Illinois Nurses Association

Approved Provider Unit Application Revised as of November 2009

ILLINOIS NURSES ASSOCIATION (INA) 105 WEST ADAMS STREET SUITE 1420 CHICAGO, IL 60603 PHONE: (312) 419-2900 FAX: (312) 419-2920

Eligibility Criteria for Approved Provider Unit Applicants

Please review the eligibility requirements on pages 2 to 4 of the Administrative Approved Provider Criteria Manual and complete the following eligibility statements. If the response is “no” to any of the five items below, please do not proceed with the application process and contact the Associate Director of Continuing Education at [email protected].

1. The provider is not a commercial interest. (Definition: A commercial Yes No interest is defined as an entity that produces, markets, sells or distributes healthcare goods or services consumed by or used on patients or that is owned or controlled by an entity that does the same. This definition allows the provider to have a sister company that is a commercial interest as long as the provider has and maintains adequate corporate firewalls to prohibit any influence or control by the sister company over the continuing nursing education (CNE) program of the provider.) 2. Over 50% of the provider’s educational activities offered in the previous Yes No calendar year were not targeted to nurses in multiple regions. (Please refer to the definition of multiple region providers on page 2 of the Administrative Approved Criteria Manual.) Please review the DHHS regional map at: www.hhs.gov/about/reiogns/. 3. There is a lead designated nurse planner who is involved in all aspects of Yes No the provider unit. This nurse planner is a registered nurse, possesses a minimum of a baccalaureate degree in nursing and has experience in the field of education or adult learning. 4. The provider unit is administratively and operationally responsible for Yes No coordinating all aspects of the CNE activities. 5. Three (3) implemented educational activities have been approved by an Yes No ANCC-accredited continuing education approver unit (CEAU), such as INA, within the last 12 months. First-time applicants: This does not include co- 1 Revised 11/09 provided activities.

(FOR INA USE ONLY)

Acct #:

Status: (type an X in the appropriate white area below) First time applicant for approved provider unit status Currently approved provider unit

Type of organization: (type an X in the appropriate white area below) Single agency, facility or hospital Hospital Group (i.e., two or more independent facilities or hospitals such as Advocate or Adventist)

Organization Information Name of Organization:

Name of Primary Contact Person: This is the individual with whom INA will correspond by phone and e-mail regarding the provider unit. He/she must be familiar with the INA criteria and the work of the approved provider unit. Day phone#: Ext.: Evening phone #: Fax#: Email: Contact Address: Name of Lead Nurse Planner:

2 Revised 11/09 Payment (This must accompany the application) Check #:

(payable to the Illinois Nurses Association)

American MasterCa Visa Express rd Account Expiration Number: Date: Signature:

Commitment to Maintain Records (The statement below must be signed before mailing the application)

(Name of Organization) agrees to maintain records in accordance with the INA criteria.

(Signature of the lead nurse planner) Date

Previous Denial or Revocation First time applicants: Has provider unit approval been denied or revoked by another ANCC accredited approver unit in the past? (Please visit the Website of the ANCC Accreditation Program to view the list of ANCC approvers) If yes, identify the approver unit and describe the circumstances of the denial or revocation.

Definition of Types of Provider Units 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 (CNE) 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 that 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.

3 Revised 11/09 1 The 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.

Type of Provider Unit

The provider unit is: (Type an X in the appropriate white area below) Note: Please keep this is in mind when completing the application. Single-focused (free-standing organization/entire organization is devoted to continuing nursing education) Multi-focused (part of a larger organization, i.e., separate unit, committee, department or division responsible for CNE within a complex, multi-focused organization)

I. Mission Statement (Beliefs and Goals) Criterion The 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 organizations supported by the administrative structure.

Key Elements:

1. Mission Statement (Beliefs and Goals) Beliefs and goals (often referred to as mission statement) of the provider unit are relevant and appropriate to prospective learners. a. Features of the Provider Unit a1. The geographic range and size of the provider unit is: (Check or “x” all that apply) Our facility Our city Our county Our state Our region (List the states below in the white field). Please review the DHHS regional map at: www.hhs.gov/about/reiogns/ .

a2. The target audience of the provider unit includes: (Check or “x” all that apply) Registered Nurses (RNs) Advanced Practice RNs Licensed Practice Nurses Multidisciplinary participants

4 Revised 11/09 Other. Please describe. a3. The usual content areas of the provider unit are: (Check or “x” all that apply and provide a description in the white field below.) Clinical topics: please describe.

Nonclinical topics: please describe.

