2022 Approved Provider ManualUpdated 2021Office of Professional DevelopmentKelly Stephens, MSN, RNAccredited Approver Program DirectorDirector of Professional DevelopmentJessica Tressler DNP, MSN, RNContinuing Education SpecialistMarian ShenbergerProfessional Development Assistant3605 Vartan Way – Suite 204Harrisburg, PA [email protected]

Introduction. 4Section I: The Application Process . 5Step 1: Approved Provider Eligibility. 5Approved Provider Eligibility Form . 6Step 2: The Application Process . 7Approved Provider Application/Required Documentation . 7Organizational Overview (OO) . 7Structural Capacity (SC) . 7Educational Design Process (EDP) . 9Structural Capacity (SC) . 8Educational Design Process (EDP) . Error! Bookmark not defined.Quality Outcomes (QO) . 10Submitting Your Application . 11Application Review Process . 12Approval Decision Process . 13Fees . 23Section II: EDP . 13Activity Types . 13Steps to Designing Your Activity . 14Relevant Financial Relationships . 17Mitigation of Relevant Financial Relationships . 17Commercial Support and Content Integrity . 19Section III: Approved Provider Responsibilities . 21Approved Provider Responsibilities: . 21Recordkeeping. 212

Glossary (Defined by ANCC) . 26References: . 293

IntroductionThis manual provides instructions on how to become an Approved Provider of NursingContinuing Professional Development (NCPD) through the Pennsylvania State NursesAssociation.1. Information in this document is obtained from the 2015 Primary AccreditationApprover Application Manual, published by the American Nurses Credentialing Centerand also reflects revisions of American Nurses Credentialing Center (ANCC)Accreditation in NCPD criteria and requirements for providers of NCPD.2. The Approved Provider Unit (APU) must have the authority to assess, plan,implement, and evaluate NCPD activities and operate APUs using ANCCAccreditation Program criteria.3. The APU is responsible to assess, plan, implement and evaluate NCPD activities.They are NOT authorized to approve activities developed by others withoutinvolvement of an Accredited Approver Unit.4. Commercial entities cannot be providers or joint providers of NCPD activities.5. Employees of commercial entities cannot be planners or presenters for activities inwhich the content is related to the products or services of the company.Approval as a provider of NCPD is recognition of a Provider Unit’s (PU) capacity to demonstrateexcellence in providing evidence-based content based on ANCC criteria. Your organization,upon achieving approval as an APU, is authorized to assess, plan, implement, and evaluateNCPD activities according to the criteria and award contact hours for those activities. The APUmay offer an unlimited number of educational activities during the three-year period ofapproval. Provider Units do not have the authority to approve their own or anyone else’sactivities.The terms “approved,” “application,” or “applicant” should never be used in connection withany NCPD activity the APU plans and presents.NCPD activities provided by the APU must be related to professional development of the nurse.Activity content should enable the learner to acquire or improve knowledge, skills and/orpractice beyond basic knowledge and enhance professional development or performance as anurse.NCPD activities include but are not limited to courses, seminars, workshops, lecture series,distance learning activities (audio/video conferences), web-based enduring materials, journalclubs, learner directed independent study activities or point of care learning. Knowledge anduse of adult learning principles should be reflected in all aspects of the educational design.4

Section I: The Application ProcessStep 1: Approved Provider EligibilityA Provider Unit is defined structurally and operationally as the members of an organization whosupport the delivery of NCPD activities. The Provider Unit may be a single focused organizationdevoted to offering NCPD activities or a separately identified unit within a larger organization.The Provider Unit may be placed within the education/professional development departmentof a hospital or school of nursing.The applicant applying for approval is the Provider Unit, not the organization. Provider Unitsassess learners’ needs and plan, implement, and evaluate NCPD activities according to thePennsylvania State Nurses Association guidelines, which are based on ANCC accreditationcriteria.Provider Units are responsible for developing individual education activities and awardingcontact hours to nurses for use in fulfilling their own goals for professional development,licensure, and certification. Each NCPD activity is led by a Nurse Planner (NP) in collaborationwith at least one other planner. Contact hours may not be awarded for activities developedwithout the direct involvement of a NP. PUs may jointly provide activities, but they may notapprove activities.To be eligible to apply for Approved Provider status, an organization must: Be one of the following:o ANA Organizational Affiliateo Constituent and State Nurses Association (C/SNA) of the American NursesAssociation (ANA)o College or Universityo Healthcare Facilityo Health-Related Organizationo Multidisciplinary Educational Groupo Professional Nursing Education Groupo Specialty Nursing OrganizationBe operational for a minimum of six months prior to applicationBe administratively and operationally responsible for coordinating the entire process ofassessing, planning, implementing, and evaluating NCPD activitiesNot be a commercial interest entity (an entity that produces, markets, resells, ordistributes healthcare goods or services consumed by or used on patients or an entitythat is owned or controlled by an entity that produces, markets, resells, or distributeshealthcare goods or services consumed by or used on patients).Identify one NP who will act as the Primary Nurse Planner (PNP) and serve as the liaison5

