Policies and Procedures

POLICIES AND PROCEDURES APPROVAL UNIT

Revised 2009

A O R N - Association of periOperative Registered NursesDenver, Colorado

POLICY AND PROCEDURE - APPROVAL UNIT

Index PageNo. No.

Selection of Continuing Education Approval Committee (CEAC) 1.a 2Duties and Responsibilities of the Continuing Education Approval Committee 1.b 3Eligibility Criteria 2.0 4Distribution of “Application for Approval of Contact Hours” and a Directions Document 3.0 5Deadline for Submission of Applications and Fee Schedule (see Appendix E) 4.0 6Categories of Approval 5.a 7Use of ANCC Accreditation Criteria and Evidence to Implement the Approval Process 5.b 8System for Awarding Credit 5.c 9Retroactive Approval 5.d 10Recognition of the ANCC Commission on Accreditation System 5.e 11Use of the Accreditation Statement 5.f 12AORN Headquarters – Provided Activities 5.g 13Quality Assurance and Monitoring of CNE Activities 5.h 14Reporting of Information to ANCC 5.i 15Maintaining Compliance with Current Criteria, Policies, and Procedures 5.j 16Termination of Accredited Approval Unit 5.k 17Use of ANCC Criteria for Review of Applications 6.a 18Type of Action that Can Be Taken on an Application 6.b 21Notification of Action Taken on an Application 6.c 22Calculation of Contact Hours (CH) 6.d 23Publication of Approved CNE Activities 6.e 24Withdrawal of Applications 6.f 25Resubmission of a Withdrawn Application 6.g 26Appeal of Action Taken on Applications 6.h 27Implementation of performance Improvement and QA Tools 6.i 30Revocation of Approval 6.j 31Conflict of Interest – CEAC member 6.k 32Confidentiality of Application Information 6.l 33Authority of Approval Unit 7.0 34Co-provided Activities 8.0 35Implementation of a Peer Review Approval Process for All Application Categories for Which Approval May Be Granted 9.0 36Expectations of Applicants Using Approval Process Regarding Recordkeeping 10.0 39Attendees Will be Made Aware of Commercial Support 11.0 40Conflict of Interest – Applicant 12.0 41

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Issue Date: August 1987 Index Number: 1.aReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

Selection of CNE Approval Committee (CEAC)

POLICY

CNE Approval Committee (CEAC) members are appointed by the President of AORN in collaboration with the Director of Education (administratively responsible for ANCC Criteria), Nurse Consultant to CEAC, and the Approval Process Project Coordinator.

PROCEDURE

Qualifications of CEAC members:

1) Potential members will complete a CEAC Willingness-to-Serve form. 2) Member of Association of periOperative Registered Nurses, Inc., and hold a minimum of a

Bachelor of Science degree in Nursing. 3) Knowledge of the CNE needs of the perioperative nurse, including some experience planning,

implementing, and evaluating educational activities – can be through chapter, state nurse’s organization, or job.

4) Knowledge of the ANCC/AORN criteria for approving CNE for nurses. 5) Ability to work independently and meet timelines. 6) Access to email and internet

Appointment:

1) Two peer review teams are appointed by the nurses responsible for Approval Unit and by the Project Coordinator annually in December and assume full committee responsibilities at the annual orientation meeting in Spring.

2) The two peer review teams will each have a team leader. Additional members to the Committee may be appointed as a "rush reviewer" who serves independently of either team.

3) A resignation from the committee requires the appointment of a replacement from the pool of CEAC Willingness-to-Serve forms.

Issue Date: August 1987 Index Number: 1.bReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

Duties and Responsibilities of the CNE Approval Committee.

POLICY

Continuing Education Approval Committee (CEAC) members' duties and responsibilities will be outlined. Members are expected to meet timelines.

PROCEDURE/CRITERIA

Member Duties and Responsibilities

1) Sign a "Committee Consent form", "Policy on Ownership form", “Acknowledgement of Timeline Requirements”, and “Release of Contact Information form”.

2) Using the American Nurses Credentialing Center's Commission on Accreditation (ANCC)/Association of periOperative Registered Nurses (AORN) criteria, review the quality of continuing nursing education (CNE) applications received. Use “Criteria Checklist” to review applications for paper applications. Website forces completion of required components.

3) Take action on applications granting: approval, approval pending, or denied.4) Return "Criteria Checklist" within the appropriate timeframe for paper applications.5) Participate in the formulation, the review, and the revision of published criteria, policies and

procedures relating to the Approval Process.6) Develop and implement evaluation procedures to assure that the Approval Process is compliant

with ANCC Commission on Accreditation (ANCC) criteria.7) Suggest Approval Process changes based on various evaluations and quality assurance

mechanisms.8) Evaluate all aspects of the Approval Unit

a) Develop an evaluation planb) Review results of all quality improvement tools utilized and make appropriate revisions.c) Using results of consumers’ input, make appropriate revisions.d) Review website application monthly.

Issue Date: August 1987 Index Number: 2.0Review Date: March 2009 Updated: March 2009

POLICY SUBJECT

Eligibility Criteria

POLICY

The AORN Approval Unit will accept appropriate categories of applications from chapters, state councils, specialty assemblies, individuals, and organizations (i.e., colleges, hospitals).

PROCEDURE

1) The Approval Unit will accept the following types of applications:a) Application for Approval of Contact Hours

2) Applications will be accepted from both AORN constituents and non-constituents with continuing nursing education content.

