Western Multi-State Division (WMSD)
Approved Provider Unit Application and Self-Study Outline
Directions: Please complete Parts 1 - 4 of this application
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:
RN License number and state
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
Indicate payment method:
☐ CHECK
☐ CREDIT CARD
Visit www.westernmsd.org to provide payment. Fees must be submitted prior to the application being
accepted for review and are non-refundable once the review process has begun.
When payment is complete, print a copy of your order confirmation and include with your application.
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PART 3 of 4
Eligibility Requirements
(check box agreeing that applicant meets requirement)
Provider Unit must be one of the following:

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, the WMSD, and the Approved Provider Unit.
Provider Unit (either single unit or within multi-focused organization) exists for the purpose of providing
continuing education.
Provider Unit is not defined as a commercial interest organization.
Provider Unit has been in operation for a minimum of 6 months prior to application.
If this is an initial application, Provider Unit has:
 successfully completed and received approval for 3 separate and distinct individual activities
through the WMSD
o each activity was a minimum of one hour (60 minutes)
o activities were not Joint Provided
o the 3 activities' files are attached to this application
Provider Unit markets more than 50% of their educational activities to nurses in their local geographic
region DHHS region and its contiguous states. See link for map (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 the 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: ___
___________________
Primary Nurse Planner for Provider Unit
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PART 4 of 4
Approved Provider Self-Study Outline/Table of Contents
Include a Table of Contents in your final document.
You may use the sample provided below. Please modify as appropriate
Page Number
APPROVED PROVIDER ORGANIZATION OVERVIEW (OO)
Structural Capacity (SC)
OO1—Demographics
OO2—Lines of Authority and Administrative Support
Educational Design Process (EDP)
OO3—Data Collection and Reporting
Quality Outcomes (QO)
OO4—Evidence
STRUCTURAL CAPACITY (SC) - Detailed Criterion
SC1
SC2
SC3
EDUCATIONAL DESIGN PROCESS (EDP) - Detailed Criterion
EDP1
EDP2
EDP3
EDP4
EDP5
EDP6
EDP7
CRITERIA—QUALITY OUTCOMES (QO) - Detailed Criterion
QO1
QO2
QO3
APPENDICES
Provide copies of the required documents and any additional appendices with a cover page for
each appendix including titles and page numbers.
Organizational Chart (s)
Position Descriptions
Demographic Information Form
Biographical Data Forms
Continuing Education Summary
Other - Describe insert additional rows as needed
3 INDIVIDUAL ACTIVITY FILES
Provide three complete CE Activity files divided by separate tabs numbered 1, 2, 3
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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
001a: Submit a description of the features of the Approved Provider Unit, including but not limited to,
size, geographic range, target audience(s), content areas, and the types of educational activities offered.
Description:
001b: If the Approved Provider Unit is part of a multi-focused organization, describe the relationship of
these dimensions to the total organization.
Description:
OO2. Lines of Authority and Administrative Support
002a: Submit a list including names and credentials, positions, and titles of the Primary Nurse Planner,
other Nurse Planner(s) (if any) in the Provider Unit.
List:
002b: Submit position descriptions of the Primary Nurse Planner and Nurse Planners (if any), in the
Approved Provider Unit.
Position Descriptions: (If attaching organization job descriptions ensure they include the Approved
Provider Unit role/position description. If they do not, provide separate position descriptions for the
Provider Unit roles below.)
Primary Nurse Planner:
Nurse Planner(s):
002c: Submit an organizational chart, flowchart or similar image depicting the structure of the
Approved Provider Unit, including the Primary Nurse Planner, other Nurse Planner(s) (if any). (This is
not your organization's chart -- only the Approved Provider Unit structure.)
Chart: insert here or reference where placed in the Appendices
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002d: 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 organization.
Chart: insert here or reference where placed in the Appendices
Educational Design Process
OO3. Data Collection and Reporting
Approved Provider organizations report data annually to the Western Multi-State Division Accredited Approver
Unit office. Forms are available on the WMSD CE Web site.
http://www.westernmsd.org/MainMenu/CE/Approved-Provider-Application
003a: *Submit the completed Demographic Information Form; and
003b: *Submit the completed Approved Provider Continuing Education Summary of all CNE offerings
provided in the past 12 months, including at a minimum, activity dates; titles; target audience; total
number of participants; number of contact hours offered for each activity; activity type, Joint Provider
status; and any commercial support, including monetary or in-kind contributions.
