ANCC MANUAL AND AzNA UPDATE FOR

APPROVED PROVIDERS

August 2012

Cyndie Koopsen, RN, BSN, MBA, HNB-BC, RN-BC

AzNA CE Review Coordinator

OBJECTIVES

At the conclusion of this session, participants will be able to:

Describe key updates and compliance issues related to new 2013 ANCC manual.

Describe the four components of the accreditation conceptual framework

Describe the process for developing activities in adherence with 2013 ANCC accreditation criteria

Compare and contrast requirements and criteria of the 2009 manual and the 2013 manual

Identify characteristics of strong documentation using a narrative format

Describe the application and review process for applicant and accredited providers

State annual reporting requirements for Accredited Providers

DOCUMENTS FOR SESSION

Provider Unit Activity Review Form AzNA Approved Provider Application AzNA Approved Provider Instructions Sample Responses CE Activity Summary

For additional information www.aznurse.org for updatesAzNA Today newsletter (bi-monthly)Arizona Nurse magazine (quarterly)

PRIMARY ACCREDITATION FRAMEWORK

Nursing Professional

Development Continuing Education

Structural CapacityCommitmentAccountability

Leadership Resources

Educational Design ProcessNeeds Assessment

PlanningDesign Principles

Achievement of Objectives

Quality OutcomesEvaluation Process

Evaluation ParticipationGoals for Improvement

Value/Benefit to Nursing Professional Development

APPLICATION OVERVIEW Eligibility Requirements—unchanged Primary Nurse Planner requirements--

unchanged Overall Structure of Self-Study—complete

revision Major criteria...Approved Provider…

Meets eligibilityActivities have meritSelf-study reflects quality in CE process

ORGANIZATIONAL OVERVIEW (OO)

Provides context for understanding the organization

Replaces Executive Summary and Self-Assessment

No Mission Statement requiredOrganizational chart, flow chart, or similar

image still required

COMPLIANCE ATTESTATION STATEMENT Attestation statement is present and is signed and dated.

Appraisers then evaluate the applicant organization in relation to the components of the attestation statement, which may include but are not limited to:

Complaints about the applicant organization as an entity, the quality of educational activities offered (accredited provider) or the quality of activities approved (accredited approver).

The organization’s response to complaints about its products or services from stakeholders or customers.

Congruence between narrative explanations in the self-study documents and evidence found in other documents, on web sites, in verbal descriptions from staff, learners, customers, presenters, etc.

Adherence to laws and regulations such as the Americans with Disabilities Act, Rehabilitation Act, harassment and discrimination laws, and laws and regulations related to copyright, trademarks or intellectual property.

EDUCATIONAL DESIGN PROCESS

New designRequirements for planning, implementing

and evaluating educational activities according to accreditation criteria

ANCC’s definition of eligible CE content: Generalizable beyond employer setting

(“transferrable”) Beyond basics for the professional registered nurse Evidence-based/based on best-available evidence

No minimum requirement for contact hours

ASSESSMENT OF LEARNER NEEDS

Variety of methods – no “right way” Method must be appropriate for your

target audience Identify and validate a gap in

knowledge, skills or practice for target audience

Evidence must be included in activity file documentation

NURSE PLANNER AND ONE OTHER PLANNER

Key role in all planning Must adhere to ANCC accreditation criteria Education expertise/experience—must be documented Target audience member requirement removed NP reviews:

Faculty/presenters/authors Content reviewers Content experts Target audience—is it appropriate? Documentation of biographical data/qualifications for role on

committee Assessment of conflicts of interest

Nurse Planner---another planning committee member must review bio form and validate no NP COI

All individuals having the opportunity to influence content must be evaluated for potential conflicts of interest

CONFLICT OF INTERESTDefinition

Relationships with commercial interest organizations Include spouse/significant other Past 12 months

Evaluation No relationship (of person/spouse now or during past 12 months) Relationship present (or in past 12 months), not relevant to content, no

resolution required (ex. Relationship w/ pharma but content is leadership, so COI relationship not relevant)

Relationship present, relevant to content, resolution required (ex. Relationship w/pharma making asthma drugs but content is on cardiac drugs)

Resolution and Assessment Remove individual with relationship Revise role for individual with relationship Don’t award contact hours Review content for bias before activity and monitor activity Review content for bias before activity and evaluate participant feedback

