I authorize inclusion of this CNE activity in the published WSNA CNE calendars.

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1 Washington State Nurses Association (WSNA) AA/IA-App Approver of Continuing Nursing Education (A-CNE) Individual Educational Activity Application 2015 Criteria (current) ELECTRONIC copy of the application must: Use WSNA A-CNE forms only Have a table of contents; Pages numbered consistent with the table of contents; Electronically submit one complete application packet to Date Received: For Office Use Only Amount Received: Check Number: A-CNE #: CAUTION: WSNA-A-CNE guidelines/forms are periodically updated; therefore, check that you are using the most current Revised Guidelines located on the WSNA A-CNE website: PLEASE NOTE THAT TO ASSIST YOU SHOULD YOU WISH TO APPLY FOR AN APPROVED PROVIDER STATUS CRITERIA (NUMBERS/LETTERS) ARE NEXT TO THE CRITERIA YOU WILL USE TO WRITE THE APPROVED PROVIDER APPLICATION. Is this continuing education? Is this learning activity intended to build upon the educational and experiential bases of the professional RN for the enhancement of practice, education, administration, research, or theory development, to improve the health of the public and RNs pursuit of their professional career goals? Yes No If no, the activity is not eligible for approval. If no, this activity is not eligible for approval. I authorize inclusion of this CNE activity in the published WSNA CNE calendars. Applicants interested in submitting an individual educational activity for approval must complete: Individual Activity Applicant Eligibility Verification Form, Individual Activity Applicant Eligibility Commercial Interest Addendum (if applicable), This form - Individual Educational Activity Application Applicant' s Name, title and credentials: 1

2 Criterion 1: Structural Capacity Individual Activity Application A. Provider Demographics: a. Name of Organization: b. Organization Address: City State Zip/Postal Country c. Identify Organization Type: Constituent Member Associations of ANA College or University Healthcare Facility Health - Related Organization Multidisciplinary Educational Group Professional Nursing Education Group Specialty Nursing Organization Other: d. Title of Activity: e. Date Form Completed: f. Number of contact hours requested: g. Activity Type: Provider-directed, provider-paced: Live (in person or webinar) o Date of live activity: Provider-directed, learner-paced: Enduring material o o Start date of enduring material: Expiration/end date of enduring material: Blended activity o o Date(s) of enduring materials (e.g. prework): Date of live portion of activity: 2

3 h. Activity Contact (Must be a Nurse Planner for this activity otherwise review will not proceed and application will not be accepted): Name, degree, and credentials: Note: Nurse Planner (NP) must be a currently licensed registered nurse with a baccalaureate degree or higher in nursing, is responsible for adherence to ANCC & WSNA A-CNE criteria; and be actively involved in planning, implementing and evaluating this CNE activity. B. Planning Committee Members Planners must include a minimum of two individuals: 1) The Nurse Planner (NP) with knowledge of ANCC & WSNA A-CNE CNE criteria and process and, 2) One other planner with relevant content expertise. (The second planner does not have to be an RN.) Other Committee members may include: Faculty/Presenters/Authors Other Nurse Planners Feedback Personnel (for Independent Studies) Each Planner must complete a BIO/COI Data Form (AA/IA-BIO/COI). Instructions: List the name, degrees (i.e., BSN, MN), credentials such as licensure, and/or certifications (i.e., RN, APRN, CNS, CCRN) for every planner. Check the appropriate box at top of the Bio Data Form, indicating the respective Planner Role(s) (i.e. NP, Content Expert, Other) and, Complete all applicable sections. The NP MUST evaluate each one for possible conflict of interest and intervene if warranted. Note: A Content Reviewer is not included on the planning committee. The purpose of a content reviewer is to evaluate a speaker(s) in an educational activity during the planning process or after it has been planned but prior to delivery to learners, for quality of content, potential bias, and COI. a. Nurse Planner Name, degree(s),credential(s): Daytime Phone number: FAX Number: Ext. Bio&COI Data Form (completed, dated, signed) is attached. Page b. Content Expert Planner (Has relevant content expertise for the activity being offered. (Does not have to be an RN) Name, degree(s), credential(s): 3

