General
Q: What is the accreditation process?
A. The ANCC system for accreditation of continuing nursing education is a voluntary recognition process. An institution, organization or agency submits to an in-depth analysis to determine the capacity of the entity to provide, or in the case of the approver, approve quality activities for nurses.
Q: How long is the accreditation?
A. New applicants can receive 2 years accreditation, during which time progress reports will be submitted to address any identified areas of non-compliance with criterion. At the end of those two years, 2 more can be awarded. For returning applicants, period of accreditation is 4 years (or possibly a 1 year probationary period if non-compliance with criterion is significant).
Q : Can international organizations apply for ANCC accreditation?
A. Yes, any organization responsible for the overall development, implementation, evaluation, and quality assurance of continuing nursing education may seek accreditation as a provider. This includes international organizations whose headquarters are located outside the United States.
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Disclosures
Q. If a speaker cancels on the day of the conference could another presenter be substituted even though the provider has none of the required documents for this substitute?
A. A substitute speaker may be used. The speaker would, of course, have to be qualified to perform this function. Her/his bio form could be secured after the conference. In terms of disclosures prior to speaking:
- The speaker needs to disclose to the provider unit any relationships that might be perceived as conflicts of interest.
- The speaker will need to sign a statement regarding their disclosures, but it can be a handwritten document rather than the formal form.
- Additionally, since the learners won't have a written disclosure, the disclosure must be made verbally to the audience.
- Someone in the audience (it can be a member of the provider unit) will need to document (within 30 days of the event) what, when, and how disclosure was made.
- This documentation is to be kept as a part of the permanent activity file.
Q. What are the requirements for electronic signatures (on disclosure statements, COI statements, etc)?
A. Signatures, electronic or original, are not required. However, if a signature is not used, then documentation that you received the disclosure information from the source of the information will be needed. For example, if the form was faxed, you would need to save the cover sheet with the person's name and phone number on it. You need to use a method that makes you comfortable that documentation has been secured, and which provides verifiable proof after the fact. It is acceptable to use a single form to meet the requirements of multiple accrediting bodies. The individual requirements for each accrediting body must be met by the form.
Q. Will you please offer some examples for the Executive Summary sections of the accreditation application that asks the applicant to conduct a "Review of the healthcare environment in which the provider/approver unit operates".
A. Some examples of changes in the healthcare environment include:
- A nursing specialty which has recently instituted a certification which requires continuing education for renewal
- The state in which the organization is based has just legislated continuing education for re-licensure
- Legislation and federal scrutiny have made it more complicated and difficult to get and to use support money from "commercial entities"
- A hospital has recently experienced a critical incident in which lack of knowledge of the nursing staff about the use of a particular piece of equipment was found to be a contributing factor
- A report that states nurses are increasingly challenged for their time and appreciate education that is available whenever they are
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Conflict of Interest
Q. Consider the case of a group of clinics in which the staff are trying to improve quality of care for women with bladder problems. The nurse planner wants to develop and offer CE credit for seminars that will be presented to the staff regarding the newest technology and standards of care for these clients. This educational activity will increase the quality of care for the client as well as enhance the nurses' clinical skills in specialized health care areas. Is there a conflict since the owners of the clinics are the same individuals that will be providing the seminar to their employees?
A. The above scenario is not considered a conflict of interest. It could be considered in-service but since the description provided indicates that the information being learned could – and should – be applied in any practice setting, it is not in-service. Although the educational content may be especially pertinent to nurses in this organization, it is not particular to this one setting. It is to be practiced in all settings.
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Contact Hours
Q: Can contact hours be awarded to participants who are not nurses?
A. Yes, anyone who attends may receive a certificate and contact hours. However, the target audience should include RNs.
Q: Can a presenter earn contact hours for the conference at which she/he is presenting?
A. Presenters and authors can only receive contact hours for portions of the activity they attend but do not present. Presenters and authors may earn contact hours for their preparation of a presentation, article, or chapter if they approach this as an independent learner directed activity.
