NURSE PEER REVIEW FORM (FORM 19)

INDIVIDUAL EDUCATIONAL ACTIVITY (IEA) APPLICATION

Process for reviewing IEA Applications:

1.  Two WNA CEAP Committee members will be ‘assigned’ to review each activity application according to the established review schedule. One reviewer will be identified as the ‘lead’ for each application.

2.  Reviewers will independently evaluate each activity application using the WNA CEAP “Nurse Peer Review Form – Individual Educational Activity Application” (NPR-IEA).

3.  When both reviewers complete their evaluation of the application, they will discuss their findings to reach consensus on whether the application meets, partially meets, or does not meet the criteria and what (if any) additional information is needed to make a decision about each criterion.

4.  The ‘lead’ will record the outcomes of this discussion on the NPR-IEA.

5.  For criteria determined “Not Met”, the ‘lead’ will contact the applicant for clarification and/or request additional or revised documents. The ‘lead’ will update the NPR-IEA throughout the review process as needed.

6.  When a final decision is made (met vs. not met) regarding each criterion, the ‘lead’ will document the decision on the NPR-IEA (in the ‘Final Criteria Determination’ columns).

7.  The ‘lead’ reviewer will inform the applicant of the approval or denial decision in writing (use email template), and the NPR-IEA, including comments for the approval/denial letter and any additional/revised documents received from the applicant, will be forwarded to Megan at the WNA office, cc-ing the Nurse Peer Review Leader.

8.  An official approval/denial letter will be sent to the applicant by the WNA office, and the NPR-IEA, including additional/revised documents received, will be filed with the original application in the WNA office.

Directions for completing form: Click on a box to ‘check’ – click again to ‘un-check’. Save completed form on your computer under a new name.

Applicant Organization:
Title of Activity:
☐ Live Event – Initial date(s): / ☐ Enduring Material – Start date:
☐ Blended Learning –date(s): / ☐ Enduring from Live – Start date:

Reviewer Attestation: As a peer reviewer for this Individual Educational Activity Application, I attest to having no conflict of interest or personal or professional relationship with this applicant that would preclude me from reviewing this application in a fair and unbiased manner.

Review Team Leader - Name and Credentials: / Date:
☐ Check this box if you designate the above as your electronic signature.
Review Team Member - Name and Credentials: / Date:
☐ Check this box if you designate the above as your electronic signature.
Review Team Member - Name and Credentials: / Date:
☐ Check this box if you designate the above as your electronic signature.

APPLICANT ELIGIBILITY TO APPLY

Before reviewing the IEA Application, please verify the organization is eligible to apply for individual activity approval. The “Verification of Eligibility to Apply” must confirm that:

• Applicant does not meet the definition of a commercial interest organization
• Planned activity meets the definition of continuing nursing education
• Nurse identified as the CNE Nurse Planner meets all requirements
• Any organization involved as a joint-provider is not a commercial interest organization
YES – Proceed to next “Verification of Eligibility question.”
NO – Contact the WNA Nurse Peer Review Leader.
Applicant disclosed any previous denial decisions and/or revocation of approval of individual activity or provider status from ANCC, WNA or other ANCC Accredited Approvers.
YES – Proceed to next “Verification of Eligibility question.”
NO – Contact the WNA Nurse Peer Review Leader.
Attestation was signed by a qualified CNE Nurse Planner.
YES – Proceed to IEA Application review.
NO – Contact the WNA Nurse Peer Review Leader.

If you have questions regarding whether the applicant organization meets the eligibility criteria, please contact the Nurse Peer Review Leader.

