Approved PU
Application Guidelines
The purpose of this document is to provide organizations or groups that wish to have Approved Provider Unit (PU) status with application and self-study guidelines.
Topic / Page1. Criteria for Approval / 2
2. Part 1 of 4
3. Part 2 of 4
4. Part 3 of 4 (Eligibility Requirements)
5. Approval Specifics / 3
6. Directions for Self-Study Submission
7. Part 4 of 4 (Approved Provider Self-Study Document) / 5
a. Organizational Overview / 5
b. Criterion 1: Structural Capacity (SC) / 5
c. Criterion 2: Educational Design Process (EDP) / 13
d. Criterion 3: Quality Outcomes (QO) / 14
Appendices
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1850 East Southern Avenue, Suite 1
Tempe, Arizona 85282-5832
Phone 480.831.0404
Fax 480.839.4780
CRITERIA FOR APPROVAL
AS AN APPROVED PROVIDER UNIT (PU) OF
CONTINUING NURSING EDUCATION
General Information (top of document)
Approval as an Approved Provider Unit (PU) by the Arizona Nurses Association (AzNA) is recognition that the applicant has a quality organization, educational processes, and capacity to award contact hours for continuing education (CE) activities. This recognition means that the Approved PU has demonstrated to AzNA their ability to appropriately assess, plan, implement, and evaluate their CE activities. The Approved PU may offer an unlimited number of educational activities during their period of approval.
An Approved PU is an organization that plans, implements, and evaluates continuing nursing education activities. An Approved PU can be a department or entity that is part of a larger organization (for example, a staff development department within a hospital or a College of Nursing within a University) or an Approved PU can stand alone (for example, a privately owned company).
Approval as an Approved PU is based on an in-depth self-study and analysis of the quality of several learning activities to estimate the likelihood of a provider's ability to continue to plan and produce such activities over a three-year period. To achieve Approved PU approval, an applicant must meet the eligibility requirements and develop internal policies and processes for the development and review of continuing nursing education.
The Approved PU is responsible for internal monitoring to assure adherence to American Nurses Credentialing Center's Commission on Accreditation (ANCC/COA) criteria and the Arizona State Nurses’ Association's (AzNA) continuing education criteria.
Annual Review
AzNA monitors PUs on an annual basis. The PU will be notified of the review and required to submit a list of activities that were provided in the previous 12 months. AzNA will select two (2) activities for review. The PU will be notified of the results, including any issues that need to be addressed. AzNA may request to review materials and activities at any time during the PU’s approval period to assure that PU is meeting accreditation criteria.
Note: Providers Do Not Approve Activities. Approved providers are granted approval to plan, implement and evaluate activities that meet criteria and rules. Providers have the ability to award contact hours. Approved providers 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 activity planned and presented by the provider.
The first step is to obtain the Approved Provider Unit Applicant and Self-Study Outline document from the AzNA website and complete Parts 1-4.
Part 4 is an outline of the Self-Study document you will need to submit for approval. You may use this outline as a way to organize your Self-Study document and may type your information directly into this outline if you wish.
Part 1 of 4
APPLICANT INFORMATION
Be sure to complete this section in its entirety before proceeding.
Part 2 of 4
PAYMENT INFORMATION
Be sure to complete this section in its entirety before proceeding.
PART 3 of 4
ELIGIBILITY REQUIREMENTS (top of document)
Any individual, group, or facility that meets the specified criteria can apply to become an Approved PU. See application for specific requirements.
PLEASE NOTE: Commercial Support Organizations: A provider is ineligible for approval if it is a commercial interest. A “commercial interest” is any entity either 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 Exceptions are made for nonprofit 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. Providers of commercial support may not be providers or co-providers of an educational activity.
This definition allows a provider to have a ‘sister company’ that is a commercial interest, as long as the accredited provider has and maintains adequate corporate firewalls to prohibit any influence or control by the ‘sister company over the CE program of the accredited provider. In this case, ANCC would expect that the accredited provider would have an adequate corporate firewall in place to prohibit any influence or control by the ‘sister company’ over the CE program.
If there are questions about a potential provider’s commercial interest status and eligibility, please complete the AzNA Approved Provider Eligibility Commercial Interest Form along with the application. Be sure to contact AzNA for complete directions.
APPROVAL SPECIFICS FOR APPLICATIONS (top of document)
Application Deadlines
Initial application for Approved PU approval may be submitted at any time.
· Approved PUs with current approval status need to submit their renewal application at least 90 days before the three-year approval ends to assure continuity of the approval.
· Renewing provider applicants that have used the 2009 self-study documentation guidelines may find it helpful to refer to a “crosswalk” to transition to the 2013 documentation format. Click here for the complete crosswalk…
Each request for approval must meet all current criteria. If approval expires, the Approved PU may not award contact hours through the AzNA CE system. Approved PUs may only award contact hours for activities implemented during the three-year approval period. An exception to this occurs when the Approved PU formally requests an extension to the application process in writing.
A courtesy reminder notice may be sent six (6) months prior to the expiration date to request intent in submitting a subsequent application. However, the Approved PU is ultimately responsible for tracking its approval period and submitting their application in a timely manner.
Approval of Individual Activities During the Application Process
The applicant may not offer CE activities as an Approved PU while the Approved Provider application is in process.
If an applicant wishes to offer approved continuing education while the initial provider application is in process, Individual Activity Applications must be submitted to AzNA following the appropriate criteria and process and accompanied by the required application fee.
Approval Period
The approval period for Approved PUs is three (3) years. During the approval period, the Approved PU can award contact hours for CE activities without submitting documentation to AzNA. However, the ANCC and AzNA criteria must be met by the Approved PU for each individual CE activity.
Documentation of meeting the criteria must be done on the CE planning forms for each activity and maintained in a secure file for six (6) years. After Approved PU approval, the applicant is responsible for maintaining these internal processes to assure adherence to ANCC and AzNA criteria during the three-year approval period.
Withdrawal of an Application
An Approved PU 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 Approved PU applicant must notify AzNA in writing of the decision to withdraw the application.
One complete application and a copy of all correspondence will be kept on file in the AzNA office for six years.
Fees will not be refunded if the review process has begun. If the review process has not begun, the application fees will be returned to the applicant minus an administrative charge.
If the applicant decides to withdraw their application, regardless of circumstance, the applicant has up to six (6) months from initial submission to resume the approval process. If the fee was returned, a new fee must accompany the request to continue with the application process.
If the application process is not resumed within six months, all eligibility criteria must be met again as a new applicant.
Denial of an Application
If an applicant is denied approved provider status, the application fee will not be refunded. A new fee must be submitted if the applicant decides to resubmit the application.
Reconsideration and Appeals
If denial of an application occurs, the applicant will receive the appeal process in writing at the time of the decision. The applicant has 14 days to appeal from the time of the decision. For more information please contact the AzNA office.
Voluntary Termination of Accreditation
Approved PUs may voluntarily terminate their accreditation at any time. They must notify AzNA, in writing, at least 30 days in advance. This written notice must include:
· Effective date of voluntary termination (which must be at least 30 days after the date that appears on the written notice);
· Reason for voluntary termination; and
· The transition plan.
Notice must be sent by email with confirmation of receipt to or certified mail with signature confirmation to the AzNA office.
The date voluntary termination is implemented, the Approved PU must immediately cease:
· Offering any CE activities
· Referring to itself in any way as an Approved PU
· Using the ANCC accreditation statement; AND
· Using any ANCC intellectual property, including but not limited to trademarks, trade names, and logos.
Approved PUs that voluntarily terminate their Approved Provider status in good standing may reapply at any time.
Approval Versus “Re-approval”
The ANCC approval system only allows for approval of Approved PUs. There is no re-approval. Each three-year approval period is independent of the one before. Approved Providers wishing to continue their “Approved” Provider status must demonstrate compliance with current criteria and guidelines of the ANCC/AzNA approval system, following the same process as new applicants.
Application Fee
The fee for application of an Approved PU is $2,000.00.
Annual Reporting Requirements
To monitor compliance with the criteria, all Approved PUs are required to submit annually a complete list of all CE offerings provided in the past 12 months to include:
· activity dates
· titles
· target audience
· total number of participants for each activity
· number of contact hours offered for each activity
· co-provider status and any sponsorship or commercial support including monetary or in-kind amount and
· any additional requirements of AzNA.
If for any reason, an Approved PU is unable to submit the required documentation within the required timeframe, the AzNA Office must be contacted as soon as possible. If the AzNA Office does not receive the required documents by the required due date and the Approved PU has failed to notify the AzNA Office regarding its delay, the approved Provider status may be suspended or revoked. The provider will receive written notification from AzNA.
Approved P PUs and organizations with pending applications must notify AzNA, in writing, within seven (7) business days of the discovery or occurrence of the following:
· Significant changes or events that impair their ability to meet Accreditation Program requirements or that make them ineligible for approved provider status.
· Loss of status as a C/SNA of the ANA
· Any event that might result in adverse media coverage related to the delivery of a CE activity
· Change in commercial interest status
The Primary Nurse Planner or designee must notify AzNA, in writing, of any change within the Approved PU within (30) thirty days, including but not limited to:
o Changes that alter the information provided in the application, including change of address or name
o A decision not to submit self-study written documentation after application
o Change in Primary Nurse Planner or an Nurse Planner or suspension, lapse, revocation, or termination of the Primary Nurse Planner’s registered nursing license
o Change in ownership
o 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.
