Western Multi-State Division (WMSD) Approver Unit
ApprovedProvider Unit Application and Self-Study
Directions:Review the Self Study Instructions and Helpful Hints Guidefound on the westernmsd.org website before writing the Self Studythen complete Sections 1 - 4 of this application. Direct all questions to the WMSD office at or call 480.831.0404.
- Section 1:Primary Nurse Planner is responsible for the application content and is the primary contact throughout the reviewprocess.
- Section 2:Review will not begin without paid application review fee.
- Section 3:Eligibility.Organizations must meet all Eligibility Requirementsbefore proceeding with the Self Study in Section 4.Direct any questions to or call 480.831.0404.
- Section 4: Insertyour Self Study description and example responses in the boxes. They will expand to fit your content.Do not remove the ANCC criterion descriptions or section headers.Complete the Table of Contents with the corresponding page numbers.
- Submit 3 Individual Activity Files with a completed and paged numbered recordkeeping checklist.
SECTION 1 of 4
Applicant Demographic Information
Name of Approved Provider UnitApplicant
(Name used in approval statement on certificates)
Name of parent organization (if different than Approved Provider Unit name)
Street Address or PO Box
City, State, ZIP Code
Enter number of facilities served by Provider Unit
Names of facilities served by Provider Unit
PRIMARY NURSE PLANNER (PRIMARY APPLICATION CONTACT)
Name and Credentials:
Street Address:
City, State, ZIP Code:
Daytime phone number (ext):
E-mail address:
ADDITIONAL CONTACT PERSON
Name
Title or Position
Daytime phone number (ext):
Email Address:
SECTION 2 of 4
Payment Information
Visit to provide payment. Fees must be submitted prior to the application being accepted for review and are non-refundable once the review process hasbegun.
Indicate payment method:☐Check ☐Credit Card
When payment is complete, print a copy of your order confirmation and include with your application.
SECTION 3 of 4Eligibility Requirements
(Acheck in the box indicates agreement that applicant meets requirement)
Check your organization type.Organizations on this list are automatically exempt from ANCC’s definition of a commercial interest* Commercial interest organizations as defined by ANCC are not eligible to apply.
*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. (i.e. pharmaceuticals, supplements, botanicals, medical devices, and medical equipment products.))
Blood Bank
Constituent Member Associations of ANA
College or University
Diagnostic laboratory
Federal Nursing Service
For-profit and not for profit hospital
For profit and not for profit rehabilitation center
Other Healthcare Facility
Health - Related Organization
Group medical practice
Government organization
Health insurance provider
Liability insurance provider
Multidisciplinary Educational Group
National nurses organizations based outside the United States
Non-health care related company
Professional Nursing Education Group
Specialty Nursing Organization
A single-focused organization devoted to offering continuing nursing education only
Organization type is not on the above list but is not a commercial interest* by the ANCC definition nor part of a multi-focused organization that is a commercial interest by the ANCC definition. STOPand contact the WMSD office to discuss and ensure your organization's eligibility to apply to be an Approved Provider before proceeding. / STOP
Organization type is a commercial interest or is part of a multi-focused organization that is a commercial interest* by the ANCC definition. STOP you are ineligible to apply. / STOP
Has your organization ever been:
- denied accreditation by ANCC?
- or denied approval by the WMSD?
- or denied approval byanother ANCC Accredited Approver?
- or had your approval suspended or revoked for an individual activity or a provider application?
No to all the above, proceed with the application
If Yes to any of the above STOP contact the WMSD and provide the date and describe the action and why to assess eligibility to proceed . / STOP
The applicant organization must designate one Primary Nurse Planner with authority to assure compliance with the ANCC Accreditation Program criteria in the provision of continuing nursing education that awards contact hours.
The Primary Nurse Plannernamed in Section accepts responsibility to serves as the primary contact for the WMSD and ensure compliance with the ANCC accreditation criteria.
All Nurse Plannersare currently licensed registered nurses with a baccalaureate degree in nursing or higher and an active member of the Provider Unit as represented on the organization chart.
The Primary Nurse Planneris responsible for the orientation of all Nurse Planners and key personnel in the organization to the current ANCC accreditation criteria.
The Provider Unit must ensure that each CNE activity has a qualified Nurse Planner who is an active participant in guiding the planning, implementing, and evaluating of each continuing nursing education activity when contact hours are awarded.
The Provider Unit must be administratively and operationally responsible for coordinating the entire process of planning, implementing, awarding contact hours,evaluatingand record keeping for all continuing nursing education activities in the organization when contact hours are awarded.
Approved Provider Unit exists for the purpose of providing continuing nursing education (whether it is a single entity, a function within an education department or department within a multi-focused organization)
To my knowledge, the applicant organization is in compliance with all applicable Local, State, Federal, and International laws and regulations that apply to the delivery of CNE.
