2019 Magnet^® Application Manual Updates and FAQs

2019 Magnet® Application Manual updates

Check the latest updates to the 2019 Magnet^® Application Manual
to ensure your application goes smoothly.

2019 Magnet® Application Manual updates - OO9

2019 Magnet® Application Manual updates - SE4EO

Frequently Asked Questions About ANCC’s 2019 Magnet Recognition Program^® Manual

The FAQs on this page offer program information and interpretive guidance on many aspects of the Magnet Recognition Program^®.

General

Application | General Questions | General EO Questions | Nursing Satisfaction, Nursing Sensitive Indicators and Patient Satisfaction (Big Five) General Questions | Download PDF

Application

Q - Is it acceptable for the organizational and/or nursing organizational charts to be updated to reflect organizational changes from time of application to document submission? (updated February 2020)

Yes, you should submit the most current Organizational and Nursing Organizational charts at the time of application, document submission and again prior to site visit (SV).

General Questions

Q - Are observational units, labor and delivery, and the OR considered to be inpatient or ambulatory units? (updated February 2020)

This is an organizational decision and it can depend heavily on how the externally managed database categorizes these units/ambulatory care settings. After the classification is determined, the areas must be consistently reported as inpatient or outpatient throughout the document.

Q - For examples that are specific to ambulatory areas, can the story take place in both inpatient and ambulatory areas? (Updated February 2021)

Ambulatory examples must be specific to the ambulatory setting; all data must be from the ambulatory setting as well.

Q - Why are Analysts unable to confirm if an outcome measure is acceptable? (June 2020)

The Senior Magnet Program Analyst (SMPA) role is that of a subject matter expert, clarifying program requirements, definitions, terms, and content in the 2019 Magnet Application manual. This role is distinctly different from the Magnet Appraisers that appraise your examples or consultants that help you to develop your examples. It is an organizational decision to seek guidance from a consulting firm.
The SMPA asks questions to help drive an appropriate outcome measure. For example, what is the impact of the initiative on the patient(s), nursing workforce, or organization? Why did you implement the process/intervention? What data-driven problem in your organization/unit prompted this initiative?

General EO Questions

Q - If an intervention is implemented on the first day of the month/quarter, can information from the month/quarter be considered post-intervention data? (FAQ December 2016. Updated February 2020)

Yes, however, only if the intervention is instituted and completed on the first day of the month/quarter (e.g., July 1st).

Q - What format should be used to present participant information for an EO SOE example? (updated February 2020)

Refer to page 17 in 2019 Magnet Application Manual. It is an organizational decision if you refer to these individuals by name or initials in the SOE example. However, the information provided in the example, must align with the information provided on the participant table. A meeting sign-in sheet is not required in addition to the participant table as a part of an EO example. A specific participant table format is not required but the name, discipline, title, and department must be included.

Q - What if my post-intervention data do not show three consecutive improvement points—the trend line is improved, but there is variability in the post-intervention data points? (FAQ December 2016, updated February 2020)

If the empirical evidence SOE requests that improvement be demonstrated, the post-intervention data may show variability; however, it must show a trend of improvement when compared to the pre-intervention data.
Trendlines are acceptable, but not a required element of an EO graph as outlined on page 17-18 in the 2019 Magnet Application Manual.
Note: Data provided during the intervention period are not included in the appraiser’s evaluation of improvement or change.

Q - What timeframe should be used to present quarters on an EO graph? (updated February 2020)

The Magnet Program Office is not prescriptive as to the units of time used. However, the timeframe must be the same for pre-intervention and post-intervention data. The timeframe must also be consecutive and should not overlap. Please see page 18 in the 2019 Magnet Application Manual.

Q - Is it acceptable to use raw numbers in an EO data presentation? (June 2020)

Outcome data must be presented as a ratio (e.g., rate, percentage, average, mean, median) consistently throughout the data collection period. The only exception is with a sentinel or never event.

