NURSE PEER REVIEW FORM

APPROVED PROVIDER (AP) APPLICATION – 2015 CRITERIA

REVIEW OF SELF-STUDY NARRATIVE

(NEW “Form 23”)

Directions: Click on a box to ‘check’ – click again to ‘un-check’. Type comments directly into table. Save completed form on your computer under a new name. This form is to be used by Nurse Peer Review Team Leader to document consensus decisions of the team, and is to be submitted with any application resubmissions to the NPRL.

Applicant Organization:
Name of Provider Unit (if different):
☐ Currently an Approved Provider - expiration date: / Current approval is through: ☐ WNA Other:
☐ First time applicant - length of time new ‘provider unit’ has been in operation: / (do not review if less than 6 months)
Did applicant disclose previous denial/suspension/revocation of accreditation or approval of an IEA/Provider application by ANCC or an ANCC Accredited Approver?
☐ NO ☐ YES (check with NPRL for instructions before reviewing application) ☐ Not answered (contact Applicant PNP to clarify before reviewing application)
Primary Nurse Planner signed/dated ‘Primary Nurse Planner Attestation’ on last page of application: ☐ YES ☐ NO (contact Applicant PNP before reviewing)
Date of Initial Review: / ☐ Final Review Date: OR
☐ Date sent to NPR for remediation: / Amount of time spent reviewing: / ______
Reviewer Attestations: As a peer reviewer for this Individual Educational Activity Application,
·  I attest to having no conflict of interest or personal or professional relationship with this applicant that would preclude me from reviewing this application in a fair and unbiased manner.
·  I have conducted an independent review of this application.
Review Team Leader - Name and Credentials: / Date:
☐ Check this box if you designate the above as your electronic signature.
Review Team Member - Name and Credentials: / Date:
☐ Check this box if you designate the above as your electronic signature.
Review Team Member - Name and Credentials: / Date:
☐ Check this box if you designate the above as your electronic signature.
Nurse Peer Review Leader - Name and Credentials: / Date:
☐ Check this box if you designate the above as your electronic signature.
Key to abbreviations:
APU = Approved Provider Unit OO = Organization Overview
PNP = Primary Nurse Planner SC = Structural Capacity
NP = Nurse Planner EDP = Educational Design Process
COI = Conflict of Interest QO = Quality Outcomes
CNE = Continuing Nursing Education CT-WNA-PA = “COMPLETING THE WNA PROVIDER APPLICATION” REFERENCE TOOL

BE SURE TO USE THE “COMPLETING THE WNA PROVIDER APPLICATION” REFERENCE TOOL FOR YOUR REVIEWS – THIS WILL HELP IDENTIFY WHAT SPECIFICALLY IS MISSING AND SPECIFIC REVISIONS TO ASK FOR.

