Arizona Nurses Association a member of the
Western Multi State Division
Approved Provider Unit Application and Self-Study Outline
Directions: Please complete Parts 1-4 of this application after you have read the Approved
Provider Application and Self-Study Instructions.
PART 1 of 4
Applicant Information
Name of Provider Unit
Type of Organization (e.g. academic, care
provider, etc.)
Name of parent organization (if different than
Provider Unit)
Street Address or PO Box
City, State, ZIP Code
Beginning Date of Operation (must be
operational at least 6 months prior to
submission of application)
PRIMARY NURSE PLANNER (PRIMARY APPLICATION CONTACT)
Name, Credentials/Title:
Street Address:
City, State, ZIP Code:
Daytime phone number (ext):
E-mail address:
ADDITIONAL CONTACT PERSON
Name
Title or Position
Daytime phone number (ext):
Fax Number:
Email Address
PART 2 of 4
Payment Information
Check Number
OR
Name on Credit Card
Type of Card (Visa/MC)
Expiration Date
PART 3 of 4
Eligibility Requirements
(check box agreeing that applicant meets requirement)
Provider Unit must be one of the following:
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
Constituent Member Association of ANA
 College or University
 Healthcare Facility
 Health-Related Organization
 Multidisciplinary Educational Group
 Professional Nursing Education Group
 Specialty Nursing Organization (SNO)
Provider Unit must be administratively and operationally responsible for coordinating the entire
process of planning, implementing, and delivering continuing nursing education.
Provider Unit must ensure that all Nurse Planners hold a current, valid license as a registered nurse
with a baccalaureate degree or higher in nursing.
Provider Unit must have at least one Nurse Planner with authority to assure compliance with ANCC
Accreditation Program criteria in the provision of continuing nursing education.
Provider Unit must have a Primary Nurse Planner who is responsible for the orientation of all Nurse
Planners and key personnel in the organization to the Accreditation criteria.
Provider Unit must ensure that each CE activity has a qualified Nurse Planner who is an active
participant in the planning, implementing, and evaluation process.
Provider Unit must designate one Primary Nurse Planner who serves as the liaison between the
ANCC, WMSD, and the approved Provider Unit.
Provider Unit (either single unit or within multi-focused organization) exists for purpose of providing
continuing education.
Provider Unit is not defined as a commercial interest.
Provider Unit has been in operation for a minimum of 6 months prior to application.
If this is an initial application, Provider Unit must:
 have successfully completed and received approval for 3 separate and distinct individual
activities through AzNA
o
o
o
o
each activity was a minimum of one hour (60 minutes)
contact hours may or may not have been offered
activities were not Joint Provided
activities files are attached to this application
Provider Unit markets more than 50% of their educational activities to nurses in their local geographic
region (in either Arizona or DHHS region 9 (http://www.hhs.gov/about/regions).
To my knowledge, the Provider Unit is in compliance with all applicable federal, state, and local laws
and regulations that affect the organization’s ability to meet ANCC Accreditation criteria.
Have you ever previously applied for and (1) been denied approval; (2) been suspended
Yes
No
from providing continuing education activities; and/or (3) had your Approver or Provider
status revoked by WMSD or an ANCC accredited organization?
If yes, please describe why?
By initialing here I am attesting that to my knowledge the organization adheres to all regional, state
and national laws and regulations and 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) so that its obligations and commitments are met.
I certify that the information in this application is complete and accurate to the best of my knowledge.
Name: _
________________________________________ Date: ___
___________________
Nurse Planner for Provider Unit
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PART 4 of 4
Approved Provider Self-Study Outline
This outline provides a place for you to enter your organizational information.
Be sure to review the Approved Provider Unit Application and Self-Study Instructions before
completing and submitting your documents.