Nursing Satisfaction, Nursing Sensitive Indicators and Patient Satisfaction (Big Five) General Questions

Q - During site visit will the appraisers expect to see updated data or will they only be validating the information provided during document submission? (updated February 2020)

The expectation is for the appraisers to validate the data presented in the document against source data provided by the vendor during site visit.
If there are deficiencies found within your Big 5 data going into site visit, the appraisers will expect only to see data that validates those particular deficiencies

Q - Can you pick different comparison groups or cohorts for each category? i.e. Autonomy academic centers, professional development national (updated February 2020)

Yes, you may present different comparison cohorts for each unit or clinic.
The comparison cohort must be same for the units or clinics presented on the same graph
The comparison cohort must be an appropriate comparison.
Please see page 55-56 in the 2019 Magnet Application Manual.

Q - Is the expectation to collect data Patient Satisfaction data in all ambulatory areas where nurses provide care? (updated February 2020)

Yes. Data must be collected for the following ambulatory care settings: Emergency Department, Ambulatory Surgery Center and all other ambulatory areas where clinical nurses provide care. Work with an externally managed database to establish appropriate ambulatory data collection.
Please see page 57 in the 2019 Magnet Application Manual.

Q - My organization has no ambulatory care settings, do I need to complete EP19EO or EP21EO? (updated February 2020)

For organizations where there are no ambulatory care settings nothing needs to be submitted for EP19EO or EP21EO.
For Magnet purposes, ambulatory care settings include emergency departments and urgent care.

Organizational Overview

OO-1 | OO-5 | OO-6 | OO-10 | Download PDF

OO-1

Q - What is the definition of demographics? (updated September 2019)
For Magnet purposes, the population and RN statistical characteristics that are pertinent to the organization. These may include, but are not limited to, age, gender, and education of the population served and nursing (RN) staff.

Q - If the description of the history of the organization is greater than 300 words, what happens? (updated September 2019)
The appraisers evaluate the first 300 words to determine if the Organizational Overview item has been met. If it is not met in the first 300 words, a request for Additional Information will be generated.

OO-5

Q - Does the continuing education assessment provided need to be completed? (Updated September 2019)
Yes, the assessment must be the summary (completed, with results) of the information gathered in the most recent needs assessment.

Q - What is meant by "all RNs" and "all settings"? (updated September 2019)
A continuing educational assessment must be offered to all registered nurses, in all areas (settings) where registered nurses work in the organization. This should include the CNO, Nurse AVP/Directors, Nurse Managers, Clinical Nurses, APRNs, and any other registered nurse position.
The continuing needs assessment must demonstrate that the needs of nurses in the various settings are being addressed (i.e. inpatient, ambulatory, administration, etc.). For instance, the clinical nurses in the ICU will have very different needs assessment than ambulatory nurses in a primary care clinic

Q - What is the meaning of the word "assessment"? (updated September 2019)
An assessment is the process the organization does to identify any potential gaps in knowledge, skills, and abilities of the registered nurses in areas where they practice. The assessment can be accomplished in numerous ways, including a self-assessment of nurses in the form of a survey or other reporting. An assessment can also be achieved with input from committees and other formal structures such as the education department, risk management, infection control and nursing leadership to identify the continuing education needs for all registered nurses. The assessment must be inclusive of all levels of nursing, including the CNO, AVP/Directors and Managers, clinical nurses, and APRNs.

Q - What levels of nursing need to be included in the education assessment? (FAQ April 2019, updated February 2020)

All registered nurses who influence or provide care in all settings of your organization must be represented in the education assessment. Use the following table as a tool to guide inclusion of all nurses.

This sample table is provided to demonstrate how an applicant may choose to organize their documentation for OO5 to ensure that an assessment of continuing education is being completed for “all RNs” in “all settings”

“All RNs who influence or provide care” (Note: It must be clear that the organization completes a continuing education assessment at all levels of nursing)	“All Settings where RNs practice” (Note: It must be clear that the organization completes a continuing education assessment for RNs in all settings, such as Inpatient, Ambulatory, and medical practice settings.)
CNO	Executive setting
AVP/Directors/Nurse Managers	Leadership, Management setting
Clinical Nurses	ICU, Medical, Surgical, Ortho, Neuro, Ambulatory Medical Clinics, Interventional Radiology, setting etc.
APRNs	Inpatient and Ambulatory Care setting
Others, e.g., Centralized Function	Case Managers, Infection Control, and other setting that may have unique educational needs, etc.
Each organization will identify the level of nurse and the settings according to their own organizational processes and provide the most recent continuing educational assessment completed with the results. Evidence must support that the organization has completed a continuing education assessment on all RNs in all settings.

