1 CENTER FOR NURSING EXCELLENCE Provider Unit Information APPLICATION FOR FACULTY DIRECTED CONTINUING EDUCATION ACTIVITY Primary Nurse Planner for BWH Nursing Provider Unit: Deborah Farina Mulloy, PhD, RN, Associate Chief Nurse, Quality and Center for Nursing Excellence; 1620 Tremont Street, Boston, MA 02120: ; Alternate Primary Nurse Planner for BWH Nursing Provider Unit: Linda A. Evans, PhD, RN, Nursing Program Director, Center for Nursing Excellence; 1620 Tremont Street, Boston, MA 02120: ; Please Completed application to: Does the content of the educational activity enable the learner to acquire or improve knowledge or skills beyond basic knowledge and enhance professional development or performance of the nurse? Yes No (if No, contact Primary Nurse Planner) Is the content of the educational activity generalizable regardless of the employer? Yes No (if No, contact Primary Nurse Planner) Has this educational activity been submitted for continuing education credits in disciplines other than nursing? Yes No If yes, please describe: Has this program been approved by another ANCC Provider? Yes No If yes, Please list: CONTACT PERSON FOR THIS ACTIVITY: Name & Credentials: Address: Daytime Phone including extension: Address:
2 Section #1 Demographic Information Program # Presentation location: Program Date (s): (for CNE to designate) Time of Program (ex 9:00-10:00 am): Title of your Program: Total # of Attendees: Live Presentation Yes No (BWH is accepted for all onsite programs) Packaged Program (enduring, video, online) Yes No Contact Hours: Contact hours are awarded to participants for those portions of the activity devoted to didactic or clinical experience and to the evaluation components of the activity. One contact hour equals 60 minutes. Contact hours may be awarded in ½ hour increments. If rounding is desired, contact hours will be rounded down. Goal of your Program: What the learner will be able to do at the end of the learning activity? Section #2 Planning Committee Please complete the table below for each person on the planning committee and include name, educational degree(s), credentials, and role on the planning committee. Planning committees must have a minimum of two members: a Nurse Planner (BSN prepared or higher) and one other planner (nurse or non-nurse) There are 3 roles on the planning committee: Nurse Planner, Target Audience Representative, Subject Matter Expert. The Nurse Planner may also be the Subject Matter Expert. The Nurse Planner must be knowledgeable regarding CE process and is responsible for adherence to the ANCC criteria. Each member of the planning committee must submit a Biographical/Conflict of Interest Form. Click here for a Biographical Data Form. Committee Member Name Credentials Degrees Role on Committee Nurse Planner Target Audience Representative Subject Matter Expert
3 Primary Nurse Planner who supported the planning committee of this activity: Linda A. Evans, PhD, RN, Nursing Program Director, Center for Nursing Excellence; 1620 Tremont Street, Boston, MA 02120: ; Dr. Evans is current on criteria set forth by ANCC and the Northeast Multi-State Division Section #3 Faculty/Presenters/Authors Faculty/Presenters/Authors must have qualifications that demonstrate their education and/or experience in the content area they are presenting. Expertise in subject matter can be evaluated based on education, professional achievements and credentials, work experience, honors, awards, professional publications, etc. Faculty/Presenters/Authors do not have to be nurses, but nurses should address nursing care and nursing implications, as applicable. Each faculty/presenter/author must submit a Biographical/Conflict of Interest Form. Click here for a Biographical Data Form. Faculty/Presenter/Author Name Credentials Degrees Qualifications of Faculty/Presenters/Authors supported by: (Check all that apply). Content expertise Demonstrated comfort with teaching methodology (e.g., web-based, etc.) Presentation skills Familiarity with target audience Other Describe: of resume/cv of faculty/presenter/author. Recommendation by colleagues. of literature written by faculty/presenter/author. Observation of previous presentation by faculty/presenter/author. New faculty/presenter/author being mentored by:
4 Section #4 Assessment of Learner Needs: 1. Identify the target audience: All RNs Advance Practice Nurses Nurses in Specialty Areas (Identify Specialty): LPNs Inter-professional (Describe; for example MD, SW, PT, and OT): Other - (Describe; for example unlicensed assistive personnel): 2. Type of needs assessment method used to plan this activity? (Check all that apply) Surveying stakeholders, target audience members, subject matter experts or similar Requesting input from stakeholders such as learners, managers, or subject matter experts ing quality studies and/or performance improvement opportunities ing evaluations of previous educational activities ing trends in literature, law and health care 3. Indicate source of supporting evidence for needs assessment data. (Check all that apply) Annual employee survey Literature Outcome Data Periodic surveys of stakeholders or learners Quality Data Requests (e.g., via phone, in person or by ) Written evaluation summary requests Needs assessment data is attached Section #5 Program Design 1. Gap Analysis: (Based on the needs assessment) Gap in Knowledge (knows) Gap in Skills (knows how) Gap in Practice (shows/does) 2. Purpose: State the purpose in relation to the outcome desired of the learner at the conclusion of the activity. This can be a restatement of your goal on page 2 and should be congruent with your desired learning outcome.
