accrediting excellence in application manualeoplugin.commpartners.com/apic/110428/2009...

appLicationmanuaLAccreditation Program®

accredit ing excellence in cont inuing nurs ing educat ion

Published by American Nurses Credentialing Center 8515 Georgia Avenue Silver Spring, MD 20910-3492

© 2009 by American Nurses Credentialing Center, Silver Spring, MD 2009 edition. A Subsidiary of the American Nurses Association

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage or retrieval system, without permission of the publisher.

disclaimer Completing all the processes within the instructional manual facilitates the Accreditation Program® application process but cannot, in and of itself, guarantee approval.

noticeChanges may be made to the Accreditation Program® and this manual without prior notice. Applicants must confirm that they are using the most current edition of this manual prior to preparing written documentation for submission to the ANCC Accreditation Program® office. For current fee structures, policy and contact information, please see our web site at www.nursecredentialing.org/continuingeducation/accreditation.aspx.

taBLE oF contEntSNotes on This Version

Part one: Background information chapter 1ANCC’s Accreditation Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 History and Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Foundations and Core Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Current Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Continuing Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Educational Activities and Contact Hours . . . . . . . . . . . . . . . . . . . . . . . 7 Accredited Providers, Accredited Approvers, and Approved Providers . . . . . . . . . 7 The Self-Study Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Program Criteria, Key Elements, and Sources of Evidence . . . . . . . . . . . . . . . 10

chapter 2Overview of the ANCC Accreditation Process . . . . . . . . . . . . . . . . . . . . . . . . . 11 Bodies Involved in the Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Phases of the Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Budget Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Responsibilities of Accredited Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Part tWo: the accreditation Processchapter 3Applying for Accreditation as a Provider of Continuing Nursing Education . . . . . . . . . . . . 23 Assessing Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Signaling the Intent to Apply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Preparing the Written Documentation of Adherence to Criteria . . . . . . . . . . . . . 26 Provider Unit Criterion 1. Mission Statement . . . . . . . . . . . . . . . . . . . . . 30 Provider Unit Criterion 2. Educational Design . . . . . . . . . . . . . . . . . . . . . 31 Provider Unit Criterion 3. Unit Operations . . . . . . . . . . . . . . . . . . . . . . 37 Provider Unit Criterion 4. Unit Evaluation . . . . . . . . . . . . . . . . . . . . . . . 38 Submitting the Application Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

chapter 4Applying for Accreditation as an Approver of Continuing Nursing Education. . . . . . . . . . . 41 Assessing Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Signaling the Intent to Apply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Becoming Accredited as Both an Approver and Provider . . . . . . . . . . . . . . . . . . 44 Preparing the Written Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Approver Unit Criterion 1. Mission Statement . . . . . . . . . . . . . . . . . . . . . 46 Approver Unit Criterion 2. Approval Process . . . . . . . . . . . . . . . . . . . . . 47 Approver Unit Criterion 3. Unit Operations . . . . . . . . . . . . . . . . . . . . . . 54 Approver Unit Criterion 4. Unit Evaluation . . . . . . . . . . . . . . . . . . . . . . 55 Submitting the Application Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

chapter 5Site Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Site Visit Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Site Visit Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

chapter 6Accreditation Decision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Accreditation Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Deferrals, Denials, Reconsiderations, and Appeals . . . . . . . . . . . . . . . . . . . . . 63

chapter 7Interim Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65 Annual Reporting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65 Suspensions and Revocations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66 Voluntary Terminations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

chapter 8Applying for Re-Accreditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67 Streamlined Re-Accreditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

chapter 9The Unified Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77

appendicesA. Accreditation Program Contact Information . . . . . . . . . . . . . . . . . . . . . . . . .79 B. Standards for Disclosure and Commercial Support . . . . . . . . . . . . . . . . . . . . .81 C. Forms and Instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .89 2008/2009 Application Fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 Intent to Apply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92 Provider Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93 Approver Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98 D Annual Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105 E. Sample Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111 F. Approved Provider Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113 Provider Criterion 1. Mission Statement . . . . . . . . . . . . . . . . . . . . . . . . . .115 Provider Criterion 2. Educational Design . . . . . . . . . . . . . . . . . . . . . . . . . .116 Provider Criterion 3. Unit Operations . . . . . . . . . . . . . . . . . . . . . . . . . . .122 Provider Criterion 4. Unit Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . .123 G. Resolution of Conflict of Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125

list of Figures1. Structure of the ANCC Accreditation Program . . . . . . . . . . . . . . . . . . . . . . .2 2. Relationship between Continuing Education and Staff Development . . . . . . . . . . . . .6 3. Flowchart of Accreditation Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

list of tables1. Credentialing Options in the ANCC Accreditation Program . . . . . . . . . . . . . . . . .3 2. Foundational Documents for the ANCC Accreditation Program . . . . . . . . . . . . . . .4 3. Making the Decision Regarding the Credentialing Body . . . . . . . . . . . . . . . . . . .8 4. Steps Accomplished by Phase of the ANCC Accreditation Process . . . . . . . . . . . . . .14 5. Cost Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 6. Responsibilities of Accredited Approver and Accredited Provider Units . . . . . . . . . . . .18 7. Eligibility Criteria for Provider Applicants. . . . . . . . . . . . . . . . . . . . . . . . . .24 8. Overview of Provider Unit Criteria and Key Elements . . . . . . . . . . . . . . . . . . . .27 9. Eligibility Criteria for Approver Applicants . . . . . . . . . . . . . . . . . . . . . . . . .42 10. Overview of Approver Unit Criteria and Key Elements . . . . . . . . . . . . . . . . . . .45 11. Approval of Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 12. Accreditation Decision Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62

Notes on This Version

The ANCC Accreditation Program is committed to ensuring the integrity of the accreditation processes and the quality of the continuing nursing education being provided to nurses, as well as the quality of inter-professional continuing professional education where the nursing community is a major component. Approximately every 2 years, the Accreditation Manual is reviewed and revised, as appropriate. While every effort is made to ensure the manual provides clarity and comprehensiveness upon its publication, occasionally the changing environment necessitates a clarification or revision. The Commission on Accreditation (COA) is committed to providing the accredited units with ample notice and ample time to accommodate any needed revisions in the Accreditation Program criteria. If an emergent need for revision is found, notice will be posted on the Accreditation Program web site, www.nursecredentialing.org, and an e-mail outlining the revision will be sent to every accredited unit. The regular review and revision process involves participation by individuals from a number of the ANCC Accreditation Program stakeholders. We would particularly like to thank the following individuals for their assistance in the development of the 2009 Accreditation Application Manual:

MANUAL REVISION TASK FORCE

Beth Benedict, DrPH, JD, RN Susan Jacob, PhD, RN Sondra Moylan, MSN, RN Wanda Douglas, MSN, RN-BC Ann Curley, PhD, RN Tanya Whitehead, PhD Karen Kelly, EdD, RN, CNE-BC Karen Wilkinson, MN,ARNP Barbara Smith, MSN, RN-BC, CNE-BC

The COA readily approved a number of recommendations from the Manual Revision Task Force. New to this manual are the following features or changes:

•Broadeningoflanguagetoincludeinter-professionalfocus•Expandedcommercialsupportguidelines(AppendixB)•Pointerstohighlightwhererequirementsdifferforfirst-time applicants•Formsandinstructionsgroupedseparatelyfromthetext(AppendixC)

In general, the Manual Revision Task Force sought to clarify the information in the manual, to place a greater focus on outcomes (while retaining the needed structure and process elements), to address the expanding learning media and approaches now being used, and to bring more consistency to the requirements of the ANCC Accreditation Program and the requirements of accrediting bodies of other healthcare professionals.

specific areas of change include (but are not limited to):

•Theminimumamountofcontacthoursthatmaybeawardedforaneducationalactivity is 0.5 contact hours (30 minutes).

•Providerunitsthattargetedmorethan50%oftheireducationalactivitiesprovidedinthepreviouscalendar year to nurses in multiple regions (use the DHHS regions: http://www.hhs.gov/about/regions/) must apply to be accredited providers.

•ContinuingNursingEducationunitsthattargetedmorethan50%oftheiractivitiesprovidedintheprevious calendar year to the nurses in a single state or region (or a state contiguous to that region) may apply to a Constituent Member Association for approval as providers.

•Afourthcategoryofaccreditedapproverwasaddedforthenationalnursingorganizationbasedoutside the United States. It may approve activities or providers within its constituency (within its country).

•LeadNursePlannerresponsibilitiesareclarified.•NursePlannersmustmaintainexpertiseineducationaldesignandadultlearningtheories,receive

orientation to, and maintain responsibility for, implementing ANCC Accreditation Program criteria in their performance of the Nurse Planner role.

•Supportingevidenceisclearlyreferredtoas“required”evidence.•Therulesforlogousagewererevised.•Aproviderisineligibleforaccreditationorapproval(approvalofanactivityorapprovalasa

provider)ifitisacommercialinterestasdefinedinthe“StandardsforCommercialSupport.”

•Aspreviously,theNursePlannermusthaveeducationorexperienceinthefieldofeducationoradultlearning.Thisrevisedmanualprovidesfurtherguidanceonevaluatingthe“experienceinthefieldofeducationoradultlearning”bystatingthat“TheNursePlannermustdemonstratecompetence in performing successfully at the expected level. Accepted demonstration of competencecanbeevaluatedbyreviewoftheNursePlanner’sprofessionalportfolio.”

•Conflictofinterestmustbedisclosedrelativetoeachactivity.Anoriginalsignatureisnotrequired.However, if an original signature is not used, the unit is advised to keep documentation supporting the source of the information.

•Enduringdocumentsmustincludeastatementthatexplainshowlongcontacthour(s)willbeawarded for an activity. This statement must appear on all marketing materials and on the title page of the educational materials.

•Criterion3nowaddressesunitoperations.•Criterion4nowaddressesunitoutcomesevaluation.•Theprovideristaskedwithidentifyingtheappropriatepeopletobeinvolvedinthe

evaluation of the provider unit.•SpecificapprovedprovidercriteriahavebeenincludedinAppendixF.•Specificpeerreview/approvalinstructionsforthelearner-directedactivityareincluded.•Astatementfortheactivity‘pendingapproval’isprovided.•Specificmonitoringrequirementsoftheaccreditedapproverunitareidentified.•Definitionsintheglossarywereaddedandrevised.•Approvedprovidersmayco-provideactivities.•Approvedactivitiesmaybeco-provided.•TheCommissiononAccreditationmaydecidetograntprobationarystatustoa

re-accreditation applicant.

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paRt onE Background Informationchapter 1ANCC’s Accreditation Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 History and Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Foundations and Core Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Current Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Continuing Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Educational Activities and Contact Hours . . . . . . . . . . . . . . . . . . . . . . . 7 Accredited Providers, Accredited Approvers, and Approved Providers . . . . . . . . . 7 The Self-Study Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Program Criteria, Key Elements, and Sources of Evidence . . . . . . . . . . . . . . . 10

chapter 2Overview of the ANCC Accreditation Process . . . . . . . . . . . . . . . . . . . . . . . . . 11 Bodies Involved in the Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Phases of the Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Budget Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Responsibilities of Accredited Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

AMERICAN NURSES CREDENTIALING CENTER // ACCREDITATION PROGRAM 1

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The Accreditation Program of the American Nurses Credentialing Center (ANCC) recognizes organizations (or components/units of organizations) that offer excellent continuing education to nurses. More than 250 organizations (or components/units of organizations) held accredited status from ANCC in 2007. ANCC’s Accreditation Program contributes to healthcare quality by providing a voluntary peer review process that defines standards for high performance in continuing nursing education and measures adherence to those standards for units that elect to apply for accreditation. This chapter describes the origins, foundations, core values, structure, and current definitions employed by the ANCC Accreditation Program.

history and structure

Changes continually affecting nursing practice require registered nurses to engage in a life-long process of active participation in learning activities. These learning activities enhance professional practice and ultimately improve the health of the public. The American Nurses Association (ANA), the national professional association of registered nurses, has emphasized throughout its history the professional growth of the registered nurse.

ANCC’s Accreditation Program originated in 1974 when the House of Delegates of the ANA approved a resolution to establish an Accreditation Program for continuing nursing education (Contemporary Strategies for Continuing Education in Nursing, Abruzzese & Hinthorn 1987). The first formal accreditation review occurred the following year, and by the late 1970s, a model had been instituted to accredit continuing nursing education approvers and providers at the state, regional, and national levels (Accreditation of continuing education: The critical elements, The Journal of Continuing Education in Nursing, DeSilets 1998).

Over the years, the structure of the Accreditation Program has evolved. In 1991, the ANCC became a separately governed, separately incorporated organization, and the accreditation activities originally housed in ANA were transferred to ANCC. Since that time, the Accreditation Program has been governed by the ANCC Commission on Accreditation (COA), whose members have expertise in continuing education, adult education, research, standard setting, and professional development.

1accreditation Program

of the american nurses credentialing center

2 APPLICATION MANUAL //ACCREDITATION PROGRAM

chaPter 1 AccredITATIoN ProgrAm of The AmerIcAN Nurses credeNTIAlINg ceNTer

Today, ANCC’s Accreditation Program represents a voluntary recognition process through which an institution, organization, a component or unit of an organization, or an agency engages in a comprehensive analysis and review of its goals and processes for continuing nursing education. It examines its capacity to achieve those goals and adhere to those processes over an extended period of time. As Figure 1 shows, two types of accreditation are available from ANCC:

Accredited PROVIDERS have demonstrated their ability to offer their own quality continuing nursing education activities to activity participants.

Accredited APPROVERS have demonstrated their ability to approve (i.e., to judge and attest to the quality of) continuing nursing education activities offered by other organizations or individuals.

Figure 1 shows how a second category of providers—approved providers—fits into the ANCC program of accreditation. The major distinctions between accredited providers and approved providers are summarized on page 7 in the definitions section of this chapter.

FIGURE 1.STRUCTURE OF THE ANCC ACCREDITATION PROGRAM

ancc accreditation Program(commission on accreditation)

accredited Providers

accredited aPProvers

approve

aPProvedProviders

educational activites

contact hours

accreDIts

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AccredITATIoN ProgrAm of The AmerIcAN Nurses credeNTIAlINg ceNTer chaPter 1

Ultimately, the functions of both accredited providers and accredited approvers result in making quality continuing education contact hours available to nurses for use in fulfilling their own goals for professional development, licensure, and certification. Contact hours are typically calculated according to the time continuing education participants spend in each educational activity. ANCC’s Accreditation Program specifies a comprehensive set of educational design criteria to ensure that continuing nursing education activities are effectively planned, implemented, and evaluated according to educational standards and adult learning principles.

Table 1 summarizes the credentialing options available in the ANCC program of accreditation. As the upper right column shows, a number of different kinds of organizations, agencies, or groups may apply for accreditation as providers. Only four types of organizations are eligible to apply for accreditation as approvers.

table 1. credentialing options in the ancc accreditation Program

credential tyPe credentialed unit

credential Period

organizations eligiBle to aPPly

AVAILABLE FROM ANCCACCREDITATION PROVIDER 2-4-6 yEARS1 ALL TyPES OF PROVIDER ENTITIES,

SUCH AS:

COLLEGES OR UNIVERSITIES

CONSTITUENT MEMBER ASSOCIATIONS OF THE ANA

FEDERAL NURSING SERVICES

HEALTHCARE FACILITIES

HEALTH-RELATED ORGANIzATIONS

MULTIDISCIPLINARy EDUCATIONAL GROUPS

ProfeSSioNAl EDUCATION GROUPS

SPECIALTy NURSING ORGANIzATIONS

ACCREDITATION APPROVER 2-4-6 yEARS1 CONSTITUENT MEMBER ASSOCIATIONS OF ANA

FEDERAL NURSING SERVICES

SPECIALTy NURSING ORGANIzATIONS

NATIONAL NURSING ORGANIzATION BASED OUTSIDE OF THE US

AVAILABLE FROM ANCC-ACCREDITED APPROVERSAPPROVAL EDUCATIONAL

ACTIVITy 2 yEARS APPROVER-SPECIFIC2

APPROVAL PROVIDER 3 yEARS APPROVER-SPECIFIC2

1Accreditation periods are limited to 2 years for first-time applicants and 4-6 years for repeat (re-accrediting) applicants – depending on the number and nature of any non-compliances with ANCC Accreditation criteria. 2 Refer to the application guidelines published by the ANCC-accredited approver of interest.

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Foundations and core values

The documents and literature cited in Table 2 below form the foundations of the ANCC Accreditation Program. The successful applicant for ANCC accreditation will thoroughly read and understand this manual and ANA’s Scope and Standards Document. ANA’s Scope and Standards of Practice for Nursing Professional Development (2000) defines the role of the professional development educator and the parameters of nursing professional development practice. It provides a practice framework for nursing professional educators in a variety of arenas, including continuing education, and has guided the development of the criteria set forth in this manual.

table 2. Foundational documents for the ancc accreditation Program

FROM THE AMERICAN NURSES ASSOCIATION:

• Scope and StandardS of practice for nurSing profeSSional development (ANA 2000)

• code of ethicS for nurSeS with interpretive StatementS (ANA 2001)

FROM TEACHING-LEARNING PRINCIPLES, EDUCATION THEORy, PEDAGOGICAL, AND ANDRAGOGICAL LITERATURE:

•ADuLT LEArNiNgPriNCiPLES–E.g.,KNowLES (1973,1990);KNowLESETAL. (1984);JArviS (1985);MErriAM (2001);MErriAM&CAFFArELLA (1991)

•BEhAviorALoBJECTivES–E.g.,BLooMETAL. (1956);KrAThwohLETAL. (1964); MAGER (1975)

A set of core values underlie the activities of the ANCC Accreditation Program and the standards from which its criteria are derived. These values state that the program and its representatives will:

• Maintaintheintegrity of the accreditation process through a consistent, fair, and honest application of the criteria;

• Promoteandmaintaincompetence in relation to standards, criteria, and components of lifelong learning;

• Fosterthepeerreviewprocessandmentoringwithin ANCC and by its consumers;• Maintainahighlevelofaccountability and responsiveness to the community of

interest of the accreditation process;• Valueandencourageinnovation in the accreditation process and in the delivery of

continuing education;• Maintainanaccreditationprocessthatispurposeful, relevant, and responsive to the

community of interest;• Focusonprovidingquality in the accreditation process and in the provision of

continuing education;• Recognizeandvaluediversity in the community of interest;• Promoteinclusiveness throughout the accreditation process;• Assure fiscal responsibility and accountability of the accreditation process;• Valueandbeengagedin life-long learning; • Promoteinter-professionalcontinuingeducationactivitiesbyentitiesthathold

accreditations for more than one health-related profession and where nursing is a major participant; and,

• Recognizetheuniquequalitiesofcontinuingprofessionaleducationthatintegratesdiscipline-specific concepts and content and fosters collaboration across health-related disciplines, and enhance continuity, quality, and cost-effective care delivery systems.

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nursing and inter-ProFessional continuing ProFessional education: Foundation and core values

The ANCC recognizes that the life-long learning needs of the nursing community change as the healthcare environment evolves. To address the increasingly complex needs of individuals, families, and populations, the health-related professions are promoting inter-professional education and continuing professional education. The ANCC COA recognizes the important development of inter-professional educational activities in continuing education. The COA supports entities that hold accreditations with more than one health discipline and that are providing and approving integrated activities. The COA has a particular understanding of activities for target audiences that include professionals in different health disciplines. The COA is actively collaborating with continuing education accrediting bodies of other health-related disciplines to maintain quality and reduce unnecessary duplication of efforts in accredited units. The unified application for accreditation is a major step forward in support of inter-professional continuing education. Also, the COA and the Accreditation Council for Continuing Medical Education (ACCME) have adopted the same Commercial Support Standards, with some minor differences in application.

current deFinitions

Like all accrediting organizations, ANCC is constantly evolving its accreditation process to accommodate advances in practice and technology as well as public demands for improved quality and accountability in institutions that serve social needs. This section provides current, updated definitions for concepts or elements central to the Accreditation Program.

continuing educationThe glossary of this manual includes definitions for each of the terms shown in Figure 2: academic education, continuing education, and staff development (in-service and orientation). Provider units accredited within ANCC’s program of accreditation are authorized to confer contact hour credits for educational activities that fit inside the upper circle of the figure labeled “continuing education”. As the glossary indicates, continuing education involves “learning activities designed to augment the knowledge, skills, and attitudes of nurses and therefore enrich the nurses’ contributions to quality health care…” (ANA, 2000, p. 24). The knowledge, skills, or attitudes gained from continuing education activities can be applied regardless of the employer of the activity participant.

In contrast, staff development activities are typically designed to enhance performance in participants’ current job roles, and are based on a specific facility’s policies and procedures, equipment, and resources. In those cases when staff development learning activities convey new content knowledge that would be transferable to other job settings, they can be considered to fall into the overlap area shown in the figure and thus be eligible to offer continuing nursing education contact hours. In-service programs may include new, transferable knowledge. Staff development departments may offer both continuing education activities and in-service activities.

For instance, orientation programs are typically facility-specific. This employer-specific content would not be eligible for continuing education contact hours. Review, or refresher, courses may focus on functioning in a particular facility or on reinforcing

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basic knowledge. In that situation the content areas would not be eligible for continuing nursing education contact hours.

However, in some cases, refresher courses provide nurses re-entering employment, following an absence of several years, with new information or a new skill set that has developed in the previous few years. In this type of refresher course, the content area would be eligible for continuing education contact hours.

Source: Adapted from ANA (1994).

ANCC accreditation criteria specify that contact hours be calculated only for that portion of the learning activity that is devoted to transmitting new or transferable knowledge. This includes the time spent completing the evaluation of the educational activity.

continuing education requirements specified by other BodiesThe ANCC Accreditation Program is not necessarily related to the continuing education requirements specified by states or by other accrediting or professional licensing bodies. While some states may have incorporated ANCC’s program of accreditation into their requirements, others states may require continuing education providers to obtain recognition for contact hours directly from the state board of nursing. Units providing continuing nursing education activities need to be familiar with the requirements of the state in which they offer those activities. Learners should also be advised to verify requirements with the licensure or certification bodies appropriate to their needs.

FIGURE 2. RELATIONSHIP BETWEEN CONTINUING EDUCATION AND STAFF DEVELOPMENT

nursing ProFessional develoPment

CONTINUINGEDUCATION

ACADEMICEDUCATION

STAFF DEVELOPMENTIN-SERVICE

ORIENTATION

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educational activities and contact hoursBoth the ANCC and the ANA define an educational activity as “a planned, organized effort aimed at accomplishing educational objectives” (ANA, 2000, p. 24). For ANCC’s Accreditation Program, an educational activity may consist of a conference, lecture, course, workshop, teleconference, live activity, printed materials, CD, or a web-based program. The distinguishing feature is that each educational activity must have a single, unifying learning goal or purpose. In effect, deciding what constitutes a unique educational activity is left to the discretion of the accredited unit.

A contact hour is defined as “a unit of measurement that describes 60 minutes (1.0 hours) of an organized learning activity that is either a didactic or clinical experience. Contact hours may be awarded only for those portions of an educational activity devoted to didactic or clinical experience and/or to the time participants spend evaluating the activity. The minimum number of contact hours that may be awarded for educational activities (other than point-of-care Internet learning) is 0.5 (30 minutes). Learning activities may be conducted asynchronously or may be bundled to allow a full learning experience to take place. Contact hours are to be awarded in units using two decimal places or less. For example, 120 minutes of learning activity equals 2.0 contact hours, or a learning activity that consists of 45 minutes equals 0.75 contact hours. If rounding is necessary to reach a one or two-decimal figure, the contact hours should be rounded DOWN to avoid credit being awarded for time not spent in education. The accredited approver units have the authority to establish a minimum number of contact hours in effect for their approved providers and approved activities. The number of contact hours to be awarded for time-open activities, those in which learners set the pace according to no pre-determined starting and ending times, should be calculated by a pilot study or another logical and defendable mechanism (such as word count, number of post-test questions, or text difficulty analysis for journal articles that offer continuing education credit). Individuals acting as ‘learners’ for the purpose of a pilot-test may receive contact hours for that educational activity when the appropriate number of contact hours has been established. The accredited unit must maintain records of the data used in deciding the number of contact hours to be awarded for participating in an activity.

accredited Providers, accredited approvers, and approved ProvidersThe purpose of the next three definitions is to emphasize the major contrasts among the three categories of continuing nursing education organizations or units served by the ANCC Accreditation Program. Abruzzese and Hinthorn (Contemporary Strategies for Continuing Education in Nursing, 1987) provided helpful distinctions by defining the purpose of accreditation as validating that certain pre-determined high standards are met and the purpose of approval as guaranteeing that accepted or minimum standards are met. The former process reviews structure, process, and outcome criteria while the latter reviews consistency in procedures and integrity in the conduct of business. Continuing nursing education providers that seek approval for their organizational units within the ANCC Accreditation Program tend to be smaller organizations with more local audiences compared to those that seek accreditation.

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• Accredited providers plan, implement, and evaluate continuing nursing education activities. They may not approve activities. The accredited provider unit may award contact hours only for any continuing nursing education activity that has been planned, implemented, and evaluated by the accredited provider unit, or as agreed upon in a co-provider agreement (addressed below). This work of planning, implementing, and evaluating is guided by a designated Nurse Planner (or planners) and is carried out in cooperation with at least one other planner for each educational activity the accredited provider unit offers. When planning inter-professional activities (not co-providing the activity), the Lead Nurse Planner will take a more collaborative role as planners from other disciplines accept responsibility for ensuring adherence to the criteria specified by their separate disciplines. Every designated Nurse Planner must be a registered nurse with a graduate degree. Either the baccalaureate or the graduate degree must be in nursing. Additionally, the Nurse Planner must have education or experience in the field of education or adult learning. Activities developed without the direct involvement of a designated Nurse Planner cannot be authorized to award contact hours. Accredited provider units autonomously determine how often an educational activity needs to be reviewed for up-to-date content and relevant objectives. Organizations or organizational units that targeted more than 50% of their educational activities provided in the previous calendar year to nurses in multiple regions* must apply to be accredited providers. *Use the DHHS regions: http://www.hhs.gov/about/regions/. (See Table 3 below) Activities offered over the Internet are considered to be targeted to nurses in multiple regions.

table 3. making the decision regarding the credentialing Body

MorEThAN50%oFThEACTiviTiESProviDEDDuriNgThEPrEviouS CALENDAR yEAR By THE PROVIDER UNIT WERE:

TARGETED TO NURSES IN A SINGLE REGION* TARGETED TO NURSES IN MULTIPLE REGIONS*

-or-

TARGETED TO NURSES IN A STATE CONTIGU-OUS TO THE SINGLE REGION SPECIFIED ABOVE

may aPPly to an accredited aPProver to Be aPProved as a Provider

must aPPly to ancc to Be accredited as a Provider

* Use the DHHS regions: http://www.hhs.gov/about/regions/

It is recommended that organizations/units that provide a minimal number of activities each year, or those that have just entered the continuing education business, have their activities approved by an accredited approver unit.

Questions regarding eligibility for accreditation or approval should be addressed to the ANCC Accreditation Program staff.

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• Accredited approvers are of four categories: Constituent Member Associations (CMAs), Specialty Nursing Organizations (SNOs), Federal Nursing Services (FNSs) and national nursing organizations based outside the United States. A national nursing organization is an organization, based outside the borders of the United States, that either is recognized by the country of origin as the regulatory body for nurses in that country, is recognized by the International Council of Nurses as a national nursing organization from that country, or is recognized by the government and/or by more than 50% of the healthcare organizations within the country as the ‘leader’ of continuing nursing education. CMAs, FNSs, and national nursing organizations based outside the United States may approve either education activities (2-year approval period) or providers (3-year approval period), or both. The approval authority of the FNSs and national nursing organizations based outside the United States extends only to the constituents of the FNS or the national nursing organization based outside the United States, respectively. SNOs may approve only continuing nursing education activities, not providers, and the approval is for a 2-year period. Whether approving providers or activities, accredited approvers determine whether the relevant ANCC criteria for delivering continuing nursing education activities have been met. The work of the accredited approver unit is carried out by a team of peer reviewers under the direction of a Nurse Peer Review Leader and may be conducted for approval of individual educational activities or for approval of organizations or organizational units to function as approved providers. Every peer review leader must be a registered nurse with a graduate degree. Either the baccalaureate or the graduate degree must be in nursing. Peer Reviewers must be registered nurses with at least a baccalaureate degree in nursing and with expertise in educational design. Each application submitted to an accredited approver for approval undergoes an established peer review process to determine whether contact hours may be awarded either for the individual activity or by the approved provider unit depending on the type of application.