between the Pennsylvania State Nurses Association and the APU.The PNP must:o Hold a current, unrestricted license as an RN and a baccalaureate degree orhigher in nursingo Have authority within the organization to ensure compliance with ANCCaccreditation criteriao Be accountable to the Accredited Approver Program Director (AAPD) at PSNA forall APU activitieso Ensure that all NPs in the APU hold current valid licenses as RNs with abaccalaureate degree or higher in nursingo Be responsible to orient, educate, and monitor all APU NPs ensure that eachNCPD activity has a qualified NP who is an active participant in the planning,implementing, and evaluation processThe target audience for at least 51% of the APU’s educational activities must be withinor contiguous to the unit’s geographic region -offices/ for map).Compliance is required with all applicable federal, state, and local laws and regulationsthat affect the organization’s ability to meet PSNA’s guidelines.Disclose previous denials, suspensions, and/or revocations received from other ANCCAccredited Approver Units and/or other accrediting /approving organizations.Initial applicants must contact the NPRL at [email protected] and have completed theprocess of assessment, planning, implementation, and evaluation for at least threeseparate individual educational activities within the last 12 months that have beenapproved by the Pennsylvania State Nurses Association or another ANCC AccreditedApprover that:o Demonstrate active involvement of a NPo Shows adherence to current ANCC accreditation criteriao Were each a minimum of one hour (60 minutes) in length were not jointlyprovidedApproved Provider Eligibility FormThe Approved Provider Eligibility Form is utilized to verify that organizations applying tobecome an Approved Provider of NCPD are eligible under ANCC eligibility requirements.Organizations deemed ineligible will not be considered for approval by the Pennsylvania StateNurses Association.This form requests information on the applicant’s demographic data and the type oforganization. All questions must be answered to determine eligibility.6

Retrieve the Approved Provider Eligibility Form at the form as identified and submit to [email protected] will receive notice when the form has been reviewed and you are eligible toproceed with the Approval application process. If there are any questions about youreligibility, you may be asked to submit further information to be reviewed.Once eligibility has been confirmed, make an appointment for a phone consultationwith the NPRL to review the application process and be sure your questions areanswered.Step 2: The Application ProcessApproved Provider Application/Required DocumentationStep 1: Download the Approved Provider Application from 2: Read the entire application to be sure you understand the requirements. NOTE: It is theresponsibility of the PNP to complete each section with assistance of NPs and otherstakeholders.The following sections are required written documentation for Approved Provider applicants: Overview (OO)Approved Provider Criterion 1: Structural Capacity (SC)Approved Provider Criterion 2: Educational Design Process (EDP)Approved Provider Criterion 3: Quality Outcomes (QO)Approved Provider Activity Submission RequirementsOrganizational Overview (OO)The OO component of the application process provides a context for understanding theorganization of the APU. The applicant must submit the following documents and/or narratives:Structural Capacity (SC)OO1a. DemographicsSubmit an executive statement summary of the Provider unit. This should include the functionsof the PU, the mission, how the mission relates specifically to NCPD activities and itsstakeholders, how the overall organization supports the PU and the impact PU has on theorganization and/or its learners. This section has a 1,000-word limit.OO1b. Letter of SupportSubmit a written letter of support from a member of executive leadership (executive director,CNO, VP, etc.) stating how the organization supports the Approved Provider Unit throughsufficient human, material and financial resources, including the relationship of the Approved7

