Individual Education Activity

INDIVIDUAL EDUCATION ACTIVITY

APPLICATION

Three (3) hard copies, three (3) flash drives OR one (1) Word or Adobe .pdf file (not exceeding 5MB) of the completed application and supporting documentation must be submitted to the Midwest Multistate Division (Midwest MSD) office at least 45 calendar days/ 30 business days prior to the date the activity will be presented. If you are unable to meet the deadline, contact the Midwest MSD Office to discuss possible options.

The approval period for educational activities is two (2) years. The appropriate application review fee must accompany the application for the review process to begin. Please ensure this page is included in your submission to aid in processing.

For additional guidance in completing the Educational Activity Application, please refer to the Application Instructions available on the website. These tools provide helpful tips on completing the application and additional detail about designing activities and adhering to the accreditation guidelines.

If you have questions, please contact the Midwest MSD Office at or 573-636-4623 ext. 102.

Application Review Fee: (Based on number of nursing contact hours being reviewed)

0.5-5 contact hours / $200.00
5.1-20 contact hours / $200.00 plus $10/contact hour
e.g. 8.5-hour activity: $200 + $85 (8.5 hrs x $10) = $285 review fee
20.1 or more contact hours / $400.00 plus $10/contact hour
e.g. 45-hours under review: $400 + $450 (45 hrs x $10) = $850 review fee

Applicant & Activity Information:

Applicant Organization:
Address:
City: / State: / Zip Code:
Activity Title:
Number of Contact Hours Submitted for Approval:
Nurse Planner Name:
Phone: / Preferred Email:
Contact for Application: / If same as Nurse Planner indicate “Same as above”
Phone: / Preferred Email:

Activity Format:

☐ Live – e.g. In-person, conference/symposium, tele- or audio-conference, webinar/webcast, meeting series/journal club

☐ Enduring – e.g. Online or printed self-study, journal/article in publication, CD/DVD, case study, web- or computer-based

☐ Blended – e.g. Hybrid courses, flipped classroom, combination of learning formats (face-to-face instruction and web-based online learning)

Will this activity be offered Multiple Times i.e. Repeated? ☐ Yes ☐ No

Date(s) to be Provided:
(Live: Insert date live activity presented; Enduring: date first offered, expiration date of enduring materials and subsequent review dates; Blended: date of live portion and start and end dates of enduring materials)
Location(s) to be Offered:
(City & State)

Payment:

☐ Check (Make checks payable to the Midwest Multistate Division or Midwest MSD)
☐ Credit Card – Visit the Midwest Multistate Division Website at www.midwestnurses.org to Pay via Credit Card

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Eligibility Requirements

Step 1: Identify the Nurse Planner for this Continuing Education Activity

A.  A currently licensed registered nurse with baccalaureate degree or higher in nursing is actively involved, as the Nurse Planner, in the planning, implementation and evaluation process of this continuing education activity, as well as the application process. NOTE: The Nurse Planner must be available to Midwest MSD Nurse Peer Reviewers to answer questions pertaining to the activity and information provided in this application.

Please list the name and credentials, email and phone number of the nurse involved/responsible for this educational activity:

Nurse Planner's Name and Credentials / Email Address

B.  Does the individual serving as Nurse Planner meet all of the following requirements?

·  Is currently licensed as a registered nurse

·  Holds a baccalaureate degree or higher in nursing

·  Is NOT an employee or representative of a commercial interest

·  Has NO relevant relationship with a commercial interest (conflict of interest) with respect to the content of the activity

·  Was actively involved with the planning, and will continue to be actively involved in the implementation and evaluation of this educational activity

·  Is in compliance with all applicable federal, state, and local laws and regulations that affect the organization’s ability to meet the ANCC/Midwest MSD accreditation criteria

☐ YES – The Nurse Planner meets all of the above requirements. Please continue to Step 2.

☐ NO – This educational activity is not eligible for review.

Step 2: Is Your Organization A ‘Commercial Interest’?

A ‘commercial interest’, as defined by ANCC, is any entity producing, marketing, reselling, 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, resells, or distributes healthcare goods or services consumed by or used on patients. Nonprofit or government organizations, non-healthcare-related companies, and healthcare facilities are not considered commercial interests.

A.  Does your organization produce, market, re-sell, or distribute health care products or services consumed by, or used on, patients?

☐ NO – Your organization is eligible to apply for approval; continue to Step 3.

☐ YES – However, my organization is one of the exempt organizations below – please check one:

☐ Constituent Member Association or Specialty Nursing Organization

☐ National nurses’ organization based outside the United States

☐ Hospital, nursing home or rehabilitation center; for-profit or nonprofit

☐ Nonprofit organization or professional association

☐ Government organization

☐ Blood bank

☐ Diagnostic laboratory

☐ Federal Nursing Service

☐ Group medical practice

☐ Health insurance providers

☐ Liability insurance providers

☐ Non-healthcare related company

☐ Provider of clinical services or clinical education

☐ Healthcare information technology company

☐ A single-focused organization devoted only to providing continuing nursing education

*If you checked ‘YES’ and your organization is not one of the types above, proceed to Step 2B to determine your eligibility to apply. Questions? Please contact the Midwest MSD office before proceeding with this application.

B. Your organization indicated it meets the definition of a commercial interest and is not an exempt organization from the list above. The following questions must be answered to assess the organization’s eligibility to offer continuing nursing education.

1. Does the applicant produce, market, re-sell, or distribute health care goods or services consumed by, or used on, patients?

☐ YES – STOP. Your organization is not eligible to apply for approval

☐ NO – Continue to Step 2B.2

2. Is the applicant owned or controlled by a multi-focused organization (MFO[1]) that produces, markets, re-sells, or distributes health care goods or services consumed by, or used on, patients?

☐ YES – Continue to Step 2B.3

☐ NO – This section of the eligibility requirements is complete. Continue to Step 3

3. Is the applicant a separate and distinct entity from the MFO?

☐ YES – Continue to Step 3

☐ NO – STOP. Your organization is not a separate and distinct entity from the MFO; therefore, you are not eligible to apply for approval.

Step 3: Does The Planned Activity Meet the Definition of Continuing Nursing Education?

A.  Does the planned educational activity meet ALL of the following requirements?

·  Content must meet the definition of continuing nursing education[2]

·  Content must enable the learner to acquire or improve knowledge or skills beyond basic knowledge

·  Content must enhance professional development or performance of the nurse

·  Content must be evidenced-based or based on the best available evidence

·  Activity must be at least 30 minutes in length

☐ YES – Please continue to Educational Design Criteria 1.

☐ NO – This educational activity is not eligible for review.

EDUCATIONAL DESIGN CRITERIA

Continuing nursing education activities are assessed, 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.

Applications may be submitted electronically if the application and supporting documentation are collated into one Word or Adobe .pdf file and the file does not exceed 5 MB in size. If the application exceeds 5MB, applicants must submit three (3) flash drives, each containing one collated PDF of the application and supporting documentation.

Applicants must address the following Criteria 1-10 and provide required supporting documentation to demonstrate their adherence:

1. Jointly Provided Activities

When an activity is jointly provided, the applicant organization is referred to as the ‘provider’ of the educational activity. The other organization(s) involved are referred to as the joint provider(s). ‘Providers’ are responsible for the following elements, when the activity is jointly provided: a) determining learning outcome(s) and content; b) selecting planners, presenters/faculty/authors, and content reviewers; c) awarding contact hours; d) developing evaluation methods; e) managing commercial support; f) recordkeeping procedures; and g) ensuring the provider’s name is prominently displayed on all marketing materials and certificates.

1.1  Is this educational activity jointly provided (collaboratively provided with another organization)?

☐ No. This activity is not jointly provided. (Proceed to Criterion 2)

☐ Yes. This activity is jointly provided with:

Organization(s) Name(s):

1.2  Submit a copy of the joint provider agreement. Use of the Midwest MSD Joint Provider Agreement is required. When educational activities are jointly provided, a joint provider agreement must be developed. The joint provider agreement must:

·  identify each organization involved in the planning of the activity

·  outline the responsibilities of each organization

·  be signed by representatives legally authorized to enter into agreements on behalf of each organization involved in the activity, including the date the agreement was signed.

☐ Joint provider agreement attached

NOTE: Please review the Application Instructions document available on the Midwest MSD for details on managing the responsibilities for jointly provided activities.