• Approved providers are approved by accredited approvers to plan, implement, and evaluate continuing nursing education activities. As Chapter 5 describes in more detail, the ANCC Accreditation Program specifies identical requirements for approved providers and accredited providers with only two exceptions: expectations for the educational preparation of Nurse Planners and the re-application timeframes for approved providers. However, ANCC-accredited approvers may choose to impose additional requirements on the providers that apply to them for approval status. Organizations/units that targeted more than 50% of their activities provided in the previous calendar year to the nurses in a single state or region (use the DHHS regions: http://www.hhs.gov/about/regions/) OR to nurses in a single state or region (or a state contiguous to that region) should apply to a Constituent Member Association for approval as providers. (See Table 3, page 8) Organizations/units that targeted more than 50% of their educational activities provided in the previous calendar year to nurses in multiple regions (use the DHHS regions: http://www.hhs.gov/about/regions/) must apply to be accredited providers.

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the self-study ProcessOrganizations or organizational units applying for accreditation must conduct in-depth analyses of the extent to which they meet the relevant criteria of the ANCC Accreditation Program. In the course of doing so, they accumulate data that provide evidence for the written documentation required in the accreditation application package.

The purpose of the self-study is for the organization/unit to analyze and document its capacity, processes, and outcomes in providing quality continuing nursing educational services in keeping with ANCC accreditation criteria over an extended period of time. The self-study is intended to function as a process that:

• Involvesallparticipantsintheprovisionofcontinuingnursingeducationservices;• Promotesacollegialself-examinationoftheaccreditedunit;• Focusesongoals,operations,results,andachievements;and• Fostersexcellencethroughtheongoingevaluationoftheaccreditedunit’soutcomes

and effectiveness.

The time and effort involved in the self-study process should represent a total effort by all who thoroughly examine the accredited unit’s success in achieving its desired outcomes in comparison to independent standards, and should also identify the additional resources necessary to meet any goals not currently being met. When fully engaged, the self-study process can serve as one mechanism for implementing continuous quality improvement.

Program criteria, Key elements, and required evidenceThe ANCC accreditation criteria presented in this manual represent accepted standards or requirements that guide the design and provision of continuing education activities to the nursing community. They accommodate a wide variety of continuing nursing education providers, program designs, and unique organizational structures including professional education groups, and multi-disciplinary inter-professional groups.

Chapters 3 and 4 describe the criteria ANCC’s Accreditation Program specifies for accredited providers and accredited approvers, respectively. Chapters 3 and 4 constitute the core of the ANCC Accreditation Program. Each criterion title is followed by a conceptual definition, a set of key elements, and a list of the required evidence necessary for attesting to the presence of those key elements and required for inclusion in the applicant’s written documentation. Each list of key elements may be thought of as a summary of the major features, aspects, or dimensions that would be expected to be evident in an organization/unit when it has implemented the relevant criterion. The key elements, and, as appropriate, the essential items within the key elements, have been identified as “major” or “minor”. Major key elements of essential items within a key element are underlined, highlighted, and are marked with the symbol . Accreditation decisions of the COA are based on the number and nature of non-compliances identified. Chapter 6 describes the decision-making process in more detail.

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2overview of the ancc

accreditation Process

The purpose of this chapter is to provide a broad orientation to the requirements, processes, and activities involved in applying to the ANCC for accreditation in continuing nursing education. It should be read in advance of the detailed instructions for compiling an application given in Part Two of this manual.

The ANCC Accreditation Program is committed to ensuring the integrity of the accreditation processes and the quality of the continuing nursing education being provided to nurses, as well as the quality of inter-professional continuing professional education where the nursing community is a major component. Approximately every 2 years, the Accreditation Manual is reviewed and revised, as appropriate. While every effort is made to ensure the manual provides clarity and comprehensiveness upon its publication, occasionally the changing environment necessitates a clarification or revision. The COA is committed to providing the accredited units with ample notice and ample time to accommodate any needed revisions in the Accreditation Program criteria. If an emergent need for revision is found, notice will be posted on the Accreditation Program web site, www.nursecredentialing.org and an e-mail outlining the revision will be sent to every accredited unit.

The ANCC Accreditation Program uses a multifaceted process of analysis and appraisal to identify organizations or organizational units that meet high standards in the provision of continuing nursing education and to monitor their sustained effectiveness. The process involves collection and review of data from multiple sources. It starts with requiring applicants to conduct in-depth self-studies of their continuing nursing education goals, operations, and adherence to ANCC accreditation criteria. The self-study documentation and associated materials are evaluated by specially-trained, independent appraisers, who follow up with site visit activities to confirm and expand on the content of the submitted materials and to address information received through public domains (e.g. web sites). The appraisers then prepare written reports to summarize their findings. These appraiser reports undergo a two-stage review, first by the ANCC Accreditation Review Committee, and then by ANCC’s COA. The COA is the sole accreditation decision-maker for ANCC. Annual reporting procedures complete the process by allowing for the monitoring of each accredited unit’s continued adherence to program standards throughout the period of accreditation.


Who may aPPly

As shown in Table 1, a wide variety of healthcare and health-related organizations can apply for accreditation as providers of continuing nursing education. Only specialty nursing organizations, federal nursing services, constituent member associations (commonly known as State Nurses Associations) of the ANA, or national nursing organizations based outside the United States may apply for accreditation as approvers in the ANCC Accreditation Program. Accredited providers may not approve continuing nursing education providers or educational activities.

Healthcare organizations that have achieved ANCC accreditation include acute care facilities and universities with continuing nursing education programs, as well as other not-for-profit and for-profit healthcare-related organizations. Many specialty nursing organizations have accredited continuing education programs, and many constituent member associations of the ANA are ANCC-accredited as providers, approvers, or both.

Bodies involved in the accreditation Process

ANCC Commission on Accreditation. The ANCC Accreditation Program is governed at the national level by the COA. Among its responsibilities, the COA develops program criteria, implements its national accreditation programs, accredits approvers and providers of continuing nursing education, and evaluates the Accreditation Program. Appointed by, and accountable to, the ANCC Board of Directors, the members of the COA are selected to represent a range of accredited organizations, consumers, nursing evaluation experts, adult education professionals, and the public at large, and include a representative from the ANA Congress on Nursing Practice and Economics.

Accreditation Review Committee (ARC). This committee reviews applications and appraiser reports and considers information in the public domain (e.g., web sites, comments received from the public, etc.) to assess the degree to which applicants have met the key elements of the accreditation criteria. The committee submits its findings on the applicant’s compliance with the key elements to the COA and makes recommendations. The ARC is composed of COA members, Accreditation Program appraisers, and other stakeholders in the accreditation process.

Accreditation Program Office. The staff members in the Accreditation Program Office provide administrative support for the ANCC Accreditation Program. Contact information for office staff is provided in Appendix A and at the Accreditation web site: http://www.nursecredentialing.org.

Accreditation Appraisers. The role of the appraisers is to collect data obtained through application review, through review of complaint and annual report information submitted to the ANCC Accreditation Program office, and through site visits. Additionally, information in the public domain may be reviewed. The appraisers report the evidence found in the self-study and site visit to the ARC and the COA in an organized fashion. Accreditation appraisers are individuals with masters-level education, expertise in educational design and implementation, and, often, recent experience in an ANCC-accredited approver or provider unit. Prior to making their first site visit, all appraisers participate in an appraiser orientation consisting of classroom and site visit observation experiences. Appraisers continue to renew their knowledge

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chaPter 2 oVerVIeW of The ANcc AccredITATIoN Process


through workshop attendance and self-directed learning activities in order to remain in the appraiser pool. Each accreditation appraiser team consists of at least two members, including a team leader and a team member. All members of the appraiser team read the application package and participate in the site visit. Team leaders, who are required to have at least 2 years of appraiser experience, are responsible for coordinating and leading the site visit activities. Additionally, the team leader is a registered nurse whose nursing education preparation is at least at the baccalaureate level. Appraisers cannot be appointed to an applicant unit’s appraiser team until the potential for any conflicts of interest has been investigated and resolved.

Phases in the Process

Table 4 outlines the major activities of each of the seven phases of the ANCC Accreditation process. Figure 3 maps the process in a flowchart format.

Accreditation is awarded to new applicants for a period of 2 years. Accreditation is awarded to renewing applicants for a period of 4 or 6 years depending upon whether they have been determined through documented evidence to fully, or partially, meet program criteria. To maintain accredited status, units must submit annual reports to demonstrate that they continue to meet program criteria, and must apply for re-accreditation at least 6 months before the expiration of their accreditation period.

Preparing to Apply. Organizations (or organizational units) should apply for initial accreditation only after studying this application manual in detail and conducting a self-study to determine their readiness to apply. Following the self-study, an organization/unit will decide either to postpone application while it continues to work on developing weak areas, or to begin writing the self-study report, which comprises the bulk of the application package. At least three months in advance of the anticipated date for submitting an application, the organization/unit should mail in a completed Intent to Apply form (see Appendix C) to allow the ANCC Accreditation Program Office to plan for the processing of the application.

Application Evaluation. Three items comprise the application package: (a) an application form (see Appendix C), (b) the written documentation (self-study report and exhibits), and (c) payment of the application fee. In the course of completing the application form, each applicant attests to its eligibility to apply for accreditation as specified in Table 6 for provider applicants or Table 8 for approver applicants. The application form identifies the primary contact person who will be responsible for coordinating and maintaining communications with the ANCC Accreditation Program Office and indicates how the name of the accredited unit should appear on the Certificate of Accreditation, if accreditation is awarded.

With the exception of the Unified Application package, application packages are limited to 50 pages for provider applicants. Pages may be doubled sided. In their applications for approver status, applicants are allowed 50 pages PLUS addendum information containing the approval application forms and communication templates of the applicant approver unit. Applications are accepted only on or before February 1 or August 1. Upon receipt of an application package, staff members of the Accreditation Program Office confirm the completeness of the application package, notify applicants if any items are missing, and identify an appraiser team to evaluate the application. Appraisers may choose to request additional information before finalizing plans for the site visit.

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oVerVIeW of The ANcc AccredITATIoN Process chaPter 2


table 4. steps accomplished by Phase of the ancc accreditation Process

Becoming accredited

PREPARING TO APPLy APPLICANT:

•DETErMiNESELigiBiLiTyToAPPLy

•ENSurESoNgoiNg iMPLEMENTATioNoFThEProgrAMCriTEriA

•SuBMiTS iNTENTToAPPLyForM

•BEgiNSSELF-STuDyANDAPPLiCATioNPrEPArATioN

ACCREDITATION PROGRAM OFFICE:

•PoSiTioNSAPPLiCANTNAMEoNAPPLiCATioNrEviEwCALENDAr

APPLICATION SUBMISSION

APPLICANT SUBMITS APPLICATION PACKAGE, WHICH INCLUDES:

•APPLiCATioNForM

•wriTTENDoCuMENTATioN(SELF-STuDyrEPorT)

•APPLiCATioNFEE

APPLICATION REVIEW ACCREDITATION PROGRAM OFFICE:

•vEriFiESCoMPLETENESSoFAPPLiCATioNPACKAgE

•ASSigNSAPPrAiSErTEAM

•SELECTSSiTEviSiTDATE

ACCREDITATION PROGRAM APPRAISER TEAM:

•EvALuATESAPPLiCATioNPACKAgE

•DrAFTSSiTEviSiTAgENDAForAPPLiCANTrEviEw

SITE VISIT APPLICANT, AT LEAST 30 DAyS PRIOR TO SELECTED SITE VISIT DATE:

•ArrANgESTrAvELANDLoDgiNgForAPPrAiSErS

ACCREDITATION PROGRAM APPRAISER TEAM MEMBERS:

•viSiTAPPLiCANTuNiTToEvALuATECoNTENToFAPPLiCATioNMATERIALS FIRSTHAND

•ADDrESS iNForMATioNrECEivEDviAPuBLiCDoMAiNSorPro -VIDED FROM ACCREDITATION PROGRAM OFFICE FILES

•PrEPArEFiNALrEPorTSuMMAriziNgFiNDiNgSoFAPPLiCATioNREVIEW AND SITE VISIT

ACCREDITATION DECISION

ACCREDITATION REVIEW COMMITTEE:

•rEADSAPPLiCATioNANDAPPrAiSErrEPorTToASSESS ADHERENCE TO KEy ELEMENTS

•PrEPArESSTATEMENToFFiNDiNgSToAPPENDToAPPrAiSErREPORT AND MAKES RECOMMENDATIONS TO THE COMMISSION

COMMISSION ON ACCREDITATION:

•rEviEwSAPPrAiSErANDACCrEDiTATioNrEviEwCoMMiTTEEFINAL REPORTS. THE APPLICATION MAy BE REVIEWED, IF NEEDED

•voTESwhEThErToACCrEDiTANDSPECiFiESPErioDoF ACCREDITATION

•NoTiFiESAPPLiCANToFACCrEDiTATioNDECiSioN

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maintaining accreditation

INTERIM MONITORING ALL ACCREDITED PROVIDER AND APPROVER UNITS:

•CoMPLETEANNuALrEPorTS

•SuBMiTANNuALFEE

•rESPoNDTorEquESTSFor iNForMATioNorigiNATiNgFroMTHE ACCREDITATION PROGRAM

RE-ACCREDITATION ACCREDITED PROVIDER AND APPROVER UNITS:

•SuBMiT iNTENTToAPPLyForM

•SuBMiTrE-ACCrEDiTATioNAPPLiCATioNANDSELF-STuDyDoCu -MENTS 6 MONTHS BEFORE ACCREDITATION PERIOD ExPIRES

The Accreditation Program Office must be notified before the site visit if any changes in address, organizational structure, or key personnel (including the Nurse Planner and other individuals as defined by the applicant organization) occur that alter the information provided in the application. An applicant may withdraw an application without prejudice to any future applications if written notice is received by the Accreditation Program Office prior to the date of the ANCC COA meeting at which the award decision is to be made for that applicant.

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Site Visit. The purpose of the site visit is to amplify, verify, and clarify the written documentation submitted with the application package. Site visits are conducted by bothoftheappraiserswhoevaluatedtheapplication.Visitstypicallylast1-2daysfor accreditation as a provider and 1-2 days for accreditation as an approver. If an organization applies for accreditation as both an approver and a provider, the same appraiser team will be used to conduct both evaluations. The site visit in this case will last at least 2 days. The agenda and activities for the site visit are pre-determined between the appraiser team leader and the applicant. However, flexibility in the agenda implementation is allowed, as needed, on site.

IMPROVE CONFORMITy TO ELIGIBILITy

AND PROGRAM CRITERIA

REVIEW CURRENT MANUAL AND CONDUCT SELF-STUDy

READINESS TO APPLy CONFIRMED

SUBMIT INTENT TO APPLy FORM

SUBMIT APPLICATION PACKAGE AND ACCREDITATION FEE

ADDiTioNALDoCuMENTATioNrEquESTEDByAPPrAiSErS OR PROGRAM OFFICE

PREPARE SELF-STUDy REPORT READy TO APPLy ON SCHEDULE?

yES

yES

NO

yES NO APPEAL DENIAL?CONTACT

ACCREDITATION PROGRAM OFFICE

REVIEW By ACCREDITATION

REVIEW COMMITTEE

REPORT WRITTEN By APPRAISERS

yES

NO

NO

CONTACT ACCREDITATION

PROGRAM OFFICE TO WITHDRAW OR POSTPONE REVIEW

OF APPLICATION

SUBMIT rEquESTEDADDITIONAL

INFORMATION

APPLy FOR RE-ACCREDITATION 6 MONTHS BEFORE

CURRENT ACCREDITATION PERIOD ExPIRES

SUBMIT ANNUAL FEES AND REPORTS

BEGIN SERVICES AUTHORIzED WITH ACCREDITED STATUS

HOST APPRAISER SITE VISIT

COMMISSION ON ACCREDITATION VOTES TO ACCREDIT

FIGURE 3. FLOWCHART OF THE ACCREDITATION PROCESS

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Accreditation Decision. For this phase of the process, appraisers first prepare an appraiser final report to document and summarize the evidence found by the appraisers in the self-study and site visit. This appraiser final report is forwarded along with the application to the ARC, which conducts a preliminary assessment of the degree to which there is evidence that the applicant has met the key elements of the accreditation criteria.

The report prepared by the ARC contains the evidence about each key element and, along with the appraiser final report, is used to inform the final deliberations of the COA. Accreditation decisions are made by a vote of the COA members based on evidence that criteria are fully or partially met.

Interim Monitoring. Interim monitoring consists of review of annual reports, review of progress reports, and review of any other information the COA has specifically requested. Units accredited for periods of less than 6 years submit progress reports to provide evidence of their continued adherence to the relevant ANCC Accreditation Program criteria. All accredited units complete annual reports that describe the amounts and types of continuing nursing education services they provided during the period, significant changes in the structure of the accredited unit, their progress toward their established unit goals, and any new unit goals that have been developed (see Appendix D).

Re-Accreditation. The re-accreditation process is conducted in the same manner as the initial application process, including a self-study report and site visit. An Intent to Apply form is submitted (electronically or in writing) to the ANCC Accreditation Program 12 months prior to the unit’s expiration date. The application and self-study documents must be received at least 6 months prior to the unit’s scheduled expiration date.

Budget considerations

Table 5 illustrates the types of costs involved with applying for, and maintaining, accreditation. Because fees may change from year to year, readers should always consult the ANCC web site or contact the Accreditation Program Office for the most current rates. The Accreditation Program Office sends invoices for the annual fee to accredited units at the beginning of each calendar year.

table 5. cost summary

Phase costs amount

APPLICATION ACCREDITATION APPLICATION FEE VARIABLE RATE (PAGES 90-91 OR SEE WEB SITE)

SITE VISIT APPRAISER TRAVEL COSTS, LODGING, PER DIEM*

COSTS INCURRED

ANNUAL MONITORING

ANNUAL FEE FLAT RATE

RE-ACCREDITATION ACCREDITATION APPLICATION FEE VARIABLE RATE (SEE WEB SITE)

* Appraisers are reimbursed directly by the ANCC offices for travel, lodging, and per diem. ANCC will invoice the applicant for these expenses.

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A portion of the application fee is refundable if an application is withdrawn prior to a site visit, in which case the applicant will pay the non-refundable administrative fee and any processing expenses that may have been incurred by ANCC to date. If an application is withdrawn after the site visit has already been conducted, the applicant is responsible for paying the full fee amount and site visit expenses and no part of the fee will be refunded. The Accreditation Program web site, www.nursecredentialing.org, contains the most current information regarding accreditation application and status maintenance costs.

resPonsiBilities oF accredited units

Table 6 itemizes the responsibilities that pertain equally to ANCC-accredited providers and ANCC-accredited approvers. Submission of an application for accreditation signifies an organization’s/unit’s agreement to fulfill these responsibilities.

table 6. responsibilities of accredited approver and accredited Provider units

consistency oF accredited services

Accredited units must meet the current criteria specified by the ANCC Accreditation Program for their type of accredited unit throughout their periods of accreditation. Therefore, accredited units must continually monitor ANCC communications and web site postings for potential changes in policies, requirements, and criteria.use oF the ancc accreditation logo

the ancc accredited unit certification mark (logo) may only be used by units granted accreditation by the ancc.Accredited units that choose to include the ANCC logo in their promotional materials ensure that:•Allletteringinsidethelogomustbereadablewhenthesymbolisusedonmaterials.ifthewords

arenotlegible,pleaseincreasethesizeofthelogo.•Thelogocannotbealteredormodified.itmayberesized,providedtheproportionsoftheentire

logo are maintained and all features of the logo are clearly distinguishable.•Thelogoshallbereproducedonly:

•inblackorinpurple(PMS528purpleorequivalent);•inasizewhichmakesallfeaturesofthemarkclearlydistinguishable;and•withoutdistortionofitsdimensions.

•Thelogocannotbeusedinisolationfromthedesignatedunit’slogo.Allmaterialsmustcontainboth the designated unit’s logo and the ANCC Accredited Unit logo.

•LogosusedonanANCCAccreditedunitwebsitemustincludeahyperlinktoANCC’sAccreditedUnit web page.

•Exceptasstatedherein,thelogomaynotbeused,reproduced,modifiedordistributed.intheeventthananorganization’sorunit’saccreditationexpires,lapses,issuspendedorrevokedorisotherwiseterminated,theorganization/unitmustimmediatelyceasealluseofthelogo.

•unauthorizedorinappropriateuseofthelogoshallbegroundsforsuspensionorrevocationofaccreditation.

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data use

Accredited units give the ANCC Accreditation Program permission to use their annual report data in the aggregate for marketing, reporting, and research purposes such as,(a)describinganonymously,andintheaggregate,thecharacteristicsofANCCaccreditedunits;(b) identifying benchmarks among accredited units to assist in decision-making about program

requirementsforaccreditationapplicants;or(c)analyzingcredentialingtrendsoraddressingotherANCC-definedresearchquestions.

notiFications to ancc

Accredited units maintain timely written or electronic communications with the ANCC Accreditation Program, which includes: (a)thesubmissionofrequiredorrequestedreports;(b) the submission of regularly sought information such as the ANCC accredited unit’s

annualreport;(c) delivering notice (written or electronic) to the ANCC Accreditation Program Office staff within

30 days of any change in •primarycontactperson•NursePlanners,NursePeerreviewLeaders,orotherkeypersonnel

(asdefinedbytheapplicantorganization)•theunit’sname,ownership,orstructureoftheunit;

(d) delivering written or electronic notice to the ANCC Accreditation Program Office staff at least 30 days prior to the implementation of any decision to terminate accredited services and the dateofimplementationofthatdecision;and

(e) notification (electronic or written) of ANCC Accreditation Program Office staff of any education ‘sentinelevents’within30daysaftertheiroccurrence.(Asentineleventisoneofhighriskandhigh impact related to the improper or inappropriate provision of continuing nursing education in compliance with the ANCC Accreditation Program criteria. Examples include, but are not limited to, misuse of accredited status, illegal actions perpetrated or experienced by the accreditedunit–oritsapprovedentities.).

WeB site PuBlication oF accredited status

Accredited units are listed by name, address, type of accreditation (approver or provider), and dates of accreditation in the list of accredited organizations posted by the ANCC Accreditation Program at www.nursecredentialing.org.

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Pa

rt tW

o

paRt tWo The Accreditation Processchapter 3Applying for Accreditation as a Provider of Continuing Nursing Education . . . . . . . . . . . . 23 Assessing Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Signaling the Intent to Apply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Preparing the Written Documentation of Adherence to Criteria . . . . . . . . . . . . . 26 Provider Unit Criterion 1. Mission Statement . . . . . . . . . . . . . . . . . . . . . 30 Provider Unit Criterion 2. Educational Design . . . . . . . . . . . . . . . . . . . . . 31 Provider Unit Criterion 3. Unit Operations . . . . . . . . . . . . . . . . . . . . . . 37 Provider Unit Criterion 4. Unit Evaluation . . . . . . . . . . . . . . . . . . . . . . . 38 Submitting the Application Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

chapter 4Applying for Accreditation as an Approver of Continuing Nursing Education. . . . . . . . . . . 41 Assessing Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Signaling the Intent to Apply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Becoming Accredited as Both an Approver and Provider . . . . . . . . . . . . . . . . . . 44 Preparing the Written Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Approver Unit Criterion 1. Mission Statement . . . . . . . . . . . . . . . . . . . . . 46 Approver Unit Criterion 2. Approval Process . . . . . . . . . . . . . . . . . . . . . 47 Approver Unit Criterion 3. Unit Operations . . . . . . . . . . . . . . . . . . . . . . 54 Approver Unit Criterion 4. Unit Evaluation . . . . . . . . . . . . . . . . . . . . . . 55 Submitting the Application Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

chapter 5Site Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Site Visit Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Site Visit Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

chapter 6Accreditation Decision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Accreditation Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Deferrals, Denials, Reconsiderations, and Appeals . . . . . . . . . . . . . . . . . . . . . 63

chapter 7Interim Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65 Annual Reporting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65 Suspensions and Revocations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66 Voluntary Terminations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

chapter 8Applying for Re-Accreditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67 Streamlined Re-Accreditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

chapter 9The Unified Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69


3applying For accreditation

as a Provider of continuing nursing education

Organizations or organizational units that provide continuing nursing education activities follow the application instructions described in this chapter.

This chapter outlines the eligibility criteria and application requirements for organizations/units applying to the ANCC for accreditation as providers of continuing nursing education. As Table 1 in Chapter 1 (page 3) demonstrated, a wide variety of organizations involved in the delivery of continuing nursing education activities may apply to become accredited as providers in the ANCC Accreditation Program.

Chapter 3 helps organizations/units to first assess their eligibility to apply for accreditation as providers and then to prepare the written documentation for the application package. Reread the section in Chapter 2 under Phases of the Process that describes the components of an application package, how to submit it, and how it is subsequently processed by the ANCC Accreditation Program.

The bulk of this chapter is devoted to itemizing the Accreditation Program criteria for accredited providers, including the key elements that clarify the major aspects of each criterion, and the required evidence needed to demonstrate the incorporation of each criterion into the provider unit’s goals and operations. Completion of the self-study process described in Chapter 1 will provide the information and data applicants need to write the self-study report, documenting adherence to the criteria for accredited providers.

Note: First-time applicants should note that this triangle symbol, bolded word ‘Note:’, and paragraph heading will be used throughout the application manual to point to any differences in application requirements for new applicants. All organizations/units that are not currently accredited must follow the application requirements specified for first-time applicants.

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assessing eligiBility

Table 7 itemizes the eligibility criteria for provider applicants. Organizations/units that do not meet these eligibility requirements must postpone their application until they have implemented the necessary conditions.

Provider Unit Authority. This eligibility criterion expresses the necessity for accredited provider units to retain sole responsibility for the full process of planning, implementing, and delivering continuing nursing education. Accredited provider units may only provide continuing nursing education. They may not approve continuing nursing education.

table 7. eligibility criteria for Provider applicants

estaBlishment as a Provider unit

Provider unit authority. The provider unit must be administratively and operationally responsible for coordinating all aspects of the continuing nursing education activities provided by the unit. A provider unit may be either

(a)asingle-focusedorganization1devotedtoofferingcontinuingnursingeducation;or(b)adistinct,separatelyidentifiedunitwithinacomplex,multi-focusedorganization2. For

example, the provider unit may be a continuing nursing education division, a staff development department,oranursingeducationcommitteewithinalargerorganization.Providerunitswithincomplexorganizationsmustdemonstratetheirautonomyforprovidingcontinuingnursing education in the written documentation they submit. In other words, as stated above, the provider unit must be administratively and operationally responsible for coordinating all aspects of the continuing nursing education activities.

1Single-focusedorganization:Thesingle-focusedorganizationexistsforthesinglepurposeofprovidingeducation.2Multi-focusedorganization:Themulti-focusedorganizationexistsformorethanthepurposeofprovidingeducation.

A provider is ineligible for accreditation or approval (approval of an activity or approval as a provider) if they are a commercial interest as defined in the Standards for Commercial Support. (A‘commercialinterest’isanyentityeitherproducing,marketing,re-selling,ordistributinghealthcare goods or services consumed by, or used on, patients or that is owned or controlled by an entity that produces, markets, re-sells, or distributes healthcare goods or services consumed by,orusedon,patients.Thisdefinitionallowsaprovidertohavea‘sistercompany’thatisacommercial interest, as long as the accredited provider had and maintained adequate corporate firewallstoprohibitanyinfluenceorcontrolbythe‘sistercompany’overthecontinuingeducationprogram of the accredited provider. In this case, ANCC would expect that the accredited provider wouldhaveanadequatecorporatefirewallinplacetoprohibitanyinfluenceorcontrolbythe‘sistercompany’overthecontinuingeducationprogram.)

designated nurse Planner(s). Also referred to as Nurse Planner(s). The provider unit must have the services of at least one Nurse Planner who is responsible for adhering to ANCC Accreditation Program criteria in the provision of continuing nursing education. The Nurse Planner must be a registered nurse with a graduate degree. Either the baccalaureate or the graduate degree must be in nursing. Additionally, the Nurse Planner must have education or experience in the field of education or adult learning. The Nurse Planner must demonstrate competence in performing successfully at the expected level. Accepted demonstration of competence can be evaluated by review of the Nurse Planner’s professional portfolio. (See definition of portfolio in glossary, page 75.)

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chaPter 3 APPlYINg for AccredITATIoN As A ProVIder of coNTINuINg NursINg educATIoN


oPeration as a Provider unit

operational status. A provider unit shall be defined as operational when it is functioning under all of the relevant criteria of the ANCC Accreditation Program with all essential provider unit personnel in place. Application is permitted once the provider unit passes two operational milestones: duration. The provider unit must have been operational for a minimum of 6 months. activities*+. The provider unit must have planned, implemented, and evaluated at least three

different educational activities provided at different events:(a)withthedirectinvolvementofadesignatedNursePlanner(asspecifiedabove);and(b) that adhere to the relevant criteria of the ANCC Accreditation Program. Each learning activity

must be at least 1 hour (60 minutes) in length. Co-provided activities may not be counted as one of these three activities. However, an activity approved by an ANCC-accredited approver unit may be counted in the three activities.

*organizations/unitsthattargetedmorethan50%oftheireducationalactivitiesprovidedintheprevious calendar year to nurses in multiple regions (use the DHHS regions: www.hhs.gov/about/regions), or in states other than those within or contiguous to a single region can only apply to be an accredited provider.+ activities offered over the Internet are considered to be targeted to nurses in multiple regions

Designated Nurse Planner(s). Also referred to as ‘Nurse Planner’, this eligibility criterion expresses both the minimum educational requirements for Nurse Planners and the necessity for all Nurse Planners to maintain expertise in educational design and adult learning theories, receive orientation to, and maintain responsibility for, implementing ANCC Accreditation Program criteria in their performance of the Nurse Planner role. The essence of the designated Nurse Planner requirement is two-fold:

• toensurethataqualifiednurseisinvolvedintheentireprocessofdelivery—fromneeds assessment through planning, implementation, evaluation, and follow-up— for every continuing nursing education activity offered by the provider unit; and

• toguaranteethatANCCAccreditationProgramcriteriaguidethedevelopment and implementation of every continuing nursing education activity offered by a provider unit.

Large provider units often need to use multiple Nurse Planners, each of whom may be functioning under a unique arrangement with the provider unit. In provider units large enough to require the services of several Nurse Planners, it is expected that one of them will be assigned to act as the Lead Nurse Planner who oversees or coordinates consistency of processes and adherence to ANCC Accreditation Program criteria across all activities. The Lead Nurse Planner is responsible for ensuring that all Nurse Planners are performing in a manner consistent with the policies, procedures, position descriptions, and expectations of the accredited provider unit and with the ANCC criteria. Note that ANCC must always have an up-to-date list of the designated Nurse Planners in accredited provider units.

Operational Status. This eligibility requirement establishes the implementation of ANCC Accreditation Program criteria and the presence of required unit personnel as the time at which the provider unit becomes operational. The phrase “relevant criteria” used in Table 7 refers to those specified in this chapter if an organization or organizational unit is applying for accredited provider status. The phrase “all essential provider unit personnel” refers to the number of designated Nurse Planners and administrative or support staff sufficient to meet the provider unit’s stated goals.

Note: First-time applicants must have planned, implemented, and evaluated at least three different learning activities (not three sessions of the same conference) using all current criteria. Each learning activity must have been at least 1 hour

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APPlYINg for AccredITATIoN As A ProVIder of coNTINuINg NursINg educATIoN chaPter 3


(60 minutes) in length. Co-provided activities may not be counted among the three completed educational activities stipulated in Table 7 (pages 24-25). When establishing a new unit, this unit’s continuing nursing education, as provided without outside collaboration or assistance, must be evaluated. Contact hours may or may not have been offered depending upon whether the activities were submitted for approval to an ANCC-accredited approver. The actual awarding of contact hours is not necessary for establishing first-time applicant eligibility.

signaling the intent to aPPly

Renewing applicants will receive an Intent to Apply form from the Accreditation Program Office approximately 1 year in advance of the expiration date for their current period of accreditation. Their application for re-accreditation is due within 6 months. The Intent to Apply form must be completed and submitted to the Accreditation Program Office at least 4 months prior to the required document submission date. The renewing applicant is to submit a list of activities planned, implemented, and evaluated by them within 12 months prior to submission of the Intent to Apply form. The Accreditation Program staff will select three activities from this list. The three activities will be selected to be representative of the kinds of activities offered by the provider unit. These selected activities will provide the reference for the narrative descriptions submitted to reflect educational design elements (Criterion 2).

Note: First-time applicants should submit an Intent to Apply form 4 months in advance of their intended submission date for the Accreditation Application Package. This gives the ANCC Accreditation Program Office time to plan for the receipt, processing, and initial evaluation stages of the application. The first-time applicant will submit, with the self-study documents, the full files (consisting of all those elements identified in provider unit criterion 2, key element 11) of the three educational activities it has provided. These files are not included in the 50 page limit of the provider unit application. An Intent to Apply form is included in Appendix C.

Preparing the Written documentation of adherence to criteriaThe self-study report is composed of a series of narrative statements, which should be written in a concise, straightforward, and easily understood manner. The goal is to explain, as clearly as possible, how program criteria have been adopted and implemented by the provider unit. Supporting exhibits may be integrated with the narrative statements or accumulated in a separate, cross-referenced section of the report.

The self-study report should address the following topics in the order listed here.

Executive Summary:• Leadershipoftheproviderunit• Currentandprojectedpracticeofcontinuingnursingeducation• Reviewofthehealthcareenvironmentinwhichtheproviderunitoperates• Structureandprocessusedforconductingtheself-studyprocess

Criteria Documentation:• Goalsandorganization• Educationaldesign• Unitoperations• Unitoutcomesevaluation

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Self-Assessment Summary:• Providerunitstrengthsandmajorareasoffocusinthefuture

The Executive Summary, which functions as an abstract, should be limited to a single page. The topics to be covered for each of the four criteria are enumerated as key elements under each criterion definition as it is given in turn throughout the remainder of this chapter. (See the definition of Key Elements given in Chapter 1.) Depending on the organizational environment, some applicants may emphasize certain key elements more than others in their self-study reports.

In the remainder of this chapter, each key element statement is followed by a description of the required evidence necessary for inclusion in the self-study report to demonstrate how the provider unit meets that key element. Key elements – or components of the key element that are considered of major impact if found non-compliant – are underlined, highlighted, and are marked with the symbol,. Further discussion of major (and minor) key elements can be found in Chapter 6, Accreditation Decision.

Table 8 summarizes the key elements that comprise the four provider unit criteria.

table 8. overview of Provider unit criteria and Key elements

criterion 1: mission statement

1. mission statement. The beliefs and goals (often referred to as mission statement) of the provider unit that are relevant and appropriate to prospective learners.

2. lines of authority and administrative support.organizationalstructuresandlines of authority support the operation of the provider unit.

criterion 2: educational design

1. assessment of learner needs. Continuing education activities are developed in response to, and with consideration for, the unique educational needs of the provider unit’s target audience (as associated with the Mission Statement).

2. Qualified Planners and Faculty. Each educational activity is planned collaboratively by at least one designated Nurse Planner (who meets the qualification criteria outlined on pages 32 and 74 of this manual) and one other planner. Each member of the planning group should represent at least one of the following areas: the relevant content expertise, the target audience, and the responsibility for adherence to ANCC accreditation criteria. Multiple areas may be represented by each person. Each planning committee must have representation of all of these three areas. Nurse Planners contribute oversight and must be actively involved in both the planning and the analysis of evaluation data for the educational activity. The planning committee assures the qualifications of the faculty member(s) are appropriate and adequate.

3. effective design Principles. Each educational activity is developed with: (a) an identified learning goal (purpose) and explicit measurable educational objectives for the

learnerthatareappropriateforthetargetaudience;(b) identified gaps in knowledge, skills, practice identified (based on the needs assessment)

which the activity is designed to address(c)contentcongruentwiththeactivity’slearninggoal(purpose)andeducationalobjectives;(d) teaching and learning strategies congruent with the activity’s objectives and content (e) criteria for judging successful completion of an activity that are consistent with the learning

goal(purpose),objectives,andteachingandlearningstrategiesaslistedabove;and(f) a method determined for verifying participation in an activity.

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4. awarding contact hours. Contact hours associated with the official accreditation statement are awarded to participants for those portions of the educational activity devoted to didactic or clinical experience or to evaluating the activity. Contact hours are calculated in a logical and defensible manner. One contact hour = 60 minutes.A provider of an educational activity may award no fewer than 0.5 contact hours for an educational activity. Learning activities may be conducted‘asynchronously’ormaybe‘bundled’toallowafulllearningexperiencetotakeplace.if‘rounding’isdesiredinthecalculationofcontacthours,theprovideristorounddowntothenearest1/100th. Contact hours may NOT be awarded retroactively.

5. activity evaluation. A clearly defined method, which includes learner input, is used to evaluate the effectiveness of each educational activity.

6. accreditation statements. The accreditation statement is a mark of the provider unit’s status. All communications, marketing materials, certificates, and other documents that refer to the provider’s ANCC-accredited status contain the official accreditation statement. The accreditation statement must stand alone. In other words, it must begin and end on a line separate from other text.

7. documentation of completion. Participants receive written verification of their successful completion of an activity, which includes at a minimum:

(a) the name of the participant learner,(b) the name and address of the provider unit,(c) the title and date of the educational activity , (d) the official accreditation statement , and(e) the number of contact hours awarded.

8. commercial support guidelines. Education must be kept separate from promotional activities. Commercial support, exhibits, or the presentation of research conducted by a commercial companyshallnotinfluencethedesignandscientificobjectivityofanyeducationalactivity.Commercially-supplied funds or sponsorship for an educational activity that are given in the form of an educational grant or in-kind assistance shall be acknowledged in the brochures and/or printed material for the continuing education activity. Read Appendix B for a complete statement of the commercial support guidelines. ANCC accredited providers are required to adhere to the Standards of Commercial Support found in Appendix B of this manual.

9. conflict of interest guidelines. Conflictofinterestdisclosurestatementsshallbeobtainedfrom all activity planners and presenters to identify the presence or absence of any potentially biasing relationship of a financial, professional, or personal nature on the part of those who have an impact on the content of an educational activity. Planners and presenters must disclose the presenceorabsenceofconflictofinterestrelativetoeachactivity.Allpotentialconflictsshallberesolved prior to the planning, implementation, or evaluation of the continuing nursing education activity.referalsototheconflictofinterestdiscussioninAppendixB.

10. disclosures Provided to activity Participants. Participants shall receive the following information regarding each and every activity in advance of, or at the time of, the event. If the disclosure is provided verbally, there will be documentation provided by someone in the audience of the activity that the disclosure wa appropriately made.

(a) Noticeofrequirementsforsuccessfulcompletion;(b) Conflictsofinterest;(c) Disclosure of relevant financial relationships and mechanism to identify and resolve

conflictsofinterest;(d) SponsorshiporCommercialsupport;(e) Non-endorsementofproducts;(f) Off-label use ;and(g) Expiration date for awarding contact hours.

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11. recordkeeping. For each provided educational activity, documentation is kept in a secure and confidential manner for 6 years.

12. co-Providerships. When educational activities are co-provided, an ANCC-accredited provider unit retains identified responsibilities: If collaborating providers are all ANCC-accredited, one is designated to retain the provider responsibilities by mutual, written agreement. The unit designated to retain these responsibilities is referred to as the provider, and the other collaborating providers are referred to as co-providers.

criterion 3: unit oPerations

1. nurse Planner. At least one RN carries out the role of the Lead Nurse Planner, with responsibility for assessing needs, planning, implementing and evaluating continuing nursing education activities. The Lead Nurse Planner is responsible for assuring that all Nurse Planners are appropriately prepared, oriented, and trained to meet the ANCC Accreditation Program requirements for that role and that they all use the same approach and policies established by the provider unit, The Lead Nurse Planner must be a registered nurse with a graduate degree. Either the baccalaureate or the graduate degree must be in nursing. Additionally, the Lead Nurse Planner must have education or experience in the field of education or adult learning.

2. resources. Sufficient human, material, and financial resources are available to carry out the administrative, educational, and supportive functions of the provider unit.

3. Business Practices. The provider unit must adhere to all regional, state, and national laws and regulations and operate the business and management policies and procedures of its continuing nursing education program (as they relate to human resources, financial affairs, and legal obligations) so that its obligations and commitments are met. The provider unit must adhere to all reasonable ethical expectations in its provision of continuing nursing education and its business practices.

criterion 4: Provider unit evaluation

1. Provider unit evaluation Process. The provider must have a mechanism in place to evaluate the effectiveness of its overall continuing nursing education program.

2. Provider unit evaluation Participants. The Lead Nurse Planner shall participate in the unit evaluation. The provider shall identify other participants to be included in the evaluation process.

3. Provider unit evaluation results. Evaluation data are used to confirm, expand, or change the operations of the provider unit.

4. Provider unit goals For improvement. Efforts toward improvement include addressing issues, identifying strategies for working on targeted goals, evaluating progress toward goals, and revising or establishing new goals.

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Provider unit criterion 1

mission statementThe documented beliefs and goals of the provider unit reflect the importance of continuing education for nurses and the needs and characteristics of the provider unit’s potential learners. The provider unit is: clearly defined, accurately, clearly, and consistently named, and, in multi-focused organizations1, supported by the administrative structure.

1 The multi-focused organization exists for more than the purpose of providing education.

Key elements:

1. Mission Statement. The beliefs and goals (often referred to as mission statement) of the provider unit are relevant and appropriate to prospective learners.

requIred eVIdeNce:

•Submit the mission statement of the provider unit. If the provider unit is part of a multi-focused organization1, describe how the mission statement of the provider unit link with the goals, mission, and functions of the total organization. Incorporate goals, beliefs, scope, target audience, and types of education activities offered. This should also include expected outcomes (i.e. changes in participants’ knowledge, competency, behavior, or patient outcomes), and how they anticipate measuring those changes and outcomes.

•Submit a description of the features of the provider unit that characterize its scope, such as its size, geographical range, target audience(s), content areas, and the type of educational activities it offers. If the provider unit is part of a multi-focused organization1, describe the relationship of these scope dimensions to the total organization.


2. Lines of Authority and Administrative Support. Organizational structures and lines of authority support the operation of the provider unit.

requIred eVIdeNce:

•Submit an organizational chart, flow sheet, or similar kind of image that depicts the organizational structure of the provider unit. Provide the name and credentials of the individual in each position identified on the organizational chart. If the provider unit is part of a multi-focused organization1, submit an additional depiction that identifies the provider unit’s lines of authority and structural location within the total organization.


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educational designThe provider unit has a clearly defined process for assessing need, planning, implementing, and evaluating continuing nursing education. Continuing nursing education activities are assessed, designed, planned, implemented, and evaluated in accordance with adult learning principles and professional education standards and ethics. The educational design process includes procedures for protecting educational content from bias, providing learners appropriate information and documentation related to their participation, and maintaining records in a secure and confidential manner.

documentation requirements:

A. Sample Activities for Submission with the Self-Study. Applicants are requested to submit a list of educational activities provided, if not already submitted with Intent to Apply Form. For each educational activity selected by the Accreditation Program staff, submit the information referenced in key elements 1 – 10 (below).

Note: First time applicant organizations applying for accreditation will submit the full files (consisting of all those elements listed in provider criterion 2, key element 11) of three educational activities planned, implemented, and evaluated using Accreditation Program criteria and under the oversight of the Nurse Planner. (Co-provided activities may not be included in this submission.) The documentation of these files is not counted in the application limit of 50 pages.

B. Provider Unit. Key Elements 11-12 below refer to descriptions of procedures in effect throughout the overall provider unit rather than those relative to specific activities.

Note: First-time applicants must become accredited before implementing those requirements marked by an asterisk.

Key elements:

1. Assessment of Learner Needs. Continuing education activities are developed in response to, and with consideration for, the unique educational needs of the provider unit’s target audience (as associated with the Mission Statement).

requIred eVIdeNce:

Submit a description (with supporting evidence) of the process of activity planning, including the:

•needs assessment;•determination of target audience; and•developmentofobjectives,content,andteaching-learningstrategiesin

response to the needs assessment.

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2. Qualified Planners and Faculty. Each educational activity is planned collaboratively by at least one designated Nurse Planner and one other planner. Each planning committee must have representation from all of the following areas: the relevant content expertise; the target audience; and the responsibility for adherence to ANCC accreditation criteria. Multiple areas may be represented by each person. Nurse Planners contribute oversight and must be actively involved in both the planning and the analysis of evaluation data for the educational activity. The planning committee assures the qualifications of the faculty member(s) are appropriate and adequate.

requIred eVIdeNce:

•Identify the Nurse Planner(s) and all other persons who participated in the planning process. Document the content expertise of the collaborating planner(s) who represents this area (required), and of the activity presenters (as appropriate).

•Describetherole(s)playedbytheproviderunit’sdesignatedNursePlanner(s) and any additional key personnel (as defined by the applicant organization) or groups involved in the process of ensuring the quality of educational activities. If the unit relies on the services of multiple and/or ad hoc Nurse Planners, describe how all designated Nurse Planners are kept up-to-date on the requirements for adhering to ANCC accreditation standards and how the provider unit ensures the performance of each Nurse Planner meets both the requirements of the provider unit and the expectations of ANCC relative to the responsibilities of the Nurse Planner.

•Submitadescriptionofthemannerinwhichtheneededqualificationsoffaculty are identified.

•Submitadescriptionofhowtheplanningcommitteeensuresthattheselected faculty meet the needed qualifications.

3. Effective Design Principles. Each educational activity is developed with: (a) an identified learning goal (purpose) and explicit measurable educational

objectives for the learner that are appropriate for the target audience;(b) identified gaps in knowledge, skills, practice identified (based on the needs

assessment) which the activity is designed to address;(c) content congruent with the activity’s learning goal (purpose) and educational

objectives;(d) teaching and learning strategies congruent with the activity’s objectives and

content;(e) criteria for judging successful completion of an activity that are consistent with

the learning goal (purpose), objectives, and teaching and learning strategies as listed above; and

(f) a method determined for verifying participation in an activity.

requIred eVIdeNce:

Submit a description of the activity’s:•learning goal (purpose), learner objectives, and related content;•identifiedgaps(basedontheneedsassessment);• teaching-learningstrategiesused,includingresources,materials,delivery

methods, and learner feedback mechanisms;•rationaleandcriteriaselectedforjudgingsuccessfulcompletion;and•methodselectedforverifyingparticipation.

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*4. Awarding Contact Hours. Contact hours associated with the official accreditation statement are awarded to participants for those portions of the educational activity devoted to didactic or clinical experience or to evaluating the activity. Contact hours are calculated in a logical and defensible manner. One contact hour = 60 minutes A provider of an educational activity may award no fewer than 0.5 contact hours for an educational activity. Learning activities may be conducted ‘asynchronously’ or may be ‘bundled’ to allow a full learning experience to take place. If ‘rounding’ is desired in the calculation of contact hours, the provider is to round down to the nearest 1/10th or 1/100th. Time spent completing the evaluation form may be counted. Contact hours may not be awarded retrospectively.


requIred eVIdeNce:

•Identify and provide supporting documentation of the number and calculation of contact hours awarded for the activity.

5. Activity Evaluation. A clearly defined method, which includes learner input, is used to evaluate the effectiveness (i.e. were the activity objectives met?) of each educational activity.

requIred eVIdeNce:

•Submit a written description of the method used to evaluate the activity•Identifythecategoryofevaluation(i.e.learnersatisfaction,knowledge

enhancement, skill and attitude change, change in practice/performance, relationship of the practice change to quality of service). It is strongly recommended that at least a portion of the activities provided be evaluated at one of the higher levels of evaluation.

•Includesupportingdocumentationforthedescriptionsabove.

*6. Accreditation Statements. The accreditation statement is a mark of the provider unit’s status. All communications, marketing materials, certificates, and other documents that refer to the provider’s ANCC-accredited status contain the official accreditation statement, as follows:

[ Name of Accredited Provider Unit ] is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s COA.

The accreditation statement must stand alone. In other words, it must begin and end on a line separate from other text.


requIred eVIdeNce:

•Submit copies of the promotional materials developed for the activity. Note: For a sample activity longer than 3 contact hours (180 minutes), submit the relevant brochure(s) and agenda for the entire activity.

7. Documentation of Completion. Participants receive written verification of their successful completion of an activity, which includes at a minimum:

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(a) the name of the participant learner; (b) the name and address of the provider unit;(c) the title and date of the educational activity; (d) *the official accreditation statement, and(e) the number of contact hours awarded.


requIred eVIdeNce:

•Submit a copy of the certificate awarded to participants upon completion of the educational activity. Note: First-time applicants should prepare and submit a sample certificate

of completion as it would appear following accreditation and containing the appropriate accreditation statements.

8. Sponsorship and Commercial Support Guidelines. Education must be kept separate from promotional activities. Commercial support, exhibits, or the presentation of research conducted by a commercial company shall not influence the design and scientific objectivity of any educational activity. Commercially-supplied funds for an educational activity that are given in the form of an educational grant or in-kind assistance shall be acknowledged in the brochures and/or printed material for the continuing education activity. Read Appendix B for a complete statement of the commercial support guidelines. ANCC accredited providers are required to adhere to the Standards of Commercial Support found in Appendix B of this manual.

requIred eVIdeNce:

Submit a description of: •Anysponsorshiporcommercialsupportrelatedtotheeducationalactivity;•How content integrity is maintained for educational activities that receive

sponsorship or commercial support, if any, including, but not limited to, the policy and associated procedures for resolving conflicts;

•What/howprecautionsaretakentopreventbiasintheeducationalcontent;and

•Submitthetemplateofthewrittenagreementusedinthepresenceofsponsorship or commercial support.

9. Conflict Of Interest Guidelines. Conflict of interest disclosure statements shall be obtained from all activity planners and presenters to identify the presence or absence of any potentially biasing relationship of a financial, professional, or personal nature on the part of those who have an impact on the content of an educational activity. Planners and presenters must disclose the presence or absence of conflict of interest relative to each activity. All potential conflicts shall be resolved prior to the planning, implementation, or evaluation of the continuing nursing education activity. Refer also totheconflictofinterestdiscussioninAppendixG.

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requIred eVIdeNce:

Submit:•Documentation of the conflict of interest disclosures (or disclosures of

absence of conflict of interest) relative to the specific activity*; * If a signed disclosure form is NOT used, the unit is advised to maintain

documentation of the source of the disclosure information.•Adescriptionofproceduresfollowedtoresolveanyrealorpotentialbiasor

conflict of interest; and•Ifavailable,asampleofadisclosurethattriggeredtheresolutionprocedure

and documentation reflecting the actions of the provider unit to resolve the issue.

10. Disclosures Provided to Activity Participants. Participants shall receive the following information regarding each and every activity in advance of, or at the time of, the event. If the disclosure is provided verbally, there will be documentation provided by someone in the audience of the activity that the disclosure was appropriately made. (See Standard 6A and 6B of the Standards for Commercial Support for further guidance.)(a) Notice Of Requirements For Successful Completion. Activity participants

are informed in advance of the learning goals (purposes) and objectives of the educational activity and the criteria to be used to determine successful completion of an educational activity.

(b) Conflicts Of Interest. Activity participants are informed of any influencing financial relationships, or lack thereof, disclosed by planners or presenters. (See further instruction, p. 86, Standards for Commercial Support.)

(c) Disclosure of Relevant Financial Relationships and Mechanism to Identify and Resolve Conflicts of Interest. (See further instruction, p. 82-83, Standards for Commercial Support.)

(d) Sponsorship or Commercial Support. Activity participants are made fully aware of the nature of any commercial support related to an educational activity. (See further instruction, p. 83-86. Standards for Commercial Support.)

(e) Non-Endorsement Of Products. Activity participants are advised that accredited status does not imply endorsement by the provider or ANCC of any commercial products displayed in conjunction with an activity.

(f) Off-Label Use Learners are notified when an educational activity relates to any product used for a purpose other than that for which it was approved by the Food and Drug Administration.

(g) Expiration Date for Awarding Contact Hours. Enduring educational documents must include a statement that explains how long contact hours will be awarded for an activity. This statement must appear on all marketing material and on the educational material.

requIred eVIdeNce:

•Submit copies of the documents (e.g., promotional brochures, letters, program schedules, presentation materials) or describe the methods that were used to inform activity participants of the above information.

11. Recordkeeping. For each provided educational activity, the following documentation is kept in a secure, confidential and retrievable manner for 6 years: (a) Planning:

• Description of the target audience;• The method and findings of the needs assessment;• Names, titles, and expertise of the activity planners and presenters;

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• Conflict of interest disclosure statements from planners and presenters, resolutions of conflict of interest, and as appropriate;

• Learning goal (Purpose), objectives, and content;• Instructional strategies, delivery methods, learner feedback mechanisms, and

resources to be used;• Methodsorprocessusedtoverifyparticipation;• Noticetolearnersidentifyinghowsuccessfulcompletionwillbemeasured;• Marketingandpromotionalmaterials;• Division of responsibilities among co-providers, if any;• Means of ensuring content integrity with sponsorship or commercial support, if

any; and• The written commercial support agreement as required in the standards of

commercial support for any activity receiving commercial support.• Thesignedco-provideragreement,ifappropriate)(Seekeyelement#12.)

(b) Implementation:• Title, location, and date of the educational activity;• All evaluation tools used, including a summative evaluation;• Participant names, and unique identifier information (For example, an

automatically generated number, a password code, the month and date of birth, an address, etc.);

• Sample certificate of completion; and• Number of contact hours associated with official accreditation statement awarded

to individual participants. • Documentation of the verbal provision of required disclosures (see Standard

6A and 6B of the Standards for Commercial Support for further guidance.)

requIred eVIdeNce:

Submit a description of the provider unit’s recordkeeping system, including:•how activity records are consistently collected, and •how they are stored and secured in a safe, confidential, logical, and

consistent manner.

12. Co-providerships. When educational activities are co-provided and one of the providing entities is ANCC-accredited, the ANCC-accredited provider unit retains the following responsibilities: (a) determination of the educational objectives and content;(b) selection of the content specialist planners and activity presenters;(c) the awarding of contact hours, as appropriate, to the individual

educational activity;(d) recordkeeping procedures; (e) evaluation methods and categories; and(f) management of any commercial support or sponsorship.

If collaborating providers are all ANCC-accredited, one is designated to retain the provider responsibilities by mutual, written agreement. The unit designated to retain these responsibilities is referred to as the provider, and the other collaborating providers are referred to as co-providers.

requIred eVIdeNce:

•Submit a description of how provider unit responsibilities are assigned and maintained for co-provided activities, if any. Submit the template of the written agreement used.

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unit operationsThe provider unit ensures the quality of continuing nursing education by following an established process involving a qualified Nurse Planner for developing, delivering, and evaluating the effectiveness of the educational activities it offers. Adequate resources are provided and utilized to support the provider unit’s full range of functions.

Key elements:

1. Nurse Planner. At least one RN carries out the role of the Lead Nurse Planner, with responsibility for assessing needs, planning, implementing and evaluating continuing nursing education activities. The Lead Nurse Planner is responsible for assuring that all Nurse Planners are appropriately prepared, oriented, and trained to meet the ANCC Accreditation Program requirements for that role and that they all use the same approach and policies established by the provider unit. All Nurse Planners (including the Lead Nurse Planner) must be registered nurses with a graduate degree. Either the baccalaureate or the graduate degree must be in nursing. Additionally, the Lead Nurse Planner must have education or experience (in planning, implementation, or analysis of evaluations) in the field of education or adult learning.

requIred eVIdeNce:

•SubmitapositiondescriptionfortheLeadNursePlannerreflectingappropriate qualifications and functions; and

•IftheproviderunitutilizesmorethanoneNursePlanner,submitadescription of the activities of the Lead Nurse Planner in assuring other Nurse Planners are appropriately prepared, oriented, and trained to function in that role. Provide accompanying evidence.

2. Resources. Sufficient human, material, and financial resources are available to carry out the administrative, educational, and supportive functions of the provider unit.

requIred eVIdeNce:

•For designated Nurse Planners and other key personnel (as defined by the applicant organization) involved in providing continuing nursing education or the overall administration of the unit, submit position descriptions that clearly identify job functions and biographical data summaries that demonstrate the qualifications of current incumbents. The position descriptions must reflect qualification requirements for the Nurse Planner(s) and roles relative to continuing nursing education that are consistent with those of the ANCC Accreditation Program.

•Submit a description of the material resources that support the functions of the provider unit.

•Submitabriefdescriptionoftheproviderunit’scurrentsourcesoffinancialsupport and projections for how financial support will be sustained throughout the period of accreditation. Do not submit detailed budget reports.

•Submitareportidentifyingtheamountandfrequencywithwhichcommercial support for educational activities is received.

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3. Business Practices. The provider unit must adhere to all regional, state, and national laws and regulations, and operate the business and management policies and procedures of its continuing nursing education program (as they relate to human resources, financial affairs, and legal obligations), so that its obligations and commitments are met. The provider unit must adhere to all reasonable ethical expectations in its provision of continuing nursing education and its business practices.

requIred eVIdeNce:

•Provide an attestation statement that the accredited unit complies with all applicable local, regional, state, or national laws and regulations and operates its business in an ethical manner. The attestation statement is to be signed by the leaders of the accredited unit.


Provider unit evaluationThe provider unit engages in an ongoing evaluation process to analyze its overall effectiveness in fulfilling its beliefs, goals, and functions, and in providing quality continuing nursing education. Plans and goals for the provider unit’s future development in continuing nursing education are identified and re-evaluated on a regular basis.

documentation requirements

Required evidence for this criterion should include a written plan for evaluation of the provider unit indicating what is evaluated, when evaluation occurs, who participates, andresults.ThisplanshouldincludethoseitemsstatedinCriterion#4,KeyElement1 (i.e., the process used and what was identified as needing change). Examples of the evaluation data that are collected, with an explanation as to how they have been used to increase the effectiveness of the provider unit, should also be included.

Note: First-time applicants are expected to have implemented their unit performance improvement plans throughout the 6 months of operational status that is required for application eligibility. Data examples should be selected that are representative of that period. New goals for the provider unit should be described under Key Element 4.

Key elements:

1. Provider Unit Evaluation Process. The provider must have a mechanism (e.g. “plan”) in place to evaluate the effectiveness of its overall continuing nursing education program.

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requIred eVIdeNce:

•Document what process was used and, what, if anything, was identified as needing change.

2. Provider Unit Evaluation Participants. The Lead Nurse Planner shall participate in the unit evaluation. The provider shall identify other participants to be included in the evaluation process.

requIred eVIdeNce:

•Identify appropriate stakeholders that are involved in the evaluation of the provider unit. (This may differ based upon the type of provider’s organization.)

3. Provider Unit Evaluation Results. Evaluation data are used to confirm, expand, or change the operations of the provider unit.

requIred eVIdeNce:

Submit a description of:•How results of the overall program evaluation process have been used to

confirm, expand, and improve the provider unit’s operations.

4. Provider Unit Goals for Improvement. Efforts toward improvement include addressing issues, identifying strategies for working on targeted goals, evaluating progress toward goals, and revising or establishing new goals.

requIred eVIdeNce:

Submit a description of how:•The provider unit’s goals for improvement over the period of accreditation

have been addressed;•Whatchangesandprogresshavebeenmadetowardmeetingthosegoals;•Whatnewgoalsforimprovementhavebeenidentified;and•Operationalplansforimplementationassociatedwiththegoals

identified above.

suBmitting the aPPlication PacKage

Formatting and assembly requirements for the self-study report are listed with the provider unit application instructions in Appendix C. These instructions also explain how to determine the accreditation fee payment to be submitted with the application. The application form itself signifies an attestation to the applicant’s eligibility to apply for accreditation and should be included as a cover sheet with the self-study report and exhibits. The application checklist must be completed, citing beginning page numbers so that the major sections of the written documentation, the executive summary, required evidence for each of the key elements, and the self-assessment summary may be easily located by appraisers and members of the ARC or the COA.

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4applying For accreditation

as an approver of continuing nursing education

Only four types of organizations may apply for accreditation as described in this chapter:

• Specialtynursingorganizations;• Federalnursingservices;• ConstituentmemberassociationsoftheANA;and• NationalnursesorganizationsbasedoutsidetheUnitedStates.

This chapter outlines the eligibility criteria and application requirements for applying to the ANCC for accreditation as approvers of continuing nursing education. Chapter 4 helps organizations (or units within a larger organization) assess their eligibility to apply for approver accreditation and to prepare the written documentation for the application package. Re-read the section in Chapter 2 under Phases Of The Process that describes the components of an application package, how to submit it, and how it is processed by the ANCC Accreditation Program.

The bulk of this chapter is devoted to itemizing the Accreditation Program criteria for accredited approvers, including the key elements that clarify the major aspects of each criterion and the required evidence necessary to demonstrate the incorporation of those program standards into the approver unit’s goals and operations. Completion of the self-study process described in Chapter 1, page 10, will have provided the information and data applicants need to write the self-study report.

Note: First-time applicants should note that this triangle symbol and paragraph heading will be used throughout the application manual to point to any differences in application requirements for new applicants. All organizations/units that are not currently accredited must follow the application requirements specified for first-time applicants.


assessing eligiBility

Table 9 itemizes the eligibility criteria for approver applicants. Organizations that do not meet these requirements must postpone application until they have implemented the necessary conditions.

Organizational Type. As noted in Table 9, only four types of organizations are eligible to apply for approver accreditation in the ANCC Accreditation Program.

Approver Unit Authority. This eligibility criterion expresses the necessity for accredited approver units to retain sole responsibility for the full process of approving continuing nursing education. Applicant approver units need to demonstrate their self-governance with regard to implementing all aspects of the peer review approval process they use to evaluate applications for approval of educational activities or provider units in continuing nursing education.

table 9. eligibility criteria for approver applicants

estaBlishment as an aPProver unit

organizational type.Theapproverunit’sparentorganizationmustrepresentaspecialtynursingorganization,federalnursingservice,nationalnursesorganizationbasedoutsidetheunitedStates,or a constituent member association of the American Nurses Association (ANA). (A national nurses organizationbasedoutsidetheunitedStatesisanorganization,basedoutsidethebordersoftheunitedStatesthat:isrecognizedbythe‘countryoforigin’astheregulatorybodyfornursesinthatcountry,orisrecognizedbytheinternationalCouncilofNursesasanationalnursingorganizationfromthatcountry,orisrecognizedbythegovernmentand/orbymorethan50%ofthehealthcareorganizationswithinthecountryasthe‘leader’ofcontinuingnursingeducation.)

approver unit authority. The approver unit must be administratively and operationally responsible for coordinating all aspects of the peer review process it uses to approve the continuing nursing education activities or programs submitted by applicants. The approver unit must be a body identifiedseparatelywithintheeligibleorganizationsuchasacouncil,committee,orcommission.

nurse Peer review leader. The approver unit must have the services of at least one Nurse Peer Review Leader who is responsible for implementing and evaluating the unit’s peer review approval process. The Nurse Peer Review Leader must maintain expertise in educational design and adult learning theories, and must be a registered nurse and hold a graduate degree. Either the baccalaureate or the graduate degree must be in nursing. Additionally, the Nurse Peer Review Leader must have education or experience in the field of education or adult learning. The Nurse Peer Review Leader may work for the approver unit as a staff member, consultant, or volunteer.oPeration as an aPProver unit

operational status. An approver unit shall be defined as operational when it is functioning under all of the relevant criteria of the ANCC Accreditation Program with all essential approver unit personnel in place. Application is permitted once the approver unit passes two operational milestones:

duration. The approver unit must have been operational for a minimum of 6 months.

note: application approvals. New applicant approver units must have completed mock reviews of at least three different educational activity applications or provider unit mock reviews to demonstrate their approval process and capabilities. The applications shall have been reviewed by the designated approver unit personnel following the relevant criteria of the ANCC Accreditation Program and using the materials, forms, formats, and processes developed by the unit for conducting approval reviews of continuing nursing education provider or activity applications.

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chaPter 4 APPlYINg for AccredITATIoN As AN APProVer of coNTINuINg NursINg educATIoN


Nurse Peer Review Leader. This eligibility criterion expresses both the minimum educational requirements for the Nurse Peer Review Leader and the necessity for all Nurse Peer Review Leaders to be responsible for implementing ANCC Accreditation Program criteria in their performance of the Nurse Peer Review Leader role. The essence of the Nurse Peer Review Leader requirement is to ensure that a qualified nurse oversees the entire approval process of the approver unit, and to guarantee that ANCC Accreditation Program criteria guide the standards by which approval applications are evaluated. The Nurse Peer Review Leader is responsible for ensuring that all nurse peer reviewers are performing in a manner consistent with the policies, procedures, position descriptions, and expectations of the accredited approver unit and the ANCC criteria

Operational Status. This eligibility requirement establishes the implementation of ANCC Accreditation Program criteria and the presence of necessary unit personnel as the starting time for calculating when an approver unit becomes eligible to apply for accreditation. The phrase “relevant criteria” refers to those specified in this chapter if an organization/unit is applying for accredited approver status. The phrase “all essential approver unit personnel” refers to the number of Nurse Peer Review Leaders, additional peer reviewers, and administrative or support staff sufficient to meet the approver unit’s stated goals.

Note: First-time applicants must set up the complete peer review process by which they would evaluate applications for approval of educational activities, and/or provider units, and conduct three mock application reviews using that process in order to complete their initial application for ANCC accreditation as approvers.

signaling the intent to aPPly

The Intent to Apply form must be completed and submitted to the Accreditation Program Office at least 4 months prior to the required document submission date. The renewing applicant is to submit a list of approvals awarded by them within 12 months prior to submission of the Intent to Apply form. The Accreditation Program staff will select at least three approvals from this list. The three approvals will be selected to be representative of the kinds of approvals awarded by the approver unit. These selected approvals will provide the reference for the narrative descriptions submitted to reflect educational design elements (Criterion 2).

Note: First-time applicants should submit an Intent to Apply form 4 months in advance of their intended submission date for the accreditation application package. This gives the ANCC Accreditation Program Office time to plan for the receipt, processing, and initial evaluation stages of the application. The first-time applicant will submit the full files (consisting of all elements identified in approver criterion 2, key element 5) of the three mock reviews it has performed. These files are not included in the 50 page limit of the approval unit applicant. An Intent to Apply form is included in Appendix C.

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APPlYINg for AccredITATIoN As AN APProVer of coNTINuINg NursINg educATIoN chaPter 4


Becoming accredited as Both an aPProver and Provider

Eligible organizations/units wishing to become ANCC-accredited as both approvers and providers must follow the complete application process for each type of accreditation separately. The dual accreditations would allow the same organization to provide and approve educational activities, but the approver and provider unit activities, including recordkeeping and evaluation, must remain completely separate and distinct functions within the organization—as specified by provider unit authority description given in Table 8 and the approver unit authority description in Table 10. This does not, however, preclude persons from serving in roles in both units. An accredited approver unit within an organization may not approve the educational activities provided by that organization. Instead, the providing organization must submit an application for activity approval to another ANCC-accredited approver or seek another means of offering contact hours.

PreParing the Written documentation oF adherence to criteria

The self-study report is composed of a series of narrative statements, which should be written in a concise, straightforward, and easily understood manner. The goal is to explain as clearly as possible how program criteria have been adopted and implemented by the approver unit. Supporting exhibits may be integrated with the narrative statements or accumulated in a separate, cross-referenced section of the report.

The self-study report shall address the following topics in the order listed here:

Executive Summary:• Leadershipoftheapproverunit;• Currentandprojectedapprovalpracticesforcontinuingnursingeducation;• Reviewofthehealthcareenvironmentinwhichtheapproverunitoperates;and• Structureandprocessusedforconductingtheself-studyprocess.

The Executive Summary, which functions as an abstract, should be limited to a single page. The topics to be covered for each of the four criteria are enumerated as key elements under each criterion definition as it is given in turn throughout the remainder of this chapter. (See the definition of key elements given in Chapter 1.) Depending on the organizational environment, some applicants may emphasize certain key elements more than others in their self-study reports.

Criteria Documentation:• MissionStatement;• ApprovalProcess;• UnitOperations;and• ApproverUnitEvaluation.

Table 10 summarizes the key elements that comprise the four approver unit criteria. Some key elements that may be abbreviated in Table 9 are fully described in the next pages.

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Self-Assessment Summary:• Approverunitstrengthsandfuturedirectionoftheapproverunit.

table 10. overview of approver unit criteria and Key elements

Major items are underlined, highlighted and marked with the symbol criterion 1: mission statement

1. mission statement. Beliefs and goals of the approver unit are relevant and appropriate to prospective applicants.

2. lines of authority and administrative support. organizationalstructuresandlinesofauthority support the operation of the approver unit.criterion 2: aPProval Process

1. Qualified reviewers. All nurse peer reviewers are registered nurses with expertise in educational design and at least a baccalaureate degree in nursing. They must possess the relevant knowledge and experience to participate in the peer review process.

2. contact hours.Theapprovalprocessauthorizescontacthourstobeawardedforthedidactic,clinical experience, or evaluation components of an activity. Contact hours are calculated in a logical and defensible manner. One contact hour = 60 minutes. The minimum number of contact hours that may be approved to be awarded for a continuing nursing education activity is 0.5 contacthours.if‘rounding’isdesiredinthecalculationofcontacthours,theprovideristorounddown. except in the case of point-of-care learner-directed educational activities, contact hours may not be awarded retrospectively. The official accreditation statement must be used when granting contact hours.

3. accreditation statements. All communications, marketing materials, and other documents that refer to the approver’s ANCC-accredited status contain the official accreditation statement, as follows:

•[NameofAccreditedApproverunit]isaccreditedasanapproverofcontinuingnursingeducation by the American Nurses Credentialing Center’s COA.

The accreditation statement must stand alone. In other words, it must start and end on a separate line.

4. conflict of interest guidelines. Conflictofinterestdisclosurestatementsshallbeobtainedfromallpeerreviewerstoidentifythepresenceorabsenceofanypotentiallyconflictingrelationships of a financial, professional, or personal nature. Peer reviewers shall disclose the presenceorabsenceofconflictofinterestrelativetoeachapplicationreviewed.Allpotentialconflictsshallberesolvedpriortoimplementationofthecontinuingeducationactivity.

5. recordkeeping. For all applications acted upon, specific documentation is retained in a confidential manner and kept in a secure location for 6 years.

6. Peer review of applications for Provider unit approval Proceeds according to specified guidelines. Retroactive approval may not be granted.

7. Peer review of applications for Provider-directed educational activity approval Proceeds according to specified guidelines. Retroactive approval may not be granted.

8. Peer review of applications for a learner-directed activity Proceeds according to specified guidelines. Approval of the point-of-care learner-directed activity may be granted up to 6 weeks retroactively. The time spent by the learner in the planning, implementation, and evaluation processes associated with the development and engagement in the learning activity may be included in the calculation of contact hours.criterion 3: unit oPerations

1. nurse Peer review leader. At least one Nurse Peer Review Leader is responsible for overseeing the entire peer review approval process. The Nurse Peer Review Leader guarantees that ANCC Accreditation Program criteria guide the standards by which approval applications are evaluated.

2. monitoring Process. Accredited approvers are responsible for ensuring that all approved applicants are following ANCC criteria. The pertinent practices of each applicant will be monitored on a regular basis (at least once during the approval period).

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3. resources. Sufficient human, material, and financial resources are available to carry out the administrative, educational, and supportive functions of the approver unit.

4. Business Practices. Accredited approver units must adhere to all regional, state, and national laws and regulations and operate the business and management policies and procedures of its continuing nursing education program (as they relate to human resources, financial affairs, and legal obligations) in an ethical manner and so that its obligations and commitments are met. criterion 4: aPProver unit evaluation

1. approver unit evaluation Process. The approver must have a mechanism in place to evaluate the effectiveness of its overall continuing nursing education program.

2. approver unit evaluation Participants. The Nurse Peer Review Leader and other appropriate individuals participate in the process used to evaluate the overall effectiveness of the approver unit.

3. approver unit evaluation results. Evaluation data are used to confirm, expand, and change the operations of the approver unit.

4. approver unit goals for improvement. Efforts toward improvement include addressing issues, identifying strategies for working on targeted goals, evaluating progress toward goals, and revising or establishing new goals.

In the remainder of this chapter, each key element statement is followed by a description of the required evidence necessary for inclusion in the self-study report to demonstrate how the approver unit meets that key element. Key elements, or components of the key element that are considered of major impact if found non-compliant, are underlined, highlighted, and are marked with the symbol. Further discussion of major (and minor) key elements can be found in Chapter 6, Accreditation Decision.

aPProver unit criterion 1

mission statementThe documented beliefs and goals of the approver unit reflect the importance of continuing education for nurses and the needs and characteristics of the approver unit’s potential applicants. The approver unit is clearly defined, accurately, clearly, and consistently named within the organization and supported by the administrative structure.

Key elements:

1. Mission Statement. Beliefs and goals of the approver unit are relevant and appropriate to prospective applicants.

requIred eVIdeNce:

•Submit the beliefs and goals of the approver unit. Describe how the beliefs and goals of the approver unit link with the goals, mission, and functions of the total organization.

•Submit a description of the features of the approver unit that characterize its scope, such as its size, geographical range, target applicant group(s), and emphasized content areas, if any. If the approver unit is part of a multi-focused organization1, describe the relationship of these scope dimensions to the total organization.

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2. Lines of Authority and Administrative Support. Organizational structures and lines of authority support the operation of the approver unit.

requIred eVIdeNce:

•Submit an organizational chart, flow sheet, or similar kind of image that depicts the organizational structure of the approver unit. Provide the name and credentials of the individual in each position identified on the organizational chart. If the approver unit is part of a multi-focused organization1, submit an additional depiction that identifies the approver unit’s lines of authority and structural location within the total organization.



approval Process Key Elements 1-5 below refer to descriptions of procedures in effect throughout the overall approver unit rather than those relative to approvals of specific providers (Criterion 6) or activities (Criterion 7).

Approval Process. The approver unit relies on qualified and impartial peer reviewers, provides consumers sufficient information for preparing their applications, conducts the peer review process in a credible and reliable manner, and maintains records in a secure and confidential manner. The approver unit employs a process for conducting the sequential phases of peer review approval that provides for application intake, action decisions following the review, and procedures for handling withdrawals, resubmissions, appeals, and revocations.


A. Approver Unit Documentation. Key Elements 1-5 below refer to descriptions of procedures for the overall approver unit.

B. Documentation of Peer Review for Provider Applications. Key Element 6 below refers to descriptions of the peer review approval process for provider unit applications.

C. Documentation of Peer Review for Activity Applications. Key Element 7 below refers to descriptions of the peer review approval process for educational activity applications.

D. Documentation of Approvals. Submit lists of activities approved and providers approved since the last annual report, if not already submitted with Intent to Apply Form.

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Key elements:

1. Qualified Reviewers. All nurse peer reviewers are registered nurses with expertise in educational design and at least a baccalaureate degree in nursing. They must possess the relevant knowledge and experience to participate in the peer review process.

requIred eVIdeNce:

•Documenttherelevantknowledgeandexperienceoftheapproverunit’scurrent peer reviewers and the Nurse Peer Review Leader. Biographical data forms or curriculum vitae may be used;

•Documentthemethodsusedtoeducatepeerreviewersaboutaccreditationcriteria and the approver unit’s peer review processes. Describe how all nurse peer reviewers are kept up-to-date on the requirements for adhering to ANCC accreditation standards;

•Submitthepositiondescriptionforpeerreviewersthatclearlyidentifyfunctions related to the role of peer reviewer. The position description must reflect qualification requirements for the nurse peer reviewers that are consistent with those of the ANCC Accreditation Program; and

•Submitadescriptionofhowtheapproverunitensuresthattheperformanceof each nurse peer reviewer meets both the requirements of the approver unit and the expectations of ANCC relative to the responsibilities of the nurse peer reviewer.

*2. Contact Hours. Contact hours associated with the official accreditation statement are awarded to participants for those portions of the educational activity devoted to didactic or clinical experience or to evaluating the activity. Contact hours are calculated in a logical and defensible manner. One contact hour = 60 minutes. An approved applicant may award no fewer than 0.5 contact hours for an educational activity. Learning activities may be conducted ‘asynchronously’ or may be ‘bundled’ to allow a full learning experience to take place. In the case of point-of-care learning, the time spent by the learner in the planning, implementation, and evaluation processes associated with the development and engagement in the learning activity may be included in the calculation of contact hours. If ‘rounding’ is desired in the calculation of contact hours, the provider is to round down. Except in the case of point-of-care learner-directed educational activities, contact hours may NOT be awarded retrospectively. The official accreditation statement must be used when granting contact hours.


requIred eVIdeNce:

•Submit a description of how instructions for the calculation of contact hours are communicated to applicants and how the approver unit ensures accurate implementation of the instructions. Provide any tools or other evidence of implementation of the described processes; and

•Submitadescriptionofhowtheapproverunitensurestheofficialaccreditation statement is used when approved applicants grant contact hours.

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3. Accreditation Statements. All communications, marketing materials, and other documents that refer to the approver’s ANCC-accredited status (e.g. letter to applicant, cover page of manual, instructions on web site, etc.) contain the official accreditation statement, as follows:

•[NameofAccreditedApproverUnit]isaccreditedasanapproverofcontinuing nursing education by the American Nurses Credentialing Center’s COA.


requIred eVIdeNce:

•Submit copies of approver unit materials that reflect compliance with this key element.

*4. Conflict of Interest Guidelines. Conflict of interest disclosure statements shall be obtained from all peer reviewers to identify the presence or absence of any potentially conflicting relationships of a financial, professional, or personal nature. Peer reviewers shall disclose the presence or absence of conflict of interest relative to each application reviewed. All potential conflicts shall be resolved prior to implementation of the continuing education activity. Refer to the conflict of interest discussioninAppendixG.


requIred eVIdeNce:

•Submit a description of the process for identifying and resolving conflict of interest for individuals involved in the peer review and approval process.

•Submitdocumentationreflectingdisclosureobtainedrelativetoatleastoneapplication.*

•IfasigneddisclosureformisNOTused,theunitisadvisedtomaintaindocumentation of the source of the disclosure information.

5. Recordkeeping. For all applications acted upon, the following kinds of records are maintained in a confidential and retrievable manner and kept in a secure location for 6 years: (a) Disclosure by the applicant of previous denials received from other ANCC-

accredited approver units;(b) Consideration and resolution of previous denials (referred to above) by the peer

reviewers of the accredited approver;(c) Assessment of eligibility,(d) Application, documentation of the review process, and actions taken;(e) Conflict of interest disclosure statements from peer reviewers, and(f) Action notifications and other correspondence,(g) A statement regarding who the target audience for marketing is.

requIred eVIdeNce:

Submit a description of the approver unit’s recordkeeping system, including:•How records of application, review, decisions, and related correspondence

are consistently collected; •Howtheyarestoredandsecuredinaconsistent,logical,safeand

confidential manner; and

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•Anytoolsoraidsusedbytheapproverunittoensureallrequiredelementsare included in the records.

6. Review of Applications for Approval of a Provider Unit. (a) Approved provider units targeted more than 50% of their activities provided

in the previous calendar year to nurses in a single state or region, or state contiguous to the region.

(b) Approval process. An established peer review approval process guides approver unit operations in which all phases (from eligibility assessment through post-evaluation activities) are incorporated for receipt of an application, peer review, actions taken, withdrawal, resubmission, appeal, and revocation.

(c) Approved provider units are approved to award contact hours for a period of 3 years.

(d) Applicants for approved provider status are instructed to meet all of the requirements specified for approved providers in Appendix F of this manual and to provide the corresponding supporting documentation in their applications. ANCC has designated the approved provider unit self-assessment and the site visit phase of the application process as optional. However, the accredited approver unit has the option to require either or both, as desired.

(e) Approved provider units are instructed to maintain timely communications with the ANCC-accredited approver by providing any requested reports and notices of significant organizational changes.

(f) Approved provider units are instructed to use the following statement indicating their approved provider status on all documents related to their activities.

•[ Name of Approved Provider ] is an approved provider of continuing nursing education by [ Name of Accredited Approver ], an accredited approver by the American Nurses Credentialing Center’s COA.

The accreditation statement must stand alone. In other words, it must start and end on a line separate from other text.

(g) Applicants for approved provider unit status are required to have an established and implemented method (e.g. policies and procedures) for delineating how the approved provider unit operates.

requIred eVIdeNce for KeY elemeNT 6 (A – g):

•Submit a written description of the process used for conducting the sequential phases of the peer review approval process relative to provider approval including, application intake action, decisions following the review, and procedures for handling withdrawals, resubmissions, appeals, and revocations;

•Copiesofanyinternalformsusedtomanageanddocumenttheprocessdescribed above;

•Acopyoftheinstructionsandapplicationpacketsgiventoapplicantsforprovider unit approval and any other materials or informational resources made available to them;

•Adescriptionofhowapprovedproviderunitsareinstructedtomaintaintimely communications with the approving unit; and

•Describe how approver unit methods and guidelines (or equivalent – e.g. policies and procedures) are reviewed.

Note: First-time applicants eligible to be awarded accredited approver status are to submit the files of the three mock reviews identified on the

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Intent to Apply form. The descriptions and forms referenced above should be reflected in the files submitted. These files are not included in the 50-page application limit.

For key elements 7 and 8, you may refer to the table below for an overview of items considered in the approval review.

table 11. approval of activities

Provider-directed activity (includes, Face-to-Face, indePendent study, WeB-Based learning, etc.)

learner-directed activity

learner-directed Point-oF-care activity

NURSE PLANNER WITH BSN OR ABOVE

yES NO NO

PLANNING COMMITTEE MEMBERS REPRESENT rEquirEDELEMENTS

yES N/A N/A

APPROVED FOR A 2-yEARS PERIOD

yES N/A N/A

DECISION PRIOR TO ACTIVITy

yES yES NO

MINIMUM NUMBER OF CONTACT HOURS = 0.5

yES yES+ yES+

DISCLOSURES OF COMMERCIAL SUPPORT OR CONFLICT OF INTEREST MUST BE MADE

yES N/A N/A

EVALUATION CATEGORy IDENTIFIED

yES yES yES

EVALUATION TOOL AVAILABLE

yES yES yES

EVALUATION COMPLETED

RECOMMENDED (BUT NoTrEquirED)

yES yES

EFFECTIVE EDUCATIONAL DESIGN PRINCIPLES USED

yES yES yES

RECORDS ARE KEPT FOR 6 yEARS

yES yES yES

+ the time Spent in planning the activ -ity may be included in calculation of the contact hourS

7. Peer Review of Applications for Approval of a Provider-Directed Activity

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(a) Approval process. An established peer review approval process guides approver unit operations in which phases are incorporated for receipt of an application, peer review, actions taken, withdrawal, resubmission, appeal, and revocation.

(b) Activities are approved to award contact hours for a period of 2 years.(c) All applications are reviewed and an approval decision is made in advance of the

implementation of the provider-directed activity.(d) Applicants are instructed to meet the following requirements in their

applications: (1) a Nurse Planner who is a registered nurse, who holds a baccalaureate or

higher degree in nursing, and has been oriented to the ANCC accreditation criterion for educational design, and who has been directly involved in planning the educational activity, and

(2) the planning and intended implementation and evaluation of the activity conform to the requirements specified by Key Elements 1-12 of accredited provider unit criterion 2 for educational design (as detailed in Chapter 3 of this manual) with the corresponding required evidence included in the application.

(e) Applicants are instructed to use the following statement of approval on all documents related to the approved activity.

•This continuing nursing education activity was approved by [ Name of Approver Unit ], an accredited approver by the American Nurses Credentialing Center’s COA.


On the occasion that a learning activity is announced prior to receipt of approval to award contact hours, the following statement will be made:

This activity has been submitted to [ Name of Approver Unit ] for approval to award contact hours. [ Name of Accredited Approver Unit ] is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center’s COA.

This accreditation statement must also stand alone. In other words, it must start and end on a separate line. There does not need to be a blank line above or below.

requIred eVIdeNce:

•Submit a written description of the process used for conducting the sequential phases of the peer review approval process relative to approval of educational activities including application intake action, decisions following the review, and procedures for handling withdrawals, resubmissions, appeals, and revocations;.

•Submitcopiesofanyinternalformsusedtomanageanddocumenttheprocess described above; and

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•Submitacopyoftheinstructionsandapplicationpacketsgiventoapplicantsfor educational activity approval and any other materials or informational resources made available to them.

Note: First-time applicants eligible to be awarded accredited approver status are to submit the files of the three mock reviews identified on the Intent to Apply form. The descriptions and forms referenced above should be reflected in the files submitted. These files are not included in the 50-page application limit.

8. Peer Review of Applications for Approval of a Learner-Directed (Point-of-Care/ Just-in-Time) Activity. (a) Approval Process. An established peer review approval process guides approver

unit operations. The process incorporates processes for:(1) receipt of an application, (2) peer review, (3) actions taken, (4) withdrawal, (5) resubmission, (6) appeal, and (7) revocation

(b) Activities are approved for a one-time implementation.(c) Point-of-care learner-directed activities are approved within 6 weeks following

completion of the education activity.(d) All other learner-directed activities are approved prior to completion of the

education activity.(e) Applicants are instructed to meet the following requirements in their

applications:(1) the planning, and the intended implementation, and evaluation of the activity

conform to the requirements specified by Key Elements 1, 3, 4, 5, 7 of accredited provider unit criterion 2 for educational design (as detailed on pages 31 - 34 of this manual). The corresponding required evidence must be included in the application;

(2) all provisions of the Standards for Commercial Support found in Appendix B of this manual are followed; and

(3) Records for each learner-directed activity will be maintained by the approver unit as well as the learner who engaged in the activity. Records shall include at least:

a) the learner-directed activity application for approval; b) the completed verification of completion; c) outcomes of the learning; d) evaluation of the effectiveness of the educational activity/experience; ande) the learner planning a learner-directed activity does not have to meet the

previously established qualifications as a Nurse Planner.

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unit operations The approver unit ensures the quality of continuing nursing education by following an established peer review approval process coordinated by a qualified Nurse Peer Review Leader. Adequate resources support the approver unit’s full range of functions.

Key elements:

1. Nurse Peer Review Leader. At least one Nurse Peer Review Leader is responsible for overseeing the entire peer review approval process. The Nurse Peer Review Leader guarantees that ANCC Accreditation Program criteria guides the standards by which approval applications are evaluated.

requIred eVIdeNce:

•Describe the role(s) played by the approver unit’s Nurse Peer Review Leader in the peer review approval process;

•Identifyanyadditionalkeypersonnelorgroupsinvolvedinthepeerreviewapproval process. Describe the roles they play; and

•FortheNursePeerReviewLeader,submitapositiondescriptionthatclearlyidentifies job functions, and a biographical data summary (or equivalent), that demonstrates the qualifications of the current incumbent. The position description must reflect roles and qualification requirements for the Nurse Peer Review Leader relative to continuing nursing education that are consistent with those of the ANCC Accreditation Program.

2. Monitoring Process. Accredited approvers are responsible for ensuring that all approved applicants are following ANCC criteria. Each approved provider will be monitored on a regular basis (at least once during the approval period). The monitoring will include, at a minimum, a review of educational design, management of commercial support, provision of appropriate disclosures to learners, and assurance that all required items are kept in the file (e.g. a checklist with all required elements on the checklist). Approved providers will also be monitored to ensure they are engaging in quality improvement activities relative to their operations and provided education. Monitoring may be accomplished utilizing a ‘desk top’ review or through personal observation and interaction.

requIred eVIdeNce

•Submit a description of the activity monitoring process that is utilized for activities that are offered repeatedly;

•Submitadescriptionofhowapprovedprovidersaremonitored.(Notapplicable for SNO accredited approver units);

•Describehowtheapproverunitensuresthatapprovedprovidersarenotapproving activities internally or externally;

•Describehowtheapproverunitensuresthatallconflictsofinterestareresolved appropriately; and

•Describetheprocessusedbytheaccreditedapproverunittorespondtoalack of compliance with the monitoring process.

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3. Resources. Sufficient human, material, and financial resources are available to carry out the administrative, educational, and supportive functions of the approver unit.

requIred eVIdeNce:

•Describe the human and material resources that support the functions of the approver unit; and

•Describetheapproverunit’scurrentsourcesoffinancialsupportandprojections for how financial support will be sustained throughout the period of accreditation. Do not submit detailed budget reports.

4. Business Practices. Accredited approver units must adhere to all regional, state, and national laws and regulations and operate the business and management policies and procedures of its continuing nursing education program (as they relate to human resources, financial affairs, and legal obligations) so that its obligations and commitments are met. The approver unit must adhere to all reasonable ethical expectations in its approval of continuing nursing education and its business practices.

requIred eVIdeNce:

•Provide an attestation statement that the accredited unit complies with all applicable local, regional, state, or national laws and regulations and operates its business in an ethical manner. The attestation statement is to be signed by the leaders of the accredited unit.


approver unit evaluationThe approver unit engages in an ongoing evaluation process to analyze its overall effectiveness in fulfilling its beliefs, goals, and functions and in providing a quality peer review approval process for continuing nursing education. Plans and goals for the approver unit’s future development in continuing nursing education are identified and re-evaluated on a regular basis.


Required evidence for this criterion should include examples of the evaluation data that are collected with an explanation as to how they have been used to increase the effectiveness of the approver unit. Applicants for re-accreditation should select data examples to be representative of the prior accreditation period.

Note: First-time applicants are expected to have implemented their unit outcomes evaluation plans throughout the minimum 6 months of operational status required for application eligibility. (See Table 6.) Data examples should be selected to be representative for that period.

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56 APPLICATION MANUAL // PATHWAy TO ExCELLENCE™ PROGRAM

Key elements:

1. Approver Unit Evaluation Process. An ongoing and systematic process is carried out at the overall unit-level to evaluate the approver unit’s: (a) administrative and operational procedures;(b) peer review approval process;(c) outcomes and results; and(d) progress toward goals for improvement.

requIred eVIdeNce:

•Submit a description of the plan for implementing the approver unit’s overall evaluation process.

2. Approver Unit Evaluation Participants. The Nurse Peer Review Leader and other appropriate individuals participate in the process used to evaluate the overall effectiveness of the approver unit..

requIred eVIdeNce:

•Submit a description of how the Nurse Peer Review Leader, all other peer reviewers, consumers, and additional unit staff as appropriate participate in the overall evaluation process.

3. Approver Unit Evaluation Results. Evaluation data are used to confirm, expand, and change the operations of the approver unit.

requIred eVIdeNce:

•Submit examples of, or a description of, how results of the overall program evaluation process have been used to confirm, expand, and improve the approver unit’s operations.

4. Approver Unit Goals For Improvement. Efforts toward improvement include addressing issues, identifying strategies for working on targeted goals, evaluating progress toward goals, and revising or establishing new goals.

requIred eVIdeNce:

Submit examples of, or a description of how the approver unit’s •Goalsforimprovementthathavebeenaddressed;•Whatchangesandprogresshavebeenmadetowardmeetingthosegoals;•Whatnewgoalsforimprovementhavebeenidentified;and•Operationalplansforimplementationassociatedwiththegoalsidentified

above.

submitting the application PackageFormatting and assembly requirements for the self-study report are listed with the provider unit application instructions in Appendix C. These instructions also explain how to determine the accreditation fee payment to be submitted with the application. The application form itself signifies an attestation to the applicant’s eligibility to apply for accreditation and should be included as a cover sheet with the self-study report and exhibits. The application checklist must be completed, citing beginning page numbers so that the major sections of the written documentation, the executive summary, the required evidence for each of the key elements, and the self-assessment summary may be easily located by appraisers and members of the ARC or the COA.

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5site visit

Site visits to the headquarters of the organizations/units applying for accreditation are a required part of the application process. The site visit is described on page 16 of this manual. To review, the purpose of the site visit is to make an accurate, first-hand assessment of the information contained in the application package. The appraisers who conduct the site visit work closely with the applicant to amplify, clarify, and verify the information presented in the self-study report and to ensure, by observation, that the report is reflective of the environment and the processes in place within the unit.

Once the self-study report has been reviewed by the appraiser team, a site visit is scheduled. The visit usually requires 1-2 full business days and is conducted by the two members of the appraiser team who reviewed the self study. When an organization is applying for both approver and provider accreditation at the same time, the 2 days required to accomplish both site visits are planned to occur consecutively whenever possible.

site visit PreParations

When the Accreditation Program Office notifies an applicant of the date selected for the site visit, it also names and provides biographical information on the appraisers who will carry out the site visit. As mentioned in Chapter 2, individual members are not assigned to the appraiser team for an applicant until the potential for conflicts of interest have been examined and resolved. However, at this point in the process, the applicant also has the opportunity to review the qualifications of the site visit team and to identify any problems or conflicts in need of resolution. A written description of the problem or conflict should be submitted.

The appraisers review copies of the application package and any other correspondence or supporting material the Accreditation Program Office has forwarded to them in relation to the application. They also access any public information about the applicant, including Internet sites, print materials, or other media used to communicate with the public about their services. If any additional information about the applicant is needed, the team leader will request it from the applicant prior to the site visit. The team leader is also responsible for preparing and sending a tentative agenda to the applicant prior to the site visit. After reviewing the draft agenda, the applicant may ask to negotiate time frames or to substitute individuals identified for interview during the visit.


chaPter 5 sITe VIsIT

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Applicants are responsible for making all travel arrangements for appraisers and for paying the expenses incurred to conduct the site visit. These expenses, which are not included in the application fee, must be paid in full before the COA renders an accreditation decision. All lodging, air, and ground travel arrangements must be confirmed for the appraiser team conducting the site visit at least 30 days in advance or the visit may be cancelled.

Applicants are expected to work with each member of the site visit team to ensure that reasonable travel choices are being made given the point of origin and the site. The site visit team will usually arrive the evening before the scheduled visit and depart on the evening of or the day following the visit. The usual costs involved for each of the two appraisers conducting the site visit include:

•Hotelreservationsfor1or2nights(2or3nightsforajointapplication);•Airandgroundtransportationandairportparking;•Aperdiemallowanceformealsandmiscellaneousexpenses;and•Mileage(iftheappraiserdrivestothesitevisit).CurrentIRSrateguidelinesare

utilized when calculating mileage reimbursement

Current per diem rates are available from www.gsa.gov/Portal/gsa/ep/home.do?tabId=0. In addition, a rental car may be required. While Accreditation Program appraisers do not receive any remuneration for their appraisal activities, ANCC will reimburse the appraisers for expenses incurred associated with the site visit. ANCC will bill these costs to the applicant. ANCC must be fully reimbursed within 30 days of invoicing for any expenses the appraisers incur during the site visit.

site visit activities

On site, appraisers conduct comprehensive interviews with selected staff and review records. Based on a reference list provided by the applicant and educational materials in the records, appraisers will also interview (by telephone or in person) selected others who have participated in the unit’s continuing nursing education services, such as volunteers, and participants, including planners and faculty. Site visits do not include formal presentations by applicants, and appraisers do not observe educational activities on provider unit visits or peer review meetings on approver unit visits.

The site visit agenda may include:

•ConferenceswithNursePlannersinproviderunitsorNursePeerReviewLeadersin approver units and other officials, administrators, or support staff to review the information contained in the self-study report;

•Reviewofappropriatedocumentsandrecordssuchasaprovider’seducationalactivity files or an approver’s peer review and application files, evaluation data, and the reports of meetings;

•Atourofthefacilities,ifappropriate;•AmeetingorinterviewwithNursePlannersorNursePeerReviewLeaders,other

officials, faculty, committee members, presenters, administration/management, support staff, learners/participants/consumers, and staff;

•Areviewofadditionalmaterials;•Anexecutivesessionforappraiserstoreviewdataandclarifyissues;and•Anecdotalclosingcomments(Thesecommentshavenorelationtothefinaloutcome,

which is left to the sole discretion of the COA.)


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During site visits to provider units, appraisers will review the full recordkeeping file for the sample activities described in the self-study report and other files to be selected randomly onsite. Copies of advertising documents, marketing brochures, and materials such as workbooks or videotapes for learner-directed activities, if any, should also be gathered and readied for review.

During site visits to approver units, appraisers will review the full recordkeeping file for the applications described in the self-study report, as well as other randomly selected files.

Copies of policies and procedures, advertising documents, application packets for activity or provider unit approvals, and other informational resources the unit makes available for consumers, should also be gathered and readied for review.

Applicants should plan to make a private work space available to appraisers for the day that has sufficient room and adequate lighting for reviewing materials. The appraisers will leave no site visit materials behind.

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6accreditation decision

To strengthen the analysis and evaluation process leading up to the accreditation deci-sion, ANCC’s Accreditation Program employs a two-stage review of application materi-als and the final appraiser report. The appraisers’ final report documents the evidence gathered by the appraiser teams from reading the application materials, examining any public materials published by, or about, the applicant, and conducting the site visit. The appraisers’ final report does not draw conclusions or make recommendations about the accreditation decision. It does describe the evidence found on site that supports the statements made by the applicant in their application. As described in Chapter 2 of the manual, the members of the two reviewing bodies, (the ARC and the COA) and the process by which they jointly review the required evidence reported by the appraisers forms the basis of the accreditation decision.

accreditation actions

Any one of four actions may be taken by the COA in response to an application: 1) accreditation, 2) deferral, 3) probation*, or 4) denial. Following a decision to accredit by the COA, the Accreditation Program Office staff will prepare a notification letter to advise the applicant of the outcome. Accreditation is effective immediately upon the date of the decision. If the applicant has been found to be non-compliant in any area, correction will be requested and the COA will request that a progress report providing evidence of the corrective action be submitted.

* One-year accreditation is granted for re-accreditation applicants receiving probationary status. This action is indicated when the re-accreditation applicant has demonstrated a level of non-compliance with the accreditation criteria as listed in the table below. A progress report describing the applicant’s correction of the non-compliant areas will be required. At the end of the 1 year probation period, a site visit will be made to appraise the organization’s performance at that time. Following review of the report of the site visit, the COA may convert the accredited unit’s status from “probationary” to “accredited”. The “accredited” status will expire 4 years following the start of the probationary period.


chaPter 6 AccredITATIoN decIsIoN

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The COA will take action based on the following guide:

table 12. accreditation decision guide

Provider unit

Major items are underlined, highlighted and marked with the symbol . RE-ACCREDITING UNITSaPProximate % comPliance

# non-comPliant major items

# non-comPliant minor items

coa action

90% 0-4 0-2 6 yEAR ACCREDITATION


60% 11-16 0-19 PROBATION*

<60% 17-40 0-19 DENIAL INITIAL APPLICANTSaPProximate % comPliance



coa action


<60% 17-40 0-19 DENIALINITIAL APPLICANTS AT END OF 2-yEAR ACCREDITATIONaPProximate % comPliance



coa action

90% 0-4 0-19 ExTENDED 4 MORE yEARS

75% 5-10 0-19 ExTENDED 2 MORE yEARS

<75% 11-40 0-19 NOT ExTENDED

aPProver units

Major items are underlined, highlighted and marked with the symbol . RE-ACCREDITING UNITSaPProximate % comPliance



coa action

100% -90% 0-3 0-3 6 yEAR ACCREDITATION

89% -75% 4-8 0-25 4 yEAR ACCREDITATION

74% -60% 9-13 0-25 PROBATION*

<60% 14-34 0-25 DENIALINITIAL APPLICANTSaPProximate % comPliance



coa action

100%-40% 0-20 0-25 2 yEAR ACCREDITATION

<40% 21-34 0-25 DENIALINITIAL APPLICANTS AT END OF 2-yEAR ACCREDITATIONaPProximate % comPliance



coa action

100% -90% 0-3 0-25 ExTENDED 4 MORE yEARS

89% -75% 4-8 0-25 ExTENDED 2 MORE yEARS

<75% 9-34 0-25 NOT ExTENDED

* One-year accreditation is granted for repeat applicants receiving probationary status. This action is indicated when the repeat applicant has demonstrated substantial non-compliance (as defined above) with the accreditation criteria. A progress report describing the applicant’s correction of the non-compliant areas will be required. At the end of the 1 year probation period, a site visit will be made to appraise the unit’s performance at that time. Following the report of the site visit, the COA will converttheunit’sstatusfrom“probationary”to“accredited”.The“accredited”statuswillexpire4yearsfollowing the start of the probationary period.


AccredITATIoN decIsIoN chaPter 6

Note: First-time applicants: 2-year accreditation for first-time applicants. This action may indicate when the COA determines that a first-time applicant has met the needed percentage of criteria items as indicated above. Progress reports are required of new organizations/units during the initial 2-year accreditation period. 1 year prior to the conclusion of that 2-year accreditation period, the accredited unit shall provide the following information:

• Aneworganizationalchartandadescriptionofanychangesinkeypersonnel(including the Nurse Planner and other individuals as defined by the applicant organization). If there have been changes, an explanation of the ways personnel changes have affected operations and how the organization has responded is required;

• Evaluationofpreviouslyestablishedgoalsanddescriptionofanynewgoals;and• Onecompletefileforeachtypeofactivityprovided(orforapprovers,foreachtype

of activity approved).

A site visit may or may not be conducted. Upon review of the submitted materials, the COA will determine whether to award an additional 2 years or an additional 4 years of accredited status to the applicant, and will decide whether to require progress reports during the additional accreditation period.

deFerrals, denials, reconsiderations, and aPPeals

A deferral decision is taken when the COA determines that more information is needed from the applicant before an accreditation decision can be made. A denial of accreditation is indicated when the COA determines that an applicant is significantly out of compliance with the criteria of the ANCC Accreditation Program.

Denial decisions are open to requests for reconsideration and are open to appeal. To file a request for reconsideration or to file an appeal, the applicant must submit its written argument to the COA within 30 business days after receiving written notice of an accreditation decision. The appeal must also be accompanied by the appeal processing fee. Applicants considering whether to appeal a decision, or to request a reconsideration of a decision, should contact the ANCC Accreditation Program Director for further instructions.

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While the accredited unit is responsible for monitoring its adherence to the ANCC Accreditation Program criteria on an ongoing basis, the COA will, on a periodic basis, confirm adherence to criteria to evaluate the standing of currently accredited units. Interim monitoring consists of review of annual reports, review of progress reports, and review of any other information the COA has specifically requested. The COA regularly studies annual report data, notices of organizational change, progress reports, complaints, and responses to complaints in the course of conducting its ongoing business.

To ensure adherence to Accreditation Program criteria an accredited unit should periodically reference the responsibilities of accredited units specified in Table 6 (page 18) of Chapter 2. Listed among them are the responsibilities to submit annual reporting data and to continuously adhere to accreditation criteria—the failure of which may result in the suspension or revocation of accredited status. This chapter explains the annual reporting process more thoroughly, describes the terms under which suspensions or revocations may occur, and, in addition, itemizes the responsibilities that remain for an accredited unit in the event it decides to terminate accreditation.

annual rePorting

Accredited units are required to submit reports on an annual basis. These reports serve three purposes. They permit the ANCC Accreditation Program to track and describe trends in the field of continuing nursing education; they enable the COA to identify those units which, because of changing environments, are particularly challenged in terms of adherence to the Accreditation Program criteria; and lastly, they provide the accredited unit with valuable feedback regarding how well its adherence to Accreditation Program criteria is reflected in its files. The annual data reporting forms are included in Appendix D.

In addition, the COA may request progress or continuous quality improvement reports on an as-needed basis. As Table 5 specifies, accredited units are expected to respond to such requests in a timely manner,

7interim monitoring


chaPter 7 INTerIm moNITorINg

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susPensions and revocations

A suspension is indicated when the COA determines the failure of an accredited unit to:

• Satisfactorilyconfirmthatrelevantprogramcriteriaarebeingmet;• Payaccreditationfeespromptly;• Fullycomplywithallrequestsforinformation;or• OtherwiseactinamannerconsistentwithANCCAccreditationProgramcriteria,

requirements, values, or goals;• Adheretothelogousagerequirementsfoundonpage18ofthismanual.

Suspended units must immediately cease (a) offering or approving ANCC-accredited contact hours, and (b) referring to itself in any way as an ANCC-accredited unit. Units that are suspended may, within 120 days of the suspension date, apply for reinstatement by submitting the applicable reinstatement fee, including other outstanding fees, if any. Reinstatement may be granted if the suspended unit adequately demonstrates that it intends to fully adhere to the ANCC Accreditation Program criteria and requisites upon reinstatement. Units that have been reinstated may be required to submit progress reports to the COA. Suspended units that fail to apply for reinstatement within 120 days shall have their accredited status revoked.

A revocation is indicated when the COA concludes that an ANCC-accredited unit does not meet Accreditation Program criteria or has failed to comply with the requisites for retainingANCC-accreditedstatus.Generally,accreditedunitsinjeopardyofhavingtheir accredited status revoked will initially be suspended. However, should the COA determine that it is in the best interest of the ANCC Accreditation Program or its consumers to revoke a unit’s accredited status without first suspending the unit, it shall do so. Units that have had their accredited status revoked are ineligible to apply for ANCC accreditation for a period of 2 years subsequent to the revocation date and shall only be awarded accreditation for a 2-year period should the submission of their first application following revocation be successful.

Suspension and revocation decisions are open to appeal. The appeal, along with an appeal processing fee, must be submitted in writing to the COA within 30 business days after receiving written notification of the suspension or revocation decision. Units considering an appeal should contact the ANCC Accreditation Program Office for more information.

voluntary terminations

Units that decide to cease the continuing nursing education services for which they are accredited must notify the COA of that intent in writing within at least 30 days prior to the implementation of that decision. The written notice is to be sent to the ANCC AccreditationProgramat8515GeorgiaAve.,Suite400,SilverSpring,MD20910.Provider units should specify in their written notice to the COA how they will continue to make activity participation records available to learners. Approver units should specify in their written notice to the COA how they will continue to make approval records available to consumers and how the oversight of approved provider units will be transferred or maintained until their approval periods expire.


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8applying for re-accreditation

Accredited units that choose to apply for re-accreditation must do so during the last year of their current accreditation period. The accredited organization that intends to seek re-accreditation should submit an Intent to Apply form (either electronically or in writing) to the ANCC Accreditation Program approximately 4-6 months prior to the date it will submit its self-study documents. Its application and self-study documents are due 6 months prior to its expiration date. (The Intent to Apply form is shown in Appendix C and is available on the ANCC Accreditation Program web site, www.nursecredentialing.org/Accred.) Except as specified below for streamlined applications, the written documentation and site visit requirements are the same for returning applicants as for initial applicants.

streamlined re-accreditation

An accredited unit may elect to submit a ‘streamlined application’ for re-accreditation if it meets the following criteria:

•Hasbeenaccreditedfortwoormore6-yearcyclesinarow—withnoprogressreportin the more recent cycle;

•Hasseenlittlechangeinkeypersonnel(includingtheNursePlannerandotherindividuals as defined by the applicant organization));

•Hasnotseensignificantstaffturnover(eitherinnumbersofstaff,e.g.,50%,orinkey personnel, including the Nurse Planner and other individuals as defined by the applicant organization) within the past 2 years; and

•Hashadnolegitimateunresolvedcomplaintsagainstitwithinthepast2years.

The accredited unit should discuss its eligibility to pursue the streamlined re-accreditation process with the Accreditation Program staff prior to preparing the re-accreditation application and self-study.

A streamlined application does not require written documentation to be submitted for Criteria 2 and 3, instead, adherence to those criteria is assessed on-site during the site visit. This effectively shifts the entire focus of the written documentation to Criteria 1 and 4, the goals and structure of the unit and the unit evaluation. The unit utilizing the streamlined application for re-accreditation will submit a list of its activities (and/or approvals, if applicable) with the Intent to Apply form.


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9 the unified application

overvieW

In 2001, the COA embarked on a process that resulted in the creation and implementation of the “unified application.” This application is referred to as “unified” because it is the product of a collaborative initiative among ANCC, the Accreditation Council for Continuing Medical Education, and the Accreditation Council on Pharmaceutical Education.

This unified application was created and implemented so that organizations/units seeking accredited status for nurses, physicians and pharmacists can better streamline the accreditation process. Organizations/units seeking accredited status may use this application process so long as the organization/unit seeks accredited status from at least two of the three collaborating accrediting bodies.

It is vital that the organization/unit using the unified application to seek ANCC accredited status, incorporate and operationalize all of the criteria delineated in this manual. In addition, eligibility requirements must be met.

For more information about using the unified application, contact the ANCC Accreditation Program. The unified application form can be accessed from www.acpe-accredit.org/pdf/Application.pdf.


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glossary

academic education. Courses taken for undergraduate or graduate credit in an institution of higher learning that may or may not lead to a degree or completion of a certificate program. Although professional development begins on entry into the basic nursing education program, for the purpose of this definition, academic education refers to those courses taken in colleges or universities after the basic nursing education program.

accreditation.Avoluntaryprocessinwhichaninstitution,organization,oragencysubmitstoan in-depth analysis to determine its capacity to provide or approve quality continuing education over an extended period of time.

adult learning Principles.“Thebasisfor,orthebeliefsunderlying,theteachingandlearning approaches to adults as learners based on recognition of the individual’s autonomy and self-direction, life experiences, readiness to learn, and problem orientation to learning. Approaches include mutual, respectful collaboration of educators and learners in the assessment, planning,implementation,andevaluationofeducationactivities”(ANA,2000,p.23).

autonomy of the Provider unit.Theproviderunit(notthelargerorganization)mustbe solely administratively and operationally responsible for coordinating all aspects of the continuing nursing education activities. Biographical data. Information required of persons involved in the peer review process or the planning and delivery of continuing education activities. The data provided should document their qualifications relevant to the continuing education process or a specific activity with respect to their education, professional achievements and credentials, work experience, honors, awards, and/or professional publications.

commercial interest. 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 organizationsandnon-healthcarerelatedcompanies.Thedefinitionallowsanaccreditedprovider to be owned by a firm that is not a commercial interest. It also allows a provider to havea‘sistercompany’thatisacommercialinterest,aslongastheaccreditedproviderhasandmaintainsadequatecorporatefirewallstoprohibitanyinfluenceorcontrolbythe‘sistercompany’ over the continuing education program of the accredited provider. In this case, ANCC would expect that the accredited provider would have an adequate corporate firewall in place to prohibitanyinfluenceorcontrolbythe‘sistercompany’overthecontinuingeducationprogram.

commercial support. 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.


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accreditation manual glossary

commercial supporter. An entity providing commercial support.

constituents. Providers that an accredited federal nursing service or specialty nursing organizationidentifiesasbeingeligibletosubmitcontinuingeducationactivitiestoitsapprovalbody, e.g., individual members, chapters, districts, or those providers offering continuing education in the nursing specialty content area. Constituency must be identified at the time of application for accreditation.

contact hour.Aunitofmeasurementthatdescribes60minutesofanorganizedlearningactivity that is either a didactic or clinical experience.

conflict of interest. Refer to Appendix B.

content.“Subjectmatterofeducationactivitythatrelatestotheeducationobjectives”(ANA,2000, p. 23).

content specialist.ANAdefinesacontentspecialist[contentexpert]as“Anindividualwith documented qualifications that demonstrate education, knowledge, and experience in a particularsubjectmatter”(ANA,2000,p.23).

continuing nursing education.“Systematicprofessionallearningexperiencesdesignedto augment the knowledge, skills, and attitudes of nurses and therefore enrich the nurses’ contributionstoqualityhealthcareandtheirpursuitofprofessionalcareergoals”(Scope and Standards of practice for nursing professional development, ANA, 2000, p. 24).

continuing education unit (ceu).TheANCCAccreditationProgramdoesnotutilizethisterm when referring to continuing nursing education unit of measurement. A specific, standard measure (10 clock hours) of educational achievement used by many universities and professional organizationsunderthecriteriaoftheinternationalAssociationforContinuingEducationandTraining (IACET) to attest to clock hour completion of continuing education activities.

co-providership. Planning, developing, and implementing an educational activity by two ormoreorganizationsoragencies.wheneducationalactivitiesareco-providedandoneof the providing entities is ANCC-accredited, the ANCC-accredited provider unit retains responsibility for particular aspects of the process to assure adherence to all the ANCC criteria. If collaborating providers are all ANCC-accredited, one is designated to retain the provider responsibilities by mutual, written agreement. The unit designated to retain these responsibilities is referred to as the provider, and the other collaborating providers are referred to as co-providers

designated nurse Planner.See“NursePlanner”.

desktop review. A review of information submitted (usually electronically or in hard copy format).Thereviewerisabletoaccomplishthereviewby‘sittingatadesk’.

educational activity.“Aplanned,organizedeffortaimedataccomplishingeducationalobjectives”(Scope and Standards of practice for nursing professional development, ANA, 2000, p. 24).


educational objectives.“Astatementofthelearneroutcome(s)ofaneducationalactivitythatismeasurableandachievablewithinthedesignatedtimeframe”(Scope and Standards of practice for nursing professional development, ANA, 2000, p. 24).

enduring materials.Anon-livecontinuingnursingeducationactivitythat“endures”overtime. Examples of enduring materials include programmed texts, audio tapes, videotapes, monograph, or computer assisted learning materials which are used alone or with printed or written materials.. Enduring materials can also be delivered via the Internet. The learning experience by the nurse can take place at any time in any place, rather than only at one time, one place, like a live CME activity. (Based in large part on http://www.accme.org/index.cfm/fa/faq.detail/category_id/47bf141f-9c79-4867-be8b-e08409083a47.cfm.)

