practice transition accreditation program application...

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Practice Transition Accreditation Program®

Application Form Complete all sections and submit via email to [email protected].

Note: Your program will receive an invoice upon approval of this application. The application fee must be paid in full prior to the Accreditation decision.

Program Name

Include the name of the organization/practice setting/system where the program is operationalized. This name will be used on the program’s certificate, plaque, and in the ANCC directory if accredited.

Organization Name

Specify name of the organization/practice setting/health system where residents/fellows practice.

Type of Program

See the PTAP Application manual for program definitions.

Type of Application

If re-accrediting, please enter the program’s PTAP number

Program Mailing Address

City:

Section I: Demographics

APM-FRM-201, PTAP Application Form, Rev 4, 05/27/2020 ©2020 American Nurses Credentialing Center. All rights reserved. The American Nurses Credentialing Center (ANCC) is a subsidiary of the American Nurses Association (ANA). Practice Transition Accreditation Program® is a registered trademark of the American Nurses Credentialing Center. All rights reserved.

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mailto:[email protected]

If successful, would you like a link to your website included in the ANCC directory of accredited practice transition program?

Program URL:

Name of Chief Nursing Officer or Designee & Credentials:

Email:

Phone:

Billing Contact Name:

Billing address if different from mailing address:

Program Director Eligibility

The RN Residency/RN or APRN Fellowship Program Director holds a current valid license as an RN or APRN, a graduate degree or higher with either the baccalaureate or graduate degree in nursing, and education or experience in adult learning. Yes No

See the PTAP Application manual for eligibility requirements. The PTAP Team may ask for verification of degree completion.

Master’s Degree (Credentials Conferred):

Baccalaureate Degree (Credentials Conferred):

Name of University: Name of University:

Location (City/State): Location (City/State):

Year of Graduation: Year of Graduation:

Date Conferred: Date Conferred:

Section II: Billing

Section III: Eligibility Verification: Program Director, Residents/Fellows, Participating Sites and Workplace Settings

Name (as it appears on RN license) and Credentials:

Email: Phone:

License Number: State of Issue:

Email:

Phone:


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Program Eligibility

The Program Director has the authority within the organization to ensure compliance with ANCC Practice Transition Accreditation Program criteria. Yes No

No At least one cohort has graduated from the residency/fellowship program. Yes

Number of Residents/Fellows for Survey How many residents/fellows have participated in the program during the 12 months preceding theapplication form submission (include current participants and graduates, regardless of their current status in the organization).

N =

This will be your program’s survey N. At least 51% of this N must respond to the survey for the program to move forward in the accreditation process.

Year program started:

Program Length (months):

Year first cohort graduated:


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The applicant:

Has evidence that residents/fellows will be paid at least the applicable minimum wage (according to Federal, State, and local requirements). Yes No

Abides by the Equal Employment Opportunity (EEO) policy to ensure freedom from discrimination on the basis of protected classes such as race, color, sex, national origin, religion, age, disability or genetic information. Yes No

Is in compliance with all applicable local, state, federal, and international laws and regulations that affect the applicant’s ability to meet the ANCC Practice Transition Accreditation Program criteria. Yes No

Was the program accreditation ever denied, suspended, or revoked by ANCC or any other organization? Yes No

If yes, describe:

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Participating Sites

List the eligible sites that participate in the Program and corresponding Site Clinical Coordinators (SCCs), if applicable. Utilize the Application Addendum Form if the program has more than 5 eligible participating sites. See the PTAP Application Manual for definitions and eligibility details, in summary site requirements include:

• A minimum of one resident/fellow must have completed the program in full at the site to be eligible for accreditation:o New applicants must have a resident/fellow participate at the site(s) within the 24-months (2-year period)

prior to self-study submission;o Reaccrediting programs must have a resident/fellow participate at the site(s) within the 48-months (4-year

period) prior to self-study submission.

1. Site Name:

Address: City:

State: Zip Code: Geographic Location:

SCC Name (as it appears on RN license) and Credentials:



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2. Site Name:

Address: City:




3. Site Name:

Address: City:




4. Site Name:

Address: City:




5. Site Name:

Address: City:




Non-Participating Sites

List the sites that DO NOT participate in the Program. Attach the Application Addendum Form if program has more than 5 non-participating sites.

Site Name 1.

2.


3.

4.

5.

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Attach organizational chart(s) - check box to confirm email attachment

The organizational chart(s) should:

• Demonstrate the relationship of key leaders within the organization

• Include all participating organizations for a multi-site program

• Clearly identify the Residency/fellowship program leadership

• Represent Residency/fellowship structure and key stakeholders

o Names, roles, and credentials should be included on charts for key program stakeholders.

For Single Site programs only (skip to page 7 if multi-site program)

Number of Residents/Fellows in Application Review Timeframe**

1. Denote which workplace setting(s) are eligible for accreditation review by placing an X in the firstcolumn of the table on page 6:

a. Refer to workplace setting definitions on the ANCC PTAP website to ensure properclassification of units/practice settings into approved categories.

2. Indicate how many residents/fellows have participated in each workplace setting during theapplication review timeframe by placing a number in the second column of the table on page 6:

a. **New programs must indicate the number of residents/fellows in each workplace settingduring the 24-months (2-year period) prior to self-study submission;

b. **Reaccrediting programs must indicate the number of residents/fellows in eachworkplace setting during the 48-months (4-year period) prior to self-study submission).

Eligibility Reminder:A minimum of one resident/fellow must have completed the programat the site to be eligible for accreditation. Additionally, a minimum of oneresident/fellow must have completed the program within the workplace setting to be eligible for accreditation.


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Workplace Setting 'X' - Participates in Program

Number of Residents/Fellows in Application Review Timeframe

Medical

Surgical

Medical-Surgical

Oncology

Step Down

Critical Care

Labor & Delivery

Ante/Postpartum

Labor, Delivery, Recovery and Postpartum (LDRP)

Neonatal Intensive Care Unit (NICU)

Pediatrics

Pediatric Intensive Care Unit (PICU)

Operating Room

Post Anesthesia Recovery Unit (PACU)

Same Day/Ambulatory Procedure

Psychiatric

Rehabilitation

Ambulatory

Emergency Department

Specialty Practice

Acuity Adaptable (universal bed)

Long Term Care

Preoperative

Home Care

Hospice

Centralized Function

TOTAL # OF RESIDENTS/FELLOWS PER WORKPLACE SETTING IN REVIEW TIMEFRAME

OTHER C ontact ANCC PTAP Team


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For multi-site programs only (skip to page 10 if single-site program)

Program Consistency –

Provide an executive summary describing how the program is consistently operationalized across all sites.

Number of Residents/Fellows in Application Review Timeframe**

1. List each site in the "site name" row in accordance with the organization names provided prior.

2. Denote which workplace setting(s) are eligible for accreditation review by placing an X in thecorresponding column of the table on pages 8 and 9:

a. Refer to workplace setting definitions on the ANCC PTAP website to ensure properclassification of units/practice settings into approved categories.

Attach the Application Addendum Form if more than 5 sites.

Eligibility Reminder:

A minimum of one resident/fellow must have completed the program at

the site to be eligible for accreditation. Additionally, a minimum of oneresident/fellow must have completed the program within the workplace

setting to be eligible for accreditation.

3. Indicate how many residents/fellows have participated in each workplace setting during theapplication review timeframe by placing a number in the corresponding column of the table onpages 8 and 9:

a. **New programs must indicate the number of residents/fellows in each workplace settingduring the 24-months (2-year period) prior to self-study submission;

b. **Reaccrediting programs must indicate the number of residents/fellows in eachworkplace setting during the 48-months (4-year period) prior to self-study submission).


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Participates in Program





Site Name 1. 2. 3. 4. 5.

Workplace Setting

Medical

Surgical

Medical-Surgical

Oncology

Step Down

Critical Care

Labor & Delivery

Ante/Postpartum

Labor, Delivery, Recovery and Postpartum (LDRP)

Neonatal Intensive Care Unit (NICU)

Pediatrics

Pediatric Intensive Care Unit (PICU)

Operating Room

Post Anesthesia Recovery Unit (PACU)

Number of Residents/Fellows in

ApplicationReview

Timeframe


ApplicationReview

Timeframe


ApplicationReview

Timeframe


ApplicationReview

Timeframe


ApplicationReview

Timeframe


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Site Name 1. 2. 3. 4. 5.

Workplace Setting

Same Day/Ambulatory Procedure

Psychiatric

Rehabilitation

Ambulatory

Emergency Department

Specialty Practice

Acuity Adaptable (universal bed)

Long Term Care

Preoperative

Home Care

Hospice

Centralized Function

OTHER:TOTAL # OF RESIDENTS/FELLOWS PER WORKPLACE SETTING IN REVIEW TIMEFRAME

Contact ANCC PTAP Team


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Provide the following information of your healthcare organization and program.

ANCC Designation Status

Magnet® Recognized

Pathway to Excellence® Designation

ANCC Accredited Provider Unit

Organization and Residency/Fellowship Descriptions

Brief description of the healthcare organization and/or health system (if applicable) (500 words or less):

Section IV: Executive Summary


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Brief history and description of the program seeking accreditation (500 words or less):

Vendor Products Used Name of vendor product:

Check if none:

Eligibility Criteria for Program Applicants: Must include graduation from an accredited nursing program, current unencumbered licensure (or international equivalent) as an RN/APRN, and certification as applicable to the program:


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Insert your organization’s name below, sign, and date electronically. Forms received without a signature incur a delay in processing which will cause a delay in the review of the accreditation application.

IMPORTANT– Please do not lock the application form when applying your electronic signature. The ANCC requires submission of an unlocked document and will return all locked applications for resubmission.

I attest, by my signature below, that I am duly authorized by: (insert name of Applicant Organization below)

(hereinafter referred to as Applicant Organization) to submit this application for program accreditation offered by the American Nurses Credentialing Center (ANCC) and to make the statements herein. On behalf of Applicant Organization, I have read the Practice Transition Accreditation Program® (PTAP) eligibility requirements and criteria. I understand that Applicant Organization is subject to all eligibility requirements and criteria for accreditation as described in the current Practice Transition Accreditation Program Application Manual and any updates thereto. I understand that program accreditation depends on successfully meeting eligibility requirements and accreditation criteria and that continued accreditation is dependent upon continued compliance. If accredited, the name of Applicant Organization Residency/Fellowship program will be included in the official listing of ANCC accredited programs with permission.

On behalf of Applicant Organization, by my signature below, I authorize ANCC staff and the Commission on Accreditation of Practice Transition Programs to make whatever inquiries and investigations that they, in their sole discretion, deem necessary to obtain or verify information submitted with or necessary for review of this application, subject to applicable policies, laws, or regulations.

On behalf of Applicant Organization, I expressly acknowledge and agree that information accumulated by ANCC through the accreditation process may be used for statistical, research, and evaluation purposes and that ANCC may enter into agreements to release anonymous and aggregate data to third parties. Otherwise, subject to the mailing list authorization, all information will be kept confidential and shall not be used for any other purposes without Applicant Organization’s permission.

On behalf of Applicant Organization, I hereby certify that the information provided on and with this application is true, complete, and correct. I further attest, by my signature on behalf of Applicant Organization, that Applicant Organization will comply with all eligibility requirements and accreditation criteria throughout the entire accreditation period, including all reapplication periods for maintaining accreditation, and that Applicant Organization will notify ANCC promptly if, for any reason while this application is pending or during any accreditation period, Applicant Organization does not maintain compliance. I understand that any misstatement of material fact submitted on, with, or in furtherance of this application for program accreditation shall be sufficient cause for ANCC to deny, suspend, or terminate accreditation of Applicant Organization’s residency/fellowship program and to take other appropriate action against Applicant Organization.

The following serves as the electronic signature of the individual completing this Application Form and attests to the accuracy of the information provided.

Completed by:

Name

Title

Date

Section V: Attestation

Email completed application to [email protected].


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mailto:[email protected]

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