruent with objectives / ☐ / ☐ / ☐ / ☐ / ☐
29. / Evidence-based references/source of content listed; current or ‘classic’ source / ☐ / ☐ / ☐ / ☐ / ☐
30. / Learner feedback mechanisms identified / ☐ / ☐ / ☐ / ☐ / ☐
31. / Method(s) to verify participation identified – appropriate to activity type / ☐ / ☐ / ☐ / ☐ / ☐
32. / Criteria for judging successful completion identified / ☐ / ☐ / ☐ / ☐ / ☐
33. / Rationale for choosing criteria for successful completion identified / ☐ / ☐ / ☐ / ☐ / ☐
34. / If post –test utilized to judge successful completion, copy attached / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
35. / Method used to calculate contact hours is “logical and defensible” for type of activity, content, teaching methods / ☐ / ☐ / ☐ / ☐ / ☐
36. / If Live Event: number of contact hours correctly calculated when checked against schedule for activity and EPTs / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
37. / If Live Event that offers varying contact hours for individual sessions attended: Contact Hour Calculation Form submitted
- all breakout/concurrent sessions listed
- calculations correct / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
38. / Process for providing certificate of completion to learner identified
- process/certificate can document which sessions were attended, if partial attendance/concurrent sessions offered / ☐ / ☐ / ☐ / ☐ / ☐
39. / Certificate attached, contains: learner name (or space for); provider name and address; activity title and date; number of contact hours awarded; correct approval statement (on own line) / ☐ / ☐ / ☐ / ☐ / ☐
ACTIVITY EVALUATION / P / I / NS / N/A / Met / Not
40. / Methods used to evaluate effectiveness of activity identified / ☐ / ☐ / ☐ / ☐ / ☐
41. / Evaluation form for entire activity attached, contains: learner’s achievement of each objective; effectiveness of teaching strategies; percieved bias question; reciept of disclosures question; PLUS:
- Live Event – expertise of each presenter
- Enduring Material – amount of time to complete activity / ☐ / ☐ / ☐ / ☐ / ☐
42. / Ways summative evaluation will be used are identified / ☐ / ☐ / ☐ / ☐ / ☐
43. / Copy of summative evaluation results for entire activity attached / ☐ / ☐ / ☐ / ☐ / ☐
PROMOTIONAL MATERIALS / P / I / NS / N/A / Met / Not
44. / Copy of each type of marketing/
promotional material utilized attached
– if mentions contact hours, contains: name of provider; purpose; content/objectives/agenda; target audience; presenters with credentials; approval statement (on own line) / ☐ / ☐ / ☐ / ☐ / ☐
COMM SUPPORT, SPONSORSHIP, EXHIBITORS / P / I / NS / N/A / Met / Not
45. / If commercial support: organizations listed and signed IEA Commercial Support Agreement (or equivalent with all requrements) attached for each / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
46. / If commercial support: means of ensuring content integrity identified / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
47. / If sponsorship: organizations listed and signed IEA Sponsorship Agreement (or equivalent with all requirements) attached for each / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
48. / If sponsorship: means of ensuring content integrity identified / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
49. / If commercial exhibits/vendors: means of ensuring content integrity identified / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
50. / Additional precautions to prevent bias/ensure content integrity identified / ☐ / ☐ / ☐ / ☐ / ☐
DISCLOSURES PROVIDED TO PARTICIPANTS / P / I / NS / N/A / Met / Not
51. / Evidence of disclosing purpose and/or objectives / ☐ / ☐ / ☐ / ☐ / ☐
52. / Evidence of disclosing criteria for successful completion / ☐ / ☐ / ☐ / ☐ / ☐
. / Evidence of disclosing Planning Committee names and credentials (includes provider’s Nurse Planner) / ☐ / ☐ / ☐ / NO LONGER REQUIRED / ☐ / ☐
53. / Evidence of disclosing presence or absence of COI for planners, presenters, faculty, authors and/or content reviewers
– includes name of individual, organization, nature of relationship / ☐ / ☐ / ☐ / ☐ / ☐
54. / If sponsorship and/or commercial support: evidence of disclosing sponsorship and/or commercial support / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
If vendors/ehibitors present: evidence of disclosing non-endorsement of products / ☐ / ☐ / ☐ / NO LONGER REQUIRED / ☐ / ☐ / ☐
55. / Enduring Material activity: evidence of disclosing expiraton date
- expiration date is not beyond Provider Approval period / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
RECORDKEEPING / P / I / NS / N/A / Met / Not
56. / Recordkeeping procedures that assure safety and security of records identified / ☐ / ☐ / ☐ / ☐ / ☐
57. / The ‘unique identifier(s)’ that will be included in participant listing identified / ☐ / ☐ / ☐ / ☐ / ☐
58. / Activity file contents – all applicable materials are checked / ☐ / ☐ / ☐ / ☐ / ☐
PLEASE TALLY THE X’s IN THE FINAL DETERMINATION BOXES AND THEN COMPLETE THE INFORMATION BELOW: / Activity #1 totals:
N/A / Met / Not Met

Determine % of compliance of ACTIVITY #1 with WNA CEAP criteria:

·  Add up the number of checked boxes in the ‘Final Criteria Determination’ columns for N/A , Met and Not Met

·  Determine the number of Applicable criteria (58 total critera minus N/A criteria = Applicable criteria)

·  Divide the total number of criteria Met by the number of Applicable criteria (from above) = % compliance with WNA CEAP criteria

NOTES for NPRL:

Thank you for your review!

ACTIVITY RECORD #2 of 3 / Title:
☒ Live Event - Initial date(s): / ☐ Enduring Material - Start date:
QUALITATIVE REVIEW CONSENSUS / FINAL CRITERIA DETERMINATON
Activity file documentation of compliance with WNA CEAP criterion / Present / Incomplete / Not Submitted / Issue and feedback for applicant letter / Not Applicable / Met / Not Met
JOINT-PROVIDERSHIP
1. / If jointly-provided: signed Agreement submitted for each organization, identifying division of responsibilities / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
2 / If jointly provided: provider’s name is prominently displayed on all marketing materials / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
ASSESSMENT OF LEARNER NEEDS / P / I / NS / N/A / Met / Not
3. / Target audience identified / ☐ / ☐ / ☐ / ☐ / ☐
4. / Method of the needs assessment identified / ☐ / ☐ / ☐ / ☐ / ☐
5. / Source(s) of supporting evidence for needs assessment identified / ☐ / ☐ / ☐ / ☐ / ☐
6. / Supporting evidence for needs assessment data attached / ☐ / ☐ / ☐ / ☐ / ☐
7 / Problem in practice or improvement need identified / ☐ / ☐ / ☐ / ☐ / ☐
8. / Gap in knowledge, skills or practice for target audience identified / ☐ / ☐ / ☐ / ☐ / ☐
9. / Purpose of learning activity identified
- written as a learner outcome statement
- identical purpose statement used throughout activity documents / ☐ / ☐ / ☐ / ☐ / ☐
QUALIFIED PLANNERS AND FACULTY / P / I / NS / N/A / Met / Not
10. / Names, credentials listed for each planner / ☐ / ☐ / ☐ / ☐ / ☐
11. / Nurse Planner and at least one content expert identified on planning committee / ☐ / ☐ / ☐ / ☐ / ☐
12. / Approved Provider CNE Nurse Planner BD form attached
- documents required RN qualifications
- documents knowledge of NP role / ☐ / ☐ / ☐ / ☐ / ☐
13. / Approved Provider CNE Nurse Planner COI form attached
- documents qualifications if also a ‘content expert’ or presenter/author for activity
- reviewed by PNP or another planner / ☐ / ☐ / ☐ / ☐ / ☐
14. / Planner/Faculty BD/COI for each additional planner attached
- documents planning experience
- documents content expertise (if planner designated as a ‘content expert’) / ☐ / ☐ / ☐ / ☐ / ☐
15. / Attributes considered essential in selecting presenters/authors identified / ☐ / ☐ / ☐ / ☐ / ☐
16. / Process for ensuring qualifications of presenters/authors identified / ☐ / ☐ / ☐ / ☐ / ☐
17. / Names and credentials of all presenters/authors listed / ☐ / ☐ / ☐ / ☐ / ☐
18. / Planner/Faculty BD/COI for each presenter/author attached
- documents appropriate experience and content expertise for role
- reveiwed by Nurse Planner / ☐ / ☐ / ☐ / ☐ / ☐