Please include a Table of Contents (TOC) in your final document. You may use the sample TOC
provided below. Please modify as appropriate
TABLE OF CONTENTS
Page Number
APPROVED PROVIDER ORGANIZATION OVERVIEW
Structural Capacity
OO1—Demographics
OO2—Lines of Authority and Administrative Support
Educational Design Process
OO3—Data Collection and Reporting
Quality Outcomes
OO4—Evidence
CRITERIA 1—STRUCTURAL CAPACITY (SC)
Commitment
SC1
SC2 (only if applicable)
Accountability
SC3
SC4
Leadership
SC5
SC6
Resources
SC7
CRITERION 2—EDUCATIONAL DESIGN PROCESS (EDP)
Assessment of Learning Needs
EDP1
EDP2
Planning
EDP3
EDP4
EDP5
EDP6
Design Principles
EDP7
EDP8
EDP9
EDP10 (only if commercial support accepted; if not, skip to EDP11)
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EDP11
Achievement of Objectives
EDP12
EDP13
CRITERION 3—QUALITY OUTCOMES (QO)
Approved Provider Unit Evaluation Process
QO1
QO2
Approved Provider Unit Evaluation Participants
QO3
Approved Provider Unit Quality Outcome Measures
QO4
Value/Benefit to Nursing Professional Development
QO5
APPENDICES
Provide copies of the required Biographical Data Forms, Job
Descriptions, Organizational Chart, additional appendices, and
policies and procedures with a cover page including titles and page
numbers.
Provide three complete CE Activity files divided by separate tabs
with a table of contents and page numbers for each file.
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APPROVED PROVIDER ORGANIZATIONAL OVERVIEW
Approved Provider Organizational Overview (OO)
The Organizational Overview (OO) is an essential component of the application process that provides a context
for understanding the Approved Provider Unit/organization. The applicant must submit the following
documents and/or narratives:
Structural Capacity
OO1. Demographics
 Submit a description of the features of the Approved Provider Unit, including but not limited to
scope of services, size, geographic range, target audience(s), content areas, and the types of
educational activities offered.
Description:

If the Approved Provider Unit is part of a multi-focused organization, describe the relationship of
these scope dimensions to the total organization.
Description:
OO2. Lines of Authority and Administrative Support
 Submit a list including names and credentials, positions, and titles of the Primary Nurse
Planner, other Nurse Planner(s) (if any), and all key personnel in the Approved Provider Unit.
List:

Submit position descriptions of the Primary Nurse Planner, Nurse Planners (if any), and key
personnel in the Approved Provider Unit.
Position Descriptions:
Primary Nurse Planner:
Nurse Planner(s):
Other Key Personnel:

Submit a chart depicting the structure of the Approved Provider Unit, including the Primary Nurse
Planner, other Nurse Planner(s) (if any), and all key personnel.
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Chart:
a.
If part of a larger organization, submit an organizational chart, flowchart, or similar image that
depicts the organizational structure and the Approved Provider Unit’s location within the
organization.
Chart:
Educational Design Process
OO3. Data Collection and Reporting
Approved Provider organizations report data, at a minimum, annually to their ANCC Accredited
Approver:
b.
Submit a complete list of all CNE offerings provided in the past 12 months, including activity
dates; titles; target audience; total number of participants; number of contact hours offered for each
activity; Joint Provider status; and any sponsorship or commercial support, including monetary or
in-kind amount.
Attach the completed list.
c.
New applicants: Submit a list of the CNE offerings provided within the past 12 months. If
available, include the items listed above; and
d.
Any additional requirements of the ANCC Accredited Approver.
Quality Outcomes
OO4. Evidence
 List Approved Provider Unit’s strategic goals with respect to CNE for the past 12 months.
List:

Submit a list of the quality outcome measures the Approved Provider collects, monitors, and
evaluates specific to the Approved Provider Unit.
List:
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
Submit a list of the quality outcome measures the Approved Provider collects, monitors, and
evaluates specific to Nursing Professional Development. (Refer to Chapter 1: The Primary
Accreditation Program, section titled Focus on Quality and Outcomes.)
List:
Note: New applicants should develop and submit with their self-study a list of strategic goals for the initial 2
years after achieving Approved Provider status and a list of quality outcome measures that will be
collected, monitored, and evaluated.
Approved Provider Criterion 1: Structural Capacity (SC)
The capacity of an Approved Provider is demonstrated by commitment, identification of and responsiveness to
learner needs, continual engagement in improving outcomes, accountability, leadership, and resources.
Applicants will write narrative statements that address each of the criteria under Commitment, Accountability,
Leadership, and Resources to illustrate how structural capacity is operationalized.
Each narrative must include a specific example that illustrates how the
criterion is operationalized within the Provider Unit.
Commitment. The Primary Nurse Planner demonstrates commitment to ensuring RNs’ learning needs are met
by evaluating Approved Provider Unit goals in response to data that may include but is not limited to aggregate
individual educational activity evaluation results, stakeholder feedback (staff, volunteers), and learner/customer
feedback.
Describe and, using an example, demonstrate the following:
SC1. The Primary Nurse Planner’s commitment to learner needs, including how Approved Provider Unit
processes are revised based on data.
Process Description:
Specific Example:
Note: Complete SC2 only if the Provider Unit is part of a larger organization.
SC2. How the organization’s leadership is committed to supporting the goals of the Approved Provider Unit.
Process Description:
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Specific Example:
Accountability. The Primary Nurse Planner is accountable for ensuring that all Nurse Planners and key
personnel in the Approved Provider Unit adhere to the ANCC accreditation criteria.
Describe and, using an example, demonstrate the following:
SC3. How the Primary Nurse Planner ensures that all Nurse Planners and key personnel of the Approved
Provider Unit maintain adherence to the ANCC accreditation criteria.
Process Description:
Specific Example:
SC4. How the Primary Nurse Planner is accountable for resolving issues related to providing CNE.
Process Description:
Specific Example:
Leadership. The Primary Nurse Planner demonstrates leadership of the Approved Provider Unit through
direction and guidance given to individuals involved in the process of assessing, planning, implementing, and
evaluating CNE activities in adherence with ANCC accreditation criteria.
Describe and, using an example, demonstrate the following:
SC5. How the Primary Nurse Planner ensures that every Nurse Planner maintains accreditation standards and
guides the Planning Committee or team for an individual educational activity.
Process Description:
Specific Example:
SC6. How the Nurse Peer Review Leader of the Accredited Approver Unit is used as a resource by the Primary
Nurse Planner and/or other Nurse Planner(s) in the Approved Provider Unit.
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Process Description:
Specific Example:
Resources. The Primary Nurse Planner advocates for and utilizes available human, material, and financial
resources to ensure that the Approved Provider Unit achieves its goal of meeting identified quality outcome
measures.
Describe and, using an example, demonstrate:
SC7. How the Primary Nurse Planner advocates for resources to ensure that the Approved Provider Unit
achieves its goals related to quality outcome measures.
Process Description:
Specific Example:
Approved Provider Criterion 2: Educational Design Process (EDP)
The Approved Provider Unit has a clearly defined process for assessing needs as the basis for planning,
implementing, and evaluating CNE. CNE activities are designed, planned, implemented, and evaluated in
accordance with adult learning principles, professional education standards, and ethics.
Each narrative must include a specific example that illustrates how the criterion is
operationalized within the Provider Unit.
Examples for the narrative component of the provider application (EDP 1-13) may be chosen from but are not
limited to those contained in the three activity files. Evidence must demonstrate how the Approved Provider
Unit complies with each criterion.
Assessment of Learning Needs. CNE activities are developed in response to, and with consideration for, the
unique educational needs of the target audience.
Describe and, using an example, demonstrate the following:
EDP1. The Nurse Planner’s methods of assessing the current learning needs of the target audience.
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Process Description:
Specific Example:
EDP2. How the Nurse Planner uses data collected to develop an educational activity that addresses the
identified gap in knowledge, skills, and/or practices.
Process Description:
Specific Example:
Planning. Planning for each educational activity must include one Nurse Planner and one other planner. One of
the planners must have appropriate subject matter expertise for the educational activity.
Describe and, using an example, demonstrate the following:
EDP3. The process used to select a planning team/committee for an educational activity, including why an
individual member was chosen.