3) The following activities are not accepted for approval:i) An application received after the activity has been presented.ii) An application that focuses on a topic that is in conflict with AORN Standards and

Recommended Practices or an official AORN position.iii) An application that focuses on financial planning for nurses rather than on continuing

nursing education, as delineated by ANCC.iv) A co-provided activityv) An application submitted from a commercial entity


POLICY SUBJECT

Distribution of “Application for Approval of Contact Hours” and a Directions Document.

POLICY

Any party interested in receiving approval for CNE may access the online application and instructions at www.aorn.org/Education/CEApprovalProcess/.

PROCEDURE

1) Inquiries received at AORN for Contact Hour approval are sent to the Approval Process Project Coordinator.

2) Constituents and non-constituents are referred to the web-based application. Directions for application are on website.

3) Information about “Application” and “Directions” are distributed at Leadership Conference.4) Revisions/clarifications of the “Application” and “Directions” occurring throughout the year are

distributed to the chapter president via the Approval Process Project Coordinator in the monthly president's mailing. Notification of revisions/clarifications are sent to non-constituents with approved activities.

5) Articles are written for the AORN Journal/ Connections to alert members to changes/revisions in directions, policy, and/or criteria.

6) “Application” and “Directions” may be requested by calling the AORN Approval Unit at (800)755-2676, extension 254 or visiting the AORN website: http://www.aorn.org/education/approval.htm

http://www.aorn.org/education/approval.htm


POLICY SUBJECT

Deadline for Submission of Applications and Fee Schedule (see Appendix E)

POLICY

Deadlines for submission of applications and fee schedule will appear in AORN publications.

PROCEDURE

1) Deadlines for submission and fee schedule are published in the “Directions" and accessible via AORN web page

2) Any changes in the deadline or fee schedule are sent in the monthly presidents' mailing. Non-constituents with approved activities are sent notification of changes.

3) Refundsa) If a payment is required and if the application is withdrawn prior to action by the Continuing

Education Approval Committee, all fees are refunded.b) The full fee is refunded for ineligible applications.c) No refunds are given after action is taken by reviewers on applications.

4) Refund requesta) A refund request is forwarded to the AORN Accounting Department by the Approval Process

Project Coordinator.b) A check is drafted by accounting for the amount of refund.c) The Approval Process Project Coordinator mails the refund to applicant.


POLICY SUBJECT

Categories of Approval

POLICY

The AORN Approval Unit will accept only those categories of activities identified as acceptable per ANCC guidelines.

PROCEDURE

1) The following categories of applications will be accepted:a) Application for Approval of Contact Hours

i) Recognition of (a) a single educational activity, or (b) a planned series of offerings which have a common theme and overall goals, which may be repeated an unlimited number of times during the two-year approval period.

ii) Recognition of a single, self-paced learning activity developed by an applicant which may be given an unlimited number of times during the two-year approval period.

2) The AORN Approval Unit will continue to accept all categories of applications for approval for which the unit is eligible.

Issue Date: August 1987 Index Number: 5.bReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

Use of ANCC Accreditation Criteria and Evidence to Implement the Approval Process

POLICY

The Approval Unit requires submission of ANCC minimum-required information submitted for review. The Approval Unit may request additional information for purposes of quality assurance/improvement.

PROCEDURE

1) The “Application” and “Directions” identify all ANCC requirements for submission. 2) The additional information for purposes of the quality assurance mechanism is identified in

“Directions”. The additional information required at this time is the following:a) Post Activity Report which includes:

i) Summary of Evaluationii) A Sample Certificate

Issue Date: August 1987 Index Number: 5.cReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

System for Awarding Credit

POLICY

Credit will be awarded based on the 60-minute Contact Hour (CH). The CEUnit (CEU) system is not used by the Approval Unit.

PROCEDURE

1) A Contact Hour is 60 minutes of an approved, organized learning experience, which is either a didactic or clinical experience and includes time to complete evaluation of activity.

2) An applicant using the CEU term incorrectly to describe Contact Hours will be notified and a change requested.

3) CEAC determines accuracy of Contact Hours by totaling the number of minutes spent in an organized learning experience (didactic or clinical) and dividing by 60 minutes.

4) 0.5 CH is the minimum amount that may be awarded.5) Contact hours are automatically calculated when the number of minutes is entered for each

objective in the web application.

Issue Date: May 1994 Index Number: 5.dReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

Retroactive Approval

POLICY

Retroactive approval will not be awarded to any activity.

PROCEDURE

1) Guidelines and criteria state that retroactive approval is not awarded.2) As activities are received, the scheduled date of presentation is reviewed for appropriate

timeframe. 3) The web-based application prevents entry of a timeframe that occurred in the past.

Issue Date: May 1994 Index Number: 5.eReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

Recognition of the ANCC Commission on Accreditation System

POLICY

The ANCC Commission on Accreditation is the source of AORN's Approval Unit accreditation. That information will be placed on all appropriate marketing materials and Certificate of Attendance.

PROCEDURE

1) The Approval Unit recognizes approval granted by other ANCC accredited approvers.2) The “Application” and “Directions” include the wording of the specific accreditation statement

that must be on the certificate of attendance and on published information about the activity.3) A sample Certificate of Attendance with the appropriate statement is included in the paper

application. The web application provides an automatically-generated Certificate of Attendance that contains the appropriate statement.

4) When a change is made in the accreditation statement, the users of the Approval Process will be notified through the monthly presidents’ mailing, email, and/or letter.

5) The accreditation statement is considered the “brand” of the Commission on Accreditation process and as such must stand by itself:

This continuing nursing education activity was approved by the Association of periOperative Registered Nurses, Inc., an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

AORN recognized this activity as continuing education for registered nurses. This recognition did not imply that AORN or the ANCC Commission on Accreditation approved or endorsed any product included in the presentation.

Issue Date: August 1987 Index Number: 5.fReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

Use of the Accreditation Statement

POLICY

The correct approval language is to be placed on all appropriate marketing materials and on Certificate of Attendance.

PROCEDURE

1) Marketing/promotional materials for activities submitted to the Approval Unit for peer review must contain the following accreditation statement:a) This activity has been submitted to the Assocation of periOperative Registered Nurses, Inc. for approval to award contact hours. The Association of periOperative Registered Nurses, Inc. is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

2) The accredited approval statement is to appear on all Certificates of Attendance and on all marketing/promotional materials distributed after the program has received approval. The web applications provides a complete Certificate of Attendance with required statement. a) This continuing nursing education activity was approved by the Association of periOperative Registered Nurses, Inc., an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

3) When a change is made in the wording of the accreditation statement, the users of the approval process will be notified by an update on the CE Approval web page.

Issue Date: August 1987 Index Number: 5.gReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

AORN Headquarters-Provided Activities

POLICY

AORN Headquarters-provided activities are not brought through the Approval Unit.

PROCEDURE

1) The Approval Unit does not accept AORN Headquarters-provided activities for review.2) AORN-headquarters’ provided activities are monitored through the Provider Unit.3) The Approval Unit and the Provider Unit are totally separate operating units.

Issue Date: May 1994 Index Number: 5.hReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

Quality Assurance and Monitoring of CNE Activities

POLICY

The Approval Unit will carry out its own quality assurance mechanisms.

PROCEDURE

1) Annually in the Spring, CEAC/Approval Process committee will review all components of the peer review Approval Process.

2) CEAC will determine and develop any additional quality improvement mechanisms. 3) CEAC will monitor approved applicants to ensure they are following ANCC Criteria.4) CEAC may choose to make changes in the quality assurance/quality improvement mechanism at

any time.5) See policy and procedure 6.i, "Implementation of Performance Improvement and Monitoring

Mechanisms.”

Issue Date: May 1994 Index Number: 5.iReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

Reporting of Information to ANCC

POLICY

The Approval Unit Nurse Administrator (Director of Education), Nurse Consultant to CEAC, and Project Coordinator are responsible for submitting information as requested or required by ANCC.

PROCEDURE

1) The nurse administrator and nurse consultant will identify information required with Approval Unit Project Coordinator.

2) The AORN Project Coordinator for the Approval Unit will submit requested information to ANCC in order to help evaluate and monitor the accreditation/approval system.

3) In order to maintain accredited status, the following must be reported to ANCC, in writing, within 30 days of:a) Confirmation of new CEAC; submit BDF for each CEAC member.b) Changes in the approval systemc) Changes in personnel directly responsible for implementing the Approval Processd) Changes in the structure of AORN that influence the ability of AORN to approve application

(Application for Approval of Contact Hours).4) Annual Report

Issue Date: August 1987 Index Number: 5.jReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

Maintaining Compliance with Current Criteria, Policies, and Procedures.

POLICY

The AORN Approval Unit will function within the ANCC's current criteria and AORN’s policies, and procedures.

PROCEDURE

1) Members of CEAC participate in a series of orientation conference calls and webinars beginning in April or May.

2) The following topics are covered:a) Philosophy, Purpose and Goals of CEACb) Approval Unit Policies & Proceduresc) American Nurses Credentialing Center (ANCC) Criteriad) Discussion of Contact Hour Approval for CNE Activitiese) Application for Approval of Contact Hoursf) Review of applications submitted for approval g) Statistical information, including:

i) Applications Received by Monthii) Breakdown of Lead Time on Applicationsiii) Hours Spent by CEAC Reviewing Applicationsiv) First Review Results by Categoryv) QA Surveysvi) Approval Process Evaluations

h) Miscellaneous Administrative Items3) The Approval Unit will provide the full range of services for which it was originally accredited.4) The Approval Unit will follow the published criteria of the ANCC Commission on Accreditation

to implement the Approval Process.5) The Approval Unit will revise, communicate, and implement, any revisions requested by ANCC

within the timeframes designated by ANCC.6) See Policy 10.0 for more details.

Issue Date: May 1994 Index Number: 5.kReview Date: March 2009

Updated: March 2009

POLICY SUBJECT

Termination of Accredited Approval Unit

POLICY

If the decision is made to terminate the Approval Unit, ANCC will be notified in writing at least six (6) months prior to termination.

PROCEDURE

1) If the decision is made to terminate the Approval Unit activities, ANCC will be notified in writing six months prior to termination.

2) The Approval Unit will request from ANCC the procedures for notifying those agencies which have received approval that the services will be terminated.

3) The Approval Unit will comply with the notification process to agencies which have received approval as identified by ANCC.

4) All other ANCC termination procedures will be followed. 5) AORN will continue to maintain records of activities for the required time period.


POLICY SUBJECT

Use of ANCC Criteria for Review of Applications

POLICY

CEAC uses ANCC criteria to review applications submitted for approval.

PROCEDURE1) Members of CEAC participate in the annual orientation conference call, webinar/meeting in the

Spring. The following topics are covered:a) Philosophy, Purpose and Goals of CEACb) Approval Unit Policies & Proceduresc) American Nurses Credentialing Center (ANCC) Criteriad) Guidelines for Contact Hour Approval for CNE Activitiese) Application for Approval of Contact Hoursf) Review of applications submitted for approval g) Statistical information, including:

i) Applications Received by Monthii) Breakdown of Lead Time on Applicationsiii) Hours Spent by CEAC Reviewing Applicationsiv) First Review Resultsv) QA Surveysvi) Approval Process Evaluations

h) Miscellaneous Administrative Items2) CEAC uses the following criteria from the ANCC to review the Application for Approval of

Contact Hours.a) Application

i) Applicant identifies if the program/activity received previous denial(s) from other ANCC accredited approver units?

b) Planning Committeei) Registered nurse(s) with a baccalaureate or higher degree in nursing is/are responsible for

the planning, development, implementation, and evaluation of CNE activities in nursing.ii) Planning committee members must represent – target audience, content expert,

knowledgeable regarding ANCC criteria.iii) Planning of activities is guided by results of needs assessment.iv) Target audience is identified. RNs are identified as a component part of the target

audience.v) Overall theme/purpose of activity is identified as CNE.vi) Conflict of Interest identified and disclosedvii)Disclosure by the applicant of previous denials from other ANCC accredited approver

unitsc) Physical facilities

i) Documentation of activity location (name, address, city, and state)d) Verifying Participation and Successful Completion

i) Identify method for verifying participation

ii) Identify method(s) to be used to identify successful completione) Recordkeeping and Storage System

i) Identify that records are maintained for six yearsii) Identify method for maintaining and retrieving records

f) Contact Hour Calculation – Live Presentationsi) Verify that contact hours requested have been calculated correctly based on the timeframes

provided in the ADF and the formula of total number of minutes presented divided by 60 = the same amount of contact hours requested.

g) Independent Studyi) Verify evaluation of effectiveness of independent studyii) Verify method of calculating contact hoursiii) Identify supportive documentation of the rationale used to determine contact hour calculation

h) Marketing/Promotional Materialsi) Verify that marketing/promotional materials contain AORN’s correct accreditation statement.ii) Commercial support is noted as appropriateiii) Co-provider activities are allowed.

i) Presentersi) Take active part in planning and evaluating activity

(1) Are selected based on their knowledge and expertise in the content area as evidenced by BDF.ii) Conflict of Interest identified and disclosed

j) Purpose/Goali) Identified and stated in one or two sentences

k) Objectivesi) Are stated in single, measurable terms on the ADFii) All major aspects of the activity as specified in the content outline are included.

l) Contenti) Recorded in outline format on ADFii) Expands on objectives

m) Timeframe – Face-to-Face Presentationsi) A timeframe is assigned for each objective or content areaii) The time allotted must be appropriate for the described content.iii) Contact Hours are calculated on the following basis: 60 minutes equal one (1) Contact Hour.

n) Evaluation Form includesi) Learner's achievement of each objectiveii) Purpose/goal of programiii) Relationship of objectives to overall purpose/goal(s) of activityiv) Expertise of each individual speakerv) Appropriateness of teaching strategiesvi) Notification of commercial support for education portion of program; notification of Conflict of

Interest of speakers; notification of off-label use or in-kind support for the education component.vii) Indication of whether information gained in program attendance will change practice.

o) Certificate of Attendancei) Name of Applicant ii) Space for participant's nameiii) Title of Activityiv) Date of Activityv) City and State

vi) Number of Contact Hours awardedvii)AORN's accreditation statement (the ANCC accreditation stands alone)viii) Name/Address of Contact Person

n) Commercial Support Identifiedi) Contract included for commercial supportii) Disclosure of how commercial bias is prevented

3) The paper application is evaluated using one of the attached Criteria Checklists.4) The Criteria Checklist is included with the application.5) The web-based process promotes the reviewer for required elements6) The web-based process forces applicants to enter information for required elements7) The reviewers determine the quality/accuracy of entered information. 8) See Policy 10.0 for more details.

Issue Date: May 1994 Index Number: 6.bReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

Type of Action that Can Be Taken on an Application

POLICY

Applications are reviewed and one of the following actions are taken: Approved, Approval Pending, or Denied.

PROCEDURE

1) Upon completion of the review process, the reviewer will select the recommended action.2) Types of recommended action are:

a) Approved means the entire application was complete and met the criteria. An electronic letter is sent stating that the activity may be presented as often as desired for a two-year period. Different presenters may be used, provided they address the same objectives and content and an approved biographical data form is submitted to the Approval Unit prior to presentation.

b) Approval Pending means Contact Hours for the activity have been placed on hold pending submission of changes requested by reviewers. Information must be received and reviewed by a committee member or CEAC Nurse Consultant prior to presentation. When the changes have been approved, an electronic letter is sent confirming that the activity is changed from Approval Pending to Approved and that the activity may be presented as often as desired for a two-year period. Different presenters may be used, provided they address the same objectives and content and an approved biographical data form is submitted to the Approval Unit prior to presentation.

c) Denied means Contact Hours may not be awarded for the activity because the content does not meet the definition of Continuing Nursing Education. The contact person will be notified by phone and letter.

3) An approved activity may have the approval revoked if the committee determines that the criteria are not being followed based on investigation of a complaint by the committee that criteria is not being followed.

4) Activities repeated during the two year approval may be adjusted/modified according to the evaluations. The applicant must notify the AORN Approval Unit of changes.

Issue Date: August 1987 Index Number: 6.cReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

Notification of Action Taken on an Application

POLICY

Applicants will be notified in a timely manner via email of action taken on their application for Contact Hours.

PROCEDURE

1) Notification via e-mail of action taken on an application is sent within two working days of receiving the reviewers’ completed review at Headquarters.

2) When an application is denied, the applicant is notified by phone and the problem areas are reviewed. A follow-up email is sent, identifying the problem areas discussed.

Issue Date: August 1987 Index Number: 6.dReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

Calculation of Contact Hours (CH)

POLICY

One Contact Hour is earned for 60 minutes of an approved, organized learning experience, or 60 minutes of planned, supervised clinical practice designed to meet educational objectives.

PROCEDURE

1) Allotment of contact hours is exclusive of time spent for meals, breaks, and introductions.2) Evaluation time, questions and answers may be included in calculation of Contact Hours (CHs).3) One 30-minute period is the minimal unit of recognition. In any education activity, the 30-minute period

must be achieved prior to awarding portions of Contact Hours.4) Contact Hours are calculated by dividing total contact time in minutes by 60. For example, 120 minutes

= 2 contact hours.5) Portion of a contact hour may be awarded. Contact hours may not be rounded up.

Issue Date: August 1987 Index Number: 6.eReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

Publication of Approved CNE Activities

POLICY

Chapter, state council, and specialty assembly CNE activities approved by AORN that are four hours or more in length, may be published in the AORN Journal "Educational Opportunities" column at no charge. The approved activities will be published on the AORN web site.

PROCEDURE

1) If publication of information is desired, the chapter, state council or specialty assembly must submit in writing or by telephone, the title, the date, the location, and the contact person to AORN Approval Unit at least three months in advance of activity date.

2) The Approval Process Project Coordinator notifies the applicant in writing of the confirmation.3) The activity will be publicized in the "Educational Opportunities" column of the AORN Journal

for at least two months before the scheduled activity date.4) The Approval Process Project Coordinator compiles a list of constituent-approved activities that

is placed on the website and updated quarterly.a) The applicant name, activity title, activity date, and number of approved Contact Hours are

included. b) The Approval Process Project Coordinator places this information on AORN’s website.

Issue Date: August 1987 Index Number: 6.fReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

Withdrawal of Applications

POLICY

An applicant may withdraw an application without prejudice to any future applications

PROCEDURE

1) Written notification of withdrawal to the Approval Unit is required.2) A copy of the application and supporting documents will be maintained in the AORN files. 3) The applicant may resubmit the application at a later date. The application will be treated as any

other application.

Issue Date: August 1987 Index Number: 6.g

Review Date: March 2009 Updated: March 2009

POLICY SUBJECT

Resubmission of a Withdrawn Application

POLICY

An application may be resubmitted after it has been withdrawn prior to review.

PROCEDURE

1) The application is submitted as any other application. 2) The required fee must be submitted.

Issue Date: August 1987 Index Number: 6.hReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

Appeal of Action Taken on Applications

POLICY

The appeal of action taken on an application is the process used by an applicant to request a reconsideration of adverse committee action taken on an application for CNE.

PROCEDURE

Appeal Committee Composition

1) The appeal committee shall be an ad-hoc committee consisting of three members familiar with CNE and hold a baccalaureate or higher degree in nursing, and be part of the CEAC.

2) The members of the ad-hoc committee would not be part of the original decision-making body.3) If a conflict of interest exists the appeal committee member would be excused and be replaced.4) The chair of the ad-hoc committee shall be chosen by its members.

Applicant's Responsibility The applicant submitting the appeal of an adverse decision on an application shall:

1) Notify the AORN Approval Unit, in writing, by registered mail, of the intent within 15 calendar days of the date of CEAC's letter of action. Instructions/responsibilities will be returned to the sender within three (3) working days.

2) Accompany the letter of intent with any clarifying statements of substantiating data deemed necessary or helpful on the applicant's behalf. (No new or revised data may be furnished for consideration at the hearing.)

3) Furnish the AORN Approval Unit with the name and title of representatives attending the hearing, if representation is desired.

4) Supply representative(s) with appropriate documents for use on behalf of the applicant.5) Make arrangements for representation at the hearing, if such is desired.6) Notify the AORN Approval Unit at least three (3) days before the hearing date if withdrawal of

the appeal is desired.7) The applicant is responsible for all of his/her expenses

Nurse Consultant to CEAC’s Functions Associated with An Appeal

1) Notify the Nurse Consultant to CEAC, who informs the vice president/executive director of notification of intent to appeal. Ad-hoc committee is formed and advised of confidentiality of proceedings.

2) Notify the applicant making the appeal of the date, time, and place of the hearing.3) Duplicate and mail, fax or email all documents necessary for each committee member's review of

the application. Documents shall include, but not be limited to, the following: original application and accompanying additions; letter from CEAC citing the original decision; reviewers' comments on original application; clarifying statements and/or substantiating data submitted by the applicant along with the intent to appeal.

4) Record and compile proceedings of hearings.5) Provide any educational consultation deemed necessary to the committee for complete and fair

review of an application.6) Send to the applicant a letter confirming the committee's action.

Committee's Functions Associated With An Appeal

Members of the appeal committee shall assume the following responsibilities associated with an appeal:

1) Determine the date and time of the hearing.2) Notify AORN Headquarters regarding the above.3) Review all documents pertinent to the appeal prior to the hearing. 4) Ascertain areas of the application and accompanying documents requiring further exploration and

discussion.5) Participate in deliberations regarding the appeal.6) Make an independent decision on action believed appropriate in the case. 7) Reach a collective decision on the action to be taken by the appeal committee.8) Compose the written notification of the appeal committee's decision along with accompanying

rationale for the applicant.9) Notify the applicant of the appeal committee's decision by telephone or overnight letter.

Hearings

Upon receipt of written notification of intent to appeal, a hearing shall be scheduled.

1) The date and time of the hearing shall be at the convenience of members of the appeal committee; however, a hearing shall be scheduled within 15 working days following receipt of written notification of intent to appeal.

2) Hearings shall be held at AORN Headquarters unless a more convenient meeting site is established, or it is determined a virtual meeting may be held.

3) All deliberations, except when a final vote is taken, are open to designated applicant representatives.

4) An applicant may have representation at a hearing at its own discretion and expense. Other expenses of a hearing will be assumed by AORN.

5) Applicant representatives attending a hearing may participate in deliberations only to the extent of responding to questions, clarifying intentions, and providing substantiating data.

6) The CEAC committee reviewers will defend the rationale for the original decision on an application.7) Only members of the committee shall vote when reaching a final decision on an appeal. The vote

shall be taken during a session closed to applicant and CEAC representatives.8) Hearings and transcription of hearing proceedings are privy to the involved applicant, to the appeal

committee, to CEAC, to the Nurse Consultant to CEAC, and to the Approval Process Project Coordinator.

9) No hearings may be scheduled once an offering has been held.

Withdrawal of Intent to Appeal

An applicant may withdraw from the appeal process by written notification to the AORN Approval Unit within three (3) days prior to the hearing date. If notification of withdrawal is not received by this deadline, the hearing will be held.

Attendance at Hearings

1) The following persons will attend appeal committee hearings:a) all three designated members of the appeal committeeb) the Nurse Consultant to CEACc) members of CEAC that reviewed application

2) The following persons may attend appeal committee hearingsa) one representative of the applicant appealing the adverse action on an application (at the

applicant's expense)b) one legal counsel in addition to, or instead of, the applicant (at the applicant's expense)c) legal counsel representing the appeal committee

Appeal Committee Action

The appeal committee acts upon appeals.

1) The actions taken by the appeal committee are the following a) original decision upheldb) original decision overturned

2) Either action shall be accompanied by written rationale appropriate to the decision.3) The decision of the appeal committee is final

Notification Of The Appeal Committee's Decision

The applicant appealing an adverse decision shall be notified of the appeal committee's decision within 48 hours by telephone, by overnight registered mail, fax or by email and within five (5) working days by letter.

Issue Date: May 1994 Index Number: 6.iReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

Implementation of Performance Improvement and QA Tools

POLICY

The Approval Unit will carry out its own performance improvement program.

PROCEDURE

1) Selected applicants are requested to submit a Post Activity Report which includes the following:a) Total number of attendees. b) Summary of evaluationsc) Certificate of Attendance

2) A random survey is sent to randomly selected consumers of the Approval Processa) The Continuing Education Approval Committee reviews the summary survey results once a

year.b) Changes may be made as a result of information obtained.

Issue Date: August 1987 Index Number: 6.jReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

Revocation of Approval

POLICY

Approval of a CNE activity may be revoked for any of the following reasons:

1) Failure to comply with criteria, policies, and procedures identified in the "Directions."2) Verification by CEAC of written complaints by participants which indicate CNE activity did not adhere

to policies, procedures, criteria as identified in the "Directions."

PROCEDURE

1) The CEAC Nurse Consultant, in collaboration with CEAC co-chairs, writes an inquiry letter or telephones, based on information received, asking for clarification.

2) CEAC members would be requested to vote by email to revoke approval of an activity if information indicated that the activity had been altered without resubmission or there was failure to comply with required changes. The majority opinion would rule either to: a) Revoke, orb) Not revoke

3) When CEAC revokes approval, the following will occur:a) A registered letter will be sent notifying the applicant of revocation and reasonsb) Revocation will be effective on the date the letter is received by the applicant

Issue Date: August 1987 Index Number: 6.kReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

Conflict of Interest – CEAC member

POLICY

A CEAC member who has a conflict-of-interest when reviewing an application must declare such a conflict. The CEAC member shall not participate in the review or be involved in the disposition of the application.

PROCEDURE

1) A conflict of interest exists when a CEAC member who is a constituent has participated in the preparation of the application or is associated with the applicant (i.e., a member of the chapter, state council, or specialty assembly submitting an application.)

2) A conflict of interest exists when a CEAC member works for or participates in the development of the application of a non-constituent application. All CEAC members declare Conflict of Interest at the time of the orientation meeting and sign a Conflict of Interest form.

3) The Approval Process Project Coordinator does not send a CEAC member an application submitted by his/her own chapter, state council, specialty assembly, or place of employment.

4) The CEAC members notify the Approval Process Project Coordinator if he/she receives an application where a conflict of interest exists. The application is then reassigned.

Issue Date: August 1987 Index Number: 6.lReview Date: March 2009 Updated: March 2009

POLICY SUBJECT

Confidentiality of Application Information

POLICY

All components of applications are considered confidential. Only those individuals involved with the Approval Process will have access to the files.

PROCEDURE

1) All components of applications are maintained in locked files, or a locked room. 2) Only authorized personnel have access to the files (Nurse Consultant and the Approval Process

Project Coordinator).3) CEAC members are notified of the confidentiality of records and are informed of this

information at the annual meeting.4) CEAC members are asked to destroy any paper applications 30 days after receipt.

Issue Date: May 1994 Index Number: 7.0Review Date: March 2009 Updated: March 2009

POLICY SUBJECT

Authority of Approval Unit

POLICY

The AORN Board of Directors delegates the authority of determining the criteria, policies, and procedures for CEAC. In that context, CEAC is responsible for maintaining the currency of the approval guidelines in relation to delineated criteria, policies, and procedures.

In addition, CEAC is charged with the responsibility of evaluating the effectiveness of the Approval Process.

PROCEDURE

1) CEAC uses the criteria identified by the American Nurses Credentialing Center's Commission on Accreditation; however, members of CEAC can expand or add criteria, based upon determination of need. Any ANCC criteria changes are communicated to CEAC on an ongoing basis.

2) CEAC delineates the policies and procedures governing the Approval Process and updates them annually as part of its evaluative process and as necessary.

3) CEAC revises the approval guidelines as needed, minimum of annually, to incorporate current criteria, policies and procedures, or suggestions resulting from the evaluation process.

4) CEAC evaluates the effectiveness of the Approval Process annually.

Issue Date: May 1994 Index Number: 8.0Review Date: March 2009 Updated: January 2007

POLICY SUBJECT

Co-provided Activities

POLICY

Co-provided activities are defined as joint endeavors between an AORN chapter, state council, or specialty assembly and hospital(s), health service educational organizations, or commercial groups, for the purpose of offering continuing education. Contracting with an institution for services such as clerical help, room rental, and audio-visual equipment is not considered co-providership.

PROCEDURE

Applicants will provide a written agreement to their co-provider and enclose a copy with their application, stating that the applicant will be responsible for the following:

1) Determination of objectives and content.2) Selection of presenters3) Awarding of Contact Hours4) Recordkeeping (including submitting post-activity reports)5) Evaluation

Issue Date: May 1994 Index Number: 9.0Review Date: March 2009 Updated: March 2009

POLICY SUBJECT

Implementation of a Peer Review Approval Process for All Application Categories for which Approval May Be Granted

POLICY

Applications will be reviewed based on ANCC criteria in a timely fashion.

PROCEDURE

Initial Steps--Approval Process Project Coordinator

Web-Based Application1) All aspects of the application and process are stored in the password-protected file on the

web.2) In administrative area, new applications are viewed under “Applications Pending

Administrative Review.”3) The applicant does not have access to application after submitting.4) Each application is reviewed for completeness of information submitted:

(a) All pages are included; legible.(b) One RN, with a BSN or MSN(c) Biographical Data information is complete (d) Target audience is RNs(e) Fee sent or notification that check is being sent under separate cover, if payment is

required.(f) Questions referring to topics or any other aspects of the applications are referred to the

CEAC Staff Nurse Administrator (Lead).5) Approval Process Project Coordinator selects reviewers on a rotating basis, and sends

application.6) Application is automatically sent to reviewers, who receive an email notification.

Rush Reviews – Paper and Web-Based Application1) Often applications are submitted which require a short turn-around time, two weeks or less.2) Since the CEA system is a service to facilitate providing continuing education to direct-care

givers, two committee members are identified as Rush Reviewers.3) The Rush Reviewers are experienced CEAC members and usually have served as the co-chair of

one of the teams.4) If there are questions regarding an application, the Nurse Consultantis involved in the review.

Peer Review Process – Web-Based Application1) Two CEAC members review each application, which has been designed using the Criteria Checklist.

Required elements automatically appear, and the reviewer is requested to approve or reject each

element. A comments area is provided. When a reviewer completes his/her review by the deadline indicated, the team leader is automatically notified by email.

2) The Team Leader completes his/her review last in a similar fashion as the previous reviewers. All comments from the two team reviewers are visible to the Team Leader, who makes the final decision, writes in his/her own comments, and submits review.

3) When the Team Leader submits the final review, the Approval Process Project Coordinator is notified by email.

4) The team leader may request assistance from the Approval Process Project Coordinator and/or CEAC Nurse Consultant at any time.

Approval Process Project Coordinator Responsibilities Related To Decisions – Web-Based Application

1) In Administration Area, reviewed applications are accessed via “View Reviewed Applications” area. The application and the review may be viewed in its entirety.

2) If the application been Approved Pending changes, the applicant will be asked to modify according to changes requested by reviewer. The letter is automatically generated with the Team Leader’s changes in the body of the letter. The Approval Process Project Coordinator reviews the requested changes for grammatical and format appropriateness, and then emails to Key Contact listed on the application. The Approval Process Project Coordinator receives a copy of this letter via email.

3) When an application is sent for changes, the applicant can access their application and make the requested changes, and then resubmits the completed application.

4) When the changes have been submitted, a Confirmation Letter stating that the application has been Approved is generated after review by Staff Nurse Administrator (Lead).

5) Denied means Contact Hours may not be awarded for the activity. The appropriate person will be notified by phone and letter.

Post Activity Report – Web

The applicant submits the Post Activity Report online within 30 days of the activity. Since the Post Activity Report is automatically generated, the content will be complete since all areas are automatically required to be completed. All Post Activity Reports may be viewed by Approval Process Project Coordinator.

Appeal Process

1) An applicant may use the appeal process to appeal any action taken on an application. 2) The applicant submitting this appeal shall do the following:

a) Notify the AORN Approval Unit in writing, by registered mail, of the intent within 15 calendar days of the date of the CEAC’s letter of action. Instructions/responsibilities will be returned to the sender within 3 working days.

b) Accompany the letter of intent with any clarifying statements of substantiating data deemed necessary or helpful on the applicant's behalf. (No new or revised data may be furnished for consideration at the hearing.)

c) Furnish the AORN Approval Unit with the name and title of representatives attending the hearing, if representation is desired.

d) Supply representative(s) with appropriate documents for use on behalf of the applicant.e) Make arrangements for representative(s) attendance at the hearing, if such is desired.f) Notify the AORN Approval Unit at least three days before the hearing date if withdrawal of the

appeal is desired.

Appeal Committee's Function With An Appeal

1) Members of the ad-hoc committee shall assume the following responsibilities associated with an appeal:a) Determine the date and time of the hearing.b) Notify AORN Headquarters regarding the above.c) Review all documents pertinent to the appeal prior to the hearing. d) Ascertain areas of the application and accompanying documents requiring further exploration and

discussion.e) Participate in deliberations regarding the appeal.f) Make an independent decision on action believed appropriate in the case. g) Reach a collective decision on the action to be taken by the appeal committee.h) Compose the written notification of the appeal committee's decision along with accompanying

rationale for the applicant.

Appeal Committee Action

1) Two actions may be taken by the appeal committee. These are:a) Original decision upheld: approval denied, approval pending, approved with conditionsb) Original decision overturned: approval granted

2) Either action shall be accompanied by written rationale appropriate to the decision.3) The decision of the appeal committee is final.

Notification Of The Appeal Committee's Decision

The applicant appealing an adverse decision shall be notified of the appeal committee's decision within 48 hours by telephone or fax and within five (5) working days by letter.

Recordkeeping – Web-Based Application

1) All approved applications are stored online and only accessible by the Approval Process Project Coordinator. Each application file contains

a) Approved Applicationb) Letters sent to applicantc) Reviewsd) Post Activity Reportse) Log-in activity report of applicant

2) All applications are kept for six (6) years online.

Issue Date: August 1987 Index Number: 10.0Review Date: March 2009Updated: March 2009

POLICY SUBJECT

Expectations of Applicants Using Approval Process Regarding Recordkeeping

POLICY

Applicants must maintain all required information in their files for six (6) years. AORN requires all applications to have all the required information on file at AORN.

PROCEDURE

1) Applicants participating in the Approval Process are required to have the following information on file at the AORN Approval Unit:a) Activity application which contains the title, date, name planning committee membersb) Biographical Data Forms of planning committee and presentersc) Name and address of physical facility where the activity is being heldd) Promotional materials with correct AORN accreditation statemente) Objectives, content, timeframes, teaching methods, and method used to evaluate the activityf) Description of target audienceg) Needs assessment methodh) List of Participants i) Number of Contact Hours awarded the activityj) Summary of participants evaluationsk) Certificate of Attendance l) Conflict of Interest obtained and disclosed for planning committee and presentersm) Commercial Support is identified and mechanism for prevention of bias. n) Written Agreement for Commercial Support if necessary

2) All participants in the Approval Process are required to maintain for six (6) years a file with all the required elements.

3) This information will be maintained by the AORN Approval Unit for a six-year period. Access to records is by authorized individuals only.


POLICY SUBJECT

Commercial Support

POLICY

Attendees will be made aware of Commercial Support

PROCEDURE

1) Applicants participating in the Approval Process are required to disclose in their application all commercial support of activity.

a) The nurse planner is responsible for all disclosures. An individual who refuses to disclose relevant financial relationships will be disqualified.

2) Application asks for disclosure of commercial support or in-kind assistance. If commercial support is disclosed, the applicant is required to submit a Written Agreement for Commercial Support.

3) Applicant is asked to agree that Commercial support or in-kind assistance provided by these organizations does not influence the objectives or the content of this activity.

4) Applicant is asked to agree that the Nurse planner discussed with commercial entity the need to prevent bias in the content

5) Applicant is asked to reveal how learners will be informed about commercial support, in-kind assistance, or off-label use in the following manner:

a) Information provided on advertising materialsb) Announcement at beginning of programc) Information on handouts given at start of eventd) A sign displayed in the exhibit areae) Other

6) The terms, conditions, and purpose of the commercial support must be documented in writing that includes the applicant and group providing the support. Both groups must sign the agreement also included in the Written Agreement.


POLICY SUBJECT

Conflict of Interest -- Applicant

POLICY

All planners/presenter(s) are required to disclose all relevant financial relationships with any entity with a commercial interest to ensure that decisions were made free from control of a commercial interest.

PROCEDURE

1) Applicants participating in the Approval Process are required to disclose in their application any conflict of interest.

a. The nurse planner is responsible for all disclosures. An individual who refuses to disclose relevant financial relationships will be disqualified.

2) Planning committee members are responsible for ensuring that all conflict of interest information for planners/presenter(s) has been resolved and disclosed.

3) Applicants are required to disclosed the type of conflict of interest as listed below:a. Consultant/Speaker’s Bureaub. Employeec. Stockholderd. Product Designere. Grant/Research Supportf. Large Gift(s)g. Other

4) Applicant is asked to disclose how the conflict was resolved.5) The presence or absence of Conflict of Interest is identified for all planning committee

members and speakers.