Q - Must the continuing education assessment include a survey? Our organization uses other tools to build the assessment such as performance appraisals and quality and risk data. (June 2020)
The methods used for the continuing educational needs assessment is an organizational decision. The actual continuing educational needs assessment may include a survey or other modalities (i.e., RN self-identified needs, risk assessments, etc.).

OO-6

Q - Are there eligibility criteria for the individual that the CNO chooses to designate to participate in the credentialing, privileging and evaluating of APRNs? (updated September 2019)
The CNO is ultimately responsible for sustaining the standards of nursing practice throughout the organization, including APRN practice, regardless of reporting relationships. The designee must be an RN and must communicate with the CNO.

Q - What is the expectation of the CNO’s (or RN designee’s) “participation” in the credentialing, privileging, and evaluating process of all advanced practiced registered nurses (APRNs)? Do we need to describe the CNO (or designee) in every phase of credentialing? (updated September 2019)
A description of the CNO’s (or RN designee’s) participation in the credentialing and evaluation of all APRNs should be a broad description of the process. It should include the CNO’s (or designee’s) roles in credentialing, privileging, and evaluating and how the CNO (or designee) are involved/participate in the process.

OO-10

Q - Can we include evidence-based practice (EBP) and “exempt” nursing research on our research table? (FAQ December 2016, updated February 2020)

Provide the institutional review board (IRB) approval date and type of review (i.e. full board, expedited, and exempt) of the nursing research study, that is ongoing and/or completed within the applicant organization(s).
Only nursing research studies are to be listed on the table. Evidence-based projects, process improvement, and quality improvement projects should not be included on the nursing research table.
This table includes nursing research studies that are completed or ongoing within the forty-eight months before documentation submission. It is acceptable for the study to begin outside the forty-eight timeframe.

Q - Can we include nursing research on our research table that is conducted at our organization by nonemployees (Ph.D./DNP students, university faculty)? (FAQ December 2016, updated February 2020)

No, the nursing research listed on the research table must be conducted by employees of the organization (i.e., PI, co-PI, and/or site PI).
As long as an employee of the organization serves in at least one of these roles, the PI, co-PI, or site PI role, a nonemployee may be involved in the nursing research.

Q - What is meant by a completed nursing research study? (updated February 2020)
For Magnet purposes, a “completed study” refers to a study that has concluded to the point of analysis and from which initial implications of the findings have been determined and dissemination has occurred or will occur. The study must be completed within the 48-month timeline. The study may start prior to the 48-month timeline.

Transformational Leadership

TL3 | TL5EO | TL6 | TL7 | TL9EO | Download PDF

TL3

Q - Does the advocacy for resources mean the resource must be acquired? Does the resource have to be a human resource? (updated February 2020)

The advocacy does not need to result in the acquisition of the resource.
The resource does not need to be a person, it could be such things as the acquisition of time, money, equipment, technology.

Q - My organization does not have all the levels that are requested in the source of evidence for TL3. How do I respond to the required source of evidence request statement? (updated September 2019)
Two examples must be provided for TL3. In the case of a flat organizational nursing leadership structure (i.e. either only Nurse Managers or only AVP/Nurse Directors) two examples are required using the nurse levels that exist in the organization. For example, if there are no Nurse Managers then the organization will need to supply two AVP/director examples.

TL5EO

Q - Does the organization-level, decision-making group also need to be interprofessional? (updated February 2020)

This source does not require the organization-level, decision-making group to also be interprofessional.

Q - Does the improved patient outcome need to be captured at the organization level? (updated February 2020)

The improved patient outcome can occur at any level within the organization (organization level, division, or unit/clinic). The narrative needs to explain how the membership in the organization-level, decision-making group led to the interventions and outcome.

TL6

Q-What is the definition of mentoring? (updated September 2019)

Mentoring is providing information, advice, support and ideas to a person in their current role. Note: The term mentor and preceptor are not used interchangeably. See glossary definition of mentor pg. 152.

Q: Does the mentor associated with a mentoring plan or program need to be a nurse? (updated September 2019)

TL6a-d: For the clinical nurse, APRN, nurse manager, and nurse AVP/Director examples, the mentor must be a registered nurse. Please refer to the definition for mentor (2019 Magnet Application Manual, pg. 152)
TL6e: For the CNO example, the mentor may be a registered nurse or a non-nurse.