Q. How do you calculate contact hours for online or home study programs?
A. These hours must be calculated in a logical and defensible manner. One approach often used is the pilot study. Another approach sometimes used with written materials online is a recognized formula using data such as word count and level of reading and level of technical difficulty.
Q: Can nurses who participate in pilot testing receive ANCC contact hours?
A. Yes.
Q: Can contact hours be awarded to participants of ACLS and PALS "canned" certification courses?
A. For initial certification, advanced skilled courses such as ACLS and PALS, ANCC contact hours can be awarded. As of June 1, 2011, ANCC contact hours cannot be awarded to nurses attending these courses in order to renew their certification in the subject area.
Also, as of June, 1, 2011, contact hours cannot be awarded to BLS and other basic "canned" courses (either initial or renewal). Basic courses – such as BLS for example – form a base upon which nursing knowledge and practice is built. Therefore they do not meet the definition of continuing nursing education.
For the BLS, ACLS, PALS, etc. Instructor courses, contact hours can be awarded for the teaching modality content only of the classroom based BLS Instructor course. Note that this does not include the content portion of the course. In addition, accredited providers and approved providers cannot award ANCC contact hours for the course offered online or on CD-ROM by AHA as these formats preclude the involvement of the accredited/approved continuing education unit in the planning or implementation of the activity.
Q. How can I calculate and award contact hours for poster sessions (such as at a convention or multi-day CNE event)?
A. To award contact hours for poster sessions, the same criteria must be followed as for any other CE activity, including a logical and defensible method of determining the number of contact hours to award. There are a number of options. The approach chosen depends on the location of the posters, the schedule of the conference, and the objectives of the poster session. Simply assigning time in the conference schedule is not sufficient. The ANCC Accreditation Program staff can assist you in identifying options for your specific poster session.
Q: When calculating the number of contact hours I find that the number is two digits past the decimal point, or more. For example, 1.666. What is the number of contact hours I should use?
A. You must round down to 1.66. Do not round up.
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Education Design
Q: Can only the designated nurse planner(s) do the planning?
A. There can be any number of planners of an activity – a nurse planner must be one of them. The planning committee is made up of at least two people. The following stakeholders must be represented: content expert, and the target audience. You may find that two planners are enough, or you may need additional planners. Only one planner, the Nurse Planner must be a nurse.
Q. What does "stand alone" mean when referring to the accreditation statement?
A. It means this statement must not be combined with any other information and must be on a separate line from any other statement. It is not necessary to have blank lines around the statement. For example:
- You have been awarded 10.25 contact hours.
- Lake Wobegon Clinic is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
- Lake Wobegon Clinic is approved through the CA BON.
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Accreditation Logo
Q: Is it permissible to put the ANCC Accreditation logo on a certificate?
A. Yes, as long as it is in a less prominent place and smaller than the provider's logo. A number of ANCC Accreditation logo files can be found on the ANCC website and are available for download.
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Commercial Support/Vested Interest
Q. If there is no conflict of interest, does the provider or approver need to disclose that?
A. The provider and approver need to secure from presenters, planners and reviewers a statement regarding conflict of interest on a vested interest form whether there is one or not. This information must be disclosed to the learners even if there are no conflicts.
Q. Our nurse planner is married to a man who works full time for a major pharmaceutical company. He owns stock and receives salary. When our nurse planner completes her disclosure, must we publish (disclose to the audience) this info for EVERY program we do of which she is a part or only those when this pharmaceutical company is financially supporting and/or exhibiting at?
A. You will only need to disclose this information when it could cause - or could cause the perception -that a bias in the continuing education being planned or implemented. In other words, if the activity is related to a product or service of the pharmaceutical company, then this would need to be disclosed. An alternative might be that you train a second nurse planner who would direct the planning committees addressing the educational activities where there might be a relationship with the pharmaceutical company.
Q. Can the sponsor logo be used on the certificate of completion?
A. No.
Q. Can a commercial supporter require that only their clients be given credit for an activity?
A. No.
Q. Is paying for food considered to be commercial support?
A. Yes.
Q: Must we, as the accredited provider, limit the promotional activities of companies that are not considered commercial entities?