Provider Unit with the larger Organization.OO2a. Lines of Authority and Administrative SupportSubmit a list of the names and credentials of the PNP and NPs (if any) in the Provider Unit.OO2b. Role DescriptionsSubmit the PNP and NP role descriptions as outlined in the PSNA Approved Provider Manual,including qualifications and responsibilities.Structural Capacity (SC)The capacity of an APU is demonstrated by commitment, identification, and responsiveness tolearner needs. Continual engagement in improving educational outcomes, accountability, andleadership. Applicants should write narrative statements that address each of the sections toshow how SC is operationalized in the PU. Each section requires a description of the processand a specific example.Commitment: The PNP demonstrates commitment to ensuring RNs’ learning needs are met byevaluating PU goals in response to data that may include, but is not limited to, aggregateindividual educational activity evaluation results, stakeholder feedback (staff, volunteers), andlearner/customer feedback.Describe and, using an example, demonstrate the following:SC 1. The PNP’s commitment to learner needs, including how APU processes are revised basedon aggregate data, which may include but are not limited to individual educational activityevaluation results, stakeholder feedback (staff, volunteers), and learner/customer feedbackAccountability: The PNP is accountable for ensuring that all NPs in the PU adhere to the ANCCaccreditation criteria.Describe and, using an example, demonstrate the following:SC 2. How the PNP ensures that all NP(s) are appropriately oriented/trained to implement andadhere to the ANCC accreditation criteriaLeadership: The PNP demonstrates leadership of the PU through direction and guidance givento individuals involved in the process of assessing, planning, implementing, and evaluatingNCPD activities in adherence to ANCC accreditation criteriaDescribe and, using an example, demonstrate the following:SC 3. How the PNP and/or NP provides direction and guidance to individuals involved in8

planning, implementing, and evaluating NCPD activities in compliance with ANCC accreditationcriteria.Educational Design Process (EDP)The PU has a clearly defined process for assessing needs as the basis for planning,implementing, and evaluating NCPD activities. Activities are designed, planned, implemented,and evaluated in accordance with adult learning principles, NCPD, and ethical standards.Examples for the narrative component of the provider application (EDP 1-7) may be chosenfrom but are not limited to those contained in the submitted activity files. Evidence mustdemonstrate how the PU complies with each criterion.Assessment of Learning Needs: NCPD activities are developed in response to, and withconsideration for, the unique educational needs of the target audience.Describe and, using an example, demonstrate the following:EDP 1. The process used to identify a problem in practice or an opportunity for improvement(professional practice gap)EDP 2. How the NP identifies the underlying educational need(s) (knowledge, skills, and/orpractice) that contribute to the professional practice gap(s) (the underlying educational need(s)emphasizes addressing where the professional practice gap exists to determine appropriateintervention strategies)Planning: In planning each educational activity, the NP must know how they will identify andevaluate a change in knowledge, skills, and/or practice prior to content development. Planningfor each activity must be independent from the influence of ineligible companies.Describe and, using an example, demonstrate the following:EDP 3. How the NP identifies, and measures change in knowledge, skills, and/or practice of thetarget audience that are expected to occur as a result of participation in the educational activityEDP4. The process to determine relevant financial relationships for all who will be in control ofeducational content. Explain your process for mitigating any relevant financialrelationships and your process for disclosing these relationships.Design Principles: The EDP incorporates best available evidence and appropriate learnerengagement strategies.Describe and, using an example, demonstrate the following:9

EDP 5. How content of the educational activity is developed based on best available currentevidence (e.g., clinical guidelines, peer-reviewed journals, experts in the field) to fosterachievement of desired outcomesEDP 6. How strategies to promote learning and actively engage learners are incorporated intoeducational activitiesEvaluation: A clearly defined method that includes learner input is used to evaluate theeffectiveness of each educational activity. Results from the activity evaluation are used to guidefuture activities.Describe and, using an example, demonstrate the following:EDP 7. How summative evaluation data for an educational activity are used to analyze theoutcomes of that activity and guide future activitiesQuality Outcomes (QO)The APU must demonstrate how its structure and processes result in positive outcomes foritself and for RNs participating in its educational activities. The Provider Unit engages in anongoing evaluation process to analyze its overall effectiveness in fulfilling its goals andoperational requirements to provide quality NCPD.Provider Unit Evaluation Process: The APU must evaluate the effectiveness of its overallfunctioning as a PU.Describe and, using an example, demonstrate the following:QO 1. The process utilized for evaluating the overall effectiveness of the Provider Unit incarrying out its work as a provider of NCPDQO 2a. Identify at least one QO the Provider Unit has established and worked to achieve overthe past 12 months to improve Provider Unit operations. Identify the metrics used to measuresuccess in achieving that outcome.Examples of QOs might include, but are not limited to: Changes in format of activities in response to learner feedback Cost savings for the Provider Unit or stakeholders in response to analysis of financialdata Volume of participants Satisfaction of learners, staff, and/or volunteers in response to feedback surveys10