During the past year, our organizationdid promote/market/advertise more than 50% of our total learning activities to nurses within our local geographic region DHHS region and its contiguous states.See link for map (
If more than 49% of your CNE activities are provided outside your geographic region,stopandcontact the WMSD to assess your eligibility to apply as an approved provider or will need to apply to ANCC to be an Accredited Provider. / STOP
The applicant organization has been operational for 6 months using the ANCC Accreditation Criteria.
If this is a first time application to the WMSD, the applicant hassuccessfully completed and received approval by the WMSD for 3 separate and distinct individual activities in the past 12 months
- Each activity was a minimum of one hour (60 minutes)
- The 3 activities were not Joint Provided
- The WMSD approved activities are the sample activity files attached to this application
Statement of Understanding by Primary Nurse Planner
An “X” in the box below serves as my electronic signature and attest to the accuracy of the information contained and I am duly authorized by my organization to submit this application as an approved provider through the WMSD as offered by the American Nurses Credentialing Center (ANCC).
Electronic Signature (Required) Date ______
______
Completed By: Primary Nurse Planner's Name and Title
(Applications received without a signature incur a delay processing and will not be moved to review.)
SECTION4 of 4
Approved Provider Self-Study Outline/Table of Contents
Enter page numbers corresponding to the location of your completed responses / Page Number(s)
ORGANIZATION OVERVIEW (OO)
Structural Capacity (SC)
OO1—Demographics
OO2—Lines of Authority and Administrative Support
Educational Design Process (EDP)
OO3—Data Collection and Reporting
Quality Outcomes (QO)
OO4—Evidence
STRUCTURAL CAPACITY (SC) -- Detailed Criterion
SC1
SC2
SC3
EDUCATIONAL DESIGN PROCESS(EDP)-- Detailed Criterion
EDP1
EDP2
EDP3
EDP4
EDP5
EDP6
EDP7
QUALITY OUTCOMES (QO)-- Detailed Criterion
QO1
QO2
QO3
APPENDICES Providea cover page for each appendix including titles and page numbers.
Organizational Chart(s)
Position Descriptions
12 Month Continuing Education Activity Summary
Other - Describeinsert additional rows as needed
INDIVIDUAL ACTIVITY FILES:Submit 3complete activity files with a completed recordkeeping checklist and place them after the Appendices divided by separate tabs labeled Activity 1, Activity 2, Activity 3
Approved Provider Organizational Overview (OO)
The Organizational Overview (OO) is an essential component of the application process that provides a context for understanding the Approved Provider Unit. The applicant must submit the following documents and/or narratives:
Structural Capacity
OO1. Demographics
001a:Submit a description of the features of the Approved Provider Unit, including but not limited to, size, geographic range, target audience(s), content areas, and the types of educational activities offered.
Description:
001b:If the Approved Provider Unit is part of a multi-focused organization, describe the relationship of these dimensions to the total organization.
Description:
OO2. Lines of Authority and Administrative Support
002a:Submit a list includingnames and credentials, positions, and titles of the Primary NursePlanner and other Nurse Planner(s) (if any) in the Approved Provider Unit.Include RN licensure information including, state of licensure, license number and expiration date for all planners.
Primary Nurse Planner(Name as appears on RN License) / Credentials / Education Level / Licensure Information
Name:
Title: / BSN
MSN
Other:______ / State:
License #:
Exp. Date:
Nurse Planners
(Name as appears on RN License) / Credentials / Education Level / Licensure Information
Name:
Title: / BSN
MSN
Other:______ / State:
License #:
Exp. Date:
Name:
Title: / BSN
MSN
Other:______ / State:
License #:
Exp. Date:
Add rows as needed
002b:Submit position descriptions of the Primary Nurse Planner and Nurse Planners (if any), in the Approved Provider Unit.
Position Descriptions:(If attaching organizationalHR job descriptions ensure they include the Approved Provider Unit role and responsibilities.If they do not, provide separate Provider Unit position descriptions specific to the Approved Provider Unit nurse planner roles and responsibilities below.)
Primary Nurse Planner:
Nurse Planner(s):
002c:Submit achart depicting the structure of the Approved Provider Unit, including the Primary Nurse Planner, other Nurse Planner(s) (if any). (This should depictonly the Approved Provider Unit structure.)
Chart:Reference where it is placed in the Appendices..
002d:If part of a larger organization, submit an organizational chart, flowchart, or similar image that depicts the organizational structure and the Approved Provider Unit's location within the organization.
Chart:Reference where it is placed in the Appendices.
Educational Design Process
OO3. Data Collection and Reporting
Approved Provider organizations report dataannually to the Western Multi-State Division Accredited Approver Unit office. Forms are available on the WMSD CE Web site.