*Include the above completed forms in the Appendices
Quality Outcomes
OO4. Evidence
Outcomes must be written in measureable terms (i.e. SMART goals) and specific to the Provider
Unit. They may support the larger organization's goals but must be written for the Provider Unit
outcome. New or First Time applicants should develop and submit with your self-study a list of quality
outcome measures that will be collected, monitored, and evaluated.
004a: Submit the quality outcome measures the Approved Provider has collected, monitored, and
evaluated over the past 12 months specific to the Approved Provider Unit. These outcomes reflect the
Provider Unit's outcome assessment its effectiveness and strategies.
List:
004b: Submit the quality outcome measures the Provider Unit has collected, monitored, and evaluated
over the past 12 months specific to Nursing Professional Development. These outcomes assess how
the activities planned, implemented and evaluated by the Provider Unit had an effect on Nursing
Professional Development goals.
List:
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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; and leadership. In this section
write narrative statements that address each of the criteria to illustrate how your Provider Unit's structural
capacity is operationalized.
Each narrative must include two parts:
1. A detailed description of your Provider Unit standard operational process. (i.e. Your procedure)
2. A specific case example that illustrates how the process was used. (How you used your procedure)
Commitment
SC1. The Primary Nurse Planner's commitment to learner needs, including how Approved Provider Unit
processes are revised based on aggregate data which may include but is not limited to individual
education activity evaluation results, stakeholder feedback (staff, volunteers) and learner/customer
feedback.
Process Description:
Specific Example:
Accountability
SC2. How the Primary Nurse Planner ensures that all Nurse Planners of the Provider Unit are appropriately
oriented/trained to implement and adhere to the ANCC accreditation criteria.
Process Description:
Specific Example:
Leadership.
SC3. How the Primary Nurse Planner provides direction and guidance to individuals involved in planning,
implementing, and evaluating CNE activities in compliance with ANCC accreditation criteria.
Process Description:
Specific Example:
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Approved Provider Criterion 2: Educational Design Process (EDP)
The Approved Provider Unit has a clearly defined process for assessing learner 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 two parts:
3. A detailed description of your Provider Unit standard operational process. (i.e. Your procedure)
4. A specific case example that illustrates how the process was used. (How you used your procedure)
EDP1. The process used to identify a problem in practice or opportunity for improvement (professional
practice gap).
Process Description:
Specific Example:
EDP2. How the Nurse Planner identifies the educational needs (knowledge, skills and/or practice(s) that
contribute to the professional practice gap.
Process Description:
Specific Example:
EDP3. The process used to identify and resolve all conflicts of interest (COI) for all individuals in a position
to control educational content.
Process Description:
Specific Example:
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EDP 4. How content of the educational activity is developed based on best-available current evidence to foster
achievement of desired outcomes (e.g. clinical guidelines, peer-reviewed journals, experts in the field).
Process Description:
Specific Example:
EDP5. How strategies to promote learning and actively engage learners are incorporated into educational
activities..
Process Description:
Specific Example:
EDP6. How summative evaluation data for an educational activity were used to guide future activities.
Process Description:
Specific Example:
EDP7. How the Nurse Planner measures change in knowledge, skills and/or practices of the target audience
that are expected to occur as a result of the educational activity.
Process Description:
Specific Example:
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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.
Each narrative must include two parts:
5. A detailed description of your Provider Unit standard operational process. (i.e. Your procedure)
6. A specific case example that illustrates how the process was used. (How you used your procedure)
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 for the Approved Provider Unit. (Refer to identified quality
outcomes list in OO4a.)
Process Description:
Specific Example:
QO3. How, over the past 12 months, the Approved Provider Unit has enhanced nursing professional
development. (Refer to identified quality outcomes list in OO4b).
Process Description:
Specific Example:
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Appendices
Provide all documentation supporting Sections 00; SC; EDP; and QO narrative descriptions in an Appendix.
Label each appendix and provide the page number in the Table of Contents
 Organizational Chart (s)
 Position Descriptions
 Biographical Data Forms
 Demographic Information Form
 Approved Provider Continuing Education Summary
 Other - Describe
Individual Activity Files: 3 complete files
As a component of the education design process, the Approved Provider applicant must select and submit 3 CNE
activity files with their Self Study application that have been planned within the last 12 months of the
application date and comply with ANCC criteria. These are placed after the Appendices.
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