A. Yes. Promotional activities should never occur within educational activities – regardless of the nature of the company wishing to promote themselves or their product(s).
- Example #1: A speaker has written a book related to the topic that s/he is addressing in the presentation.
Acknowledgement of the speaker's expertise in the area may be made but the speaker may NOT encourage the learners to buy the book ‘in order to learn more' or for any reason. Additionally, if there is to be a 'book signing', it should NOT be mentioned before, during or subsequent to the educational activity and it should occur in an area OTHER THAN the education areA.
- Example #2: A not-for-profit healthcare entity agrees to sponsor education. They wish to include ‘an invitation to practice' at their hospital in the education material provided to the learner.
While the not-for-profit healthcare entity does not meet the definition of "commercial entity", the scenario in question mixes educational activity with promotional activity. This is not allowed. The sponsor must be acknowledged but that acknowledgement cannot result in a promotion of the sponsor. Learners should not feel "pressured" or marketed to by the sponsor of the program or should not receive promotional information because they participated in a CNE activity.
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Confidentiality of Records
Q. At our conference, we would like to distribute a list of participant names and contact info to all who attend. Is this permitted?
A. Since the names of participants and their contact info is confidential information, it is permitted only if you secure approval before the conference from the individuals whose names are on the list. The registration form might include a question asking for this approval and providing an "opt out" checkbox for those who wish to deny permission.
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Miscellaneous
Q. What is the difference between co-sponsor and co-provider?
A. Co-Providership is the planning, developing, and implementing an educational activity by two or more organizations or agencies. ANCC Accreditation criterion requires that the accredited organization be fully responsible for the particular aspects of the process to assure adherence to all the ANCC criteriA. A written co-provider agreement is completed.
Sponsorship is support (monetary or ‘in kind') furnished to the provider of the education activity. Sponsorship must be acknowledged to learners. A written agreement is completed and signed by both organizations. When an educational activity is supported by more than one entity, each entity is a co-sponsor. Sponsors and co-sponsors do NOT participate in planning, developing and implementing the educational activity.
Q. When a hospital is approved, but is part of a larger organization system, can they offer programs for the entire system under their name?
A. The approved provider unit can use their approved status only for those activities their provider unit plans, implements and evaluates. However, this provider can co-provide with other hospitals (either within the hospital system or without).
Q. What is the value of ANCC accreditation status vs. California Board of Nursing approval? (It seems that other accreditation might be a cheaper and easier way to be approved)
A. The California BON does claim that their approval is nationally recognized by all other BONs. However, this has not been verified. Approval through an ANCC approver is recognized by all BONs with the following exception: the CA and IA BONs will not recognize an approved provider's CE if that provider enters those states to offer their CE, without the respective BONs approval. If the approved provider does not go into the states of CA or IA, then those BONs will recognized the provider's contact hours awarded (this is true for internet courses and other home study courses as well).
Approval through an ANCC approver is also recognized by many certifying agencies such as the American Association of Diabetes Educators and ANCC.
Additionally, a strong benefit of obtaining ANCC accreditation is related to the relative standards required to receive accreditation. Since approval through an ANCC accredited approver is reportedly found to be more rigorous than approval through the California BON, accreditation becomes a tool for the provider to know they are on target in their pursuit of excellence in planning, implementing and evaluating of their CE, and organizations are assisted in finding a way to improve if they are not on target.
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For The Approver Unit Only
Q. How long does the Approver Unit need to keep application documents of approved activities and approved providers?
A. Six years
Q. Should the approved provider keep their activity records for six years, which is how long the accredited provider needs to keep their records?
A. Yes
Q. Providers who submit their self study to ANCC do not submit three activities, but instead submit a list of activities (from which ANCC picks three to be reviewed during the site visit). Should the approved provider applicant send a list of activities or three sample activities?
A. The approved provider applicant must submit three activity files (of at least 1 contact hour) with their application. If a sample activity is 3 hours or greater, the applicant is permitted to submit documentation for only three contact hours of the activity. (The applicant is expected to maintain documentation for the full activity.) The accredited approver has the freedom to request documentation for as many hours as they wish.
Q. If an provider-directed activity is submitted for approval that is longer than three hours, does documentation for all hours need to be submitted?
A. No. See above.
Q.
Does a qualified reviewer need to have a graduate degree?
A. No. They must have at least a baccalaureate in nursing. Only the Nurse Peer Review Leader must have a graduate degree (and either the baccalaureate or the graduate degree must be in nursing).
Q. Can co-provided activities be approved?
A. Yes
Q. Can a first-timer provider applicant submit a co-provided activity as one of the three sample activities?
A. No.
Q. Can an approved provider co-provide?
A. Yes
Q. Must the "pending approval" statement stand alone, or can it be on the same line as other information?
A. The pending approval statement must stand alone.
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Questions Most Frequently Asked of Approvers
ANCC Staff asked accredited approvers what questions their providers often asked. Here are some of those questions with the answers.
Q: Can contact hours be awarded to participants of ACLS, PALS, BLS, and BLS Instructor courses?
A. For the BLS Instructor course, contact hours can be awarded for the teaching modality content only of the classroom based BLS Instructor course. Note that this does not include the BLS content portion of the course. In addition, accredited providers and approved providers cannot award ANCC contact hours for the course offered online or on CD-ROM by AHA as these formats preclude the involvement of the accredited/approved continuing education unit in the planning or implementation of the activity.
Q. What is the difference between co-sponsor and co-provide?
A. From the web: Co-Providership: Planning, developing, and implementing an educational activity by two or more organizations or agencies. ANCC Accreditation criteria requires that the accredited organization be responsible for particular aspects of the process to assure adherence to all the ANCC criteriA. A written co-provider agreement is completed.
Sponsorship: Support (monetary or ‘in kind’) furnished to the provider of the education activity. Sponsorship must be acknowledged to learners. A written agreement is completed. When an educational activity is supported by more than one entity, each entity is a co-sponsor. Sponsors and co-sponsors do NOT participate in planning, developing and implementing the educational activity.
Q. How can I calculate and award contact hours for poster sessions (such as at a convention or multi-day CNE event)?
A. To award contact hours for poster sessions, the same criteria must be followed as for any other CE activity, including a logical and defensible method of determining the number of contact hours to award. There are a number of options. The approach chosen depends on the location of the posters, the schedule of the conference, and the objectives of the poster session. Simply assigning time in the conference schedule is not sufficient. The ANCC Accreditation Program staff can assist you in identifying options for your specific poster session.
Q. When a hospital is approved, but is part of a larger organization system, can they offer programs for the entire system under their name?
A. The approved provider unit can use their approved status only for those activities their provider unit plans, implements and evaluates. However, this provider can co-provide with other hospitals (either within the hospital system or without).
Q. In the above scenario, does the larger organization need to be accredited? Or does it depend more on their individual organizational structures?
A. The answer is the same.
Q. What is the value of ANCC accreditation status vs. California Board of Nursing approval (a cheaper and easier way to be approved)?
A. The California BON does claim that their approval is nationally recognized by all other BONs. However, this has not been verified. Approval through an ANCC approver is recognized by all BONs with the following exception: the CA and IA BONs will not recognize an approved provider’s CE if that provider enters those states to offer their CE, without the respective BONs approval. If the approved provider does not go into the states of CA or IA, then those BONs will recognized the provider’s contact hours awarded (this is true for internet courses and other home study courses as well).
Approval through an ANCC approver is also recognized by many certifying agencies such as the American Association of Diabetes Educators and ANCC.
Additionally, because approval through an ANCC accredited approver is reportedly found to be more rigorous than approval through the California BON, accreditation becomes a tool for the provider to know they are on target with their planning, implementing and evaluating of their CE, and a way to improve if they are not on target.
Q. How do you calculate contact hours for online or home study programs?
A. These hours must be calculated in a logical and defensible manner. One approach often used is the pilot study. Another approach sometimes used with written materials online is a recognized formula using data such as word count and level of reading and level of technical difficulty.
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