2. Effective Design Principles

Continuing education activities are developed in response to, and with consideration for, the unique educational needs of the target audience. At a minimum for CNE the target audience must include Registered Nurses. The educational design process incorporates identified gap(s), measurable learning outcomes, best available evidence, and appropriate learner engagement strategies. Applicants must document the following in their files for each session/ presentation:

(a)  measurable learning outcomes

(b)  outline of related content

(c)  time spent on each section of content

(d)  presenter(s)/faculty/author(s) for each session/presentation

(e)  learner engagement strategies

(f)  references/resources used in the development of the content

Applicants must document the above-mentioned elements for the entire activity in their files using the Educational Planning Form. Educational Planning Forms for up to 10.0 contact hours of content is required to be submitted with the application.

NOTE: Applicants providing an inter-professional activity are only required to document the information above for the sessions/presentations eligible for continuing nursing education. The Midwest MSD reserves the right to request any additional documentation as needed to validate compliance.

2.1  Identify the professional practice gap(s) (difference between current state and desired state) in knowledge, skills or practice revealed by the needs assessment, which the activity was designed to address (e.g. change in practice, problem in practice, opportunity for improvement).

NOTE: The planning committee should use information from the needs assessment to identify the current level of knowledge, skill or practice of the target audience. They then determine the difference between the prospective participant’s current level of knowledge, skill or practice and where it should be; this difference is the ‘problem in practice’ or ‘gap’. If the identified gap can be closed by education the educational activity is designed to address the “missing” knowledge, skill or practice.

☐ Completed Gap Analysis Worksheet attached

☐ Gap(s) Identified/Described below– at least one gap (knowledge OR skills OR practice) must be identified and described

Gap(s) in Knowledge (does not know):
Gap(s) in Skills (does not know how):
Gap(s) in Practice (does not show/do in practice):

2.2  Select the evidence used to validate the professional practice gap(s) for this activity. (Check all that apply)

☐ Written needs assessment or survey of stakeholders, target audience members, subject matter experts or similar

☐ Individual input from stakeholders such as learners, managers, or subject matter experts

☐ Requested by nursing management, based on internal quality measures or identified need

☐ Quality studies/performance improvement activities

☐ Evaluation data from previous educational activities

☐ Trends in literature, law and/or health care

☐ Trends in practice, treatment modalities, and/or technology

☐ Other - (Describe):

2.3  Provide a brief summary of data gathered in #2.2 that supports the need for this activity.

2.4  Identify the target audience for the educational activity. (Check all that apply)

☐ Registered Nurses – RNs

☐ Advance Practice Registered Nurses – APRNs

☐ Registered Nurses in a Specialty Area – (Identify Specialty):

☐ Inter-professional e.g., Physicians, Pharmacists, Social Workers – (Describe):

☐ Other – (Describe):

Desired Learning Outcome(s) – Outcomes are evaluated to determine the impact of educational activities on patient care and professional development of the learner. NOTE: Specific outcomes related to this activity must be documented on the Educational Planning Form.

2.5  Submit Educational Planning Form(s) for each session/presentation as indicated in the table below based on the total number of contact hours under review. Use of the Midwest MSD Educational Planning Form is required.

Total # of Activity Contact Hours / Educational Planning Form(s) Documenting:
0.5 – 5.0 contact hours / Content for entire activity
5.1 – 20 contact hours / Minimum of 5 hours of content
20.1 or more contact hours / Minimum of 10 hours of content

☐ Educational Planning Form(s) for the entire activity submitted

☐ Educational Planning Form(s) for a minimum of 5.0 contact hours of content submitted

☐ Educational Planning Form(s) for a minimum of 10.0 contact hours of content submitted

NOTE: The Midwest MSD reserves the right to request the Education Planning Form(s) for the remainder of the activity as needed for review.

3. Qualified Planners & Presenters/Faculty/Authors/Content Reviewers

Complete the table below for each person on the planning committee including name, credentials, educational degree(s), role on the planning committee, and conflict of interest and resolution methods that substantiates their role. Applicants are required to maintain Nurse Planner and Planner/ Faculty Biographical Data and COI Forms for all individuals involved in the educational activity.