Q-Does the mentor have to be from within the organization? (updated February 2020)

It is acceptable to use system-level organization mentor programs or plans, as long as the mentoring is occurring within and supported by the organization. The mentorship can be formal or informal.
The organization must employ the mentee. The organization or system must employ the mentor.
All registered nurses must be mentored by registered nurses or APRNs, except for the CNO.
TL6e (CNO): The CNO may be mentored by nurses or non-nurses, within or outside the organization; however, the narrative must reflect organizational support for this mentoring.

TL7

Q-What is the definition of succession planning? (updated September 2019)

Succession planning is preparing a nurse to move into a new role. For Magnet purposes, the succession planning activities of the individual does not have to result in entrance into the new role. However, the activities that move(d) them into the new role must have occurred. See glossary definition on pg. 161

The intent is that nurses are being prepared through succession-planning activities to move into one of the four options listed. For example, succession-planning activities for the CNO role might include activities for the Associate CNO or another nurse executive preparing to assume (or already assumed) the CNO’s responsibilities.

Q-My organization does not have all the levels that are requested in the source of evidence for TL7. How do I respond to the required source of evidence request statement? (updated September 2019)

Three examples must be provided for TL7 (one from an ambulatory setting) using the nurse levels that exist in the organization. If the applicant organization has a flat structure, the organization must provide three examples using the nurse levels that exist in the organization.

Q-Can I use a role not expressly identified in the four options listed? We have nurse educators, infection control, and other professional development specialist roles. (updated September 2019)

Only if one of these roles meets the definition of the four options provided. We recognize there are other opportunities for succession-planning but these four are the only options included in the Sources of Evidence.

TL9EO

Q-For the communication between the clinical nurse and the CNO/AVP/nurse director/nurse manager, does it need to be direct or indirect communication? (updated February 2020)

Either direct or indirect communication is acceptable for TL9EO. In either type of communication, it must be clear that the communication is two-way.
When communication is indirect, it must be clear that messages are received and returned from/to the clinical nurse and the nurse leader in the example.

Structural Empowerment

SE2EOa

Does the professional organization need to be a nursing organization? (June 2020)

The clinical nurse’s or clinical nurses’ affiliation is not limited to nursing professional organizations but must be with a professional organization.
Collaboratives, consortiums, think-tanks, and conferences are examples that do not meet the definition of professional organization in the 2019 Magnet manual because they do not offer individual membership or set standards of practice for the profession.

What is the definition of affiliation? (June 2020)

For Magnet purposes, affiliation does not require membership of a professional organization. Affiliation activities may involve a clinical nurse(s) reading an article or attending a conference of a professional organization that may stimulate your organization to rethink an evidence-based change in nursing practice, resulting in an improved patient outcome.

SE2EOb

What is the definition of participation? (June 2020)
Participation in a nursing professional organization may include membership, conference attendance, meeting attendance, etc. The clinical nurse(s) in the example must have participated in a nursing professional organization and learned of the application of nursing standards of practice resulting in an improved patient outcome.

SE3/SE5

Is it is okay for the target to be established outside the 48-month window? (September 2019)
If an organization has established a target outside of the 48-months, there must be narrative and supporting evidence that shows how this goal was re-established during the 48-month timeframe.

SE4EO

Is the list of National Certifications currently Included in the DDCT changing to include only board certifications? (October 2021)
Yes, the list of National Certifications currently Included in the DDCT is changing to include only board certifications. The current list will be in effect until December 31, 2023. Please refer to information on the Magnet Website related to Accepted Certifications in the DDCT (https://www.nursingworld.org/organizational-programs/magnet/program-tools/accepted-certifications/) about implementation of the new process.

What certifications are acceptable to use for Magnet designation? (updated February 2020)
Please refer to the list of accepted National Certifications.

Do we need to provide a certification goal for each year presented, or can we develop a goal for our organization to meet by the end of year two? (FAQ December 2016, February 2020)

You may provide a yearly goal OR a goal for improvement by the end of year two. In either case, three years’ worth of graphed data must be provided.
If you choose to develop a goal for improvement by the end of year two, you must include progression data for year one.
You must demonstrate that nursing has met the targeted goal for improvement (or maintenance as applicable) in professional nursing certification.