DIRECTIONS FOR SELF-STUDY SUBMISSION
Accreditation decisions are determined on the basis of compliance with the ANCC Accreditation Program criteria. In order to validate compliance, the AzNA Review Team must receive comprehensive, well-organized, clearly written self-study and documents (including narrative descriptions for each criterion, activity files demonstrating compliance, and supplemental evidence as required or requested).
SELF-STUDY FORMATTING GUIDELINESApplication materials are limited to no more than 50 sheets of paper. Double sided sheets are permitted. (Do not include record files for three activities in this count.). Damaged documents will be returned.
Documents must be numbered by page.
All photocopies must be readable.
Only typed applications using this form will be accepted. Use a common, 12-point font such as Times New Roman, Arial, Garamond, or Courier for the text body.
Define acronyms and abbreviations upon first use in the text and include them in a glossary.
Narrative statements should be straight-forward and concise and include minimal extraneous information. They should refer to data for the 12 months prior to submission. Data older than 12 months may be submitted sparingly for specific purposes, such as showing long-term commitment to monitoring data, documenting trends, highlighting best practices, or illustrating continuation of long-term projects.
Include a Table of Contents and number all pages of the report, including appendices, in sequence.
a. Use an Appendix for all supporting documentation (including, but not limited to sample continuing education activities documents, policies and procedures, biographical data forms, job descriptions, etc.). Do NOT place supporting documentation in the body of the application. Only information relating to the 4 sections of the application should be placed in the body of the application.
b. Refer to appendix materials within the body of the application by specific page number.
c. Documents must be cross-referenced.
Provide required documentation for each criterion and section by name and be sure to number them in sequence.
Each Criterion must be answered in narrative format – submission of activity files alone is not sufficient evidence to validate adherence.
Supporting evidence to validate or demonstrate adherence may include but is not limited to the following: meeting minutes, email or written communication, digital pictures, copies of policies or procedures, copies of templates of contracts.
Identify sections with tabs that are clearly marked and visible when the volumes are closed.
Two (2) complete, spiral-bound, collated, typed, double-sided paper copies must be submitted. Do not send electronic copies of the application.
Policies and procedures should be included in the self-study. These policies can be in draft form and do not need to be approved by the organization’s policy and procedure process to be submitted.
Approved PU policies that must be submitted with the self-study include (at a minimum) the following:
· Nurse Planner: Selection and Responsibilities
· Support Staff: Selection and Responsibilities
· Selection of Other Staff for Approved PU (if applicable)
· Use of ANCC Commission on Accreditation Educational Design Criteria to Plan and Implement All Continuing Nursing Education Activities
· System for Awarding Contact Hours
· Use of Appropriate ANCC Language
· Activity Evaluation
· Verifying Participation and Successful Completion of Activities
· Educational Activities and Certificate of Completion
· Conflict of Interest Guidelines
· Sponsorship and Commercial Support Guidelines (if applicable)
· Sample Commercial Support Agreement (if applicable)
· Sample Exhibitor Agreement (if applicable)
· Honoraria (if applicable)
· Record Storage, Confidentiality, and Retrieval
· Coprovidership (if applicable)
· Providers Cannot Approve Activities
· Monitoring
· Enduring Materials (if applicable)
All the 3 activity files must be submitted in their entirety. Each activity should be labeled separately and each activity must contain the following items, in the following order:
a. Complete Continuing Education Planning Form
b. Needs Assessment Data
c. Education Planning Table
d. Completed Biographical Data Forms for all planners, presenters, authors, and faculty (including conflict of interest information, etc.) in alphabetical order
e. Content of activity (such as handouts, Power Point lectures, outlines, etc.) (NOTE: if the activity is more than 3 contact hours, submit the Educational Planning Table with a minimum of 3 hours of content along with the schedule and advertising for the full activity)
f. Disclosure Form
g. Evaluation Form
h. Certificate of Completion (NOTE: First time applicants should prepare and submit a sample certificate of completion containing the accreditation statement to be used once approval is attained.)
i. All marketing and promotional materials demonstrating use of ANCC approval statement;
j. Signed written commercial support agreement (if applicable);
k. Co-provider agreement (if appropriate);
l. List of participant names and contact information (DO NOT collect or use Social Security numbers)
m. Summary of evaluation results
n. Follow up form (if used) describing actions taken as a result of CE activity evaluation results
Activity files selected for submission with the self-study should demonstrate a variety of different types of educational activities including but not limited to as appropriate:
· Live educational activities
· Web-based or enduring materials
· Activity that was co-sponsored
· Activity that received sponsorship or commercial support
· Activity with multiple presenters or topics