INITIAL QUALITATIVE REVIEW CONSENSUS / FINAL CONSENSUS DECISION
Self-study documentation of compliance with ANCC criterion / Complete / Incomplete / Not Submitted / Issues/Clarifications/Documents needed/Due date / Complete / Incomplete / Comments/Page number
ORGANIZATIONAL OVERVIEW:
STRUCTURAL CAPACITY / Com / Inc / Not / Com / Inc
OO1. Demographics
a. / Description of the APU features, including but not limited to scope of services, size, geographic range, target audience(s), content areas, and the types of educational activities offered. (SEE CT-WNA-PA REFERENCE TOOL PAGE 1 – 2) / ☐ / ☐ / ☐ / ☐ / ☐
b. / If APU is part of a multi-focused organization, description of the relationship of these scope dimensions to the total organization
(SEE REFERENCE TOOL PAGE 2) / ☐ / ☐ / ☐ / ☐ NOT APPLICABLE / ☐ / ☐ / ☐ NOT APPLICABLE
Self-study documentation of compliance with ANCC criterion / Complete / Incomplete / Not Submitted / Issues/Clarifications/Documents needed/Due date / Complete / Incomplete / Comments/Page number
OO2. Lines of Authority and Administrative Support
a. / List of all names and credentials, positions, and titles of the PNP, other NPs) (if any), and all key personnel in the APU.
(SEE REFERENCE TOOL PAGE 2) / ☐ / ☐ / ☐ / ☐ / ☐
b. / Position descriptions for the PNP, other NP(s) (if any), and all key personnel in the APU.
(SEE REFERENCE TOOL PAGE 2) / ☐ / ☐ / ☐ / ☐ / ☐
c. / Chart depicting the structure of the APU, including the PNP, NP(s) if any, and all key personnel.
(SEE REFERENCE TOOL PAGE 2) / ☐ / ☐ / ☐ / ☐ / ☐
d. / If APU is part of a larger organization, an organizational chart, flow sheet, or similar image that depicts the organizational structure and the APU’s location within the organization.
(SEE REFERENCE TOOL PAGE 2) / ☐ / ☐ / ☐ / ☐ NOT APPLICABLE / ☐ / ☐ / ☐ NOT APPLICABLE
ORGANIZATIONAL OVERVIEW:
EDUCATION DESIGN PROCESS / Com / Inc / Not / Com / Inc
OO3. Data Collection and Reporting
a. / Completed Approved Provider Continuing Education Summary of all CNE offerings provided in the past 12 months (or previous calendar year).
(SEE REFERENCE TOOL PAGE 2 - 3) / ☐ / ☐ / ☐ / ☐ / ☐
ORGANIZATIONAL OVERVIEW:
QUALITY OUTCOMES / Com / Inc / Not / SEE “DEVELOPING OUTCOMES FOR YOUR APPROVED PROVIDER UNIT” DOCUMENT – IF APPLICANT’S OUTCOMES ARE NOT DOCUMENTED SIMILAR TO THE EXAMPLES HIGHLIGHTED ON PAGE 3 OF THAT DOCUMENT, SEND THAT DOCUMENT TO THE PROVIDER TO HELP THEM REVISE THEIR APU OUTCOMES ! / Com / Inc
OO4. Evidence
a. / List of the quality outcome measures the APU collects, monitors, and evaluates specific to the Approved Provider Unit STURCTURE AND PROCESS. (ALL Applicants: at least TWO one measurable outcomes)
(SEE REFERENCE TOOL PAGE 3 AND DEVELOPING OUTCOMES DOCUMENT) / ☐ / ☐ / ☐ / ☐ / ☐
b. / List of the quality outcome measures the APU collects, monitors, and evaluates specific to Nursing Professional Development.
(ALL Applicants: at least TWO measurable outcomes)
(SEE REFERENCE TOOL PAGE 4 AND DEVELOPING OUTCOMES DOCUMENT) / ☐ / ☐ / ☐ / ☐ / ☐
Comments:
Response must include:
Narrative = describes how the APU complies with each criterion by explaining the APU’s process
Example = specific example demonstrates how the APU’s process was used/implemented to meet the criterion / Scoring scale:
4 = response exceeds criteria requirement
3 = response meets criteria requirement
2 = response partially meets criteria requirement
1 = response fails to meet criteria requirement / If provider scores all “1’s” on initial review, please contact WNA CEAP NPRL.
INITIAL QUALITATIVE REVIEW CONSENSUS / SECOND REVIEW CONSENSUS FINAL SCORE
Self-study documentation of compliance
with ANCC criterion / 4 - Exceeds / 3 - Meets / 2 – Partially meets / 1 – Fails to meet / Issues/Clarifications/Due date / Re-sub NARRATIVE / Re-sub EXAMPLE / 4 - Exceeds / 3 - Meets / 2 – Partially meets / 1 – Fails to meet / Resubmissions requested – Due date / 4 - Exceeds / 3 - Meets / 2 – Partially meets / 1 – Fails to meet
APPROVED PROVIDER CRITERION 1:
STRUCTURAL CAPACITY (SC) / 4 / 3 / 2 / 1 / Resubmit  / Nar / Ex / 4 / 3 / 2 / 1 / 4 / 3 / 2 / 1
SC1. / Description and example demonstrate how the PNP is committed to learner needs, including how APU processes are revised based on data.
(SEE REFERENCE TOOL PAGE 4 – 5) / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
SC2. / Description and example demonstrate how the Primary Nurse Planner ensures all Nurse Planners in the Approved Provider unit are appropriately oriented/trained to implement and adhere to the ANCC/WNA CEAP criteria.
(SEE REFERENCE TOOL PAGE 5) / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
SC3. / Description and example demonstrate how the Primary Nurse Planner provides direction and guidance to individuals involved in planning, implementing, and evaluating CNE activities in compliance with ANCC/WNA CEAP criteria.
(SEE REFERENCE TOOL PAGE 5) / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
# checked in column:
Multiply by: / 4 / 3 / 2 / 1
= column score:
Add all column scores:
MEAN SCORE for STRUCTURAL CAPACITY Divide by number of criteria (3):

If applicant “meets” all three criteria after one request for revisions, record their score. If applicant does not meet all three criteria after one request for revisions, please contact WNA CEAP NPRL.