If we choose to use a maintenance goal, does it have to be the same as the current level (i.e. current level is 60%, can maintenance goal be 55%)? (updated February 2020)
Maintenance is based on if the organization is >51%. If the current level is 60% it is acceptable to have a maintenance goal as low as 51%

For SE4EO, what can be considered as organization level? For example, can organizational level be all clinical nurses or all nurse managers/directors or all specialty nurses? (June 2020)
An organization-level group includes nurses from all departments or divisions, e.g., all nurse managers across the applicant organization both inpatient and outpatient, or all specialty nurses.

SE4EOa

Are cohort groups at the organizational level an acceptable presentation for an improvement in organizational level professional nursing certification? (June 2020)
An organization-level cohort is an acceptable presentation, e.g. all nurse managers across the organization.

SE4EOb

Are cohort groups at the unit or division level an acceptable presentation for an improvement in unit or division level professional nursing certification? (June 2020)
A unit- or division-level cohort is an acceptable presentation, e.g. all clinical nurses across the division.

SE4EO/SE6EO

Is narrative required for SE4EOa and b and SE6EO? (February 2020)
No, narrative is not required.

An explanation is required if an organization experiences a merger, acquisition or expansion occurs within the three years altering the ability to meet the established goal, the organization is allowed to reestablish a goal and show progress toward the revised goal.

Do the three years of graphed data need to be presented as calendar years? (February 2020)
No, any three completed years of graphed data are acceptable as long as the timeframes are complete.

SE6EO

If we choose to use a maintenance goal, does it have to be the same as the current level (e.g., current level is 85%, can maintenance goal be 82%)? (February 2020)

Maintenance is based on if the organization is >80%. If the current level is 85% it is acceptable to have a maintenance goal as low as 80%
You must demonstrate that nursing has met the stated goal for improvement (or maintenance if applicable) in baccalaureate or higher degree in nursing.

SE8EO

Can the nursing continuing education assessment include multiple professions? (September 2019)
An interprofessional needs assessment is acceptable, however, the supporting evidence must demonstrate the registered nurses are a part of the needs assessment and implementation plan. The example provided, should be specific to nursing.

SE9

What New Graduate transition programs are on the list of recognized programs in the 2019 manual? (September 2019)
“Three national accreditation programs that meet Magnet criteria are ANCC Practice Transition Accreditation Program (PTAP), Commission of Collegiate Nursing Education (CCNE), and Accreditation Commission for Education in Nursing (ACEN).” The ANCC PTAP program accredits RN Residency, RN Fellowship, and APRN Fellowship programs. CCNE accredits entry-to-practice nurse residency programs.
Learn more about ANCC’s PTAP at: https://www.nursingworld.org/organizational-programs/accreditation/ptap/
Learn more about CCNE accreditation at www.ccneaccreditation.org

If an organization obtains the RN residency program accreditation at a corporate level, would that meet the SE9 standard at the organization level? (September 2019)
Since Practice Transition Accreditation Program (PTAP) and Commission on Collegiate Nursing Education (CCNE) accreditations are programmatic credentials, the entities in a System included in the accreditation are all eligible for meeting SE 9 in the 2019 Magnet® Application Manual.
The System certificate (or other documentation) needs to identify the entities within the System associated with the credential. The applicant entity must be named in the certificate to meet the requirement for SE9.

Can we use system transition to practice programs to meet the required elements for SE9b-f? (February 2020)
It is acceptable to use a system-level organization transition to practice program, as long as the example provided is for an individual employed by the applicant organization, and the required elements show use by the applicant organization.

Are we able to have six pieces of evidence for SE9 since there are six elements of transition to practice? (February 2020)
No, only five pieces of evidence are permitted per example. One piece of evidence may meet multiple elements.

Does the evidence of participation in one of the two approved transition programs need to include more than just the New Graduate transition? (June 2020)
Any nurse residency or transition program can be evaluated by either ANCC or CCNE and if credentialed by either body, that certification is acceptable and fully meets SE9 (2019 Magnet Application manual).
During site visit, the appraisers will validate that principles of the six elements of transition to practice programs are evident in the organization.

