2015 Accreditation Program Overview Kathy Chappell, PhD, RN, FAAN, FNAP VP, Accreditation Program and Institute for Credentialing Research

What is the ultimate purpose of continuing nursing education?

Accreditation What is the value (or is there value) in using accreditation standards?

Burning question What is the one thing you want to make sure I cover before the end of today?

Effective Continuing Education Incorporates needs assessments (gap analysis) to ensure that the activity is controlled by and meets the needs of health professionals; Is interactive (e.g., group reflection, opportunities to practice behaviors); Employs ongoing feedback to engage health professionals in the learning process; Uses multiple methods of learning and provide adequate time to digest and incorporate knowledge; and Simulates the clinical setting. Redesigning Continuing Education in the Health Professions, 2010

To develop competence, learners must have: Adult Learners To develop competence, learners must have: A deep foundation of factual learning They must understand facts and ideas in the context of a conceptual framework And they must organize knowledge that facilitates retrieval and application Bransford and colleagues, 2000 How People Learn

PROFESSIONAL PRACTICE GAP

Starting out Problem in practice or opportunity for improvement (professional practice gap) How do you know it is a problem? What data do you have to validate the problem? What is the reason that the problem exists?

Professional Practice Gap Gap is the difference between the current state of “what is” and the desirable or achievable state “what should be or desired”

Professional practice gap

What should be: annual dilated exams Traditional continuing education What is: 35-50% screened What should be: annual dilated exams Traditional continuing education

Typical CE and transfer Clinical Practice Typical CE Clinical Practice

Outcomes-based CE and transfer Clinical Practice Outcomes Based CE Clinical Practice

Miller’s Model of Clinical Competence Knows: learner has knowledge about the topic/subject Knows how: learner is capable of applying the knowledge Shows how/does: learner is able to apply knowledge and skills in a simulated setting (shows how) or the practice environment (does)

Gap due to knowledge – doesn’t know Determining the underlying reason for a gap Gap due to knowledge – doesn’t know Gap due to skills – doesn’t know how Gap due to practices – not able to show or do in practice

Educational Design Process Assess knowledge (knows): Simple knowledge tests (multiple choice or similar) Assess skill (knows how): Case studies/extended matching multiple choice Case presentations Essay questions Assess practice (shows/does): Simulation (Objective Structured Clinical Examination) Observation in the practice setting * ACCME uses the analogous terms knowledge, competence and performance

Moore’s Model of CME Outcomes Traditional CME

Educational outcome: the result of an educational activity or program. What is an outcome? An outcome is the result of an activity or program. Educational outcome: the result of an educational activity or program. What kinds of educational outcomes are there?

What is the underlying educational need? Planning What is the underlying educational need? Knowledge, skill, practice, none What is the desired learning outcome? How will you evaluate change?

Gap analysis worksheet

Evidence to validate gap Gap due to knowledge, skill and/or practice Let’s practice Current state Desired state Identified gap Evidence to validate gap Gap due to knowledge, skill and/or practice Learning outcome Method of evaluation   New monitors have been purchased for the ICU Nurses know how to set up and use the monitors accurately and safely Nurses currently do not know how to use the new monitors The majority of nurses in the ICU have no experience with the new monitors; new technology Knowledge – have not had exposure to new monitor; do not know basic features of monitor system Skill – don’t know how to use the new monitor Practice – have not used the new monitor in patient care Nurses will successfully demonstrate knowledge related to use of new monitoring system Nurses will pass post-test with score of 90% or greater with content focused on safe use of new monitoring system.

Evidence to validate gap Gap due to knowledge, skill and/or practice Let’s practice Current state Desired state Identified gap Evidence to validate gap Gap due to knowledge, skill and/or practice Learning outcome Method of evaluation   Pediatric patients in respiratory distress are placed on a non-rebreather facemask within 5 minutes of presentation to the Emergency Department 100% of the time but frequently the facemask is not applied correctly Pediatric patients in respiratory distress are placed on a non-rebreather facemask applied correctly within 5 minutes of presentation to the Emergency Department 100% of the time Frequent inappropriate non-rebreather facemask application for pediatric patients in respiratory distress Direct observation by Clinical Nurse Specialist; comments from respiratory therapist in ED; comments from ED medical staff Lack of skill in correctly applying facemask to pediatric patients in respiratory distress Registered nurses in the Emergency Department will apply a non-rebreather facemask correctly to all pediatric patients in respiratory distress Successful return demonstration of application of a non-rebreather facemask for pediatric patients in respiratory distress

Evidence to validate gap Gap due to knowledge, skill and/or practice Let’s practice Current state Desired state Identified gap Evidence to validate gap Gap due to knowledge, skill and/or practice Learning outcome Method of evaluation   40% of patients 65 and older in our community health clinic are receiving the pneumococcal vaccine consistent with national guideline 100% of patients 65 and older in our community health clinic receive the pneumococcal vaccine consistent with national guideline 60% of patients 65 and older in our community health clinic are not receiving the pneumococcal vaccine consistent with national guideline Chart audit of patient files; interviews with nurses; 75% of nurses report they are not familiar with updated national guideline and therefore were not providing information about the vaccine Knowledge – unaware of updated guidelines Registered nurses will demonstrate they know the updated vaccine recommendations for all patients 65 and older Complete post-test with passing rate of 80% or greater

Nurse Educators Other examples Knowledge Skill Practice Components of high quality evidence Skill How to evaluate evidence Practice Using/applying evidence in practice

Nurse Administrators Other examples Knowledge Skill Practice Components of a business case proposal Skill How to calculate return on investment Practice Creating, tracking and revising a budget

Share again: Share with table/group Think, Pair, Share Think: Of a problem in practice or opportunity for improvement you want to address Pair: Find someone you don’t know and describe the problem or opportunity; define the professional practice gap Share: Switch roles Share again: Share with table/group

EDUCATIONAL INTERVENTION

Clinical Scenario There has been an increase in the number of patients returning to the hospital within 30 days. More re-admitted patients have a post-surgical diagnosis rather than a medical diagnosis. The Chief Surgical Officer has evaluated performance outcomes for surgeons in his department. Patients of two surgeons are significantly more likely to be readmitted when compared to patients of peers. When questioned, the two surgeons dispute the trend and both blame difficulties communicating with the nurses on the surgical floor. The nursing staff from the surgical floor rate physician-nurse collaboration as poor. Of the 10 surgeons admitting patients into the hospital, 6 describe physician-nurse collaboration as moderate to strong and 4 describe collaboration as fair to poor. The nursing staff rates physician-nurse collaboration as fair to poor. 80% of patients who return to the hospital within 30 days were discharged after 6 pm. 60% of patients who return to the hospital within 30 days state that they did not understand their discharge instructions when they left the hospital. The nursing staff says when they try to tell a surgeon that a patient is not ready for discharge, their concerns are rarely acknowledged.

References Miller, G. E. (1990). The Assessment of Clinical Skills/Competence/Performance. Academic Medicine, 65(9), S63 – S67. Moore, D. E., Green, J. S. & Gallis, H. A. (2009). Achieving Desired Results and Improved Outcomes: Integrating Planning and Assessment Throughout Learning Activities. Journal of Continuing Education in the Health Professions, 29(1), 1 – 15.

PLANNING COMMITTEE

Nurse Planner Content Expert Others as desired Planning Committee Active, unencumbered nursing license Prepared at baccalaureate degree or higher Responsible for compliance of activity being planned Content Expert Content expertise in subject matter Others as desired

LEARNING OUTCOMES

Eliminated objectives Require learning outcome(s) Learning outcome Eliminated purpose Eliminated objectives Require learning outcome(s) Learning outcome Outcomes-based approach Learner-centric Explicit description of what a learner should know, be able to apply and/or be able to do as a result of participating in the educational activity Measurable, objective Capable of being assessed

Must be based on the desired outcome of the educational activity Learning Outcome Must be based on the desired outcome of the educational activity Need to start with the end in mind What do you want learners to know, be able to do, can do after participating in the educational activity? Strategies: 5 Whys Diagram (fishbone)

Learning Objective Learning Outcome List 5 side effects of anti-hypertensive agents Discuss risks associated with untreated hypertension State normal range for blood pressure Knowledge: Demonstrate knowledge of evidence-based treatment for hypertensive patients by passing post-test with score of ≥ 80% Competence/Skill: Correctly identify required actions to manage patients in hypertensive crisis by analyzing a case study. Performance: Utilize an evidence-based protocol when caring for hypertensive patients

Learning Objective Learning Outcome Describe characteristics of effective communication styles List 5 methods of creating a safe environment for holding a confidential conversation Define SBAR Apply the principles of SBAR when communicating critical information Knowledge: At conclusion of the educational activity, participants will self-report knowledge gain of effective communication styles using Likert scale Competence/Skill: At conclusion of the educational activity, participants will self-report intent to change practice by applying evidence-based communication strategies Performance: At 6 month post-program evaluation, participants will self-report actual change in practice Patient Outcomes: At 9 month post-program evaluation, participants will self-report impact on patient outcomes as a result of change in communication strategies

Learning Outcomes Objectives can be written "out of context", but learning outcomes connect the identified practice gap with the related educational need Learning outcomes frame the context for objectives Learning outcomes demonstrate why "list", "discuss", and "state" are important Learning outcomes provide the measurable evidence of progress in closing the practice gap - objectives don't do that

PLANNING

What content are you going to use within the activity? Planning What content are you going to use within the activity? How are you going to engage learners? What criteria are you going to use for successful completion? How are you going to evaluate the activity?

Content: Evidence-based or based on best-available evidence Resources: Planning document has categories for choosing evidence http://www.nursingworld.org/Research-Toolkit

Evidence continued Peer-reviewed journals or peer-reviewed textbooks ensures that the article or content has been critically evaluated by experts in the field. Web-based resources that require peer review or only allow content that has been peer-reviewed ensures that readers have access to high-quality evidence. Organizations such as the Agency for Healthcare Research and Quality (AHRQ), National Quality Forum (NQF), or Centers for Disease Control (CDC) regularly post evidence related to particular diseases or treatment of disease. Evidence-based clinical guidelines are posted on sites such as www.guidelines.gov. Content for educational activities should also be chosen from resources that have been recently published. One guideline is to look for articles that have been published within the past 5 – 7 years, or as appropriate for the content area.

Strategies to engage learners may include but are not limited to: Engaging Learners Strategies to engage learners may include but are not limited to: Integrating opportunities for dialogue or question/answer Including time for self-check or reflection Analyzing case studies Providing opportunities for problem-based learning Active learner engagement may function as an opportunity for formative assessment during the educational activity by providing the presenter with immediate learner feedback.

Criteria for Successful Completion Criteria may include but are not limited to: Awarding credit commensurate with participation in the activity Requiring attendance for a specified period of time (e.g., 100% of activity, or miss no more than 10 minutes of activity) Successfully completing a post-test (e.g., attendee must score X% or higher) Completing an evaluation form Successfully completing a return demonstration Criteria should be based on the desired learning outcome

Evaluation Options Evaluation Short-Term Long-Term   Evaluation Options Short-Term Long-Term Intent to change practice Active participation in learning activity Post-test Return demonstration Case study analysis Role-play Self- reported change in practice Change in quality outcome measure Return on Investment (ROI) Observation of performance

Awarding contact hours Planning Awarding contact hours Live Enduring Blended 60 minute hour Method must be defensible Mergener’s formula

Identifying and resolving any conflicts of interest Identifying and Resolving COI Identifying and resolving any conflicts of interest All individuals in a position to control content Disclose all relationships with commercial interest organizations or relevant relationships with commercial interest organizations Within past 12 months To include relationships of spouse/significant other http://www.nursecredentialing.org/Accreditation-CEContentIntegrity.pdf

Eligibility to participate in planning/presenting Employees of commercial interest organizations are not permitted to serve as planners, speakers, presenters, authors and/or content reviewers if the content of the educational activity is related to the products or services of the commercial interest organization. Employees of commercial interest organizations are permitted to serve as planners, speakers, presenters, authors and/or content reviewers if the content of the educational activity is NOT related to the products of the commercial interest organization. Individuals who have non-employee relationships with commercial interest organizations (see bullet 2 below) are permitted to serve as planners, speakers, presenters, authors and/or content reviewers as long as the Provider has implemented a mechanism to identify, resolve and disclose the relationship as outlined in these standards.

Conflict of Interest The potential for conflict of interest exists when an individual has the ability to control or influence the content of an educational activity and has a financial relationship with a commercial interest,* the products or services of which are relevant to the content of the educational activity.

Commercial Interest Organization The American Nurses Credentialing Center (ANCC) defines an organization as having a commercial interest (“Commercial Interest Organization”)* if it: Produces, markets, sells or distributes health care goods or services consumed by or used on patients; Is owned or operated, in whole or in part, by an organization that produces, markets, sells or distributes health care goods or services consumed by or used on patients; or Advocates for use of the products or services of commercial interest organizations.

Relevant Relationships Relevant relationships, as defined by ANCC, are relationships with a commercial interest if the products or services of the commercial interest are related to the content of the educational activity. Relationships with any commercial interest of the individual’s spouse/partner may be relevant relationships and must be reported, evaluated, and resolved. Relationships are considered relevant if they have occurred within the past 12 months

Resolution Process – may include but not limited to… Removing the individual with conflict of interest from participating in all parts of the educational activity. Revising the role of the individual with conflict of interest so that the relationship is no longer relevant to the educational activity. Not awarding continuing education contact hours for a portion or all of the educational activity. Undertaking review of the educational activity by the Nurse Planner to evaluate for potential bias, balance in presentation, evidence-based content or other indicator of integrity and absence of bias AND monitoring the educational activity to evaluate for commercial bias in the presentation. Undertaking review of the educational activity by the Nurse Planner to evaluate for potential bias, balance in presentation, evidence-based content or other indicator of integrity and absence of bias AND reviewing participant feedback to evaluate for commercial bias in the activity Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicator of integrity and absence of bias AND monitoring the educational activity to evaluate for commercial bias in the presentation. Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicator of integrity and absence of bias AND reviewing participant feedback to evaluate for commercial bias in the activity

Decision Matrix Identify who has the opportunity to influence the content of the educational activity. For all individuals who have the opportunity to influence content: document relationships the individual (including spouse/significant other) has with commercial interest organizations within the past 12 months. Evaluate relationships individuals have with commercial interest organizations. Are the products or services of the commercial interest relevant to content of educational activity? If relationship is relevant, resolution is required

Scenarios – COI or not?

Commercial Support commercial support. Financial or in-kind contributions given by a commercial interest that are used to pay for all or part of the costs of a CNE activity. Providers of commercial support may not be providers or joint providers of an educational activity.

Commercial support What if the representative of the proposed commercial interest organization refuses to sign the commercial support agreement? What if a commercial interest organization stipulates that, in order to receive funds, advanced practice nurses must be in the target audience for the session?   A commercial interest organization wants to give learners note pads featuring the commercial entity’s logo. What is the Accredited Provider’s responsibility? The sales representative from the commercial interest organization providing support for the Accredited Provider’s conference wants to attend conference sessions. Is this permissible?

Commercial Support A commercial interest organization providing commercial support wants to use her/his company’s written agreement rather than the Accredited Provider’s. Is that acceptable? A commercial interest organization providing commercial support wants to include a full-page advertisement on the inside cover of the course syllabus. What is permissible?   Can a commercial interest organization provide food for a “lunch and learn” planned by the Accredited Provider? I’m the Nurse Planner working on a learning activity for which a commercial interest organization gave $5000 to support the event. Do I need to keep a record of how this money is spent? May the Accredited Provider include the logo of a commercial interest organization on its marketing material?

Financial or in-kind support for the activity: Decision Matrix Financial or in-kind support for the activity: Yes or No? If yes, classify the organization providing the support: commercial interest or not? If commercial interest = commercial support If not, no requirement to document

Exhibitors, Vendors, Advertising Revenue attained from exhibitor, vendor or advertising is not considered commercial support. Commercial support is relevant when the money is directly tied to an educational activity awarding ANCC contact hours

Joint Providership Two organizations working together to plan, implement and evaluate an educational activity One is provider, one is joint provider Joint provider may not be a commercial interest organization Provider awards contact hours Marketing materials must reflect the provider awarding contact hours Learners must be informed of joint providership

Achieving the outcome Educational Design Process Using summative data Measuring a change in nursing practice or Nursing Professional Development Go back to the outcome of the activity What did you want to achieve? Did you close the gap? Why or why not? What next?

Recordkeeping Professional Practice gap COI documentation for all individuals in a position to control content Current state Desired state Evidence of resolution process if applicable Evidence to validate gap Educational need that underlies gap Number of contact hours awarded Description of target audience Method of calculation Certificate of completion Desired learning outcome(s) Commercial support agreement if applicable Description of content with references or resources Required information to learners: Learner engagement strategies Accreditation statement Criteria for awarding contact hours Description of evaluation method Presence or absence of COI for all individuals in a position to control content Evidence that change in knowledge, skills and/or practices was assessed Commercial support if applicable Names and credentials of all individuals in a position to control content Expiration date if applicable Joint providership if applicable Nurse Planner Summative evaluation Content Expert

Not an accreditation criteria requirement! Return on Investment Not an accreditation criteria requirement! Think about the return on investment for educational activities NOT the “smiley scale” Cost reduction Efficiency Effectiveness

Questions?