5 3. Evidence Base of Content: (i.e. Current References, literature, web source, expert resource, organizational expertise etc): 4. Learner Feedback: Learners will be provided feedback via: Question and answers during activity. Self-check questions. Engaging learners in dialogue. Return results of testing. Return demonstration Role play 5. Successful Completion of Education Activity: A. Criteria for successful completion for live and enduring material/web-based activities include: (Check all that apply) Attendance at entire event or session Completion/submission of evaluation form Completion of a Pre and Post Test Return demonstration B. Rationale for method selected above to determine successful completion: (Check all that apply) Method of evaluation selected Importance of content knowledge Importance of content application Required by employer or organization C. Contact Hour Calculation: What was the method for calculating the contact hours? (Select one) Pilot Study Historical Data
6 Complexity of content and data Request of target audience 5. Verify Participation Attendance/participation will be verified through sign in sheets/registration form. Signed attestation by participant verifying completion of entire or part of the activity. Collection of participation electronic verification via HealthStream. No partial credit is awarded Contact hours awarded based on # of sessions attended Section #6 Evaluation A. Check or describe the methods of evaluation to be used: (Check all that apply) Evaluation Form Pre and/or Post-test (Attach a copy if testing is to be used) Return Demonstration Case Study Analysis Role Play Longitudinal study with self-reported change in practice (long term method) Data Collection related to quality outcome measure (long term method) Observation of performance in practice (long term method) Other Describe: (Attach a copy) B. Upon completion of the activity, a summative evaluation is generated and will be reviewed to assess the activity's effectiveness by the Nurse Planner and to identify how results may be used to guide future educational activities. Section #7 Activity Approval Statement for Publicity Materials All communications, marketing materials, certificates, and other documents that refer to awarding contact hours or continuing education credit for an individual educational activity must include the following statement. The statement must be displayed clearly to the learner and must be worded as written below. The accreditation/approval statement must stand alone on its own line of text. When referring to contact hours, the term "awarded is used. Brigham and Women s Hospital is an Approved Provider of continuing nursing education by the Northeast Multistate Division, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. Type of advertising used: Flyer/brochure Memo/Letter Meeting Notice Web site Social Media Other - Describe
7 Copy of advertising materials must be included in the activity file. Section #7 Commercial Support and Sponsorship A commercial interest is defined by ANCC as any entity either producing, marketing, re-selling, or distributing health care 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 health care goods or services consumed by, or used on, patients. Exceptions are made for non-profit or government organizations and non-health care related companies. Commercial Support is financial, or in-kind contributions given by a commercial interest, which is used to pay all or part of the costs of a CNE activity. A sponsor is identified as an organization that does not meet the definition of commercial interest. Sponsorship is financial, or in-kind, contributions given by an entity that is not a commercial interest, which is used to pay all or part of the costs of a CNE activity. Commercial support or sponsorship will be received Yes No If No, skip to Section #8 Disclosures If Yes, complete items A, B, C, D and attach the signed agreement(s). A. Commercial support/sponsorship will be provided by the following: Name of Organization Funding or In-Kind Donation Type of Organization (commercial interest or non-commercial interest) B. Content integrity will be maintained by: (Check all that apply) The commercial support/sponsorship policy/procedure has been discussed with those providing commercial support or sponsorship. The commercial support/sponsorship policy/procedure has been shared in writing with those providing commercial support/sponsorship. Faculty/Presenters/Authors have been informed of the policy/procedure re: commercial support and sponsorship and agree to not promote the products or entity providing the financial or in-kind services. In conjunction with above, the session will be monitored and violators of policy will not be asked to present again. C. Bias will be prevented by: (Check all that apply). Commercial support/sponsorship and bias has been discussed with each presenter. Each Faculty/Presenter/Author has signed a statement that says s/he will present information fairly and without bias. In addition to the above, the session will be monitored and violators of policy will not be asked to present again. D. Signed commercial support or sponsor agreement attached.