4 Bio Data Form describes the relevant content expertise of the Content Expert (i.e., education, experience, certification, publication, research) Bio & COI Data Form with potential or real or resolution COI (completed, dated, signed) is attached. Page: c. Other Planners (see WSNA attachment A)Complete this table for each person in a position to control content of the educational activity. There must be a NP and one other planner with expertise for theducational activity List name(s), degree(s), credentials, nature of relationship of all planners on WSNA attachment A. Page: d. Content Reviewer (Optional Role and not included on the planning committee. Does this activity have a Content Reviewer? Yes No If yes, list name, degree(s), Credential(s) Bio &COI Data Form(s) with potential or real COI (completed, dated, signed) is attached. Page: Criterion 2: Educational Design Process A. Assessment of Learner Needs Which needs assessment method(s) and supporting needs data were used to plan this activity? NOTE: Evidence of needs assessment data sources and findings must be retained in the activity file and be available to WSNA A-CNE upon request. Identify the applicable missing gap(s): the difference (gap) between actual and desired knowledge, skills, practice that will be addressed by this educational activity. This is based upon analysis of the needs assessment data. (Only address those gaps that are applicable for this activity.) a. Describe the learner s current state. What is the problem? (EDP1) b. Describe the desired state: c. Identified gap: 4

5 B. Evidence to Validate the Professional Practice Gap (check all methods/types of data that apply) Survey data from stakeholders, target audience members, subject matter experts or similar Input from stakeholders such as learners, managers, or subject matter experts Evidence from quality studies and/or performance improvement activities to identify opportunities for improvement Evaluation data from previous education activities Trends in literature, law and health care Direct observation Other Describe: a. Please Provide a Brief Summary of Data Gathered that Validates the Need for this Activity: C. Educational Need that Underlies the Professional Practice Gap (e.g. knowledge, skill and/or practices) (EDP2) Gap In Knowledge (knows) Gap in Skills (knows how) Gap in Practice (shows/does Other (Describe): D. Description of the Target Audience (check all that apply): All RNs Advance Practice RNs RNs in Specialty Area: (Identify Specialty): LPNs Interprofessional (Describe): Other (Describe): E. Desired learning Outcome(s): (What will the outcome be as a result of participation in this activity?) What is the desired learning outcome for the learner? What should the nurse be able to do or achieve after participating in this event? (Be sure this is congruent with A through D above.) a. Area of Impact (check all that apply): Nursing Professional Development Patient Outcome Other Describe: 5

6 F. Outcome Measure (A quantitative statement as to how the outcome will be measured): G. Content of Activity. (A description of the content with supporting references or resources (EDP4) Educational Planning Table (See WSNA attachment B) Page: H. Content for this Educational Activity was Chosen From (references should be within past 5-7 years): Information available from the following organization/web site: Information available through peer-reviewed journal/resources: Clinical Guidelines (e.g. ): Expert Resource (Individual, organization, educational institution, book, article): Textbook Reference Other: I. Learner engagement strategies (EDP5): See Educational Planning Table (WSNA attachment B). Page: J. Contact Hours: Contact hours are awarded to participants for those portions of the educational activity devoted to didactic or clinical experience and to evaluating the activity. The appropriate measure of credit is the 60-minute contact hour. If rounding is desired in the calculation of contact hours, the provider must round down to the nearest 1/10th or 1/100th (e.g., should be 2.75 or 2.7, not 2.8). They may not be rounded up! Educational activities may also be conducted asynchronously and contact hours awarded at the conclusion of the activities. Time frames must match and support the contact hour calculation for live activities. Evidence may include, but is not limited to, agenda for the activity, outline of content to be delivered in the activity, and/or other marketing materials. Time for breaks and meals should be clearly delineated and not included in total contact hours awarded. For enduring materials such as print, electronic, web-based, etc., the emthod for cacluating the contact hours must be identified. The method may include, but is not limited to, a pilot study, historical data, or completity of content. Criteria for Awarding Contact Hours (Consistent with outcome, content, and learning strategies). Check all that apply: a. Attendance for a specified period of time (e.g., 100% of activity, or miss no more than 10 minutes of activity) 6

