NURSE PEER REVIEW FORM
APPROVED PROVIDER (AP) APPLICATION – 2015 CRITERIA
REVIEW OF SELF-STUDY NARRATIVE
(NEW “Form 23”)
REMINDER: Do not tell a Provider that you are recommending or not recommending approval. This is based on final NPRL Scoring with ANCC tool.
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):
This organization is
☐ Current Approved Provider / If yes, expiration date: / Current approval is through: ☐ WNA or ☐ Other:☐ First time applicant / ‘Provider unit’ has been in operation six months: / ☐ YES or ☐ NO
If no, contact WNA office or WNA NPRL and do not review application.
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 or ☐ NO – Contact Applicant PNP before reviewing.REMINDER: Do not tell a Provider that you are recommending or not recommending approval. This is based on final NPRL Scoring with ANCC tool.
Reviewer Attestation: As a peer reviewer for this Approved Provider application, I attest that:
· I have 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.
Date of Initial Review:☐ Final Review Date OR ☐ Date sent to NPR for remediation:
Amount of time spent reviewing:
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.
REMINDER: Do not tell a Provider that you are recommending or not recommending approval. This is based on final NPRL Scoring with ANCC tool.
Key to abbreviations:APU = Approved Provider Unit OO = Organization Overview SC = Structural Capacity EDP = Educational Design Process QO = Quality Outcomes PNP = Primary Nurse Planne
NP = Nurse Planner COI = Conflict of Interest CNE = Continuing Nursing Education CT-WNA-PA = “COMPLETING THE WNA PROVIDER APP REFERENCE TOOL”
PLEASE USE THE “COMPLETING THE WNA PROVIDER APPLICATION” REFERENCE TOOL WHEN YOU DO YOUR REVIEWS!
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)
Scope = Single or mutli-facility system? Number of locations served? Nursing target audience? Jointly provide?
Size = Number of: nurse planners, activities, learners served, or other aspects. If a Health or Ed system: number of sites you provide education to /are there nurse planners at those sites or if program is managed centrally
Geographic range = Where service is provided - Facility? Community? Other?
Target audience = types of nurses (RNs, APRNs, etc.) What practice areas? Inter-professional groups?
Content areas = (clinical, non-clinical; – give examples of broad categories (e.g. leadership, ed. curriculum, QI nursing, etc.)
Type = live? enduring material? blended learning? Other? / ☐ / ☐ / ☐ / ☐ / ☐
Self-study documentation of compliance with ANCC criterion / Complete / Incomplete / Not Submitted / Issues/Clarifications/Documents needed – Due date / Complete / Incomplete / Comments/Page number
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)
Organization’s geographic range, population served, and size.
Describe how the activities of the APU fit into the organization’s goals, strategic plan and educational system. / ☐ / ☐ / ☐ / ☐ NOT APPLICABLE / ☐ / ☐ / ☐ NOT APPLICABLE
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)
Should reflect the responsibilities of each person related to his/her role in the provider unit. / ☐ / ☐ / ☐ / ☐ / ☐
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
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:
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
Must have a target for each measure – see “Developing Outcomes for Your Approved Provider Unit” document for how outcomes should be written. / 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) / ☐ / ☐ / ☐ / ☐ / ☐
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 è / 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)
How does the Primary Nurse Planner (PNP) use feedback to change or improve provider unit processes or learning activities?
What feedback is used?
How are learner needs assessed?
How do you know what styles of learning fit your learners best or what learning modalities (live, webinars, independent study, etc.) they prefer?
What do you do with this information? / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
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)
How do you orient new nurse planners to your provider unit?
How do you keep them updated on changes?
How do you monitor to be sure they are doing the right things on a consistent basis? / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
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)
As PNP, how do you make your expectations clear to other nurse planners and others involved with CNE activities? (How do all involved know what to do?)
What process do you implement to support others who participate on planning committees or engage in the work of providing CNE?
How do you help nurse planners problem-solve when challenges or questions arise? / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
# 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):
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 è / 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 )
How do you define a professional practice gap?
How do you determine what the real issue is that needs attention?
What sources of data might alert you to the existence of a professional practice gap?
How do you know when a gap exists? / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
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
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 )
How do you determine why a professional practice gap exists? (In Other Words: how do you figure out the problem causing the gap?)
How do you then do a more targeted assessment of the needs of the learners expected to participate in this activity to determine how to focus the content of the session to match the gap in knowledge, skills or practice?