SE10

I am a nurse who runs a camp for kids with medical issues, that is a part of my role and I am paid to attend (including weekends). Does this meet the intent of organizational support? (June 2020)
The intent is the nurse is a volunteer, working for or on an initiative outside of their role expectations. Organizational support is related to how the organization supports the RNs who volunteer for these types of initiatives

SE10a

Nurses volunteer for international outreach trips on behalf of our organization. Do international trips meet the intent for this Source of Evidence? (September 2019)
No. The Source of Evidence specifically references local or regional community healthcare initiative(s). Local or regional reflect geographically near the healthcare organization.

SE11

Does the example need to describe both culturally and socially sensitive care? (September 2019)
No; it is acceptable to submit an example that describes culturally and/or socially sensitive care.

SE12

I heard that organizations cannot use the DAISY award for this example. (June 2020)
The DAISY award may be used for SE12 as long as the contributions of the nurse or group of nurses addresses the strategic priorities of the organization.

Exemplary Professional Practice

EP1EOa/b

Q - Should we submit a schematic of the PPM for both EP1EOa and EP1EOb? (updated September 2019)
Yes, each example should have the schematic of the PPM included. Since the PPM must align with each example; it would be helpful if the applicable part of the PPM is highlighted for the appraiser’s review.

EP2EO

Q - Our nurse satisfaction vendor, does not include "all nurses” (i.e. not only clinical nurses, inclusive of APRNs and nursing leaders) in the survey or in the presentation of data for nurse satisfaction. Since the SOE requires “all nurses”, how should we handle this? (updated September 2019)
It is required to “include all nursing levels collected and benchmarked by the vendor”. You must also provide an explanation in your Unit Level Data Crosswalk (ULDC) when your vendor does not survey a nursing level or area of care.

Q - Do organizations have to outperform on their nursing satisfaction survey to move to Site Visit? (Effective February 1, 2019)
To progress to Site Visit, applicant organizations must meet the thresholds of nursing excellence including demonstrating outperformance of the national vendor’s benchmark for at least three out of four selected nurse satisfaction categories on the majority of reporting units/settings.
https://www.nursingworld.org/~495227/globalassets/docs/ancc/web-notice-12518.pdf

EP5

Q - What does spectrum of healthcare services mean? (updated February 2020)
Spectrum of healthcare services is inclusive of all services and settings where the organization provides care.
The spectrum of healthcare services describes the transition of care across an entire organization using an interdisciplinary approach to identify factors that may affect clinical outcomes.

EP6EO

Q - What is meant by a defined patient population? (June 2020)
A defined patient population is a group of healthcare consumers to include but not limited:

Age (e.g., teens, elderly, infants)
Gender (e.g., males, females, transgender)
Diagnosis specific (e.g., diabetes, COPD, CHF)
Care specific (e.g., ventilated patients, critical care)

EP8EO

Q - Is the interprofessional education activity referring to education for patients or staff? (Updated September 2019)
Interprofessional education is education for patients, inter-professionals, or nurses led or co-led by a nurse and inclusive of other professions (e.g., occupational therapy, medicine, surgery, physical therapy)

EP9a

Q - Is the unit-level staffing need specific to registered nurses? (Updated February 2020)
Addressing an identified unit-level staffing need is not limited to registered nurses. However, the example must demonstrate clinical nurses collaborated with an AVP/nurse director to address the unit-level staffing need related to groups such as physician, respiratory, or unlicensed assistive personnel.

EP9a and b

Q - My organization does not have all the levels that are requested in the source of evidence for EP9a and EP9b. How do I respond to the required source of evidence request statement? (June 2020)
The applicant organization must provide two examples, one for EP9a and one for EP9b. In the case of a flat organizational nursing leadership structure (i.e. either Nurse Manager or AVP/Nurse Director) two examples are required using the nurse level that exists in the organization.

EP9b

Q - What is considered an operational need? (June 2020)
An operational need is an identified gap that inhibits the ability of nurses to work in an efficient and effective manner (e.g., equipment, supplies, or time) to perform their jobs.

EP10EOa

Q - Are cohorts accepted for the organization’s turnover rate? (updated September 2019)
No. The intention for this source is the organization’s nurse turnover rate.