Comments for approval letter: STRUCTURAL CAPACITY SECTION
Response must include:
Narrative = describes how the APU complies with each criterion by explaining the APU’s process
Example = specific example demonstrates how the APU’s process was used/implemented to meet the criterion / Scoring scale:
4 = response exceeds criteria requirement
3 = response meets criteria requirement
2 = response partially meets criteria requirement
1 = response fails to meet criteria requirement / If provider scores all “1’s” on initial review, please contact WNA CEAP NPRL.
INITIAL QUALITATIVE REVIEW CONSENSUS / SECOND REVIEW CONSENSUS FINAL SCORE
Self-study documentation of compliance
with ANCC criterion / 4 - Exceeds / 3 - Meets / 2 – Partially meets / 1 – Fails to meet / Issues/Clarifications/Due date / Re-sub NARRATIVE / Re-sub EXAMPLE / 4 - Exceeds / 3 - Meets / 2 – Partially meets / 1 – Fails to meet / Resubmissions requested – Due date / 4 - Exceeds / 3 - Meets / 2 – Partially meets / 1 – Fails to meet
APPROVED PROVIDER CRITERION 2:
EDUCATIONAL DESIGN PROCESS (EDP) / 4 / 3 / 2 / 1 / Resubmit  / Nar / Ex / 4 / 3 / 2 / 1 / 4 / 3 / 2 / 1
EDP1. / Description and example demonstrate the process used to identify a problem in practice or an opportunity for improvement (professional practice gap).
(SEE REFERENCE TOOL PAGE 6 ) / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
EDP2. / Description and example demonstrate how the Nurse Planner identifies the educational needs (knowledge, skills, and/or practice(s)) that contribute to the professional practice gap.
(SEE REFERENCE TOOL PAGE 6 ) / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
EDP3. / Description and example demonstrate the process used to identify and resolve all conflicts of interest for all individuals in a position to control educational content.
(SEE REFERENCE TOOL PAGE 6 - 7) / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
EDP4. / Description and example demonstrate how the content of the educational activity is developed based on best-available current evidence (e.g., clinical guidelines, peer-reviewed journals, experts in the field) to foster achievement of desired outcomes.
(SEE REFERENCE TOOL PAGE 7) / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
EDP5. / Description and example demonstrate how strategies to promote learning and actively engage learners are incorporated into educational activities.
(SEE REFERENCE TOOL PAGE 8) / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
EDP6. / Description and example demonstrate how summative evaluation data for an educational activity were used to guide future activities.
(SEE REFERENCE TOOL PAGE 8) / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
EDP7. / Description and example demonstrate how the Nurse Planner measures change in knowledge, skills, and/or practices of the target audience that are expected to occur as a result or participating in the educational activity.
(SEE REFERENCE TOOL PAGE 8 - 9) / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
# checked in column:
Multiply by: / 4 / 3 / 2 / 1
= column score:
Add all column scores:
MEAN SCORE for EDUCATIONAL DESIGN PROCESS Divide by number of criteria (7):

If applicant “meets” at least 5 of 7 criteria after one request for revisions, record their score. If applicant does not meet at least 5 of 7 criteria after one request for revisions, please contact WNA CEAP NPRL.

Comments for approval letter: EDUCATIONAL DESIGN PROCESSES SECTION
Response must include:
Narrative = describes how the APU complies with each criterion by explaining the APU’s process
Example = specific example demonstrates how the APU’s process was used/implemented to meet the criterion / Scoring scale:
4 = response exceeds criteria requirement
3 = response meets criteria requirement
2 = response partially meets criteria requirement
1 = response fails to meet criteria requirement / If provider scores all “1’s” on initial review, please contact WNA CEAP NPRL.
INITIAL QUALITATIVE REVIEW CONSENSUS / SECOND REVIEW CONSENSUS FINAL SCORE
Self-study documentation of compliance
with ANCC criterion / 4 - Exceeds / 3 - Meets / 2 – Partially meets / 1 – Fails to meet / Issues/Clarifications/Due date / Re-sub NARRATIVE / Re-sub EXAMPLE / 4 - Exceeds / 3 - Meets / 2 – Partially meets / 1 – Fails to meet / Resubmissions requested – Due date / 4 - Exceeds / 3 - Meets / 2 – Partially meets / 1 – Fails to meet
APPROVED PROVIDER CRITERION 3:
QUALITY OUTCOMES (QO) / 4 / 3 / 2 / 1 / Resubmit  / Nar / Ex / 4 / 3 / 2 / 1 / 4 / 3 / 2 / 1
QO1. / Description and example demonstrate the process utilized for evaluating effectiveness of the APU in delivering quality CNE.
(SEE REFERENCE TOOL PAGE 9) / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
QO2. / Description and example demonstrate how the evaluation process for the APU resulted in the development or improvement of an identified quality outcome measure.
(refer to identified quality outcomes list in OO4).
(SEE REFERENCE TOOL PAGE 9 -10) / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
QO3. / Description and example demonstrate how, over the past 12 months, the Approved Provider Unit has enhanced nursing professional development (refer to identified quality outcomes list in OO4).
(SEE REFERENCE TOOL PAGE 10) / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
# checked in column:
Multiply by: / 4 / 3 / 2 / 1
= column score:
Add all column scores:
MEAN SCORE for QUALITY OUTCOMES Divide by number of applicable criterion (3):

If applicant “meets” all three criteria after one request for revisions, record their score. If applicant does not meet all three criteria after one request for revisions, please contact WNA CEAP NPRL.