EDUCATIONAL DESIGN PROCESS

Teaching/learning strategies Methods used to teach Learner feedback mechanism

Successful completion & criteria for determining with rationale

Method to ensure content integrity and prevention of bias (if financial or in-kind support accepted)

Activity Purpose—learner focused (not provider focused) Content—based on current available evidence Evaluation

Short-term Long-term Congruent w/purpose of activity (ex. Practice change is not “short-

term”) Category of evaluation—No longer required

Accreditation statement Certificate of completion Marketing materials

COMMERCIAL SUPPORT VS. SPONSORSHIP

Commercial Support: financial or in-kind contribution given by a commercial interest that is used to pay for all or part of an educational activity

Sponsorship: financial or in-kind contribution given by a non-commercial interest organization that is used to pay for all or part of an educational activity

Money for exhibit space is not considered commercial support or sponsorship

The organization providing commercial support or sponsorship may not co-provide the educational activity

Commercial support or sponsorship agreement required

EDUCATIONAL DESIGN PROCESS

Disclosures Required:

Requirements for successful completion including purpose or objectives (ex. Attend all of activity)

Criteria used to determine successful completion (ex. Complete and submit evaluation form)

Presence or absence of conflicts of interest If applicable:

Commercial supportSponsorshipNon-endorsement of products (provider and

ANCC)Expiration date (enduring materials only)Off label use—no longer required

QUALITY OUTCOMES

PU’s process for evaluating effectiveness of unit (vs. courses)

PU’s strategic goals for past 12 months Input from specific stakeholders and why

these stakeholders participate in evaluation process

Quality outcome measures specific to PU for next 12 months

Quality outcome measures specific to Nursing Professional Development for next 12 months

QUALITY OUTCOMES (CONT’D)

Sample Provider Unit Outcome Measures Cost savings for customers Cost savings for PU # of participants in CE activities # of CE activities Staff/volunteer satisfaction Learner satisfaction Faculty satisfaction Change in format of CE activities to meet learner needs Change in operations to achieve strategic goals Operational improvements Quality/cost measures Turnover/vacancy for PU staff/volunteers Professional development opportunities for

staff/volunteers

QUALITY OUTCOMES (CONT’D)

Sample Nursing Professional Development Goals and OutcomesProfessional practice behaviorsLeadership skillsCritical thinking skillsNurse competencyHigh-quality care based on best-available

evidence Improvement in nursing practice Improvement in patient outcomes Improvement in nursing care delivery

DOCUMENTATION OVERVIEW

Self-Study and Activity FilesSubmit by due dateSelf-study is narrative response with supporting

evidence/example for each criterion Evidence/examples may be chosen from

supplemental files submitted if desired, but not required

Activity files are chosen by AzNA Representative of different types of activities (as

applicable)“live” activityEnduring material activityWeb-based activityCommercial support/sponsorship activity

WRITING THE NARRATIVES & EXAMPLES Narrative documentation with supporting

evidence/examples “Telling a story” “Description of the wonderful work done by your

organization for registered nurses” Examples may be chosen from supplemental

activity files but may also come from other activities or work done within the organization “Describe” – tell the story “Demonstrate” – provide evidence to substantiate

the story

SAMPLE REVIEW & DISCUSSION Handout (“Sample Responses”)

TIPS FOR WRITING YOUR RESPONSE

Pause and reflect on the intent of the question Answer the question directly Do not add unnecessary extraneous

information (do not “data dump”) If an individual’s name is used in the

narrative, indicate the position/title of the individual to ensure the reader can follow the response

Give enough background/context for the reader to understand the response

Ask several colleagues to read the responses and tell you if they make sense

HOW WRITTEN DOCUMENTATION IS EVALUATED

Threshold not met—organization is not ready to proceed forward; approval deferred to CE Coordinator; summary report provided to the organization regarding strengths and deficiencies

Additional documentation required—additional clarification is required to demonstrate adherence to accreditation criteria and determine whether threshold has been met

Threshold met—approval granted; final email and letter sent to AzNA Approved Provider

ANNUAL REVIEW REQUIREMENTS Annual Approved Provider Continuing

Education Summary Form Annual activity documentation Annual documentation requested by

AzNA (progress reports, response to complaints, or similar)

QUESTIONS?