Process Description:
Specific Example:
EDP 4. The process used to identify all actual and potential conflicts of interest for all members of the Planning
Committee, presenters, authors, and content reviewers.
Process Description:
Specific Example:
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EDP5. The process for resolution of an actual or potential conflict of interest and the outcome achieved.
Process Description:
Specific Example:
EDP6. The process utilized during the planning phase of the educational activity to determine how participants
will successfully complete the learning activity.
Process Description:
Specific Example:
Design Principles. The educational design process incorporates measurable educational objectives, bestavailable evidence, and appropriate teaching methods.
Describe and, using an example, demonstrate the following:
EDP7. How measurable educational objectives are developed that address the change in nursing practice or
nursing professional development.
Process Description:
Specific Example:
EDP8. How the content of the educational activity is selected based on best-available current evidence (e.g.,
clinical guidelines, peer-reviewed journals, experts in the field).
Process Description:
Specific Example:
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EDP9. How content integrity is maintained for CNE activities, including what precautions are taken to prevent
bias and how those precautions are implemented.
Process Description:
Specific Example:
Note: If the applicant or approved provider organization never accepts commercial support/sponsorship,
do not provide a narrative for EDP10, and proceed to EDP11.
EDP10. In the presence of commercial support/sponsorship, how additional precautions are taken to maintain
content integrity for CNE activities, including what precautions are taken to prevent bias and how those
precautions are implemented.
Process Description:
Specific Example:
EDP11. How teaching methods were chosen that are appropriate to achieve the purpose and objectives of the
CNE activity.
Process Description:
Specific Example:
Achievement of Objectives. A clearly defined method that includes learner input is used to evaluate the
effectiveness of each educational activity. Results from the activity evaluation are used to guide future
activities.
Describe and, using an example, demonstrate the following:
EDP12. How summative evaluation data for an educational activity were used to guide future activities.
Process Description:
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Specific Example:
EDP13. How evaluation data were collected to measure change in nursing practice or nursing professional
development.
Process Description:
Specific Example:
Approved Provider Criterion 3: Quality Outcomes (QO)
The Approved Provider Unit engages in an ongoing evaluation process to analyze its overall effectiveness in
fulfilling its goals and operational requirements to provide quality CNE.
Approved Provider Unit Evaluation Process. The Approved Provider Unit must evaluate the effectiveness of
its overall functioning as an Approved Provider Unit.
Each narrative must include a specific example that illustrates how the
criterion is operationalized within the Provider Unit.
Describe and, using an example, demonstrate the following:
QO1. The process utilized for evaluating effectiveness of the Approved Provider Unit in delivering quality
CNE.
Process Description:
Specific Example:
QO2. How the evaluation process for the Approved Provider Unit resulted in the development or improvement
of an identified quality outcome measure. (Refer to identified quality outcomes list in OO4.)
Process Description:
Specific Example:
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Approved Provider Unit Evaluation Participants. The Approved Provider Unit shall include a variety of
stakeholders, comprising those with a vested interest in Approved Provider Unit outcomes, in the evaluation
process.
Describe and, using an example, demonstrate the following:
QO3. Why the Approved Provider Unit selects specific stakeholders to participate in the evaluation process.
Process Description:
Specific Example:
Approved Provider Unit Quality Outcome Measures. The Approved Provider Unit must demonstrate quality
improvement efforts including strategies for working on targeted goals, evaluating progress toward goals, and
revising or establishing new goals.
Describe and, using an example, demonstrate the following:
QO4. How input from stakeholders resulted in development of or an improvement in quality outcome measures
for the Approved Provider Unit. (Refer to identified quality outcomes list in OO4.)
Process Description:
Specific Example:
Value/Benefit to Nursing Professional Development. The Approved Provider Unit shall evaluate data to
determine how the approved Provider Unit, through the learning activities it has provided, has influenced the
professional development of its nurse learners.
Describe and, using an example, demonstrate the following:
QO5. How, over the past 12 months, the Approved Provider Unit has enhanced nursing professional
development. (Refer to identified quality outcomes list in OO4.)
Process Description:
Specific Example:
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APPENDICES
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