7 Credit awarded commensurate with participation Attendance at 1 or more sessions Completion/Submission of evaluation form Successful completion of post test (e.g. attendee must score % or higher) Successful completion of a return demonstration Other Describe: b. Independent Study Activity. How were the contact hours calculated (Check the best description that applies): Pilot Study Historical Data Mergener Formula Other: Describe: Note: Identify Pharmacotherapeutic minutes or hours if the activity is for APRNs and the content relates to pharmacotherapeutics. (Refer to the Guidelines for more information.) c. Show Evidence of How Contact Hours Were Calculated (i.e., 240/60 = 4 contact hours) K. Evaluation. Check the method(s) of Evaluation (EDP6 & 7) a. Short-Term Evaluation Options: Active participation in learning activity Post-test Return demonstration Case study analysis Role-play Other Describe: Copy of Evaluation attached. Page: b. Long-Term Evaluation Options: Self-reported change in practice Change in quality outcome measure 7

8 Individual Activity Application Return on Investment (ROI) Observation of performance Other Describe: NOTE: A copy of a summative evaluation must be kept in the activity file for six years. A summative evaluation is the compilation of the results of the learners comments in a statistical format and a listing of all comments made by the learners. E.g.: if ten participants stated they met outcome 1, you would insert the number L. Quality Improvement Process or Form for End of Activity. Copy of QI attached. Page: M. Commercial Support: A commercial interest is defined by ANCC as any entity either producing, marketing, re-selling, 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, re-sells or distributes healthcare goods or services consumed by, or used on, patients. Exceptions are made for non-profit 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 - A provider of commercial support may not be on an educational planning committee, be a joint-provider of the activity, or the provider of the activity. - If commercial support is provided for a CE activity, an employee from the organization providing commercial support may not be a speaker. Note: You are not required to have a commercial support agreement for those who are only exhibiting at the event. This activity has no commercial support. Commercial support has been provided by the following: (List name of organization(s): Signed commercial support agreement attached. Page: N. Joint-Providership This activity will not be jointly provided, OR Joint providership of this activity has been arranged with: (List organization name): As the educational provider, we will maintain responsibility for adherence to criteria for this activity Our name as the educational provider and the names of the joint providers will be prominently listed in advertising. The signed, dated, written joint-provider agreement is attached. Page: 8

9 L. Advertising: Check all that apply: Attach a copy of each one checked including relevant pages off the web site (if applicable) Flyer/brochure. Attached Page: Memo/letter Attached Page: Attached Page: Website Attached Page: Social media Attached Page: Other Attached Page: Describe: M. Written Disclosures Provided to Activity Participants. Learners must receive written disclosure of required items prior to beginning the learning activity. (If a disclosure is provided verbally, an audience member must document both the type of a disclosure and the inclusion of all required disclosure elements. ) The following are required on ALL Disclosures: Criteria for successful completion; Presence or absence of conflict of interest for planners, presenters, faculty, authors and content reviewers. Must disclose name of individual, name of commercial interest, and nature of the relationship the individual has with the commercial interest; Approved provider statement (see sample below); b. Include the following in relevant situations: Commercial support, if applicable (name of each supporter and nature of support); Joint Providers, if applicable (name of each provider); For independent study only include the expiration date for awarding contact hours NOTE: Select the appropriate Approved Provider Statement Prior to Approval (If contact hours are mentioned) This activity has been submitted to the Washington State Nurses Association Approver of Continuing Nursing Education (A-CNE) for approval to award contact hours. The Washington State Nurses Association Approver of Continuing Nursing Education (A-CNE) is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. Post Approval: All promotional/advertising material must include the following statement once application has been approved and contact hours are listed: This continuing nursing education activity was approved by the Washington State Nurses Association Approver of Continuing Nursing Education (A-CNE), an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation The disclosure is attached. Page: 9

10 N. Documentation of completion. Document/certificate must include: Name of learner Name and address of Approved Provider Unit (web address acceptable) Title & date of completion of educational activity Number of contact hours awarded Official Approved Provider Unit statement (see below) Include pharmacotherapeutic hours if applicable (e.g., 4 contact hours including 1.5 Pharm contact hours) A copy of the certificate is attached. Page: O. Recordkeeping and Storage System: All correspondence, a complete copy of the application form and all attachments and corrections, records of attendance, summative evaluation(s), contact hours and other items listed in the Guidelines for this activity will be maintained in a retrievable file (electronic) accessible to authorized personnel for six years 10