APPROVED PROVIDER APPLICATION
TABLE OF CONTENTS
ORGANIZATION NAME:
I. Approved Provider Eligibility Verification Page____
II. Operational Requirements Page____
III. Approved Provider Application Page____
Structural Capacity Page____
OO1. Demographics
a. Description of Provider Unit Page____
b. Provider Unit relationship to total MFO Page____
OO2. Lines of Authority and Administrative Support
a. List of names credentials Page____
b. Position Descriptions (Lead Nurse Planner & Nurse Planners) Page____
c. Organizational Chart Page____
d. Provider Unit’s location within Organization Page____
Educational Design Process Page____
OO3. Data Collection and Reporting
a. Provider Demographic Information Form Page____
b. Summary of CNE offerings in the past 12 months Page____
OO4. Evidence
**Note: OO4a. and OO4b. have been moved to Quality Outcomes section
Provider Criterion 1: Structural Capacity (SC) Page____
SC1: LNP Commitment to Learner Needs Page____
SC2: LNP Commitment to Nurse Planner’s adherence to criteria Page____
SC3: LNP Commitment to Leadership (Description & Example) Page____
Provider Criterion 2: Educational Design Process (EDP) Page____
EDP1: Process to identify professional practice gap Page____
EDP2: Process to identify educational need Page____
EDP3: Process to identify and resolve conflicts of interest Page____
EDP4: Process to develop activity content Page____
EDP5: Process to incorporate learner engagement strategies Page____
EDP6: Process to guide future activities through summative evaluation data Page____
EDP7: Process to measure changes in knowledge, skill or practice Page____
Provider Criterion 3: Quality Outcomes (QO) Page____
QO1: Process to evaluate Provider Unit effectiveness Page____
Evidence: **OO4a: List of quality outcome measures collected (Provider unit) Page____
QO2: New Outcome measure resulting from evaluation process Page____
Evidence: **OO4b: List of quality outcome measures collected Page____
(Nursing Professional Development)
QO3: How Provider Unit enhanced Nursing Professional Development Page____
GLOSSARY Page____
IV. THREE (3) CNE Activities: Pages____
Title of Activity#1:______Page____
Title of Activity#2:______Page____
Title of Activity#3:______Page____
Below is the information required for each of the (3) three activity files
1. Activity Review Forms and Review emails
2. Activity Planning Form (to include the bulleted content below)
· Title of Activity
· Number of Contact hours awarded & calculation method
· Activity Location
· Type of activity format: Live or Enduring
· Date live activity presented or, for ongoing enduring activities, date first offered and subsequent review dates.
· Description of professional practice gap
· Evidence that validates the professional practice gap
· Educational need that underlies the professional practice gap
· Description of target audience
· Desired learning outcomes
· Description of evidence based content with supporting reference or resources
· Learner engagement strategies used
· Criteria for awarding of contact hours
· Description of evaluation method (Evidence that change in knowledge, skills, and/or practices of learners was assessed)
· Names and credentials of all individuals in a position to control content (planners presenters, faculty, authors, and/or content reviewers). Must identify individual filling roles of Nurse Planner and content experts
3. Educational Planning Tables
4. Conflict of Interest Evaluation of all individuals in a position to control content
(Planners &Presenters)
If conflict of interest is found provide:
· Name of Individual with conflict of interest
· Type of conflict of interest
· Resolution of conflict of interest
5. Certificate of Successful Completion (to include the bulleted content below)
· Title and presentation date of educational activity
· Name and address of provider of educational activity
· Number of contact hours awarded
· Accreditation approval statement
· Participant’s name
6. Marketing materials to promote activity
7. Agenda for entire CNE activity
8. Evidence of disclosing activity disclosures (to include the bulleted content below)
· Accreditation Statement
· Criteria for Successful Completion
· Absence or Presence of Conflict of Interest for all individuals in a position to control content
· Commercial Support (if applicable)
· Joint Providership (if applicable)
· Expiration Date for contact hours (if enduring activity)
9. Commercial Support Agreement (if applicable)
10. Copy of Evaluation Tool Used
11. Summary of Evaluation Responses
12. Copy of Roster completed by Activity Attendees
Approved Provider TOC
Rev Oct 2017