QO 2b. Using one of the QOs identified in QO2a, explain how the most recent evaluationprocess (QO1) resulted in the development and/or improvement of an identified outcome forPU operations, including how that outcome was measured and analyzed. Provide an example.Example:Aggregate data from feedback surveys of all attendees indicated a desire to have more onlineactivities. This led to the development of an outcome to increase the percentage of onlineactivities by 10% from one year to another. Plan was developed to determine which activitieswere most appropriate for online presentation and activities were developed. The number andquality of the activities were measured through further feedback surveys.Value/Benefit to Nursing Professional Development: The PU shall evaluate data to determinehow the PU, through the learning activities it has provided, has influenced the professionaldevelopment of its nurse learners. Nursing professional development is defined as “The lifelongprocess of active participation by nurses in learning activities that assist in developing andmaintaining their continuing competence, enhancing their professional practice, and supportachievement of their career goals” (Nursing Professional Development: Scope and Standards ofPractice, ANA, 2016).Examples of professional development outcomes include, but are not limited to: Changes in leadership skills certificationNursing care deliveryImproved patient outcomesProfessional practice behaviorsChanges in nursing practiceDescribe and, using an example, demonstrate the following:QO3a. Identify at least one QO the PU has established and worked to achieve over the pasttwelve months to improve the professional development of nurses. Identify the metrics used tomeasure success in achieving that outcome.QO3b. Using one of the outcomes identified in QO3a, explain how the most recent evaluationprocess (QO1) resulted in the development and/or improvement of an identified outcome toimprove the professional development of nurses, including how that outcome was measuredand analyzed. Provide an example.Submitting Your ApplicationAll information must be organized within the outline on the Approved Provider Applicationform, with sections clearly titled and pages numbered. Be sure to follow the outline andcomplete all sections, typing directly on the form.11

1. The following documents must be included and submitted in the following order:a. Self-Study complete with required attachments (on one form)b. Three (3) complete Individual Activity files (one pdf per activity)2. Submit the Self-Study and 3 provided activities to [email protected] Ensure that all documentation reaches the Pennsylvania State Nurses Associationbefore the deadline (three months before expiration of your current provider status ifrenewing).4. Send the application fee. Fees must be submitted prior to review and application doesnot guarantee approval.Application Review ProcessStep 1: Upon receipt of your application and required forms, a quantitative review will becompleted to determine that all elements are present in the application.NOTE: Missing documentation will be requested and must be submitted within three weeksfrom the request. Failure to submit the requested documentation will result in immediatedenial. The application will not be sent for review by the Nurse Peer Reviewer (NPR) until thisstep is complete.Step 2: The application is sent to the NPR to complete an independent qualitative review.Step 3: Once the NPR review is complete it is sent to the NPRL who conducts the finalqualitative review.Step 4: The final decision is made by the NPRL based on evidence of adherence to the criteria.Step 5: Possible outcomes are as follows:1. Approval with distinction for three years: Evidence supports exemplary work of thePU in adherence to criteria2. Approval for three years: Evidence supports the ability of the PU to adhere to criteria3. Provisional approval for up to one year: Evidence supports the need for closemonitoring of the PU to ensure adherence to criteria. If monitoring demonstratesimprovement and success in demonstrating adherence to criteria, approval will beextended for the balance of the approval period. Failure to demonstrate this during aprovisional approval will result in suspension or revocation of approval.4. Denial: Evidence demonstrates that the applicant is not in adherence to criteria andhas not recognized deficiencies or established plans to address those deficiencies. Anorganization whose application has been denied does have the right to appeal thedecision. The appeal procedure is available from the NPRL upon request. If youreceive a denial notification letter you must wait 12 months to submit a newapplication. During this time, you can apply to provide individual activities.12

Approval Decision ProcessYou will be notified in writing of the approval decision by the NPRL. If additional information isrequired details of those requirements as well as due dates will be specified.You will receive a certificate of Approved Provider status once your PU is approved for yourrecords.You will receive instructions for annual reporting as required by ANCC/Pennsylvania StateNurses Association.Section II: EDPThis section describes the process of planning, implementing, and evaluating educationalactivities according to ANCC guidelines and criteria. Applicants must ensure that allexpectations are met and the APU offers individual activities that adhere to ANCC accreditationcriteria.Activities planned must address: Professional practice gapProof of active involvement on the part of the NPUnderlying educational need (K/S/P)Identified learning outcomesLearning strategiesContent based on best and most current available evidenceMust be independent from the influence of any CIOActivity TypesProvider-Directed, Provider-Paced: The provider controls all aspects of learning in this type ofactivity. The provider determines the learning outcomes based on a professional practice gapand selects content for the learning activity based on the best evidence, chooses appropriatelearning strategies and identifies methods for collecting and analyzing evaluation data.(Examples include live activities and live Webinars.)Provider-Directed, Learner-Paced: The provider controls the content of the learning activity,including the learning outcomes based on a needs assessment and gap analysis, the content ofthe learning activity based on best evidence, chooses appropriate learning strategies, andidentifies methods for collecting and analyzing evaluation data. The learner determines thepace at which the learner engages in the learning activity. (Examples include print articles,13

online courses, e-books, and self-learning modules/independent studies.)Learner-Directed, Learner-Paced: With guidance from the NP, the learner takes initiative andidentifies his/her own learning needs, formulates learning outcomes, chooses and implementslearning strategies and evaluating learning outcomes. The learner also determines the pace atwhich they engage in the activity.Steps to Designing Your ActivityDescription of Professional Practice Gap: NCPD activities are developed in response to, andwith consideration for, the unique educational needs of the target audience. The process ofplanning begins with the identification of a practice problem or an opportunity forimprovement. The NP analyzes data to identify the professional practice gap, the differencebetween the current state, and the desired state of practice. Once a gap is identified, the NPselects individuals to assist with planning an educational activity.Planning Committee: Planning committees must have a minimum of one NP and one contentexpert to plan each educational activity. The NP must be an RN with a current unrestrictednursing license and hold a baccalaureate degree or higher in nursing. The NP is knowledgeableabout the NCPD process and is responsible for adherence to ANCC accreditation criteria. Oneplanner (content expert) needs to have appropriate subject matter expertise for theeducational activity being offered. If additional individuals, such as faculty, presenters, orauthors, will be creating or delivering content for the educational activity, planning committeemembers must identify the needed qualifications of the individuals chosen.Faculty/presenters/authors must have documented qualifications that demonstrate theireducation and/or experience in the content area they are developing or presenting. Expertise insubject matter may be evaluated based on characteristics such as education, professionalachievements and credentials, work experience, honors, awards, professional publications, orsimilar.Evidence to Validate the Professional Practice Gap: The evidence that validates a professionalpractice gap is a description of the current state of practice and how one’s practice could bebetter. Sources of supporting evidence that validate the professional practice gap and supportthe underlying educational need include, but are not limited to: Request for the educationInput from audience membersImprovement of previously presented activitiesBased on evaluations of previous educational activitiesReview of researchQuality improvementIdentifying Underlying Educational Needs: The NP and planning committee analyze the data to14

identify the root causes of the professional practice gap. This group conducts a needsassessment to determine the underlying educational needs, what the nurses do not know(knowledge deficit), do not know how to do (skill deficit), or are not able to do in practice(practice deficit). Once the educational need has been identified the NP and planningcommittee identify the target audience for the learning activity and formulate learningoutcomes.Learning Outcomes: The learning outcome is a written statement of what the learner will know(knowledge), be able to demonstrate (skills), or apply in their practice (practice) as a result ofcompleting the educational activity. Learning outcomes must be observable and measurableand address the knowledge, skills and/or practices that contribute to the professional practicegap. The learning outcomes can be evaluated over the short term or long term.Evidence-Based Resources: The NP and planning committee work in collaboration with allmembers of the planning team. This includes presenters, authors, and content experts. Contentshould be chosen based on the most current available evidence and address the educationalneed as well as the learning outcomes. Evidence to support the content of the activity can befound in: Current evidence-based practicesPeer-reviewed journalsCurrent clinical guidelinesContent expertsCurrent best practicesLearner Engagement: As part of the design process, the planning committee will developstrategies to engage the learners. This can include but is not limited to Q&A sessions (during orat

o Be responsible to orient, educate, and monitor all APU NPs ensure that each NCPD activity has a qualified NP who is an active participant in the planning, implementing, and evaluation process The target audience for at least 51% of the APU’s educational activities must be