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Documenting Evidence of Effectiveness

in Your Approved Provider

Fall 2014 Webinar Series

Structural Capacity Providing the Evidence

Session 2

Ohio Nurses Association and

Montana Nurses Association

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Series Planners & Faculty

Pam Dickerson, PhD, RN-BC, FAAN CE Director, Montana Nurses Association

Terry Pope, MS, RN President, Nursing Institute for Continuing Education

Zandra Ohri, MA, MS, RN CE Director, Ohio Nurses Association

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Session 2Structural Capacity

Providing the Evidence

Objective: Identify evidence to validate the structural capacity of your approved provider unit to implement its work.

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Disclaimer / Disclosures• Requirements for successful completion:

Attendance at event & turning in an evaluation form.

• Conflict of interest: Planners & faculty have declared no COI

• The Ohio Nurses Association (OBN-001-91) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

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Accreditation Conceptual Framework

Nursing Professional

Development: Continuing

Nursing Education

Structural Capacity

• Commitment• Accountability• Leadership• Resources

Structural Capacity

• Commitment• Accountability• Leadership• Resources

Educational Design Process• Assessment of Learning Needs • Planning and Faculty• Design Principles • Achievement of Objectives

Educational Design Process• Assessment of Learning Needs • Planning and Faculty• Design Principles • Achievement of Objectives

Quality Outcomes• Evaluation Process• Evaluation Participation• Goals for Improvement• Value/Benefit to Nursing Professional Development

Quality Outcomes• Evaluation Process• Evaluation Participation• Goals for Improvement• Value/Benefit to Nursing Professional Development

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SC 1: Commitment• The Primary Nurse Planner’s commitment to

learner needs, including how Approved Provider Unit processes are revised based on data.

• Key points:• Key words – PNP, commitment, needs, process

revisions• Focus on primary nurse planner – not

everyone in provider unit• Focus on commitment to learner needs in

general – not for a specific activity• How is this commitment evident in provider

unit processes?

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SC 1: Description

•Our provider unit cares about and is committed to our learners. We do an annual needs assessment and develop our activities based on what learners want. We review our processes once a year and make modifications as needed.

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What Do You Think?

• Is this a strong description of the primary nurse planner’s commitment to learner needs?

• Yes•No

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What elements are not clear?

•Where is the primary nurse planner?

•What does an annual needs assessment have to do with the commitment of the primary nurse planner?

•What processes are reviewed annually?

•What modifications are made based on learner needs?

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SC 2: Commitment• How the organization’s leadership is

committed to supporting the goals of the Approved Provider Unit• Key points:• Key words – leadership, committed, goals, APU• Focus is on leadership of the organization• If goals were not clear in OO4, it will be hard to

explain how leadership supports them!• What evidence shows that there is “commitment”

from leaders?

• Note: If you are a single-focused organization, this criterion is not applicable.

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SC 2 - Example• The leadership of our organization (CEO, CNO, and Vice

President of Human Services) are 100% committed to the success of our provider unit. In fact, one of the components of our mission statement is “fostering the professional development of our team”. As an example, the primary nurse planner met with executive leadership on August 1 to discuss emerging evidence supporting interprofessional education. As a result of deliberations around this issue, administration is moving to consolidate the CNE, CME, and other educational offices into one “Professional Development” department that will be co-led by the primary nurse planner and the director of medical education. Risk management participated in this discussion and enthusiastically described better patient outcomes that could be attained by this change.

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What Do You Think?

• Is this a strong example to support the organizational leadership’s commitment to the provider unit?

• Yes•No

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Considerations•Provides information about who the key

leadership “players” are

•Demonstrates leadership’s attentiveness to information provided by the primary nurse planner

•Provides specific evidence – date of meeting, participants, action plan

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SC 3: Accountability• How the Primary Nurse Planner ensures that all Nurse

Planner(s) and key personnel in the approved provider unit adhere to the ANCC Accreditation Criteria

• Key Points:• Key words – PNP, all planners & key personnel, adhere• Focus is back to primary nurse planner• Addresses relationship between primary nurse planner

and others in provider unit• What does “adherence” mean?

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SC 3: Things To Think About•Orientation

• Education about changes

•Monitoring

• Evaluating

• Resources provided

•What to do if people have questions or concerns

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SC 4: Accountability

• How the primary nurse planner is accountable for resolving issues related to providing CNE

• Key points:• Key words – Primary Nurse Planner, accountable,

issues• Why is the PNP the accountable party?• How does the PNP resolve issues r/t providing

CNE?

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Considerations• Think about the common questions or situations

that may occur day to day in your provider unit.

• Types of issues: resource issues, speaker concerns, quality concerns

• What is a situation that has arisen that you had to deal with? What did you do?

• How do you as the PNP handle problems that arise within your provider unit?

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SC4: Description

• The PNP is accountable for revision of CNE activities based on assessment of program outcomes, learner needs, societal trends, and available resources. The PNP is accountable for allocating available funds as needed based on current issues/concerns, survey outcomes, and previous comments from learners

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What Do You Think?

• Is this a strong description statement that supports the PNP’s accountability for resolving issues related to the provider unit?

• Yes•No

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SC4: Description

• The PNP is given the authority by the organization to be the one who is accountable and responsible for resolving all issues r/t to the provision of CNE activities. All members of the PU are aware of the PNP’s responsibility for resolving any issues that they cannot within their planning committees. The type of issue presented determines the response and actions taken by the PNP. If the issue is lack of funding for an activity, the PNP will work with the dept director to see if funds from other areas might be accessed. If the issue is a NP not following criteria, a personal meeting would be arranged to discuss the issue and provide additional education as necessary.

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What Do You Think?

• Is this a strong description statement that supports the PNP’s accountability for resolving issues related to the provider unit?

• Yes•No

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SC 5: Leadership• How the primary nurse planner ensures that

every nurse planner maintains accreditation standards and guides the planning committee or team for an individual activity.

• Key Points:• Key Words - Primary Nurse Planner, ensures,

maintains, guides• What does ‘ensures” mean in this sentence?• What does ‘maintains” mean in this sentence?

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Considerations•As the PNP, how do you role model

maintenance of standards?

•How do you make your expectations clear to other nurse planners?

•What processes may be in place to support nurse planners as they guide planning committees?

•How do you help NP’s problem solve when issues arise?

•How do you keep your NP’s apprised of changes in the CNE criteria?

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SC5 Description• The PNP attends the annual Provider Update and

participates in webinars to remain current on the CNE criteria and to be a role model for the provider unit. The information learned is shared in both verbal and written formats with the NP’s so they remain up to date and can appropriately guide their planning committees and maintain all accreditation standards. Every update received from ONA regarding CNE criteria changes is reviewed with each NP at monthly staff meetings. To further ensure that criteria is being followed, each learning activity is reviewed by the PNP to ensure that accreditation standards were maintained. Feedback is given to each individual NP following a review of the learning activity’s documentation by the PNP

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What Do You Think?• Is this a strong description statement

that supports the primary nurse planner leadership in ensuring that every nurse planner maintains accreditation standards and guides the planning committee or team for an individual activity?

• Yes•No

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SC6: Leadership

•How the Nurse Peer Review Leader (NPRL) of the Approver Unit is used as a resource for the PNP and/or other NP’s in the provider unit

•Key Points:• Key Words – NPRL, resource, nurse

planners

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Considerations•Who is your NPRL at ONA OR AT MNA?

•How do you interact with the NPRL?

•Under what circumstances would you call or email the NPRL?

•What resources has the NPRL provided to you that enhanced your functioning as a PNP?

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SC7: Resources•How the PNP advocates for resources to

ensure that the provider unit achieves its goals related to quality outcomes

•Key Points:• Key words – PNP, advocates, resources,

and quality outcomes•What does ‘advocates for” mean?

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Considerations

• How do you as PNP advocate for resources for your provider unit?

• What do you do when you need additional resources to deliver a CNE activity?

• Does your provider unit have its own budget? Does the PNP have input to the budget process?

• What strategies do you use, and with whom, to advocate for the provider unit?

• What has the provider unit identified as their quality outcome measures?

• How does the provider unit use these resources to achieve its goals r/t quality outcome measures (004)?

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SC7 Description• Our PNP advocates for resources to ensure the provider

unit meets its quality outcome goals by working with the dept director on an annual basis to assure that the provider unit is supported within the Education Dept’s budget. Once the budget has been approved, the PNP completes a requisition for any additional resources that may be needed to deliver a CNE program and to meet the provider unit’s goals. This requisition includes a narrative that includes the benefits, costs, why the funds are needed, and how these funds will allow the provider unit to meet its quality outcome measures. The PNP will also occasionally advocate for additional human resource assistance to help manage large, on site, CNE events.

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What Do You Think?

• Is this a strong description statement that identifies how the primary nurse planner advocates for resources to ensure the provider unit achieves its goals r/t quality outcomes?

• Yes•No

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SC7 Example• The PNP works with the NP’s to develop

a unit budget every year. The budget and the provider unit’s current quality outcome measures are reviewed with the dept. director. On an annual basis the PNP reviews the staffing needs for the provider unit and recruits/trains new NPs as needed to meet the quality outcome goals of the provider unit.

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What Do You Think?

• Is this a strong example statement that shows how the primary nurse planner advocates for resources to ensure the provider unit achieves its goals r/t quality outcomes?

• Yes•No

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In Summary

• The structural capacity is intended to demonstrate that the commitment, accountability, leadership, and resources to provide the minimum necessary support required for the operation of the approved provider unit, are available from both the organization and the PNP.

• Application reviewers are looking to see that the above elements are described in full within the Structural Capacity section.

• The next session of the application focuses on the Educational Design Process (EDP) used in assessing, planning, implementing, and evaluating the provider unit’s individual CNE activities.

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Pam Dickerson, PhD, RN-BC, FAANDirector, Continuing EducationMontana Nurses AssociationTelephone: 406-465-9126pam@mtnurses.org

Zandra Ohri, MA, MS, RNDirector, Continuing EducationOhio Nurses AssociationTelephone: 614-448-1027zohri@ohnurses.org

For Further Information