Other. Please describe. a4. The types of educational activities that are typically offered include: (Check or “x” all that apply) Live or face-to-face/real-time learning (conferences, workshops, webinars, etc.) Independent studies

b. If the provider unit is part of a larger organization (e.g., functions within a department, division or committee, describe the relationship of these scope dimensions to the larger organization. Please skip this and proceed to the next question if a free standing organization which only provides continuing education. If the answer is located on an attached document, see page #: c. List the mission statement (i.e., beliefs and goals) of the provider unit. If the answer is located on an attached document, see page #:

d. If the provider unit is part of a larger organization (e.g., functions within a department, division or committee), describe how the mission statement (beliefs and goals) of the provider unit link with the goals, mission and functions of the larger organization. Please skip this and proceed to the next question if a free standing organization which only provides continuing education. If the answer is located on an attached document, see page #:

e. The outcomes the provider unit plans to achieve are: (Check or “x” all that 5 Revised 11/09 apply) Learner satisfaction Change in participants’ knowledge Change in participants’ practice Change in patient outcomes Other: Please Describe. f. The achievement of these outcomes will be measured by: (Check or “x” all that apply) Learner satisfaction surveys Testing Return demonstrations Follow-up surveys of previous participants Other: Please Describe.

2. Scope and Administrative Support Organizational structures and lines of authority support the operations of the provider unit. a. Submit an organizational chart, flow sheet or similar kind of image that depicts the organizational structure of the provider unit. If the provider unit is part of a larger organization this should be a depiction of the department, division or committee that identifies the provider unit personnel and the lines of authority. Note: If this is a chart depicting the larger/parent organization, highlight the location of the provider unit and its personnel. See page #:

b. Provide the name and credentials of the individual in each position identified on the organizational chart of the provider unit. It is preferred that the names and credentials are listed on the chart; however, it is acceptable if they are listed in the assigned white field below. If the answer is located on an attached document, see page #:

c. If the provider unit is part of a larger organization (e.g., functions within a department, division or committee,) submit an additional depiction that identifies the provider unit’s lines of authority and structural location within the larger/parent organization. Tip: Where does the provider unit fit within the larger organization and

6 Revised 11/09 to whom does it report administratively? See page #:

II. Unit Operations Criterion The 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 necessary to support the provider unit’s full range of functions.

Key Elements:

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

Human Resources: *Designated Nurse Planner(s) and Key Personnel (*Please refer to the data regarding designated nurse planners and changes to the Provider Unit in the Administrative Approved Provider Criteria Manual. Reminder: INA must be notified in writing when Nurse Planners change during the three-year period of approval. The New Nurse Planner form is available from the INA Approver Unit upon request.) a. The designated nurse planner(s), i.e., staff, volunteer and/or consultant, of the provider unit is/are as follows: (Add additional boxes as necessary) Name, Credentials and Present Position/ Title of Lead Designated Nurse Planner: At least one BSN or higher RN carries out the role of the Lead Nurse Planner and is overall responsible for assessing needs, planning and implementing and evaluating CNE activities. Name, Credentials and Present Position/ Title of other Designated Nurse Planner:

Name, Credentials and Present Position/ Title of other Designated Nurse Planner:

b. Approved Provider Application First Time/Renewal of Status and Nurse Planner Update Biographical Data form(s) for the designated nurse planner(s) is/are attached. The completed 7 Revised 11/09 information on this form must demonstrate a) the baccalaureate or higher degree in nursing and b) education or experience in the field of education or adult learning of the nurse planner(s). Note: This specific version of the INA form must be used. Curriculum vitae must not be submitted in lieu of Biographical Data forms as completion of the one-paged document is sufficient and facilitates the INA CEAU’s Peer Review Process. See page #: c. Job or position description(s) for designated the nurse planner(s) is/are attached. Note: The document(s) must identify the appropriate qualifications and job functions relative to continuing nursing education that are consistent with INA/ANCC criteria. If a job description that lists many other responsibilities is being used, highlight the areas that pertain to the CNE provider unit. See page #: d. I, the Lead Nurse Planner, affirm that all continuing nursing education standards, operational requirements and INA/ANCC criteria will be met and maintained throughout the period of approval as a provider unit. (The Lead Nurse Planner must initial or sign in the white field below)

e. If the provider unit utilizes more than one Nurse Planner, the Lead Nurse Planner ensures that they are appropriately prepared, oriented and trained to meet the INA/ANCC requirements for that role and that they all use the same approach and policies established by the provider unit through the following means: (Check or “x” all that apply of the five items that appear below) Orientation/meeting when new information is released (required) Read and share a copy of the current approved provider Criteria Manuals (required) Read and share (if applicable) provider unit newsletter when it is issued Update all internal documents as appropriate Conducting regular internal workshops Doing inter-rater reliability analyses Other. Please describe. f. Key personnel, if any, (i.e., nursing and non-nursing staff other than the officially designated RNs identified above in Unit Operations section 1a) that are involved on a regular basis with the functions of the provider unit is/are as follows: (Add additional boxes as necessary.) Note: Please type non applicable (N/A) in the first box below if there are no 8 Revised 11/09 personnel other than the designated nurse planners assigned to the provider unit.

Name and Role:

Name and Role: g. Approved Provider Application First Time/Renewal of Status and Nurse Planner Update Biographical Data form(s) for the key personnel identified above is/are attached. See page #: h. Job or position descriptions for the key personnel identified above are attached. Note: The document(s) must identify the job functions relative to the provider unit. If a job description that lists many other responsibilities is being used, highlight the areas that pertain to the CNE provider unit. See page #: i. Material resources that support the functions of the provider unit include: (Check or “x” all that apply) Computer and other technology support Adequate office space Conference/meeting room Other. Please describe. j. Sources of financial support for the provider unit include: (Check or “x” all that apply) Registration fees from learners Internal department funding Funding from larger organization Sponsorship (e.g., commercial support) Other. Please describe. k. Financial support for the provider unit will be sustained throughout the period of approval by: (Check or “x” all that apply) Continuation of above source(s) of funding Other. Please describe.