Federal nursing service. This term can be used in two ways: 1) It is a constituent member of ANA, and 2) it is a designation for a type of governmental entity that is national in scope and provides nursing services, e.g., the Indian Health Service.

gift ‘in-kind’. Non-monetary support (e.g., marketing assistance, meeting room, event registration assistance, etc.) provided by the giver to the taker. (In the Accreditation community, the“taker”istheproviderofthecontinuingeducation.)

goal. An object or end that one strives to attain.

in-service educational activities.“Learningexperiencesprovidedintheworksettingforthe purpose of assisting staff members in performing their assigned functions in that particular agencyorinstitution”(ANA,2000,p.24).

‘just-in-time’ learning. See“Point-of-Care”definition.

lead nurse Planner. role: The Lead Nurse Planner is responsible for ensuring that all Nurse Planners are performing in a manner consistent with the policies, procedures, position descriptions, and expectations of the accredited provider unit and with the ANCC criteria. All Nurse Planners contribute oversight and must be actively involved in both the planning and the analysis of evaluation data for the educational activity.

Qualifications: The Lead Nurse Planner of an accredited provider unit must:•bearegisterednurseandholdagraduatedegree.Eitherthebaccalaureateorthe

graduate degree must be in nursing.•demonstratecompetenceinperformingsuccessfullyattheexpectedlevel.Accepted

demonstration of competence is evaluated by review of the Nurse Planner’s curriculum vitae, biographical data form, or professional portfolio. The information should demonstrate the presence of the following knowledge and skills: knowledge of the Accreditation Program and its requirements, knowledge of adult learning theory, ability toanalyze/synthesizeinformationrelatedtomeetingthecriteriaandkeyelements(as evidenced by having planned, implemented and evaluated continuing nursing education activities), understanding of the policies/procedures of the Accreditation Program, knowledge of the Scope and Standards of Practice for Nursing Professional Development,


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Qualifications: The Lead Nurse Planner of an approvedproviderunitmust”•bearegisterednursewithabaccalaureateorgraduatedegree.Eitherthe

baccalaureate or graduate degree must be in nursing.•haveeducationorexperienceinthefieldofeducationoradultlearning.Thiseducation

or experience may be demonstrated in a professional portfolio as described above.

learner-directed activity. A learning activity in which the learner takes the initiative, with or without the help of others, in diagnosing his/her learning needs, formulating learning goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies, and evaluating learning outcomes. Learner-directed activities may be developed with or without the help of others, but they are engaged in by only one individual.

learner-Paced. A continuing nursing education activity where the learner determines the pace at which s/he engages in the learning activity.

learning goal. A statement describing why and for whom an educational program has been designed. (Synonym: Purpose)

multi-Focused organization.Themulti-focusedorganizationexistsformorethanthepurpose of providing education.

needs.“Discrepancybetweenwhatisdesiredandwhatexists”(Scope and Standards of practice for nursing professional development, ANA, 2000, p. 24).

nurse Peer review leader. The Nurse Peer Review Leader is responsible for implementing and evaluating the unit’s peer review approval process.

Qualifications: The Nurse Peer Review Leader must: •bearegisterednurseandholdagraduatedegree,Eitherthebaccalaureateorthe

graduate degree must be in nursing.•mustmaintainexpertiseineducationaldesignandadultlearningtheories.The

expertiseineducationdesignandadultlearningtheoriesshouldbereflectedinthenurse’scurriculumvitae,biographicaldataform,orprofessionalportfolioreflectinghis/her knowledge, skills, and abilities. The information should demonstrate the presence of the following knowledge and skills: knowledge of the Accreditation Programanditsrequirements,knowledgeofadultlearningtheory,abilitytoanalyze/synthesizeinformationrelatedtomeetingthecriteriaandkeyelements(asevidencedby having engaged in reviewing the record of an activity to ensure all necessary components are present and compliant with the ANCC Accreditation Program criteria and key elements), understanding of the policies/procedures of the Accreditation Program, knowledge of the Scope and Standards of Practice for Nursing Professional Development.

nurse Peer reviewer. The nurse peer reviewer must:•possessexpertiseineducationaldesign,•bearegisterednursewithabaccalaureateorhigherdegree(eitherthebaccalaureate

or the higher degree must be in nursing), and •possesstherelevantknowledgeandexperiencetoparticipateinthepeerreview

process. The knowledge and experience of the nurse peer reviewer is evaluated via the nurse’s curriculum vitae, biographical data form, or professional portfolio. The information should demonstrate the presence of the following knowledge and skills: knowledge of the Accreditation Program and its requirements, knowledge of adult

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learningtheory,abilitytoanalyze/synthesizeinformationrelatedtomeetingthecriteriaand key elements (as evidenced by having engaged in reviewing the record of an activity to ensure all necessary components are present and compliant with the ANCC Accreditation Program criteria and key elements), understanding of the policies/procedures of the Accreditation Program, knowledge of the Scope and Standards of Practice for Nursing Professional Development.

nurse Planner. The Nurse Planner is actively involved in all aspects of planning, implementation, and evaluation of the continuing nursing education activity. Typically, the Nurse Planner is responsible for ensuring appropriate educational design principles are used and processes are consistent with the requirements of the ANCC Accreditation Program.

Qualifications: The Nurse Planner of an accredited provider unit must:•bearegisterednurse.•holdagraduatedegreeandeitherthebaccalaureateorthegraduatedegreemustbe

in nursing. •demonstratecompetenceinperformingsuccessfullyattheexpectedlevel.Accepted

demonstration of competence is evaluated by review of the Nurse Planner’s curriculum vitae, biographical data form, or professional portfolio. The information should demonstrate the presence of the following knowledge and skills: knowledge of the Accreditation Program and its requirements, knowledge of adult learning theory, ability toanalyze/synthesizeinformationrelatedtomeetingthecriteriaandkeyelements(as evidenced by having planned, implemented and evaluated continuing nursing education activities), understanding of the policies/procedures of the Accreditation Program, knowledge of the Scope and Standards of Practice for Nursing Professional Development.

Qualifications: The Nurse Planner of an approved provider unit must:•bearegisterednurse•holdabaccalaureateorhigherdegreeandeitherthebaccalaureateorthehigher

degree must be in nursing. •demonstratecompetenceinperformingsuccessfullyattheexpectedlevel.Accepted

demonstration of competence is evaluated by review of the Nurse Planner’s curriculum vitae, biographical data form, or professional portfolio. The information should demonstrate the presence of the following knowledge and skills: knowledge of the Accreditation Program and its requirements, knowledge of adult learning theory, ability toanalyze/synthesizeinformationrelatedtomeetingthecriteriaandkeyelements(as evidenced by having planned, implemented and evaluated continuing nursing education activities), understanding of the policies/procedures of the Accreditation Program, knowledge of the Scope and Standards of practice for nursing professional development, ANA, 2000,

Qualifications: The Nurse Planner of an activity for which approval is applied must:•bearegisterednurse•competentlyutilizetheANCCAccreditationProgramEducationalDesigncriterionin

planning, implementing, and evaluating the activity.

nursing Professional development.“Thelifelongprocessofactiveparticipationbynursesin learning activities that assist in developing and maintaining their continuing competence, enhancingtheirprofessionalpractice,andsupportingachievementoftheircareergoals”(ANA,2000, p. 24).

off-label use. Using products for a purpose other than that for which it was approved by the Food and Drug Administration (FDA).

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orientation.“Theprocessofintroducingnursingstafftothephilosophy,goals,policies,procedures, role expectations, and other factors needed to function in a specific work setting. Orientation takes place both for new employees and when changes in nurses’ roles, responsibilities,andpracticesettingsoccur”(Scope and Standards of practice for nursing professional development, ANA, 2000, p. 25).

organizational chart. A diagram or other schematic used to depict informal and formal linesofcommunicationandrelationshipswithintheoverallorganizationaswellastheapproverand/or provider unit.

outcome.“Theendresultofalearningactivity–usuallyachangeinknowledge,competence,practice,orpatientcare-measuredbywrittenevaluationorchangeinpractice”(Scope and Standards of practice for nursing professional development, ANA, 2000, p. 25). (The overall learning goal (purpose) of a learning activity is different from measured outcomes. An outcome may measure whether an activity’s learning goal (purpose) is met but may also address other elements of learning.)

When referring to outcomes of an evaluation of the accredited unit, the outcomes should address, learning goals (purposes), process, and outcomes relative to the mission, vision, beliefs, goals and operations of the accredited unit.

Parent company.Anentitythatownsmorethan50%ofthevotingsharesoftheaccreditedprovider or that otherwise has a controlling interest in the accredited provider.

Point-of-care learning. Learning conducted in the practice setting. (This is also sometimes referredtoas“bedsidelearning”or“just-in-time”learning.)Thelearningconsistsofalearning“project”relatedtoanimmediateneedofthenurse/nursesforknowledgetoguidethenurse’s/nurses’ practice. The learning project must be conducted in a manner consistent with the ANCC Accreditation Program educational design framework (e.g., self-determined: need identified, intended objective for conducting the learning, subject (content) searched and reviewed, and evaluation of search and review outcome). The content of the learning activity is often drawn from Internet searches or searches of enduring materials (textbooks, journals, etc.). The point-of-carelearningmaybedone“asynchronously”(withitbeinginitiatedinthepracticesettingto address an emergent need for knowledge to guide the nurse’s practice) or multiple activities addressingasingleunifyinglearninggoalorpurposemaybe“bundled”asoneactivity.The minimum number of contact hours allowed remains 0.5. The time spent in planning and developing the activity may be included in the calculation of contact hours.

Portfolio.Acollectionofdocuments,articles,andexhibitsthatsummarizesanindividual’sabilities, skills, growth, achievements and specific accomplishments attained over an extended period of time.

Professional development.See“nursingprofessionaldevelopment”above.

Provider-directed activity. The provider controls all aspects of the learning. The provider determines the learning objectives based on needs assessments, content of the learning activity, the method by which it is presented and evaluation methods. Provider-directed activities may bepresentedinanumberofdifferentvehicles–electronic,journal,lecture,etc.itispossibleforanactivitythatis‘learner-paced’tobeproviderdirected.Anexamplemightbeacontinuingeducation activity presented as a journal article.

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Purpose.“Astatementdescribingwhyandforwhomaneducationalprogramhasbeendesigned”(Scope and Standards of practice for nursing professional development, ANA, 2000, p. 25). (Synonym: Learning goal)

sentinel event. A sentinel event is one of high risk and high impact related to the improper or inappropriate provision of continuing nursing education in compliance with the ANCC Accreditation Program criteria. Examples include, but are not limited to, misuse of accredited status,illegalactionsperpetratedorexperiencedbytheaccreditedunit–oritsapprovedentities.

single-focused organization.Thesingle-focusedorganizationexistsforthesinglepurposeof providing education.

sister company.Anentitythatsharesgreaterthan50%commonownershipwiththeaccredited provider.

specialty nursing organization (sno). A national nursing body that has a majority ofvotingmemberswhoareregisterednursespracticinginaspecializednursingarea,assodefinedintheorganization’sgoverningdocuments.organizationsthat,inwhole,orinpart,have previously disaffiliated with the American Nurses Association are ineligible for SNO status.

sponsorship.Support(monetaryor‘in-kind’)furnishedtotheprovideroftheeducationactivity. Sponsorship must be acknowledged to learners. A written agreement is completed. When an educational activity is supported by more than one entity, each entity is a co-sponsor. Sponsors and co-sponsors do NOT participate in planning, developing, and implementing the educational activity.

staff development.“Thesystematicprocessofassessment,developmentandevaluationthat enhances the performance or professional development of healthcare providers and their continuingcompetence(NationalNursingStaffDevelopmentorganization1999)”(Scope and Standards of practice for nursing professional development, ANA, 2000, p. 25).

target audience.“groupforwhichaneducationalactivityhasbeendesigned”(Scope and Standards of practice for nursing professional development, ANA, 2000, p. 26).

teaching strategies. Instructional methods and techniques that are in accord with principles of adult learning.

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references

Abruzzese,r.S.(1996).Nursing Staff Development, 2nd Ed. 245-255. St. Louis, MO: Mosby year-book, Inc.

Abruzzese,r.S.,&hinthorn,P.C.(1987).Credentialing.Pg.277-303inPuetz,B.E.,contemporary Strategies for continuing education in nursing. Rockville, MD: Aspen Publishers, Inc.

American Nurses Association (ANA). (1994). Standards for nursing professional development: continuing education and Staff development. Washington, D.C.: American Nurses Association.

American Nurses Association (ANA). (2000). Scope and Standards of practice for nursing professional development. Washington, D.C.: American Nurses Publishing.

American Nurses Association (ANA). (2001). code of ethics for nurses with interpretive Statements. Washington, D.C.: American Nurses Publishing.

Bloom, B.S. (1984). taxonomy of educational objectives. Boston, MA: Pearson Education.

Bloom, B.S. et. al. (1956). taxonomy of educational objectives: handbook 1: cognitive domain. New york, Ny: David McKay.

DeSilets, L. D. (1998). Accreditation of continuing education: The critical elements. the Journal of continuing education in nursing, 29(5):204-210.

Dickerson, P. S. (2005). evaluation: part i: evaluating learning activities. Journal of Continuing Education in Nursing. 36(5) 191-192.

Dickerson, P. S. (2005). part ii: evaluating a provider unit. Journal of Continuing Education in Nursing. 36(6), 240-241.

NationalNursingStaffDevelopmentorganization(NNSDo).(1999).Strategic plan 2000. Pensacola,FL:NationalNursingStaffDevelopmentorganization.

Gronlund, N.E. (2004). writing instructional objectives for teaching and assessment, 7th Ed. Upper Saddle River, NJ: Pearson Prentice Hall.

Hamm, M. S. (1997). the fundamentals of accreditation. Washington, D.C.: American Society of Association Executives.

holzemer,w.L.(1992).evaluation methods in continuing education, Journal of Continuing Education in Nursing. 23(4) 174.

Jarvis, P. (1985). the Sociology of adult and continuing education. Beckenham, England: Croom Helm.

Knowles, M. S. (1973, 1990). the adult learner: a neglected Species. Houston, Tx: Gulf Publishing Company.

Knowles, M. et. al. (1984). andragogy in action: applying modern principles of adult education. San Francisco, CA: Jossey-Bass.

Krathwohl, D. R. et. al. (1964). taxonomy of educational objectives: handbook ii: affective domain. New york, Ny: David McKay.

Mager, R.F. (1997). measuring instructional results, 3rd edition. Atlanta, GA: CEP Press.

Mager, R.F. (1997). preparing instructional objectives - a critical tool in the development of effective instruction (3rd ed). Atlanta, GA: CEP Press.

Mager, R.F. (1975). preparing instructional objectives. Belmont, CA: Fearon Publishers.

Merriam, S. B. (Ed.). (2001). a new update on adult learning theory: new directions for adult and continuing education Series (No. 89). San Francisco, CA: Jossey-Bass.

Merriam,S.B.,&Caffarella,r.S.(1991).learning in adulthood: a comprehensive guide. San Francisco, CA: Jossey-Bass.

Schweer, J. E. (ed) (1981). defining behavioral objectives for continuing education offerings in nursing: a four level taxonomy. Thorofare, N.J.: Charles B. Slack, Inc.


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Mailing Address for the Accreditation Program Office:

AccreditationAmerican Nurses Credentialing Center8515GeorgiaAvenue,Suite400Silver Spring, MD 20910-3492

Mailing Address for Fees and Payments (please indicate ANCC Accreditation Program on the memo line of your check):

ANCCP.O. Box 79120Baltimore, MD 21279-0120

Telephone: 1.800.284.2378Fax: 301.628.5342Web site: www:nursecredentialing.org

AaPPendix a

accreditation Program contact information


These Standards have been adapted from the Accreditation Council for Continuing Medical Education (ACCME), which articulates its policies for disclosure and commercial support in:

(1) The Standards For Commercial Support: Standards to Ensure Independence in CME Activities, as adopted by ACCME in September 2004; and

(2) ACCME policies applicable to commercial support and disclosure.

standard 1: indePendence

1.1 An entity has a commercial interest if it is:1. An entity that produces, markets, sells or distributes health care goods or services

consumed by or used on patients; OR2. An entity that is owned or operated, in whole or in party, by any entity that produces,

markets, sells or distributes health care goods or services consumed by or used on patients.

An entity is NOT a commercial interest if it is:1. A government entity;2. A non-profit (503(c)) organization; or3. A non-healthcare related entity.

This definition permits an accredited provider to be owned by an entity that is not a commercial interest. It also allows a provider to have a ‘sister company’ or parent 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 or parent company over the continuing education 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 continuing education program.

ANCC does not consider providers of clinical service directly to patients to be commercial interests.

1.2 A continuing nursing education provider must ensure that the following decisions were made free from the control of a commercial interest: (a) identification of continuing nursing education needs,

BaPPendix B

standards For disclosure and commercial support

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(b) determination of educational objectives,(c) selection and presentation of content,(d) selection of all persons and organizations that will be in a position to control the

content of the continuing nursing education,(e) selection of educational methods, and(f) evaluation of the activity.

1.3 An entity with a commercial interest cannot take the role of non-accredited partner in a co-provider relationship.

standard 2: resolution oF Personal conFlicts oF interest

2.1 An individual must disclose any financial relationships with an entity with a commercial interest (see STANDARD 1).

2.2 The provider must be able to show that each individual who is in a position to control the content of an education activity has disclosed all financial relationships with any entity with a commercial interest in the provider. ANCC defines “financial relationships” as those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options, or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial relationships can also include ‘contracted research’ where the institution gets the grant and manages the funds and the individual is the principal or named investigator on the grant. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking, and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received or expected. ANCC considers relationships of the person involved in the continuing nursing education activity to include financial relationships of a spouse/partner. Financial relationships must be disclosed to the learners during the time when the relationship is in effect and for 12 months afterward.

With respect to personal financial relationships, ‘contracted research’ includes research funding where the institution gets the grant and manages the funds and the person is the principal or named investigator on the grant.

ANCC considers financial relationships in any amount occurring within the past 12 months as “relevant” in terms of creating a conflict of interest.

2.3 An individual who refuses to disclose financial relationships will be disqualified from being a planning committee member, a teacher, or an author of continuing nursing education and cannot have control of, or responsibility for, the development, management, presentation, or evaluation of the CNE activity.

2.4 The provider must have implemented a mechanism to identify and resolve all conflicts of interest prior to the education activity being delivered to learners.

1Thesematerialscanbefoundatwww.accme.orgunderAccreditationrequirements–ACCMEEssentialAreas&Elements(Element3.3).ACCMEprovidesadditionalinformationaboutcommercialsupportanddisclosureintheformoffrequentlyaskedquestionsunderthe“AskACCME”tabonitsweb site.

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aPPendix B sTANdArds for dIsclosure ANd commercIAl suPPorT


sTANdArds for dIsclosure ANd commercIAl suPPorT aPPendix B

2.5 ANCC considers a “conflict of interest” to exist when an individual has an opportunity to affect continuing nursing education content in relation to a commercial interest with which he/she has a financial relationship.

ANCC considers “opportunity to affect continuing nursing education content” to include content about specific agents/devices, but not necessarily about the class of agents/devices, and not necessarily content about the whole disease class in which those agents/devices are used.

With respect to financial relationships with commercial interests, when a person divests himself/herself of a relationship, it is immediately not relevant to conflicts of interest but it must be disclosed to the learners for 12 months.

standard 3: aPProPriate use oF commercial suPPort

3.1 The provider must make all decisions regarding the disposition and disbursement of commercial support.

ANCC defines “commercial support” as financial, or in-kind, contributions given by a commercial interest, which is used to pay all or part of the costs of a continuing nursing education activity.

ANCC does not consider providers of clinical service directly to patients to be commercial interests. For the purposes of eligibility, ANCC considers the following types of organizations eligible for accreditation and free to control the content of continuing nursing education (Standard 1):

• Liabilityinsuranceproviders• Healthinsuranceproviders• Groupmedicalpractices• Acutecarehospitals(for-profitandnot-for-profit)• For-profitrehabilitationcenters• For-profitnursinghomes• Universitieswithnursingdevelopmentandcontinuingnursing

education programs• SpecialtyNursingOrganizations• ConstituentMemberAssociations• FederalNursingServices• NationalnursesorganizationsbasedoutsidetheUnitedStates• Asingle-focusedorganization1 devoted to offering continuing nursing education

1The single-focused organization exists for the single purpose of providing education.

3.2 A provider cannot be required by an entity with a commercial interest to accept advice or services concerning teachers, authors, or other education matters, including content, from the entity as conditions of contributing funds or services.

3.3 All commercial support associated with a continuing nursing education activity must be given with the full knowledge and approval of the provider.

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Written agreement documenting terms of support3.4 The terms, conditions, and purposes of the commercial support must be documented

in a written agreement with the entity that includes the provider and its educational partner(s). The agreement must include the provider, even if the support is given directly to the provider’s educational partner or a co-provider.

3.5 The written agreement must specify the entity that is the source of commercial support.

3.6 Both the entity and the provider must sign the written agreement regarding the support to be provided/accepted.

expenditures for an individual providing continuing nursing education3.7 The provider must have written policies and procedures governing honoraria and

reimbursement of out-of-pocket expenses for planners, teachers, and authors.

3.8 The provider, the co-provider, or designated educational partner must directly pay any teacher or author honoraria or reimbursement of out-of–pocket expenses in compliance with the provider’s written policies and procedures.

3.9 No other payment shall be given to the director of the activity, planning committee members, teachers or authors, co-provider, or any others involved with the supported activity.

3.10 If teachers or authors are listed on the agenda as facilitating or conducting a presentation or session, but participate in the remainder of an educational event as a learner, their expenses can be reimbursed and honoraria can be paid for their teacher or author role only.

expenditures for learners3.11 Social events or meals at continuing nursing education activities cannot compete

with, or take precedence over, the educational events.

3.12 The provider may not use commercial support to pay for travel, lodging, honoraria, or personal expenses for non-teacher or non-author participants of a continuing nursing education activity. The provider may use commercial support to pay for travel, lodging, honoraria, or personal expenses for bona fide employees and volunteers of the provider, co-provider, or educational partner. This element applies only to nurses whose official residence is in the United States.

accountability3.13 The provider must be able to produce accurate documentation detailing the receipt

and expenditure of commercial support.


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standard 4. aPProPriate management oF associated commercial Promotion

Commercial exhibits and advertisements are promotional activities and not continuing nursing education. Therefore, monies paid by commercial interests to providers for these promotional activities are not considered ‘commercial support.’ However, accredited providers are expected to fulfill the requirements of Standard 4, and to use sound fiscal and business practices with respect to promotional activities.

4.1 Arrangements for commercial exhibits or advertisements cannot influence planning or interfere with the presentation, nor can they be a condition of the provision of commercial support for continuing education activities.

4.2 Product-promotion material or product-specific advertisement of any type is prohibited in or during continuing nursing education activities. The juxtaposition of editorial and advertising material on the same products or subjects must be avoided. Live (staffed exhibits, presentations) or enduring (printed or electronic advertisements) promotional activities must be kept separate from continuing nursing education.

• Print, advertisements and promotional materials shall not be interleafed within the pages of the continuing nursing education content. Advertisements and promotional materials may face the first or last pages of printed CNE content as long as these materials are not related to the continuing nursing education content they face and are not paid for by the entities with commercial interests in the continuing nursing education activity.

• Computer-based, advertisements and promotional materials shall not be visible on the screen at the same time as the continuing nursing education content and shall not be interleafed between computer ‘windows’ or screens of the continuing nursing education content

• Audio and video recording, advertisements and promotional materials shall not be included within the continuing nursing education. There will be no ‘commercial breaks.’

• Live, face-to-face continuing nursing education, advertisements and promotional materials shall not be displayed or distributed in the educational space immediately before, during, or after a continuing nursing education activity. Providers shall not allow representatives of an entity with commercial interests to engage in sales or promotional activities while in the space or place of the continuing nursing education activity.

4.3 Educational materials that are part of a continuing nursing education activity, such as slides, abstracts, and handouts, shall not contain any advertising, trade name, or a product-group message.

4.4 Print or electronic information distributed about the non-continuing nursing education elements of a continuing nursing education activity that are not directly related to the transfer of education to the learner, such as schedules and content descriptions, may include product promotion material or product-specific advertisement.

4.5 A provider shall not use an entity with a commercial interest as the agent providing a continuing nursing education activity to learners, e.g., distribution of self-study continuing nursing education activities or arranging for electronic access to continuing nursing education activities.

sTANdArds for dIsclosure ANd commercIAl suPPorT aPPendix B a

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standard 5. content and Format Without commercial Bias

5.1 The content or format of a continuing nursing education activity or its related materials must promote improvements or quality in health care and not a specific proprietary business interest of an entity with a commercial interest.

5.2 Presentations must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If the continuing nursing education educational material or content includes trade names, when available, trade names from several companies should be used, not just trade names from a single company.

standard 6. disclosures relevant to Potential commercial Bias

Relevant financial relationships of those with control over continuing nursing education content.

Disclosure of information about provider and faculty relationships may be disclosed verbally to participants at a continuing nursing education activity. When such information is disclosed verbally at a continuing nursing education activity, providers must be able to supply ANCC with written verification that appropriate verbal disclosure occurred at the activity. With respect to this written verification:

A. A representative of the provider who was in attendance at the time of the verbal disclosure must attest, in writing:

• thatverbaldisclosuredidoccur;and• itemizethecontentofthedisclosedinformation(Standard6.1)orthattherewas

nothing to disclose (Standard 6.2).

B. The documentation that verifies that adequate verbal disclosure did occur must be completed within one month of the activity.

6.1 The accredited provider is responsible for ensuring that learners are aware of any relevant financial relationship(s), to include the following information:

•Thenameoftheindividual,•Thenameofthecommercialinterest(s),and•Thenatureoftherelationshipthepersonhaswitheachcommercialinterest.

6.2 For an individual with no relevant financial relationship(s), the learners must be informed that no relevant financial relationship(s) exist.


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commercial support for the continuing nursing education activityThe provider’s acknowledgment of commercial support as required by Standard 6.3 and 6.4 may state the name, mission, and areas of clinical involvement of the company or institution and may include corporate logos and slogans, if they are not product-promotional in nature.

6.3 The source of all support from entities with commercial interests must be disclosed to learners. When commercial support is other than monetary support, the nature of the support must be disclosed to learners.

6.4 ‘Disclosure’ must never include the use of a trade name or a product-group message.

timing of disclosure6.5 A provider must disclose the above information to learners prior to or at the time of

the beginning of the educational activity.

sTANdArds for dIsclosure ANd commercIAl suPPorT aPPendix B a

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•2008/2009ApplicationFees•IntenttoApply•ProviderApplication•ApproverApplication

CaPPendix c

Forms and instructions

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aPPlication Fees

The current application fee schedule for re-accrediting applicants is listed below. The 2009 fee schedule is also listed.

All fees associated with the ANCC Accreditation Program will experience at least a cost-of-living adjustment every 2 years.

re-accrediting applicants

organization Provider or aPProver Both Provider and aPProver

2007-2008 2009-2010 2007-2008 2009-2010

PROFESSIONAL EDUCATION GROUP OR COMPANy, NATIONAL HEALTH CARE ORGANIzATION, NATIONAL NURSING ORGANIzATION, MULTI -DISCIPLINARy GROUP, AND OTHERS

$6,500 $8,000 N/A N/A

HOSPITAL AND HEALTH CARE FACILITy

$6,500 FEE BASED ON NUMBER OF RN FTES1:

$4,500 - $8,000

N/A N/A

COLLEGE OR UNIVERSITy $4,500 $5,250 N/A N/A

SPECIALTy NURSING ORGANIzATION, FEDERAL NURSING SERVICE, NATIONAL NURSING ORGANIzATION OUTSIDE THE U.S.

$4,500 $4,500 $6,500 $6,500

ANA ORGANIzATIONAL AFFILIATE

$4,000 $4000 $5,500 $5,500

ANA CONSTITUENT MEMBER ASSOCIATIONS

$3,500 $3500 $5,000 $5,000

1 FEE BASED ON NUMBER OF RN FTES:

1.5–598rNFTES=$4,500

599–748rNFTES=$6,500

>750 RN FTES = $8,000

(ASSUME: 1.5 RNS/BED OR, IF #RN FTES NOT AVAILABLE, THEN uSE26%oFToTALFTES)

For a complete list of fees, see www.nursecredentialing.org/ContinuingEducation/Accreditation/AccreditationProcess.aspx.

The current application fee schedule for initial applicants is listed below. The 2009 fee schedule is also listed. All organizations applying for the first time for both Provider and Approver status must submit separate applications and self-studies, and pay the 2-year fee for each applicant and self study. Upon application for continuation of accredited status for 4 more years the continuation appraisal fee will be calculated as one organizational assessment fee ($2,500.00). All fees associated with the ANCC Accreditation Program will experience at least a cost-of-living adjustment every 2 years.

aPPendix c forms ANd INsTrucTIoNs

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initial (new) applicants

organization Provider or aPProver

2007-2008 INITIAL

2009-2010 INITIAL

2007-2008 CONTINUATION

2009-2010 CONTINUATION

PROFESSIONAL EDUCATION GROUP OR COMPANy, NATIONAL HEALTH CARE ORGANIzATION, NATIONAL NURSING ORGANIzATION, MULTI -DISCIPLINARy GROUP, AND OTHERS

$4,000 $5,000 $2,500 $3,000

HOSPITAL AND HEALTH CARE FACILITy


$2,000 - $5,000


$2,500 - $3,000

COLLEGE OR UNIVERSITy $2,000 $2,500 $2,500 $2,750

SPECIALTy NURSING ORGANIzATION, FEDERAL NURSING SERVICE NATIONAL NURSING ORGANIzATION OUTSIDE THE U.S.

$2,000 $2,000 $2,500 $2,500

ANA ORGANIzATIONAL AFFILIATE

$1,500 $1,500 $2,500 $2,500

ANA CONSTITUENT MEMBER ASSOCIATIONS

$1,000 $1,000 $2,500 $2,500

1 FEE BASED ON NUMBER OF RN FTES:

1.5–598rNFTES=$2000 iNiTiAL/$2500CoNTiNuATioN

599–748rNFTES=$4,000 iNiTiAL/$2500CoNTiNuATioN

>750 RN FTES = $5000 INITIAL/$3000 CONTINUATION

(ASSUME: 1.5 RNS/BED OR, IF #RN FTES NOT AVAILABLE, ThENuSE26%oFToTALFTES)

forms ANd INsTrucTIoNs aPPendix c a

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american nurses credentialing center accreditation Program intent to apply Form — 2009

all aPPlicants

INTENDED APPLICATION TyPE: PROVIDER UNIT APPROVER UNIT BOTH

INTENDED REVIEW CyCLE: yEAR: __________ FALL (APPLICATIONS DUE AUGUST 1) SPRING (APPLICATIONS DUE FEBRUARy 1)

NAME OF APPLICANT UNIT:

ORGANIzATION (IF DIFFERENT):

STREET ADDRESS:

P.O. BOx (IF ANy):

CITy/STATE/zIP: COUNTRy:

PRIMARy CONTACT PERSON: TELEPHONE:

EMAIL ADDRESS: FAx NUMBER:

IS THIS yOUR ORGANIzATION’S FIRST APPLICATION FOR ANCC ACCREDITATION? NO yES*

IF NO, IN WHAT yEAR AND MONTH WAS ANCC ACCREDITATION ORIGINALLy AWARDED? MONTH: yEAR:

PLEASE SUBMIT A LIST OF ACTIVITIES PROVIDED (FOR PROVIDERS) OR LISTS OF APPROVED ACTIVITIES AND APPROVED PROVIDERS (FOR APPROVERS) FOR THE THREE yEARS PREVIOUS TO THE DATE OF SUBMISSION OF THIS FORM.

*IF yES, THE APPLICANT MUST BE OPERATIONAL FOR 6 MONTHS PRIOR TO SUBMISSION OF THE SELF STUDy AND, PRIOR TO SUBMITTING THE SELF-STUDy, MUST HAVE IMPLEMENTED AT LEAST THREE EDUCATIONAL ACTIVITIES UTILIzING THE ANCC ACCREDITATION PROGRAM.

*IF yES, WHAT ARE THE REASONS ACCREDITATION IS BEING SOUGHT NOW?

ApplicantsmustalsocompleteandsubmittheorganizationalAssessmenttoDetermineEligibilityfor Accreditation (or Approval). The form is found at http://www.nursecredentialing.org/continuingeducation/accreditation/resourcesservices/Formstools.aspx.

Submissionofthisformdoesnotobligateyourorganizationinanyway.Theintenttoapplymaybe withdrawn at any time. To postpone an intended application to a later cycle, please notify the Accreditation Program Office in writing at the address shown below.

Late applications incur a $500 late fee and cannot be accepted after August 31 for the Fall review cycle or February 28 for the Spring review cycle.mail this Form to:

AMERICAN NURSES CREDENTIALING CENTER ACCREDITATION PROGRAM 8515 GEORGIA AVENUE, SUITE 400 SILVER SPRING, MD 20910-3492


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ancc accreditation Program instructions to comPlete Provider aPPlication Form — 2009

DEADLINES. Applications must be received by February 1 or August 1 depending upon scheduled review cycle. Late applications (due by February 28 or August 31) incur a $500 late fee.

Part i: Fact sheet • Entertheproviderunitnameasitappearsinyourpromotionalmaterialsfor

continuing nursing education.• Entertheentirelegalnameoftheapplicantorganization(ifdifferentfromthe

provider unit name). • Includestreetaddressevenifapostofficeboxisusedastheprimarymailingaddress.• Specifythenamethatwillbeusedinallofficialaccreditationstatementsforthe

certificate of accreditation.

Part ii: eligibility confirmation All organizations, including those currently accredited, must complete Part II in its entirety. The date ANCC accreditation criteria were implemented must precede the signature date by 6 months. For multiple Nurse Planners, enter information for the Lead Nurse Planner on the form and attach additional pages.

Part iii: application checklist checklist Page numbers

The column of page number locations must be completed. Enter the beginning page number of the supporting text for each itemized section of written documentation.

APPlIcATIoN PAcKAge AssemBlY requIremeNTs

•Compile the components of the package in the order shown on the Application Checklist.

•Useacommon,12-pointfontsuchasTimesNewRoman,Arial,Garamond,or Courier for the text body.

•Application materials are limited to no more than 50 sheets of paper. Double sided sheets are permitted. (First time applicants do not include their record files for three activities in this count.)

•Include the two-page application form.•Include a table of contents and number all pages of the report, including

appendices, in sequence.•Identify sections with tabs that are clearly marked and visible when the

volumes are closed.•Provide required documentation for each criterion and key element by name

and number in sequence.•If desired, organize frequently cited materials into an appendix and refer to

them by specific page number.•Be sure that all photocopies are readable and all charts and diagrams have a

descriptive title.


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•Define acronyms and abbreviations upon first use in the text and include them in a glossary.

•Choose a binding method that allows pages to turn easily.•Do not use loose-leaf binders, rubber bands, metal rings, or paper clips.•Submissions may also be made electronically. Portions of the self-study may

be submitted electronically with other portions submitted in printed form.

shipping instructions Ship the application package and fee payment at the same time according to the instructions below.

application Package

• Organizationsapplyingasbothapproversandprovidersmayshiptheirapplicationsin a single box.

• SubmitsixcopiesoftheapplicationformandpackagetoAmericanNursesCredentialingCenter,AccreditationProgram,8515GeorgiaAvenue,Suite400,SilverSpring, MD 20910-3492.

Fee Payment

• MakecheckspayabletotheANCC Accreditation Program. • Mailtheapplicationfeepaymentwithacopy of the two-page application form

to American Nurses Credentialing Center, P.O. Box 79120, Baltimore, MD 21279-0120.


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american nurses credentialing center accreditation Program Provider application Form — 2009

Part i: Fact sheetPROVIDER UNITNAME OF PROVIDER UNIT:

ORGANIzATION (IF DIFFERENT):

NAME USED ON CERTIFICATES:

STREET ADDRESS:

PO BOx (IF ANy):


WEB ADDRESS ( IF ANy):

SHOULD ANCC’S DIRECTORy OF ACCREDITED ORGANIzATIONS INCLUDE A HyPERLINK TO yOUR WEB SITE? yES NO

IDENTIFy yOUR ORGANIzATION TyPE:

ANA CONSTITUENT MEMBER ASSN.

COLLEGE OR UNIVERSITy

COMMERCIAL PRODUCT COMPANy

FEDERAL NURSING SERVICE

HEALTH CARE FACILITy

MULTI -DISCIPLINARy ED. GROUP

HEALTH-RELATED ORGANIzATION

NATIONAL NURSING ORGANIzATION

PROFESSIONAL EDUCATION GROUP

ANA CONSTITUENT MEMBER

SPECIALTy NURSING ORGANIzATION

NATIONAL NURSING ORGANIzATION BASED OUTSIDE THE UNITED STATES

OTHER, PLEASE SPECIFy

ARE THE PROVIDER UNIT AND THE TOTAL ORGANIzATION ONE AND THE SAME? yES NO

NUMBER CE ACTIVITIES PROVIDED EACH yEAR: PROVIDER DIRECTED_________________________ LEARNER DIRECTED_________________________PRIMARy CONTACT PERSONCONTACT PERSON: TELEPHONE:

TITLE OR POSITION: FAx NUMBER:

THIS PERSON IS (CHECK ONE): NURSE PLANNER ADMINISTRATOR STAFF

EMAIL ADDRESS:

PLANNING DETAILSIDENTIFy PERSON IN CHARGE OF APPRAISER TRAVEL ARRANGEMENTS:

NAME:

TELEPHONE/EMAIL:

Part ii: eligiBility conFirmation

DATE THE PROVIDER UNIT IMPLEMENTED ANCC ACCREDITATION CRITERIA: MONTH: yEAR:

1ST TIME SEEKING ACCREDITATION? yES No ( iF “yES”–CoMPLETEThEELigiBiLiTyADDENDUM)LEAD NURSE PLANNERATTACH BLANK SHEETS AS NECESSARy TO LIST ADDITIONAL NURSE PLANNERS.

NAME:

CREDENTIALS:

POSITION/TITLE:

DEGREES AND FIELD OF STUDy

BACCALAUREATE:

GRADUATE:


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ATTESTATION SIGNATURE

Thesignaturebelowofthe____________________________________[Title]indicatesthatheorshe:•hasreviewedtheprocess,feestructure,andrefundpoliciesoftheANCCAccreditationProgram;•hasreviewedandunderstandstheeligibilityandprogramcriteriarequirementsspecifiedfor

providerunitsinthe2009AccreditationProgramapplicationmanual;and•atteststotheproviderunit’sfullcompliancewiththesecriteriaforaperiodofatleast6months

prior to the submission date of this application.•understandsthatprovidingfalse,misleading,orincompleteinformationisgroundsfordenialof

the application.NAME (PLEASE PRINT/TyPE)

SIGNATURE DATE

Part iii: aPPlication checKlist

COPy OF THIS SIGNED APPLICATION FORM (PLEASE FLAG ORIGINAL SIGNATURE COPy.)

WRITTEN DOCUMENTATION PAGE

selF-study rePort executive summary

Provider unit criterion 1. mission statement

1. MISSION STATEMENT

2. LINES OF AUTHORITy AND ADMINISTRATIVE SUPPORT

Provider unit criterion 2. educational design

NEW APPLICANTS ONLy

PAGE NUMBERS FOR EACH SAMPLE ACTIVITy ADDRESSED: PAGE

1. ASSESSMENT OF LEARNER NEEDS

2.quALiFiEDPLANNErS

3. EFFECTIVE DESIGN PRINCIPLES

4. CONTACT HOURS

5. ACTIVITy EVALUATION

6. ACCREDITATION STATEMENTS

7. DOCUMENTATION OF COMPLETION

8. COMMERCIAL SUPPORT GUIDELINES

9. CONFLICT OF INTEREST GUIDELINES

10. DISCLOSURES PROVIDED TO ACTIVITy PARTICIPANTS

11. RECORDKEEPING PAGE

12. CO-PROVIDERSHIPS

Provider unit criterion 3. unit oPerations

1. NURSE PLANNER

2. RESOURCES

3. BUSINESS PRACTICES

Provider unit criterion 4. unit outcomes evaluation

1. PROVIDER UNIT EVALUATION PROCESS

2. PROVIDER UNIT EVALUATION PARTICIPANTS

3. PROVIDER UNIT EVALUATION RESULTS

4. PROVIDER UNIT GOALS FOR IMPROVEMENT

Provider unit selF-assessment summary

_ neW aPPlicants only: comPlete Files oF three activities imPlemented using accreditation Program criteria:

ACTIVITy #1 TITLE:

ACTIVITy #2 TITLE:

ACTIVITy #3 TITLE:

american nurses credentialing center accreditation Program Provider application Form — 2009 (continued)


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american nurses credentialing center accreditation Program eligiBility addendum — 2009

the accredited Provider Part 1: Fact sheet eligibility

Does the organization have a separate, defined provider unit administratively and operationally responsible for providing CE? Yes No

Month and year became operational*: ______________________________ (Must be at least 6 months prior to application date)

Operational* for at least 6 months: Yes No *Operational means using ANCC Accreditation Program criteria.

Name and credentials of Nurse Planner(s) (Criterion II, Key Element 1): (Must have a graduate degree, one degree in nursing).

Planned, implemented, and evaluated three different activities at different events by time of application – listed title and date presented/Implemented. Yes No

Were any of the Nurse Planners listed above included in planning these three activities? Yes No

Activities done on own? Yes No Not co-provided? Yes No

shipping instructions(1) Application Package: Mail six sets of the items specified in the above checklist

to:AmericanNursesCredentialingCenter,AccreditationProgram,8515GeorgiaAvenue, Suite 400, Silver Spring, MD 20910-3492.

(2) Fee Payment: Mail a separate copy of this two-page form with your accreditation fee payment in the amount of $ ___________ to: American Nurses Credentialing Center, P.O. Box 79120, Baltimore, MD 21279-0120. On the memo line of the check, please write: 3001450000 - 40040. Thank you.


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american nurses credentialing center accreditation Program instructions to comPlete aPProver aPPlication Form — 2009

DEADLINES. Applications must be received by February 1 or August 1 depending upon scheduled review cycle.

Part i: Fact sheet • EntertheApproverUnitnameasitappearsinyourpromotionalmaterials.• Entertheentirelegalnameoftheapplicantorganization(ifdifferentfromthe

Approver Unit name). • Includestreetaddressevenifapostofficeboxisusedastheprimarymailingaddress.• Specifythenamethatwillbeusedinallofficialaccreditationstatementsforthe

certificate of accreditation.

Part ii: eligibility confirmation • Allorganizations,includingthosecurrentlyaccredited,mustcompletePartIIinits

entirety. • ThedateANCCaccreditationcriteriawereimplementedmustprecedethesignature

date by 6 months.• Enterinformationfortheleadnursepeerreviewer.

Part iii: application checklist checklist Page numbers

• Thecolumnofpagenumberlocationsmustbecompleted.• Enterthebeginningpagenumberofthesupportingtextforeachitemized

section of written documentation.

application Package assembly requirements

• Compilethecomponentsofthepackageintheordershownontheapplicationchecklist section of the form.

• Useacommon,12-pointfontsuchasTimesNewRoman,Arial,Garamond,orCourier for the text body.

• Includeatableofcontentsandnumberallpagesofthereport,includingappendices,in sequence.

• Applicationmaterialsarelimitedtonomorethan50sheetsofpaper.Doublesidedsheets are permitted. (First time applicants do not include their record files for three activities in this count.) Appendices containing the application materials provided by the approver unit to its applicants are not included in the count of 50 sheets of paper.

• Includethetwo-pageapplicationform• Identifysectionswithtabsthatareclearlymarkedandvisiblewhenthevolumes

are closed.• Providerequireddocumentationforeachcriterionandkeyelementbynameand

number in sequence.• Ifdesired,organizefrequentlycitedmaterialsintoanappendixandrefertothem

by specific page number.• Besurethatallphotocopiesarereadableandallchartsanddiagramshavea

descriptive title.• Defineacronymsandabbreviationsuponfirstuseinthetextandincludethemin

a glossary.


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• Chooseabindingmethodthatallowspagestoturneasily.• Donotuseloose-leafbinders,rubberbands,metalrings,orpaperclips.• Submissionsmayalsobemadeelectronically.Portionsoftheself-studymay

be submitted electronically with other portions submitted in printed form.

shipping instructions Ship the application package and fee payment at the same time according to the instructions below.

application Package

• Organizationsapplyingasbothprovidersandapproversmayshiptheirapplicationsin a single box.

• SubmitsixcopiesoftheapplicationformandpackagetoAmericanNursesCredentialingCenter,AccreditationProgram,8515GeorgiaAvenue,Suite400,SilverSpring, MD 20910-3492.

Fee Payment

• MakecheckspayabletotheANCC Accreditation Program. • Mailtheapplicationfeepaymentwithacopy of the two-page application form

to American Nurses Credentialing Center, P.O. Box 79120, Baltimore, MD 21279-0120.


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american nurses credentialing center accreditation Program approver application Form — 2009

Part i: Fact sheet

APPROVER UNIT

NAME OF APPROVER UNIT:

ORGANIzATION:

NAME USED ON CERTIFICATES:

STREET ADDRESS:

PO BOx (IF ANy):


WEB ADDRESS ( IF ANy):

SHOULD ANCC’S DIRECTORy OF ACCREDITED ORGANIzATIONS INCLUDE A HyPERLINK TO yOUR WEB SITE? yES NO

IDENTIFy yOUR ORGANIzATION TyPE:

FEDERAL NURSING SERVICE

SPECIALTy NURSING ORGANIzATION

ANA CONSTITUENT MEMBER ASSOCIATION

NATIONAL NURSING ORGANIzATION BASED OUTSIDE THE UNITED STATES

AVERAGE NUMBER CE ACTIVITIES/PROVIDERS (AS APPROPRIATE) APPROVED EACH yEAR:

PRIMARy CONTACT PERSONCONTACT PERSON: TELEPHONE:

TITLE OR POSITION: FAx NUMBER:

THIS PERSON IS (CHECK ONE): EMAIL ADDRESS: NURSE PEER REVIEW LEADER ADMINISTRATOR STAFFPLANNING DETAILSIDENTIFy PERSON IN CHARGE OF APPRAISER TRAVEL ARRANGEMENTS:

NAME: TITLE:

TELEPHONE/EMAIL:

Part ii: eligiBility conFirmation

DATE THE APPROVER UNIT IMPLEMENTED ANCC ACCREDITATION CRITERIA: MONTH: yEAR:

1ST TIME SEEKING ACCREDITATION? yES No ( iF “yES”–CoMPLETEThEELigiBiLiTyADDENDUM)NURSE PEER REVIEW LEADERNAME: DEGREES AND FIELD OF STUDy

CREDENTIALS: BACCALAUREATE:

POSITION/TITLE: GRADUATE

:


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ATTESTATION SIGNATURE

Thesignaturebelowofthe____________________________________[Title]indicatesthatheorshe:•hasreviewedtheprocess,feestructure,andrefundpoliciesoftheANCCAccreditationProgram;•hasreviewedandunderstandstheeligibilityandprogramcriteriarequirementsspecifiedfor

Approverunitsinthe2009AccreditationProgramapplicationmanual;and•atteststotheApproverunit’sfullcompliancewiththesecriteriaforaperiodofatleast6months

prior to the submission date of this application.•understandsthatprovidingfalse,misleading,orincompleteinformationisgroundsfordenialof

the application.NAME (PLEASE PRINT/TyPE)

SIGNATURE DATE

Part iii: aPPlication checKlist

COPy OF THIS SIGNED APPLICATION FORM (PLEASE FLAG ORIGINAL SIGNATURE COPy.)

WRITTEN DOCUMENTATION PAGE

selF-study rePort executive summary

aPProver unit criterion 1. mission statement

1. MISSION STATEMENT

2. LINES OF AUTHORITy AND ADMINISTRATIVE SUPPORT

aPProver unit criterion 2. aPProval Process

1.quALiFiEDrEviEwErS

2. CONTACT HOURS

3. ACCREDITATION STATEMENTS

4. CONFLICT OF INTEREST GUIDELINES

5. RECORDKEEPING

6. PEER REVIEW OF APPLICATIONS FOR PROVIDER UNIT APPROVAL

7. PEER REVIEW OF APPLICATIONS FOR A PROVIDER DIRECTED EDUCA-TIONAL ACTIVITy APPROVAL

8. PEER REVIEW OF APPLICATIONS FOR A LEARNER-DIRECTED ACTIVITy APPROVAL

APPROVER UNIT CRITERION 3. UNIT OPERATIONS

1. NURSE PEER REVIEW LEADER

2. MONITORING PROCESS

3. RESOURCES

4. BUSINESS PRACTICES

aPProver unit criterion 4. unit outcomes evaluation

1. APPROVER UNIT EVALUATION PROCESS

2. APPROVER UNIT EVALUATION By PARTICIPANTS

3. APPROVER UNIT EVALUATION RESULTS

4. APPROVER UNIT GOALS FOR IMPROVEMENT

APPROVER UNIT SELF-ASSESSMENT SUMMARy

_ neW aPPlicants only: comPlete Files oF three ‘mocK’ aPProvals using accreditation Program criteria. (mocK aPProvals must reFlect the entities —activities, Providers, or Both—the accredited aPProver aPPlicant is eligiBle to aPProve.)

APPROVAL #1 TITLE:

APPROVAL #2 TITLE:

APPROVAL #3 TITLE:


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(2) Fee Payment: Mail a separate copy of this 2-page form with your accreditation fee payment in the amount of $ to: American Nurses Credentialing Center, P.O. Box 79120, Baltimore, MD 21279-0120.


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american nurses credentialing center accreditation Program eligiBility addendum — 2009

the accredited approver Part 1: Fact sheet eligibility

Does the organization have a separate, defined approver unit administratively and operationally responsible for approval process for at least 6 months? Yes No

Month and year became operational*:______________________________ (Date must be at least 6 months prior to the application date.) * Operational means using ANCC Accreditation Program criteria.

Name and credentials of Nurse Peer Review Leader (Criterion 3, Key Element 1): (Must have a graduate degree, one degree in nursing).

Reviewed three different activities (1st time applicants – mock review) – listed title and date reviewed. Yes No



(2) Fee Payment: Mail a separate copy of this two-page form with your accreditation fee payment in the amount of $ ____________ to: American Nurses Credentialing Center, P.O. Box 79120, Baltimore, MD 21279-0120.


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The goal of the annual report is to assist the accredited organization to reflect on its quality and integrity. The annual report seeks to gather information that reveals the quality and character of the accredited organization. It provides the organization the opportunity to compile information that may be used to prepare for its future experiences as an accredited organization. The information may also serve to bring to light areas that may be problematic for the organization in the future.

DUE APRIL 15 (POSTMARK DATE)

sample annual report 2009 accredited Provider unit demographic Profile Name of Organization:

Name of Provider Unit: (i.e., department/division/unit within the organization responsible for providing nursing continuing education)

Address:

Contact Person:

Title or Position:

This individual is the: Administrator Nurse Planner Staff

Telephone Number: Fax Number:

E-mail Address:

DaPPendix d

annual reporting

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The signature below of the –––––––––––––––––––––––––––––––––––––––[Title] indicates that he or she understands that knowingly providing false, misleading, or incomplete information is grounds for revocation of accredited status.

Name (please print/type)

Signature Date

1. Please answer the following questions regarding changes that occurred within the past 2 years:

• Hastherebeenamajorchangeintheorganizationalstructure(includeschangeinownership, mergers, acquisitions, significant change in job responsibilities, etc.)? If so, please provide a current organizational chart.

• Hastherebeensignificantstaffturnover(eitherinnumbersofstaff,e.g.,50%,orin key personnel including the Nurse Planner and other individuals as defined by the applicant organization)?

• Weretherechangesinkeypersonnel(includingtheNursePlannerandotherindividuals as defined by the applicant organization)?

• Arethereanynewconflictsofinterest(includingcommercialsupport)?• Werethereanycomplaintslodgedagainsttheaccreditedorganization?

If yes to any of the above, please describe the unit’s response to the issue:

2. Please: • shareyourunit’sgoalsfor2008,• describehowthesegoalswereestablished(who,what,why,how,etc.),and• describeyourunit’sactivitiesthroughouttheyeartoaddressthesegoals.

3. Provide a list of activities completed in previous year.

Accredited organizations are asked every other year (excluding the year they apply for accreditation), or as needed, to provide one complete file (consisting of all those elements identified in provider unit criterion 2, key element 11) for each type of activity implemented. Included will be a narrative of how the activities were planned and a description of how records are maintained for participants.

In 2010, accredited organizations will be asked to submit – in addition to the above information – the following data relative to the operations of the previous calendar year:

• #ActivitiesImplemented1

• #Learners2

• #Contacthours3

• #Activitieswithcommercialsupport1

• Amt.of$(total)receivedincommercialsupport• #Activitieswithsponsorship1

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• Amt.of$(total)receivedinsponsorship• #ofentitiesfromwhichcommercialsupportreceived4

• #ofentitiesfromwhichsponsorshipreceived5

• #ofactivitieswhenalearnerperceivedconflictofinterestorbias• #ofactivitiesevaluatinglearnersatisfaction6

• #ofactivitiesevaluatingknowledgeenhancement6

• #ofactivitiesevaluatingskill&attitudechange6

• #ofactivitiesevaluatingachangeinpracticeorperformance6

• #ofactivitiesevaluatingtherelationshipofthepracticechangetoqualityofservice6

1Thisisa‘duplicated’list.Forinstance,ifanactivityisrepeatedthreetimes,itiscountedhereasfouractivities(theoriginal+three‘repeats’)

2Thisisa‘duplicated’list.ifthesamelearnerattendsthreeactivities,thenumberoflearnerswouldbethree.

3Thisisnota‘duplicated’list.Forinstance,ifanactivityawardsthreecontacthoursandtheactivityis repeated four times, the number of contact hours is counted only once (= three contact hours)

4Thisisan‘unduplicated’list.Forinstanceifasinglecommercialinterestprovidessupportfortwodifferent activities, the commercial interest entity is counted only once.

5Thisisan‘unduplicated’list.Forinstanceifasingleentityprovidessponsorshipfor2differentactivities, the sponsor entity is counted only once.

6Thisisan‘unduplicated’list.Forinstance,ifanactivityisrepeated,itiscountedonlyonce.(Theassumption is that the evaluation is unchanged.)

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annual rePorting

Due April 15 (Postmark Date)

sample annual report 2009 accredited approver unit demographic Profile Name of Organization:

Name of Provider Unit: (i.e., department/division/unit within the organization responsible for providing nursing continuing education)

Address:

Contact Person:

Title or Position:

This individual is the: Administrator Nurse Planner Staff

Telephone Number: Fax Number:

E-mail Address:

The signature below of the –––––––––––––––––––––––––––––––––––––––[Title] indicates that he or she understands that knowingly providing false, misleading, or incomplete information is grounds for revocation of accredited status.

Name (please print/type)

Signature Date

1. Please answer the following questions regarding changes that occurred within the past 2 years:

• Hastherebeenamajorchangeintheorganizationalstructure(includeschangeinownership, mergers, acquisitions, significant change in job responsibilities, etc.)? If so, please provide a current organizational chart.

• Hastherebeensignificantstaffturnover(eitherinnumbersofstaff,e.g.,50%,orinkey personnel, e.g., the Lead Nurse Peer Reviewer and other individuals as defined by the applicant organization)?

• Weretherechangesinkeypersonnel(includingtheLeadNursePeerReviewerandother individuals as defined by the applicant organization)?

• Arethereanynewconflictsofinterest?• Werethereanycomplaintslodgedagainsttheaccreditedorganization?

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If yes to any of the above, please describe the unit’s response to the issue:

2. Please: • shareyourunit’sgoalsfor2008,• describehowthesegoalswereestablished(who,what,why,how,etc.),and• describeyourunit’sactivitiesthroughouttheyeartoaddressthesegoals.

3. Provide a list of activities approved and, as appropriate, providers approved, in previous year.

Accredited organizations are asked every other year (excluding the year they apply for accreditation), or as needed, to provide one complete file (consisting of all those elements identified in approver unit criterion 2, key element 5) for each type of application approved (live activity, electronic learning activity, printed learning activity, provider unit application, etc.). Included will be a narrative of how the process was accomplished and a description of how records of approval are maintained.

In 2010, accredited organizations will be asked to submit – in addition to the above information – the following data relative to the operations of the previous calendar year:

• #Activitiesapprovedthatreceivedcommercialsupport1

• #Contacthoursapprovedtobeawarded2

• #Activitiesapprovedthatreceivedfinancialor‘in-kind’supportfromentitiesOTHER THAN commercial interests1

• #ofactivitiesevaluatinglearnersatisfaction3

• #ofactivitiesevaluatingknowledgeenhancement3

• #ofactivitiesevaluatingskill&attitudechange3

• #ofactivitiesevaluatingachangeinpracticeorperformance3

• #ofactivitiesevaluatingtherelationshipofthepracticechangetoqualityofservice3

1Thisisa‘duplicated’list.Forinstance,ifanactivityisrepeatedthreetimes,itiscountedhereasfouractivities(theoriginal+three‘repeats’)

2Thisisan‘uNduplicated’list.Forinstance,ifanactivityawardsthreecontacthoursandtheactivityis repeated four times, the number of contact hours is counted only once (= three contact hours)

3Thisisan‘unduplicated’list.Forinstance,ifanactivityisrepeated,itiscountedonlyonce.(Theassumption is that the evaluation is unchanged.)

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Please see the ANCC Accreditation Program web site: www.nursecredentialing.org/ContinuingEducation/Accreditation.aspx

While the list below is not comprehensive, some of the sample forms available are:

• ConflictofInterestDisclosureForm• FinancialDisclosureForm• Bio-DataForm• Bio-DataForm(withconflictofinterestandcommercialsupport

questions included)• CommercialSupportAgreementForm• Co-ProviderAgreementForm• ActivityOutlineForm• ActivityReviewChecklist• OverallEvaluationPlan• ScriptofDisclosurestoParticipants• OrganizationalAssessmenttoDetermineEligibilityforAccreditation(orApproval)

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estaBlishment as a Provider unit

PROVIDER UNIT AUTHORITY. The provider unit must be administratively and operationally responsible for coordinating all aspects of the continuing nursing education activities provided by the organization. A provider unit may be either:

(a) a single-focused organization1 devoted to offering continuing nursing education; or (b) a distinct, separately identified unit within a complex, multi-focused organization2.

For example, the provider unit may be a continuing nursing education division, a staff development department, or a nursing education committee within a larger organization. Provider units within complex organizations must demonstrate their autonomy for providing continuing nursing education in the written documentation they submit. In other words the provider unit (not the larger organization) must be administratively and operationally responsible for coordinating all aspects of the continuing nursing education activities.

1The single-focused organization exists for the single purpose of providing education.2 The multi-focused organization exists for more than the purpose of providing education.

A provider is ineligible for approval if it is a commercial interest as defined in the “Standards for Commercial Support.” (A ‘commercial interest’ is any entity either producing, marketing, re-selling, or distributing healthcare goods or services consumed by, or used on, patients or that is owned or controlled by an entity the produces, markets, re-sells, or distributes healthcare goods or services consumed by, or used on, patients. 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.)

Designated Nurse Planner(s). The provider unit must have the services of at least one Nurse Planner who is responsible for adhering to ANCC Accreditation Program criteria in the provision of continuing nursing education. The Nurse Planner must be a registered nurse with either a baccalaureate or graduate degree in nursing. Additionally, the Nurse Planner must have education or experience in the field of education or adult learning. The Nurse Planner must demonstrate competence in performing successfully

FaPPendix F

approved Provider criteria

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at the expected level. Accepted demonstration of competence is evaluated by review of the Nurse Planner’s curriculum vitae, biographical data form, or professional portfolio (seedefinitioninGlossary,page75).

oPeration as a Provider unit

Operational Status. A provider unit shall be defined as operational when it is functioning under all of the relevant criteria of the ANCC Accreditation Program with all essential provider unit personnel in place. Application is permitted once the provider unit passes two operational milestones:

• Duration. The provider unit must have been operational for a minimum of 6 months.

• Activities*. The provider unit must have planned, implemented, and evaluated at least three educational activities (not three sessions of the same conference) (a) with the direct involvement of a designated Nurse Planner (as specified above), and (b) that adhere to the relevant criteria of the ANCC Accreditation Program. Each learning activity must be at least one hour (60 minutes) in length. Co-provided activities may not be counted as one of these three activities. However, an activity approved by an ANCC-accredited approver unit may be counted in the three activities.

* Organizations that targeted more than 50% of their educational activities provided in the previous calendar year to nurses in multiple regions (use the DHHS regions: www.hhs.gov/about/regions/) must apply for accreditation to the national accrediting body - ANCC. Organizations that targeted more than 50% of their activities provided in the previous calendar year to the nurses in a single state or region (or a state contiguous to that region) may apply to a constituent member association for approval as providers.

• Approved providers are approved by accredited approvers to plan, implement, and evaluate continuing nursing education activities. As Chapter 5 describes in more detail, the ANCC Accreditation Program specifies identical requirements for approved providers and accredited providers with only two exceptions: (1) expectations for the educational preparation of Nurse Planners, and (2) the re-application timeframes (3 years) are different for approved providers. However, ANCC-accredited approvers may choose to impose additional requirements on the providers that apply to them for approval status. For example, to accommodate regulatory differences between states. Organizations that targeted more than 50% of their activities provided in the previous calendar year to the nurses in a single state or region (or a state contiguous to that region) should apply to a constituent member association for approval as providers.

aPPendix F APProVed ProVIder crITerIA

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aPProved Provider criterion 1

mission statementThe documented beliefs and goals of the provider unit reflect the importance of continuing education for nurses and the needs and characteristics of the provider unit’s potential learners. The provider unit is clearly defined and, in multi-focused organizations1, supported by the administrative structure.


Key elements:

1. MISSION STATEMENT. Beliefs and goals (often referred to as mission statement) of the provider unit are relevant and appropriate to prospective learners.

requIred eVIdeNce:

•Submit the beliefs and goals of the provider unit. If the provider unit is part of a multi-focused organization1, describe how the mission statement of the provider unit links with the goals, mission, and functions of the total organization. This should also include expected outcomes (i.e., changes in participants’ knowledge, competency, behavior, or patient outcomes) and how they anticipate measuring those changes and outcomes.

•Submit a description of features of the provider unit that characterize its scope such as its size, geographical range, target audience(s), content areas, and the type of educational activities it offers. If the provider unit is part of a multi-focused organization1, describe the relationship of these scope dimensions to the total organization.


2. Scope and Administrative Support. Organizational structures and lines of authority support the operation of the provider unit.

requIred eVIdeNce:

•Submit an organizational chart, flow sheet, or similar kind of image that depicts the organizational structure of the provider unit. Provide the name and credentials of the individual in each position identified on the organizational chart. If the provider unit is part of a multi-focused organization1, submit an additional depiction that identifies the provider unit’s lines of authority and structural location within the total organization.


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aPProved Provider unit criterion 2

educational designThe provider unit has a clearly defined process for assessing need, planning, implementing, and evaluating continuing nursing education. Continuing nursing education activities are assessed, designed, planned, implemented, and evaluated in accordance with adult learning principles and professional education standards and ethics. The educational design process includes procedures for protecting educational content from bias, providing learners appropriate information and documentation related to their participation, and maintaining records in a secure and confidential manner.


• SampleActivitiesforSubmissionwiththeSelf-Study. Three sample activities must be submitted with the self-study documents. Activities selected for inclusion in the application for approved provider status must be at least one hour in length. If the activity selected is 3 contact hours (180 minutes) or less, submit documentation for all contact hours. If the sample activity is more than 3 contact hours (180 minutes), submit documentation for at least 3 contact hours. However, documentation for the complete activity must be kept on file and must be accessible.

• Provider Unit. Key elements 11-12 below refer to descriptions of procedures in effect throughout the overall provider unit rather than those relative to specific activities.

Note: First-time applicants must become approved before implementing those requirements marked by an asterisk.

Key elements:

1. Assessment of Learner Needs. Continuing education activities are developed in response to, and with consideration for, the unique educational needs of the provider unit’s target audience (as associated with the Mission Statement).

requIred eVIdeNce:

Submit a description (with supporting evidence) of the process of activity planning, including the:

•needs assessment;•determination of target audience;•development of objectives, content, and teaching-learning strategies in

response to the needs assessment.


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2. Qualified Planners and Faculty. Each educational activity is planned collaboratively by at least one designated Nurse Planner and one other planner. The approved provider unit’s designated Nurse Planner(s) must be a registered nurse and must hold a baccalaureate degree in nursing or a higher degree in nursing. Additionally, the designated Nurse Planner must have education or experience in the field of education or adult learning. Each member of the planning group should represent at least one of the following areas: the relevant content expertise; the target audience; and the responsibility for adherence to ANCC accreditation criteria. Each planning committee must have representation of all of these three areas. Nurse Planners contribute oversight and must be actively involved in both the planning and the analysis of evaluation data for the educational activity. The planning committee assures the qualifications of the faculty member(s) are appropriate and adequate.

requIred eVIdeNce:

•Identify the Nurse Planner(s) and all other persons who participated in the planning process. Document the content expertise of the collaborating planner(s) who represents this area (required), and of the activity presenters (as appropriate).

•Describetherole(s)playedbytheproviderunit’sdesignatedNursePlanner(s) and any additional key personnel or groups involved in the process of ensuring the quality of educational activities. If the unit relies on the services of multiple and/or ad hoc Nurse Planners, describe how all designated Nurse Planners are kept up-to-date on the requirements for adhering to ANCC accreditation standards. Also describe how the provider unit ensures the performance of each Nurse Planner meets both the requirements of the provider unit and the expectations of ANCC and the accredited approver unit relative to the responsibilities of the Nurse Planner.

•Submit a description of the manner in which the needed qualifications of faculty are identified.

•Submitadescriptionofhowtheplanningcommitteeensuresthatthe selected faculty meet the needed qualifications.

3. Effective Design Principles. Each educational activity is developed with: (a) an identified learning goal (purpose) and explicit educational objectives for the

learner that are appropriate for the target audience;(b) identified gaps in knowledge, skills, practice identified (based on the needs

assessment) which the activity is designed to address;(c) content congruent with the activity’s learning goal (purpose) and educational

objectives;(d) teaching and learning strategies congruent with the activity’s objectives and

content;(e) criteria for judging successful completion of an activity that are consistent with

the learning goal (purpose), objectives, and teaching and learning strategies as listed above; and

(f) a method determined for verifying participation in an activity.

requIred eVIdeNce:

Submit a description of the activity’s:•learninggoal(purpose),learnerobjectives,andrelatedcontent,• identifiedgaps(basedontheneedsassessment)


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•teaching-learningstrategiesused,includingresources,materials,deliverymethods, and learner feedback mechanisms,

•rationaleandcriteriaselectedforjudgingsuccessfulcompletion,and•methodselectedforverifyingparticipation.

*4. Awarding Contact Hours. Contact hours associated with the official accreditation statement are awarded to participants for those portions of the educational activity devoted to didactic or clinical experience or to evaluating the activity. Contact hours are calculated in a logical and defensible manner. One contact hour = 60 minutes. A provider of an educational activity may award no fewer than 0.5 contact hours for an educational activity. Learning activities may be conducted ‘asynchronously’ or may be ‘bundled’ to allow a full learning experience to take place. If ‘rounding’ is desired in the calculation of contact hours, the provider is to round down to the nearest 1/100th. Contact hours may not be awarded retrospectively.


requIred eVIdeNce:

•Identify and provide supporting documentation of the number and calculation of contact hours awarded for the activity.

5. Activity Evaluation. A clearly defined method, which includes learner input, is used to evaluate the effectiveness (i.e., were the activity objectives met?) of each educational activity.

requIred eVIdeNce:

•Submit a written description of the method used to evaluate the activity•Identifythecategoryofevaluation(i.e.learnersatisfaction,knowledge

enhancement, skill and attitude change, change in practice/performance, relationship of the practice change to quality of service). It is strongly recommended that at least a portion of the activities provided be evaluated at one of the higher levels of evaluation.

•Include supporting documentation for the descriptions above.

*6. Approval Statements. The approval statement is a mark of the status of the provider unit. All communications, marketing materials, certificates, and other documents that refer to the status of approval by an ANCC-accredited approver must contain the official approval statement:

• [NameofApprovedProvider]isanapprovedproviderofcontinuingnursingeducation by [ Name of Accredited Approver ], an accredited approver by the American Nurses Credentialing Center’s COA.

The approval statement must stand alone. In other words, it must start and end on a line separate from other text.


requIred eVIdeNce:

•Submit copies of the promotional materials developed for the activity. Note: for a sample activity longer than 3 contact hours (180 minutes), submit the relevant brochure(s) and agenda for the entire activity.


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7. Documentation of Completion. Participants receive written verification of their successful completion of an activity, which includes at a minimum:(a) the name of the participant learner;(b) the name and address of the provider unit;(c) the title and date of the educational activity;(d) *the official accreditation statement (Note: see above Note statement); and(e) the number of contact hours awarded.

requIred eVIdeNce:

•Submit a copy of the certificate awarded to participants upon completion of the educational activity.Note: First-time applicants should prepare and submit a sample certificate

of completion as it would appear following approval and containing the appropriate approval statements.

8. Sponsorship and Commercial Support Guidelines. Education must be kept separate from promotional activities. Commercial support, exhibits, or the presentation of research conducted by a commercial company shall not influence the design and scientific objectivity of any educational activity. Commercially-supplied funds for an educational activity that are given in the form of an educational grant or in-kind assistance shall be acknowledged in the brochures and/or printed material for the continuing education activity. Read Appendix B for a complete statement of the commercial support guidelines.

requIred eVIdeNce:

Submit a description of: •Any sponsorship or commercial support related to the educational activity;•Howcontentintegrityismaintainedforeducationalactivitiesthatreceive

sponsorship or commercial support, if any, including (but not limited to) the policy and associated procedures for resolving conflicts;

•What/howprecautionsaretakentopreventbiasintheeducationalcontent;and

•Thetemplateofthewrittenagreementusedinthepresenceofsponsorshiporcommercial support.

9. Conflict of Interest Guidelines. Conflict of interest disclosure statements shall be obtained from all activity planners and presenters to identify the presence or absence of any potentially biasing relationship of a financial, professional, or personal nature on the part of those who have an impact on the content of an educational activity. Planners and presenters must disclose the presence or absence of conflict of interest relative to each activity. All potential conflicts shall be resolved prior to the planning, implementation, or evaluation of the continuing nursing education activity. Refer also totheconflictofinterestdiscussioninAppendixG.

requIred eVIdeNce:

Submit:•Documentation of the conflict of interest disclosures (or disclosures of

absence of conflict of interest) relative to the specific activity**If a signed disclosure form is NOT used, the organization is advised to

maintain documentation of the source of the disclosure information.


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•A description of procedures followed to resolve any real or potential bias or conflict of interest; and

•Ifavailable,asampleofadisclosurethattriggeredtheresolutionprocedureand documentation reflecting the actions of the provider unit to resolve the issue.


10. Disclosures Provided to Activity Participants. Participants shall receive the following information regarding each and every activity in advance of, or at the time of, the event. If the disclosure is provided verbally, there will be documentation provided by someone in the audience of the activity that the disclosure was appropriately made (see standard 6A and 6B of the Standards for Commercial Support for further guidance).(a) Notice of requirements for successful completion: Activity participants

are informed in advance of the learning goals (purposes) and objectives of the educational activity and the criteria to be used to determine successful completion of an educational activity.

(b) Conflicts of interest: Activity participants are informed of any influencing financial relationships or lack thereof disclosed by planners or presenters. (see further instruction, p. 86, Standards for Commercial Support)

(c) Disclosure of Relevant Financial Relationships And Mechanism To Identify And Resolve Conflicts of Interest. (See further instruction, p. 82-83, Standards for Commercial Support).

(d) Sponsorship or Commercial support: Activity participants are made fully aware of the nature of any commercial support related to an educational activity. (See further instruction, p. 83-85. Standards for Commercial Support)

(e) Non-endorsement of products: Activity participants are advised that accredited status does not imply endorsement by the provider or ANCC of any commercial products displayed in conjunction with an activity.

(f) Off-label use: Learners are notified when an educational activity relates to any product used for a purpose other than that for which it was approved by the Food and Drug Administration.

(g) Expiration Date for Awarding Contact Hours: Endurable educational documents must include a statement that explains how long contact hours will be awarded for an activity. This statement must appear on all marketing material and on the educational material.

requIred eVIdeNce:

•Submit copies of the documents (e.g., promotional brochures, letters, program schedules, presentation materials) or describe the methods that were used to inform activity participants of the above information.

11. Recordkeeping. For each provided educational activity, the following documentation is kept in a secure, confidential, and retrievable manner for 6 years. (a) Planning:

•Description of the target audience;•The method and findings of the needs assessment;•Names, titles, and expertise of the activity planners and presenters;•Conflict of interest disclosure statements from planners and presenters;•Learning goal (purpose), objectives, and content;


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•Instructional strategies, delivery methods, learner feedback mechanisms, and resources to be used;

•Methods or process used to verify participation;•Notice to learners identifying how successful completion will be measured,•Marketing and promotional materials;•Division of responsibilities among co-providers, if any; and•means of ensuring content integrity with sponsorship or commercial support,

if any; and•The written commercial support agreement as required in the Standards of

Commercial Support for any activity receiving commercial support.(b) Implementation:

•Title, location, and date of the educational activity;•All evaluation tools used, including a summative evaluation;•Participant names, and unique identifier information (For example, an

automatically generated number, a password code, the month and date of birth, an address, etc.);

•Sample certificate of completion; and•Number of contact hours associated with official accreditation statement

awarded to individual participants*. •Documentation of the verbal provision of required disclosures (see Standard

6A, 6B of the Standards for Commercial Support for further guidance.)


requIred eVIdeNce:

Submit a description of the provider unit’s recordkeeping system, including:•How activity records are consistently collected; and •Howtheyarestoredandsecuredinaconsistent,logical,safe,and

confidential manner.

12. Co-Provided Activities. When educational activities are co-provided, the approved provider unit retains the following responsibilities: (a) Determination of the educational objectives and content;(b) Selection of the content specialist planners and activity presenters;(c) The awarding of contact hours, as appropriate, to the individual educational

Activity;(d) Recordkeeping procedures;(e) Evaluation methods and categories; and(f) Management of any sponsorship or commercial support.

requIred eVIdeNce:

Submit a description of how responsibilities are assigned and maintained for co-provided activities, if any. (The co-provider agreement must be signed by each party involved in the provision of the activity and must identify the responsibilities of each party.)


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unit operationsThe provider unit ensures the quality of continuing nursing education by following an established process involving a qualified Nurse Planner for developing, delivering, and evaluating the effectiveness of the educational activities it offers. Adequate resources are provided and utilized to support the provider unit’s full range of functions.

Key elements:

1. Nurse Planner. At least one nurse carries out the role of the Lead Nurse Planner, with responsibility for assessing needs, planning, implementing, and evaluating continuing nursing education activities. The Lead Nurse Planner is responsible for assuring that all Nurse Planners are appropriately prepared, oriented, and trained to meet the ANCC Accreditation Program requirements for that role and that they all use the same approach and policies established by the provider unit. The Lead Nurse Planner must be a registered nurse with a baccalaureate or higher degree in nursing. Additionally, the Lead Nurse Planner must have education or experience in the field of education or adult learning.

requIred eVIdeNce:

•Submit a position description for the Lead Nurse Planner reflecting appropriate qualifications and functions; and

•If the provider unit utilizes more than one Nurse Planner, submit a description of the activities of the Lead Nurse Planner in assuring other Nurse Planners are appropriately prepared, oriented, and trained to function in that role. Provide accompanying evidence.

2. Resources. Sufficient human, material, and financial resources are available to carry out the administrative, educational, and supportive functions of the provider unit.

requIred eVIdeNce:

•For designated Nurse Planners and other key personnel (individuals as defined by the applicant organization) involved in providing continuing nursing education or the overall administration of the unit, submit position descriptions that clearly identify job functions and biographical data summaries that demonstrate the qualifications of current incumbents. The position descriptions must reflect qualification requirements for the Nurse Planner(s) and roles relative to continuing nursing education that are consistent with those of the ANCC Accreditation Program.

•Submitadescriptionofthematerialresourcesthatsupportthefunctionsofthe provider unit.

•Submitabriefdescriptionoftheproviderunit’scurrentsourcesoffinancialsupport and projections for how financial support will be sustained throughout the period of accreditation. Do not submit detailed budget reports.

•Submitareportidentifyingtheamountandfrequencywithwhichcommercial support for educational activities is received.


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3. Business Practices. The provider unit must adhere to all regional, state, and national laws and regulations and operate the business and management policies and procedures of its continuing nursing education program (as they relate to human resources, financial affairs, and legal obligations) so that its obligations and commitments are met. The provider unit must adhere to all reasonable ethical expectations in its provision of continuing nursing education and its business practices.

requIred eVIdeNce:

•Provide an attestation statement that the approved unit complies with all applicable local, regional, state, or national laws and regulations and operates its business in an ethical manner. The attestation statement is to be signed by the leaders of the approved unit.


Provider unit evaluationThe provider unit engages in an ongoing evaluation process to analyze its overall effectiveness in fulfilling its beliefs, goals, and functions, and in providing quality continuing nursing education. Plans and goals for the provider unit’s future development in continuing nursing education are identified and re-evaluated on a regular basis.

documentation requirements

Required evidence for this criterion should include a written plan for evaluation of the provider unit indicating what is evaluated, when evaluation occurs, who participates, andresults.ThisplanshouldincludethoseitemsstatedinCriterion#4,KeyElement1. Examples of the evaluation data that are collected, with an explanation as to how they have been used to increase the effectiveness of the provider unit, should also be included.

Note: First-time applicants are expected to have implemented their unit performance improvement plans throughout the minimum 6 months of operational status that is required for application eligibility. Data examples should be selected that are representative of that period. New goals for the provider unit should be described under key element 4.

Key elements:

1. Provider Unit Evaluation Process. The provider must have a mechanism (e.g., a plan) in place to evaluate the effectiveness of its overall continuing nursing education program.

requIred eVIdeNce:

•Document what process was used, what was identified as needing change (or not).


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2. Provider Unit Evaluation Participants. The Lead Nurse Planner shall participate in the unit evaluation. The provider shall identify other participants to be included in the evaluation process.

requIred eVIdeNce:

•Identifyappropriatestakeholdersthatareinvolvedintheevaluationofthe provider unit. (This may differ based upon the type of provider’s organization).

3. Provider Unit Evaluation Results. Evaluation data are used to confirm, expand, or change the operations of the provider unit.

requIred eVIdeNce:

Submit a description of:•Howresultsoftheoverallprogramevaluationprocesshavebeenusedto

confirm, expand, and improve the provider unit’s operations; and

4. Provider Unit Goals for Improvement. Efforts toward improvement include addressing issues, identifying strategies for working on targeted goals, evaluating progress toward goals, and revising or establishing new goals.

requIred eVIdeNce:

Submit a description of how:•Theproviderunit’sgoalsforimprovementovertheperiodofaccreditation

have been addressed;•Whatchangesandprogresshavebeenmadetowardmeetingthosegoals;•Whatnewgoalsforimprovementhavebeenidentified;and•Operationalplansforimplementationassociatedwiththegoals

identified above.


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GaPPendix g

resolution of conflict of interest

A conflict of interest exists if an entity that is in a position to benefit financially from the success of a CE activity is ALSO in a position to influence the content, design, or implementation of the CE activity.

1.1 If an organization or an individual within the organization is in a position which affords him/her the opportunity to affect CE content with products or services from which, if purchased, the individual or organization might receive personal financial benefit, the individual or organization must disclose to the CE activity provider his/her/its relationship to the product or service developer, manufacturer, distributor, or seller.

1.2 The provider must be able to show that each individual who is in a position to control the content of an education activity has disclosed all relevant relationships with any entity in a position to benefit financially from the success of the CE activity. Examples of relevant relationships include (but are not limited to) those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options, or other ownership interest, excluding diversified mutual funds), or other financial benefit. Relevant relationships can also include ‘contracted research’ where the institution receives a grant and manages the grant funds and the individual is the principal or a named investigator on the grant. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking, teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received or expected. ANCC considers relationships of the individual involved in the continuing nursing education activity to include financial relationships of the individual’s spouse/partner. Relevant relationships must be disclosed to the learners during the time when the relationship is in effect and for 12 months afterward.

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ANCC considers relationships occurring within the 12 months prior to the implementation date of the activity as “relevant” to conflict of interest. When a person divests himself/herself of a relationship, it ceases to be a conflict of interest but it must be disclosed to the learners for 12 months after the termination of the relationship.

1.3 An individual who refuses to disclose relevant relationships will be disqualified from being a planning committee member, a teacher, or an author of continuing nursing education and cannot have control of, or responsibility for, the development, management, presentation, or evaluation of the CE activity.

1.4 The provider must have implemented a mechanism to identify and resolve all conflicts of interest prior to the education activity being delivered

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aPPendix g resoluTIoN of coNflIcT INTeresT

8515 Georgia Avenue, Suite 400 Silver Spring, MD 20910-3492

1.800.284.2378 301.628.5000 tel 301.628.5342 fax www.nursecredentialing.org

appLication manuaL 2009Accreditation Program®

ISBN 0-9793811-8-5ISBN-13 978-0-9793811-8-8

The American Nurses Credentialing Center (ANCC) has successfully achieved ISO 9001:2000 certification for professional services rendered in the administration of the Magnet Recognition Program®forexcellenceinhealthcareorganizationsandtheAccreditation Program for excellence in continuing nursing education. ISO 9001:2000 certification is the firmly established globalstandardforassuringstakeholdersofanorganization’sability to satisfy quality-related requirements.

The American Nurses Credentialing Center (ANCC), a subsidiary of the American Nurses Association (ANA), provides individuals and organizationsthroughoutthenursingprofessionwiththeresourcestheyneedtoachievepracticeexcellence.ANCC’sinternationallyrenownedcredentialingprogramscertifynursesinspecialtypracticeareas;recognizehealthcareorganizationsforpromotingsafe,positiveworkenvironmentsthroughthePathwaytoExcellence™Program;andaccreditprovidersofcontinuingnursingeducation.inaddition, ANCC offers an array of informational and educational services and products to support its core credentialing programs. ANCCistheworld’slargestandmostprestigiousnursecredentialingorganization.ANCCcertificationexamsvalidatenurses’skills,knowledge, and abilities. More than a quarter million nurses have been certified by ANCC since 1990. More than 75,000 advanced practice nurses are currently certified by ANCC. The ANCC Accreditation Program®recognizeshealthcareorganizationsthatprovidetheverybestinnursingcareandprofessionalismin nursing practice. The program also provides a vehicle for disseminating best practices and strategies among nursing systems. The ANCC Accreditation Program is the gold standard for nursing excellence. ANCC Accreditation of a continuing nursing education program is the hallmark of quality. ANCC is the nation’s leader in accreditation of continuing nursing education programs. ANCC produces a variety of educational services and products to support those seeking certification, Magnet recognition, or accredita-tion. Review and resource manuals, review seminars, and web-based learning all support individuals who are on the path to certifica-tion.ANCC’sNationalMagnetConferences,workshops,andconsultingservicessupportorganizationsontheJourneytoNursingExcellence. Consultants are available to assist continuing nursing education Accreditation Programs in achieving the highest caliber education.

The Pathway to Excellence™ Program and ANCC Accreditation Program® names and logos are registered trademarks of the American Nurses Credentialing Center. Magnet™, Journey to Nursing Excellence™, and National Magnet Conference™ are trademarks of the American Nurses Credentialing Center. All rights reserved.

© 2008 American Nurses Credentialing Center. All rights reserved.

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