- Submit the completed Approved Provider Continuing Education Summary of all CNE offerings provided in the past 12 months, including at a minimum, activity dates; titles; target audience; total number of participants; number of contact hours offered for each activity; activity type, Joint Provider status; and any commercial support, including monetary or in-kind contributions.
List:Reference where it is placed in the Appendices..
If New Applicant, completed list of the CNE offerings provided within the past 12 months.If available, includes the items listed above.
Quality Outcomes
OO4. Evidence
A provider organization must demonstrate how its structure and processes result in positive outcomesfor itself and for registered nurses participating in its educational activities.
Outcomes must be written in measureable terms(i.e. SMART goals) and specific to the Approved Provider Unit.They may support the larger organization's goals but must be written for the Approved Provider Unit outcome.(Examples for OO4a and bfound in Instructions and Helpful Hints).
Note:New applicants should develop and submit a list a list of quality outcome measures that will be collected, monitored and evaluated in the coming year.
004a:Submit a list of the quality outcome measures the Approved Provider has collected, monitored, and evaluated over the past 12 monthsspecific to theApproved Provider Unit.
List:
004b:Submit a list of the quality outcome measures the Approved Provider Unithas collected, monitored, and evaluated over the past 12 months specific to Nursing Professional Development.These outcomes assess how the activities planned, implemented and evaluated by the Approved Provider Unit had an effect on Nursing Professional Development goals.
List:
Approved Provider Criterion 1: Structural Capacity (SC)
The capacity of an Approved Provider is demonstrated by commitment, identification of, and responsiveness to learner needs, continual engagement in improving outcomes; accountability; and leadership. Inthis section write narrative statements that address each of the criteria to illustrate how your Approved Provider Unit's structural capacity is operationalized.
Commitment.The Primary Nurse Planner demonstrates commitment to ensuring that RNs’ learning needs are met by evaluating Provider Unit processes in response to data that may include but are 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:
SC1.ThePrimary Nurse Planner's commitment to learner needs, including how Approved Provider Unit processes are revised based data.
Process Description:
Specific Example:
Accountability.ThePrimary Nurse Planner is accountable for ensuring that all Nurse Planners in the Provider Unit implement adhere to the ANCC accreditation criteria.
Describe and, using an example, demonstrate the following:
SC2.How the Primary Nurse Planner ensures that all Nurse Planners of the Approved Provider Unit are appropriately oriented/trained to implement and adhere to the ANCC accreditation criteria.
Process Description:
Specific Example:
Leadership.ThePrimaryNursePlannerdemonstratesleadershipofthe ProviderUnitthroughdirection andguidancegiventoindividualsinvolvedin assessing, planning, implementing,and evaluatingCNEactivities in compliancewithANCCaccreditationcriteria.
Describe and, using an example, demonstrate the following:
SC3. 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.
Process Description:
Specific Example:
Approved Provider Criterion 2:Educational Design Process (EDP)The Approved Provider Unit has a clearly defined process for assessing learner 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.
Examples for the narrative component of the provider application (EDP 1-7) may be chosen from but are not limited to those contained in the 3 activity files. Evidence must demonstrate how the Provider Unit complies with each criterion.
Assessment of Learner 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:
EDP1.The process used to identify a problem in practice or opportunity for improvement (professional practice gap).
Process Description:
Specific Example:
EDP2. How the Nurse Planner identifies the educational needs (knowledge, skills and/or practice(s) that contribute tothe professional practice gap.
Process Description:
Specific Example:
Planning. Planning for each educational activity must be independent from the influence of commercial interest organizations.
Describe and, using an example, demonstrate the following:
EDP3.The process used to identify and resolve all conflicts of interest (COI)for all individuals in a position to control educational content.
Process Description:
Specific Example:
Design Principles. The educational design process incorporates best-available evidence and appropriate teaching methods.
Describe and, using an example, demonstrate the following:
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).
Process Description:
Specific Example:
EDP5. How strategies used to promote learning and actively engage learners are incorporated into educational activities.
Process Description:
Specific Example:
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.
Describe and, using an example, demonstrate the following:
EDP6. How summative evaluation data for an educational activity were used to guide future activities.
Process Description:
Specific Example:
EDP7. How the Nurse Planner measures change in knowledge, skills and/or practices of the target audience that are expected to occur as a result of participating in the educational activity.
Process Description:
Specific Example:
Approved Provider Criterion 3: Quality Outcomes (QO)The Approved 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 the following:
QO1.The process utilized for evaluating effectiveness of the Approved Provider Unit in delivering quality CNE.
Process Description:
Specific Example:
QO2.How the evaluation process for the Approved Provider Unit resulted in the development or improvement of an identified quality outcome measure for the Approved Provider Unit.(Refer to your quality outcomes list in OO4a.)
Process Description:
Specific Example:
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 the following: