maryland nurses association · web viewrev 3-2018 maryland nurses association accredit ed prov ider...

Maryland Nurses AssociationACCREDITED PROVIDER PLANNING TEMPLATE

For MNA Districts

MNA DistrictActivity Title

ACTIVITY TABLE OF CONTENTS

A.) PLANNING TEMPLATE

B.) COI REVIEW-FOR PLANNERS& PRESENTERS

C.) MARKETING MATERIAL

D.) AGENDA/SCHEDULE

E.) CONTACT HOUR CALCULATION SHEET

F.)EVALUATION METHOD(S)

G.) METHOD USED TO VERIFY PARTICIPATION

Option 2 Accredited Provider Planning Template for Educational Activity Oct2017


For MNA Districts

District #______________

Title of Activity: Click here to enter text.

Number of Contact hours for this activity: Click here to enter text.

Activity Location: Click here to enter a date.

Activity Type:

☐Provider-directed, provider-paced: Live (in person or webinar) Date of live activity: Click here to enter a date.

☐Provider-directed, learner-paced: Enduring material Start date of enduring material: Click here to enter a date. Expiration/end date of enduring material:

☐Blended activity Date(s) of enduring materials (e.g. pre-work): Click here to enter a date. Date of live portion of activity: Click here to enter a date.

Nurse Planner contact information for this activity. Name and credentials: Click here to enter text.Email Address: Click here to enter text.Mailing Address (to send final packet): Click here to enter text.

A. Description of the professional practice gap (e.g. change in practice, problem in practice, opportunity for improvement)

1. Describe the current state: (Identify the current knowledge skill or practice that requires improvement, review, updating or correction in the nursing profession or regarding patient outcomes)

2. Describe the desired state:


The Nurse Planner must be a registered nurse who holds a current, unencumbered nursing license (or international equivalent) AND hold a baccalaureate degree or higher in nursing (or international equivalent) AND be actively involved in planning, implementing and evaluating this continuing education activity.


For MNA Districts

(Describe the level of practice this activity is seeking to achieve or seeking to have nursing professionals work towards)

B. Educational need that underlies the professional practice gap (e.g. knowledge, skill and/or practices)☐ Knowledge ☐ Skill ☐ Practice

C. Evidence to validate the professional practice gap (check all methods/types of data that apply)

☐ Survey data from stakeholders, target audience members, subject matter experts or similar☐ Input from stakeholders such as learners, managers, or subject matter experts☐ Evidence from quality studies and/or performance improvement activities to identify

opportunities for improvement.☐ Evaluation data from previous education activities☐ Trends in literature, law and health care☐ Direct observation☐ Other—Describe:

D. Please provide a brief summary of data gathered that validates the need for this activity:(DO NOT PROVIDE A LIST OF REFERENCES) Provide a summary of the information obtained from the evidence checked above, which indicates there is a need for this activity.)

E. Description of the target audience. (You can select more than one target audience).

1. Choose an item. 2. Choose an item. 3. Choose an item.


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Sample list of verbs for used to form measureable learner outcomes

To create learner outcomes that provide specific behavioral indicators participants can achieve as a result of participating in an activity, this list identifies a sample list of verbs used to create learner outcomes that can be measured to determine the success of your activity.

NOT ACCEPTABLE in learner outcome statements: “Participants will be able to UNDERSTAND……” Understand cannot be measured. Unacceptable.

Acceptable in learner outcomes are the following verbs listed belowThe Learner will be able to……………..

Cognitive outcomes:Knowledge Comprehension Application Analysis Evaluation SynthesisDefine Translate Interpret Distinguish Appraise ComposeRepeat Restate Apply Analyze Evaluate PlanRecord Discuss Employ Differentiate Rate ProposeList Describe Use Calculate Compare DesignRecall Recognize Demonstrate Experiment Value FormulateName Explain Dramatize Test Revise ArrangeRelate Express Practice Compare Score AssembleUnderline Identify Illustrate Contrast Select Collect

Locate Operate Criticize Choose ConstructReport Schedule Diagram Assess CreateReview Shop Inspect Estimate Set upTell Sketch Debate Measure Organize

Inventory Judge ManageQuestion PrepareRelate SynthesizeSolve ComposeExamine PlanCategorize Propose

Affective Outcomes Psychomotor OutcomesAcknowledge Argues Assemble Design MendShare Debates Build Dismantle MixShows Declares Calibrate Fasten SketchActs Defends with Change Follow StartWillingly Responds Clean Grip StirListens to Shows interest Compose Identify UsePractices Acts consistently Connect Locate WeighAccepts Is accountable Construct Make WrapAcclaims Stands for Correct ManipulateAgrees Help CreateCooperates Respects


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F. Desired learning outcome(s) : Using measureable verbs, (see sample list on previous page) identify what knowledge skills or practice will participants will be able to demonstrate after participating in this activity.

G. Outcome Measure(s): What methods of data collection or what data collection tool(s) will be

used to determine if participants have accomplished the outcomes stated for this activity (Examples: Evaluation, Post-Test, Quiz, etc). Submit a copy

H. Criteria for Awarding Contact Hours (Check all that apply)☐Attendance for a specified period of time (e.g., 100% of activity, or miss no more than 10 minutes of activity)☐Credit awarded commensurate with participation☐ Attendance at 1 or more sessions ☐ Completion/submission of evaluation form ☐ Successful completion of a post-test (e.g., attendee must score % or higher)☐ Successful completion of a return demonstration ☐ Other - Describe:

I. Description of evaluation method: Describe how the evaluation method determines that participants have accomplished/met the outcomes stated for this activity. (Your evaluation must show evidence that the gap identified in “A1” has improved)

J. Evaluation Options:

Short-term evaluation options:☐ Intent to change practice☐ Active participation in learning activity☐ Post-test☐ Return demonstration☐ Case study analysis☐ Role-play☐ Other – Describe:

Long-term evaluation options:☐ Self-reported change in practice☐ Change in quality outcome measure☐ Return on Investment (ROI)☐ Observation of performance☐ Other – Describe:

Individuals in a Position to Control Content


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Complete the table below for each person in a position to control content of the educational activity and include name, credentials, educational degree(s), role on the planning committee, and expertise that substantiates their role. Must have 2 RN’s on Planning Committee. There must be one Nurse Planner with a BSN or higher and one other planner to plan each educational activity. The Nurse Planner is knowledgeable of the CNE process and is responsible for adherence to the ANCC criteria. One planner needs to have appropriate subject matter expertise for the educational activity being offered (Content Expert).

Complete the table below for each person in a position to control activity contentThe individuals who fill the roles of Nurse Planner and Content Expert must be identified.

LIST PLANNERS AND PRESENTERSA B C D E

Name and credentials Role in activity

Planning committee member? (Yes/No)

Conflict of interest?(Yes/No)

Related experience that deems individual qualified (for the activity role identified in Column B)

Example: Jane Smith, RN-MSN

Nurse Planner

Yes No MSN, trained & fully knowledgeable of ANCC’s criteria, remain up-to-date with ANCC criteria with current ANCC manuals, 12+ years planning CNE activities

Example: Sue Brown, RN, NCLEX-RN

Content Expert

Yes No NCLEX-RN, 6 years in LTC Nursing working with the elderly with debilitating injuries and illnesses. LTCNA Member

Example: John Doe, DNP Presenter

No No LTC Nursing Director at County Clinic of Essex for 15 years planning, coordinating and managing care services


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District #____PARTICIPANT EVALUATION

Activity Title:

Presentation Date:

Please rate your ability to achieve the stated outcomes following your participation in this activity

High to Low

I. Achievement of Stated Activity Outcomes 5 4 3 2 1

Outcome 1:

Outcome 2:

Outcome 3:

II. Presenter Effectiveness (Rate presenter’s knowledge of topic, clarity of presentation and willingness to answer questions)

Presenter Name & Credentials

Was the activity free of commercial bias? Yes No

Was an announcement was made regarding activity disclosures? Yes No

How will this activity contribute to your professional development?

Additional Comments:

A completed evaluation is required by MNA to receive a certificate of completion.

Thank you!The Maryland Nurses Association is accredited as a provider of continuing nursing education by the American Nurses

Credentialing Center’s Commission on Accreditation.


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Activity Title:

Activity Presentation Date(s):

District #____ACTIVITY DISCLOSURES

Participants must review this information prior to start of educational activity

1. ANCC Accreditation Statement The Maryland Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

2. Criteria for Successful Completion In order to successfully complete this activity and receive full contact-hour credit for this CNE activity, you must:

3. Conflicts of Interest Was a conflict of interest or potential bias found for any activity planners and/or presenters of this educational activity? No Yes If yes, identify the individuals and the conflict of interest:

4. Commercial Support Is this activity supported by an unrestricted or in-kind donation from a commercial interest?No Yes If yes, list the commercial interest organization(s) and the type of support received:

5. Joint Provider Is this activity is activity jointly-provided?No Yes If yes, identify the joint providing organization(s):

6. Date Contact Hours for this activity will expire (for enduring activities only) Is this an enduring/learner-paced activity? No Yes If yes, provide the expiration date/ last date learners will be able to access this activity to receive contact hours:


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Maryland Nurses Association6 Park Center Court, Suite 212

Owings Mills, MD 21117

Certificate of Successful Completion

AWARDED TO: First Middle Last

ACTIVITY TITLE:

ACTIVITY CODE: CONTACT HOUR(S)

PRESENTATION DATE(s)

PRESENTATION LOCATION:

Kathy Martin DNP, RN, CNE

Authorized Signature Signature of Nurse Attendee

The Maryland Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.


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EDUCATIONAL PLANNING TABLE – Live/Enduring

Title of Activity: _____________________________________________________________________________________________________DEFINITION OF LEARNER OUTCOME(S) Describes the behavior participants will be able perform at the conclusion of the activity.

LEARNER OUTCOME(S):_______________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

NOTE: THE EVALUATION METHOD MUST DETERMINE PARTICPANTS TO ACHIEVE THE LEARNER OUTCOME(S) AND/OR OBJECTIVES FOR THIS SESSION

CONTENT

(List/Summarize the discussion topics)

TIME

FRAME PRESENTER/ AUTHOR TEACHING METHODS

Provide an outline of the content, a summary of topics or the learner objectives below

Approximate time required for content List the Author List the Teaching methods to be used by Faculty, Presenters,

Authors

Total Minutes divided by 60 = contact hour(s)


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(Continued) EDUCATIONAL PLANNING TABLE – Live/Enduring

Learner engagement strategies (LIVE activities)☐ Dialogue or question/answer ☐Including time for self-check or reflection ☐ Analyzing case studies☐ Problem-based learning ☐Other:

Learner engagement strategies (ENDURING activities)☐ Email ☐ Video Chat ☐Video Conferencing ☐Opportunity to learn new online tools & applications☐Other:

Area of Impact:☐ Nursing Professional Development ☐ Improving Patient Outcomes ☐ Other: Describe _________________________

REFERENCESContent for this activity was chosen from: (check all that apply)☐ Organization/web site ☐ Peer-reviewed

journal/resource☐ Clinical guidelines (ie.: www.guidelines.gov)

☐ Expert resource (individual, organization, educational institution, book, article or website)

☐ Textbook reference

List the evidence-based references (from the works checked above) used to develop the content for this educational activity (within the past 7 years)

Author Title Year/Release date Source, Volume#, Page #

1.

2.

3.

4.

5.

______________________________________________________________ ____________________________________Completed By: Name and Credentials Date


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District #___________

6 Park Center Court, Suite 212Owings Mills, MD 21117Telephone (443) 334-5110 Fax: (443) 334-5109

Continuing Education Activity - Activity Attendance Record

Activity Title:

Location Name & Address:

ACTIVITY CODE NUMBER CONTACT HOURS VALID THROUGH (DATE)

Name RN or other Specialty Email Address Signature1.

2.

3.

4.

5.

6.

7.

8.

9.


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