8 Section #8 Disclosures Learners must receive disclosure of required items prior to the start of an educational activity. In live activities, disclosures must be made to the learner prior to initiation of the educational content. In enduring materials (print, electronic, or Web-based activities), disclosures must be visible to the learner prior to the start of the educational content. If a disclosure is provided verbally, an audience member must document both the type of disclosure and the inclusion of all required disclosure elements. A. Disclosures always required: 1. Successful Completion: Purpose and/or objectives and criteria for successful completion Information on advertising material. Written information on handouts for activities/directions (Attach copy). Verbal statement and someone in the audience will witness and document the verbal Disclosure. (Reminder: place a signed notation in the file to describe the verbal disclosure) Slide visible to all participants (Attach copy) (Attach copy) 2. Absence or Presence of Conflict of Interest for planners and faculty/presenters/authors/content reviewers disclosed to learners by: Information provided in advertising. Slide visible to all participants (Attach Copy) Information provided on handouts. (Attach copy) Information provided in print at the start of the non-live activity (Attach copy) Verbal statement and someone in the audience will document the verbal disclosure (Reminder: place a signed notation in the file to describe the verbal disclosure) (Attached copy) Planners disclose a conflict of interest relative to this educational activity. List name(s): Faculty/Presenters/Authors/Content ers disclose a conflict of interest relative to this educational activity. 3. Commercial support: Not applicable Slide visible to all participants (Attach Copy) Information provided in advertising. Information provided in handouts. (Attach copy) Information provided in print at the start of the non-live activity (Attach copy) Verbal statement and someone in the audience will document the verbal disclosure (Reminder: place a signed notation in the file to describe the verbal disclosure) Slide visible to all participants (Attached copy) 4. Sponsorship: Not applicable Information provided in advertising. Information provided in handouts. (Attach copy) Information provided in print at the start of the non-live activity (Attach copy) Verbal statement and someone in the audience will document the verbal disclosure (Reminder: place a signed notation in the file to describe the verbal disclosure)
9 (Attached copy) 5. Non-endorsement of products discussed/displayed in conjunction with this activity: NO Products are being displayed. (No statement needed.) Information provided in advertising. Information provided in handouts. (Attach copy) Information provided in print at the start of the non-live activity (Attach copy) (Attach copy) 6. Expiration date for awarding enduring materials contact hours visible to the learner prior to the start of the educational content Not applicable - not enduring material Learners notified how long contact hours will be awarded for the activity on advertising. Learners notified how long contact hours will be awarded for the activity on directions page. Section #9 Documentation of Completion Learners receive documentation of successful completion of the educational activities. Document/certificate must include: Name and address of provider of the educational activity (Web address acceptable) Title and date of completion of educational activity Number of contact hours awarded Official approval/accreditation statement Name of learner Section #10 Record Keeping Records filed and stored at The Center for Nursing Excellence Activity file records must be maintained in a retrievable file (electronic or hard copy) accessible to authorized personnel for 6 years. Section #11 Joint Providership This activity will not be Joint Provided with another institution or provider unit. (Go to Section #12) This activity will be Joint Provided with another institution or provider unit: A. Joint Provider(s): B. If Joint-Provided the following is required: Name of Approved Provider is prominently displayed in all marketing material and certificates The name(s) of the organization(s) acting as the co-provider(s) Statement of responsibility of the Approved Provider, which must include: Determination of educational objectives and content
10 Selecting planners, presenters, faculty, authors and/or content reviewers Awarding of contact hours Recordkeeping procedures Developing evaluation methods and categories Management of commercial support or sponsorship Name and signature of the individual legally authorized to enter the agreement on behalf of the Approved Provider Name and signature of the individual legally authorized to enter into contracts on behalf of joint provider(s) Date the agreement was signed Section #12 Content Outline (Name and Credentials) (Name and Credentials) (Name and Credentials) Educational Planning Table/CONTENT ACTIVITY FORM LIVE PRESENTATIONS OBJECTIVES CONTENT (Topics) TIME FRAME List learner s objectives in behavioral terms. Use Bloomberg s Taxonomy for a Reference Beginning of Program Activities Provide an outline of the content for each objective. It must be more than a restatement of the objective. 1. Mandatory Announcements 2. Disclosures 3. Learning Objectives 4. Criteria for successful completion of program State the time frame for each objective in Minutes (DO NOT include this cell in calculation of contact hours) PRESENTER List the Faculty for each objective. Please put credentials TEACHING METHODS Describe the teaching methods, strategies, materials & resources for each objective End of Program Activities 1. Evaluation process 2. Evaluation time frame 3. Evaluation (Include time allotment in this cell in calculation of contact hours)
11 Section #13 : Nurse Planner Signature Name/credentials attesting to adherence of ANCC requirements: Date: Brigham and Women s Hospital is an Approved Provider of continuing nursing education by the Northeast Multistate Division, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation.