1 APPROVED PROVIDER GENERAL EDUCATION PLANNING FORM Name of Provider Unit: A. General Information: a. Title of Activity: b. Date Form Completed: c. Activity Type: Provider-directed, provider-paced: Live (in person or webinar) o Date of live activity: Provider-directed, learner-paced: Enduring material o Start date of enduring material: o Expiration/end date of enduring material: Blended activity o Date(s) of enduring materials (e.g. pre-work): o Date of live portion of activity: Learner-directed, learner-paced: (Must have Nurse Planner oversight) o Date (s) of live activity: Name of Nurse Planner Supervising activity: d. Nurse Planner contact information for this activity. Name and credentials: Note: The Nurse Planner (NP) must be a registered nurse who holds a current, unencumbered nursing license AND hold a baccalaureate degree or higher in nursing (or international equivalent) AND be actively involved in planning, implementing and evaluating this continuing education 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 anrn.) Other Committee members may include: Faculty/Presenters/Authors Other Nurse Planners Feedback Personnel (for Independent Studies) Note: A Content Reviewer is not included on the planning committee. The purpose of a 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. PNP, Content Expert, Other) and, Complete all applicable sections. The PNP MUST evaluate each one for possible conflict of interest and intervene if warranted. 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. Attachment A: Individuals in Position of Control Content C. Assessment of Learner Needs 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. 1
2 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.) Describe the professional practice gap (e.g. change in practice, problem in practice, opportunity for improvement) a. Describe the current state: b. Describe the desired state: c. Identified gap: D. 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: Please provide a brief summary of data gathered that validates the need for this activity: 2
3 E. Educational need that underlies the professional practice gap (e.g. knowledge, skill and/or practices) Gap In Knowledge (knows) Gap in Skills (knows how) Gap in Practice (shows/does) Other (Describe): F. Description of the target audience. (You can select more than one target audience). All RNs Advance Practice RNs RNs in Specialty Area: (Identify Specialty): LPNs Interprofessional (Describe): Other (Describe): G. Desired learning outcome(s) (What will the outcome be as a result of participation in this activity?) a. Where was the impact area of the learning outcome (check all that apply): Nursing Professional Development Patient Outcome Other Describe: H. Outcome Measure(s) (A quantitative statement as to how the outcome will be measured): I. Content of activity: A description of the content with supporting references or resources a. Content for this educational activity was chosen from: Information available from the following organization/website 3
4 Information available through peer-reviewed journal/resource Clinical guidelines (example - www.guidelines.gov): Expert resource (individual, organization, educational institution) (book, article, website) Textbook reference: Other: J. Learner engagement strategies K. Criteria for Awarding 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. The minimum number of contact hours to be awarded is 0.5 (30 minutes). Contact hours can be calculated to the hundredths (i.e. 1.45, 0.91, etc.) They may not be rounded up! a. Criteria for awarding contact hours for live and enduring material activities include: (Check all that apply) Attendance for a specified period of time (e.g., 100% of activity, or miss no more than 10 minutes of activity) Credit awarded commensurate with participation Attendance at 1 or more session Completion/submission of evaluation form Successful completion of a post-test (e.g., attendee must score % or higher) Successful completion of a return demonstration Other - Describe: 4
5 b. If a Faculty Directed Activity is Two Hours or Less. (Insert the amount of time, in minutes, for each applicable section): Content Pharmacotherapeutic time/content if applicable Testing/return demonstration Evaluation c. If a Faculty Directed Activity is Greater Than Two Hours; Include an Agenda (Welcome, introductions, breaks, tours, and non-education components do not count.) The agenda is attached. Page: d. 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.) e. Show Evidence of How Contacts Hours Were Calculated (i.e., 240/60 = 4 contact hours) L. Description of evaluation method: Evidence that change in knowledge, skills and/or practices of target audience was assessed a. Short-term evaluation options: Intent to change practice Active participation in learning activity Post-test Return demonstration Case study analysis Role-play Other Describe: 5
6 b. Long-term evaluation options: Self-reported change in practice Change in quality outcome measure 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 M. Quality Improvement Process or Form for End of Activity. Copy of QI FORM OR PROCESS attached. Page: N. 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: 6
7 O. Joint-Providership This activity will not be jointly provided. 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: P. 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: E-mail Attached Page: Website Attached Page: Social media Attached Page: Other Attached Page: Describe: Q. 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. ) a. The following are required on ALL Disclosures: Criteria for successful completion; Presence 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 The disclosure is attached. Page: 7
8 R. 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: S. 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. Attachment B: WSNA-A-CNE Checklist for Activities 8