9 Revised 11/09 l. Commercial support Does the organization receive commercial support from entities that produce, market, sell or redistribute products that are used in patient care? (Check or “x” all that apply) No Proceed to section Unit Operations, Key Element 2 below. Yes Answer the following questions in sections L1 and L2 L1. The amount of commercial support that has been received during the current period of approval is approximately: (Type the answer in the white field to the right.) L2. The frequency with which commercial support has been received is: (Check or “x” all that apply) Less than 10% of the CNE activities 10 – 25% of the CNE activities 26 – 50% of the CNE activities 51 – 75% of the CNE activities 76 – 100% of the CNE activities

2. Operational Procedures The provider unit has a clearly defined process for assuring that INA/ANCC criteria are used to plan and implement continuing nursing education. a. Describe the provider unit’s process for the following, including the title and role of the personnel involved with each step:  Assessment of the needs of the learners  Planning the activities Tip: This must be a description of the process for the actual planning/development of educational activities. See the articles entitled, “The Role of a Provider Unit and “Basic Operational Procedures for Educational Activities of a Provider Unit” in the Unit Operations section of the Administrative Approved Provider Criteria Manual.  Implementation of the activities, Tip: This must be a description of what happens at the event after the planning/ development stage of the process. Note: This information may be submitted in the form of a flow chart, narrative (e.g., policies and procedures) or any method that clearly presents the process that is used by the provider unit. If the answer is located on an attached document, see page #:

10 Revised 11/09 b. Describe the following components of the record keeping process:  Type of storage system  Security  Confidentiality  Retrieval of records  Period of storage If the answer is located on an attached document, see page #:

3. Attestation for Business Practices As an agent, employee or officer, of the organization, I attest that the Provider Unit complies with all applicable local, regional, state and national laws and regulations. I further attest that the Provider Unit operates the business and management policies and procedures of its continuing nursing education program (as they relate to human resources, financial affairs and legal obligations) to ensure that its obligations and commitments are met in an ethical manner. (The initials or signature of the Lead Nurse Planner or designee of the organization must be placed in the white box that appears below.)

III. Provider Unit Evaluation Criterion: The 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.

Key Elements:

1. Provider Unit Evaluation Process The provider unit must have a mechanism (e.g. a plan) in place to evaluate the effectiveness of its overall continuing nursing education program. Describe a) what is evaluated, b) when evaluation occurs, c) who participates, d) findings (results) of the most recent evaluation, including what needed change and e) the date of the most recent evaluation. The three items listed below should be included in “what is evaluated”.  Achievement of goals  Implementation of operational procedures and human, material and financial resources  Educational activities

11 Revised 11/09 Note: This must be about more than the assessment of educational activities. The entire business unit must be assessed. Reminder: The attached sample format for an evaluation plan may be used.

First time applicants Describe the evaluation plan, addressing the criteria listed above, that will be used during the three-year period of approval. If the answer is located on an attached document, see page #:

2. Provider Unit Evaluation Participants The Lead Nurse Planner will participate in the unit evaluation. The participants of the provider unit evaluation are:(Check or “x” all that apply) Lead Nurse Planner (required) Other Nurse Planners Other organizational representatives Learners Presenters/content specialists Other: Please Describe.

3. Provider Unit Evaluation Results Evaluation data are used to confirm expand or change the operations of the provider unit. Describe, specifically, two or three examples of how the findings of the overall evaluation process described in Provider Unit Evaluation section 1 above have been used to confirm, expand and improve operations of the provider unit. Tip: In other words, what changes have been made based on these findings? Note: This section must be completed by both first time and renewal of status applicants. If the answer is located on an attached document, see page #:

12 Revised 11/09 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. 4a. The provider unit’s goals for improvement over the past three years of approval as a provider (or last 12 months for first time applicants) are: (Check or “x” all that apply) Regular meetings of provider unit staff Performance improvement/process improvement initiatives Changes in educational activities Changes in provider unit personnel and/or roles Other. Please describe. 4b. Describe the changes and progress that have been made toward meeting those goals. If the answer is located on an attached document, see page #:

4c. Describe the new goals that have been identified. If the answer is located on an attached document, see page #:

4d. Describe the plans for implementing the new goals. If the answer is located on an attached document, see page #:

 Requirements: Please refer to the requirements in the educational design section (criterion 4) of the Administrative Approved Provider Criteria Manual.  Reminder: A list of all the educational activities offered during the most recent period of approval must be included in the application. The list must provide the title, date(s), contact

13 Revised 11/09 hours and the number of nurses that attended each activity. Note: This does not apply to first time applicants.  First Time Applicants: Please contact the INA Continuing Education Approver Unit for assistance as different forms are designated for the educational activities of provider units.

14 Revised 11/09