EP11

Q - What are the expectations for peer feedback? (Updated June 2020)

Please see the definition of peer feedback on page 156 of the 2019 Magnet Manual.
Outside of the CNO, a peer should be a registered nurse or an APRN, who possesses a similar role and education, clinical expertise, and level of licensure.
The CNO may receive peer feedback from other disciplines outside of nursing as long as the peer can be substantiated.
The MPO is not prescriptive about the formatting or timing of the peer feedback. The organization must follow their established peer feedback process, describe the peer review process and provide evidence to substantiate the process.
For nurses and APRNs who may be the only nurse within a setting, consider other resources, including but not limited to committee members and shared governance councils to ensure these nurses are receiving and providing peer feedback.

Q - As a part of the periodic formal performance review, are we expected to present the performance review from the current year? (June 2020)
The 2019 Magnet Application Manual does not require a formal performance review for the current year; however, the Magnet Program Office (MPO) does expect an organization to follow its own policy related to the frequency of a formal performance review. At a minimum, the example must fall within 48-months prior to documentation submission.

EP14

Q - What constitutes an interprofessional group? (Updated February 2020)

Please refer to the definition of interprofessional collaborative practice on page 151 of the 2019 Magnet Manual
Within the context of the example, the interprofessional group may include professionals in non-clinical roles (e.g., Security Director), however the group must encompass nursing.

EP15EO

Q - What is meant by the organization’s safety strategy? (Updated February 2020)

The organization’s safety strategy should be a plan or a framework for achieving the organization's safety objectives.
The organization’s safety strategy can be overarching with broad categories, (e.g., patient safety, employee/workplace safety).

Q1 and Q2 2020 Data Presentation

Q1 and Q2 2020 Data Presentation for EP18EO, EP19EO, EP20EO and EP21EO (Updated May 2020)
Organizations without a disruption to Q1 and Q2 2020 in data collection and reporting for EP18EO, EP19EO, EP20EO and EP21EO must submit as required in the 2019 Magnet Application Manual^®.
Organizations with a disruption in data collection and reporting for Q1 and Q2 2020 data for EP18EO, EP19EO, EP20EO and/or EP21EO due to COVID-19, must submit the most recent available eight quarters. To do this, the organization may need to present additional quarters (up to a total of 10 quarters) to account for the missing quarters indicated as unavailable.

For each missing quarter of data, the organization will record “COVID-19”, on the graph, data table and Unit Level Data Crosswalk (ULDC).
If unable to indicate COVID-19 in data table, please indicate explanation for missing data under the data table.

As always, please reach out to your assigned Senior Magnet Program Analyst for any questions.

Sample data table:

	2Q2018	3Q2018	4Q2018	1Q2019	2Q2019	3Q2019	4Q2019	1Q2020	2Q2020	3Q2020
Unit A	2.22	2.47	3.77	4.01	1.98	1.43	1.55	COVID-19	COVID-19	1.17
Unit B	1.87	1.23	1.43	2.17	1.06	2.13	2.76	COVID-19	COVID-19	3.44
[Specify: National Database National comparison cohort; National benchmark statistic]	1.78	1.93	2.37	3.10	2.59	1.99	2.44	COVID-19	COVID-19	3.00

Sample of data table with explanation of missing data below:

	2Q2018	3Q2018	4Q2018	1Q2019	2Q2019	3Q2019	4Q2019	1Q2020	2Q2020	3Q2020
Unit A	2.22	2.47	3.77	2.47	3.77	4.01	1.98	*	*	1.17
Unit B	1.87	1.23	1.43	1.23	1.43	2.17	1.06	*	*	3.44
[Specify: National database; National comparison cohort; National benchmark statistic]	1.78	1.93	2.37	1.93	2.37	3.10	2.59	*	*	3.00

Sample ULDC (click here for pdf version):

EP18EO

Q - What data needs to be submitted for EP18EO for an International Organization?
Please refer to: https://www.nursingworld.org/organizational-programs/magnet/international/

Q - Since we must use a national benchmark for EP18EO a through d, if the vendor does not provide unit level data, but rather organization level data, would this be acceptable? (Updated September 2019)
No, you must provide 8 quarters of nationally benchmarked data at the unit level, where the vendor collects the clinical indicator. If unit level data is not available, another clinical indicator should be selected. Remember, Falls with Injury and HAPI stage 2 and above are required.

EP18EO/EP20EO

Q - I am in an organization with no inpatient units, what is my requirement for EP18EO and EP 20EO? (June 2020)
Organizations without inpatient units do not need to submit substitute data for EP18EO or EP20EO.