FINALCRITERIA

INITIAL QUALITATIVE REVIEW CONSENSUS CORRECTIVE ACTION REQUIRED/OUTCOME DETERMINATION

Activity file documentation of compliance with WNA CEAP criterion / Not Applicable / Met / Partially Met / Not Met / Issue with submitted documentation / Corrective actions required to meet criterion:
- list additional/revised documents requested
- written/verbal clarification requested
- note resubmission deadline
- note results/clarification received / Not Applicable / Met / Not Met
JOINT-PROVIDERSHIP
1. / If joint-provided: signed WNA CEAP Joint Provider Agreement attached for each Joint Provider organization, identifying division of responsibilities; no typed signatures; document is signed and dated by both parties
(an alternate form which meets WNA CEAP criteria may be used) / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
2. / If joint-provided: provider’s name is prominently displayed on all marketing materials; if joint provider logo is used, IEA applicant logo is used / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
3. / If joint provided: joint provider statement on all marketing materials (NEW) “(Applicant) is the provider of CNE in a joint provider relationship with (joint provider)” or similar statement / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
EDUCATIONAL DEVELOPMENT / N/A / Met / Part / Not / N/A / Met / Not
4. / A. Target audience identified / ☐ / ☐ / ☐ / ☐ / ☐
5. / B. Summary of practice gap (contains background information so you understand the situation and what the problem in practice is).
(Watch for things that are not educational issues e.g., lack of tools, systems issues). / ☐ / ☐ / ☐ / ☐ / ☐
6. / C. Describe the current state (what is happening now r/t nursing knowledge, skills, practice [K-S-P]; relates back to the problem). / ☐ / ☐ / ☐ / ☐ / ☐
7. / D. Describe the desired state (what should nurses be doing in practice; how would it address the problem/reduce the gap). / ☐ / ☐ / ☐ / ☐ / ☐
8. / E. Evidence to validate professional practice gap – method(s) checked. / ☐ / ☐ / ☐ / ☐ / ☐
9. / E. Evidence to validate professional practice gap – Supporting evidence is attached; relevant information highlighted (if you can’t readily find the relevant information, ask for a revision for the applicant to highlight relevant information, e.g., for long survey results summaries, articles, etc.); for literature reviews – request citations (minimum of two citations + look for quality of citation/date [w/in last five years preferable]). / ☐ / ☐ / ☐ / ☐ / ☐
10. / F. Summary of what the evidence above (#8) showed to indicate there is a problem in practice/need for improvement (narrative summary of what the evidence above showed). / ☐ / ☐ / ☐ / ☐ / ☐
11. / G. Is the educational need r/t knowledge, skill or practice – box(es) checked; (Do the box(es)checked make sense based on B – F?) / ☐ / ☐ / ☐ / ☐ / ☐
12. / H. Learning outcomes – At least one outcome is listed; outcome written in correct format; outcome matches underlying need (K-S-P); and outcome focuses on what can be accomplished for THIS activity. (There may be one broad outcome or more focused outcomes. If one broad outcome, look at EPT and agenda – does the outcome make sense? Is there something that ties the outcome to all/ most of the content?
Conferences – if only one outcome is stated for a conference, does it cover most sessions?) / ☐ / ☐ / ☐ / ☐ / ☐
13. / I. EPT - Content to help learners achieve outcome – Section 1 is optional; Main Points in Column 1 of table is optional; Content outline – is there enough detail to determine adequacy in addressing learning outcome(s)? / ☐ / ☐ / ☐ / ☐ / ☐
14. / J. EPT - If Live Event: time frames – may be actual times or time frames (e.g., “2 hours”); is there adequate time for content; do the numbers add up to the total minutes for sessions listed on EPT? / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
15. / J. EPT - If Live Event, presenters listed for each content area; if Enduring Material, at least one author listed. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
16. / K. EPT - Learner engagement strategies listed for each session; consistent with desired outcomes (K = lecture, Q&A, on-line information giving; S = demonstration; P = Live or on-line with case study, problem-based learning). Applicant may need education to understand that the learner engagement strategies should be consistent with the gap in in K-S- and/or-P, and desired outcomes – e.g., that lecture alone should not be expected to produce a practice change. / ☐ / ☐ / ☐ / ☐ / ☐
17. / J. EPT - On what evidence is content based - Evidence-based references/source of content listed; if listing only people, more than one is listed; most sources should be within the past 5 to 7 years – exception may be a text book or references to Maslow, Erickson, and other pioneers of theory. Look for overall quality – if sources are poor, ask applicant is this is best available evidence and if not, what evidence might be stronger? Share an evidence hierarchy if needed. (Note for future applications -- for websites, date information was accessed should be noted). / ☐ / ☐ / ☐ / ☐ / ☐
18. / L. How will outcomes be measured – what data or information will be used to determine if education was successful? This response should be a specific outcome measure. This may be repetitive of “H” above. If so, that’s okay. We may take this question out. / ☐ / ☐ / ☐ / ☐ / ☐
19. / M. Learning outcome related to NPD, Patient outcomes, both, other – does the answer make sense given the information so far?
(Note for future applications - Patient outcome should be marked only when there is patient outcomes data available to analyze.) / ☐ / ☐ / ☐ / ☐ / ☐
CONTENT QUALITY & INTEGRITY / N/A / Met / Part / Not / N/A / Met / Not
20. / A. Planning CTE table at the end of the application is completed: Names, credentials, and role listed for each person in control of content. / ☐ / ☐ / ☐ / ☐ / ☐
21. / A. Nurse Planner and at least one content expert identified on Planning CTE. / ☐ / ☐ / ☐ / ☐ / ☐
22. / A. Presenter /author table completed: Name, credentials, role listed for each person.
(If more than 10 presenters, a different list can be submitted or agenda with names and credentials clearly identified.) / ☐ / ☐ / ☐ / ☐ / ☐
23. / A. WNA CEAP Biographical Data Form attached for:
·  Nurse Planner
·  All planners WHO ARE content experts
·  Content Reviewers / ☐ / ☐ / ☐ / ☐ / ☐
24. / A. WNA CEAP BDF or Nurse Planner
- documents planning experience (#1)
- if applicable, documents content expertise (#2)
- documents how NP has knowledge of ANCC criteria (#3)
- documents experience r/t NP role
(Information can be located anywhere on the form – e.g., information on planning may be in content box, etc. As long as you can find it on the form, even if it’s not in the right box, it’s okay. An alternate form which meets WNA CEAP criteria may be used.) / ☐ / ☐ / ☐ / ☐ / ☐
25. / A. WNA CEAP BDF for Content Expert on Planning CTE
- documents role(s) check boxes, and demographic information
- documents planning experience (#1)
- documents content expertise (#2)
(Information can be located anywhere on the form; an alternate form which meets WNA CEAP criteria may be used.) / ☐ / ☐ / ☐ / ☐ / ☐
26. / A. WNA CEAP BDF for Content Reviewer
- documents planning experience (#1)
- documents content expertise (#2)
(Information can be located anywhere on the form; an alternate form which meets WNA CEAP criteria may be used.) / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
27. / A. If a “Content Reviewer” is identified, they must be marked as a content expert; documentation identifies correctly who will review content.
Applicant should only designate a person as a Content Reviewer if they are NOT on the Planning Committee. A Content Reviewer is someone not on the planning CTE brought in when Planning CTE lacks needed expertise to review content. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
28. / B. COI forms are present for all in control of content: NP, ALL planners, content reviewers, presenters, authors, and any other faculty. / ☐ / ☐ / ☐ / ☐ / ☐
29. / B. COI forms
- document role(s), check boxes, and demographic information
- Questions 1, 2, content integrity statement, and statement of understanding signature completed on each COI form. / ☐ / ☐ / ☐ / ☐ / ☐
30. / B. No employees of commerical interest (CI) on planning CTE (WNA requirement);
No employees of comerical interest as speakers/authors IF activity content is relevant to CI products and services. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
31. / B. NP has appropriately evaluated any disclosures and selected correct procedure fo resolve COI; box with correct resolution procedure must be marked with an “X”.
- if ‘other procedure to resolve COI’ used, it was discussed with WNA CEAP first. / ☐ / ☐ / ☐ / ☐ / ☐
32. / B. Nurse Planner signature on each COI form except his/her own. / ☐ / ☐ / ☐ / ☐ / ☐
33. / B. Nurse Planner COI is reviewed by someone else on Planning CTE; (NP reviews all other forms except for his/her own – cannot evaluate own COI.) / ☐ / ☐ / ☐ / ☐ / ☐
34. / C. Process for ensuring qualifications
identified:
- One or more method(s) are selected;