NHSN SIR (FAQ May 2017, updated February 2020)

Q - May we use the NHSN Standardized Infection Ratio (SIR) metric when submitting CLABSI and CAUTI (or other nurse-sensitive clinical indicator) data?
Information from the CDC National Healthcare Safety Network (NHSN), A Guide to the SIR (Jan. 2017) indicates that “SIRs are currently not calculated when the number of predicted infections is less than 1.0”. Consequently, there is a high likelihood that quarterly, nationally benchmarked, unit-level SIR data may not be consistently available to organizations in order to demonstrate outperformance of a national benchmark over the majority of the most recent eight quarters. Since majority outperformance of a national benchmark over the majority of the most recent eight quarters is required to meet Magnet expectations for each EP18EO nurse-sensitive clinical indicator (NSI), the SIR is unacceptable for use as a national benchmark for nurse-sensitive clinical indicator data, unless a calculated SIR is available for at least the majority of the eight quarters of unit-level data for the majority of applicable units.

EP18EOc and/or d

Q - Can we use the core measure VTE-1 (VTE prophylaxis on admission or by Hospital day 1)? (updated September 2019)
No, the Core Measure of VTE describes process, not an outcome measure. For instance, prophylaxis or other methods to prevent VTE represent process. The outcome of that process is a decrease in the VTE.

EP19EO/EP21EO

Q - My organization has no ambulatory areas, what is my requirement for EP19EO and EP21EO? (June 2020)
Organizations without ambulatory areas do not need to submit substitute data for EP19EO or EP21EO. Note, the Magnet Recognition Program considers the Emergency Department an ambulatory area.

EP19EO

Q - Is an explanation about how the selected indicator is nurse sensitive required for each source? (current FAQ as of September 2019, updated February 2020)

Yes, an explanation must be included for “how the selected indicator is nurse sensitive” in the organization.
If the outcome measure is on the pick list on pages 53 and 54 of the 2019 Magnet Application Manual, no explanation is required for how the selected indicator is nurse sensitive.
Nurse Sensitive Clinical Indicators for Ambulatory must be provided for each SOE for both clinics (2 examples) and/or standalone ambulatory facilities (4 examples).

Q - Should data be presented for just the ambulatory surgical center patient burns or for all ambulatory patient burns? (June 2020)
The data presentation is dependent upon where the vendor collects the data. If data is collected at multiple locations, the expectation is to present the data at the clinic level where it is collected.

EP20EO/EP21EO

Q - How is patient satisfaction evaluated? (Updated February 2020)

You must present four patient satisfaction categories for the inpatient setting (EP20EO) and four patient satisfaction categories for the ambulatory setting (EP21EO). Therefore, a total of eight SOE examples are required and evaluated individually for patient satisfaction.
Applicant organizations must meet the threshold of nursing excellence including demonstrating outperformance of the national vendor’s benchmark for at least five out of eight quarters on the majority of the reporting inpatient units/ambulatory units or clinics.

EP21EO

Q - How should data be presented if there is a change in vendors during the 8 quarter prior to document submission? (Updated February 2020)
Present separate graphs for data from the two vendors. For example, four quarters from the old vendor then a new graph with four quarter from the new vendor. Each graph should be set up according to the instructions in the 2019 Manual, on page 55-56 or use vendor graphs where applicable.

New Knowledge Innovations and Improvements

New Knowledge, Innovations and Improvements

NK1

Q - What is a “completed” study? (updated September 2019)
For Magnet purposes, a “completed study” refers to a study that has concluded to the point of analysis and from which initial implications of the findings have been determined and dissemination has occurred or will occur. The study must be completed within the 48-month timeline. The study may start prior to the 48-month timeline.

NK2

Q - For our nursing research can we use the same study for NK2 as we use for NK1? (updated September 2019)
No. The applicant organization must use a different study for NK2 than is used for NK1. Both studies (NK1 and NK2) must have been completed within the 48-month application timeframe.

Q - Must a clinical nurse be listed as an investigator (Principal or sub-investigator) on the nursing research protocol used as the example for NK2? (updated September 2019)
Clinical nurses do not have to be PI or co-PI for NK2 but they need to have a level of knowledge and understanding of the applicant organization’s study to be able disseminate to internal and external audiences.

Q - Can I use the same study for NK2 a and b? (updated September 2019)
The applicant organization may use the same study for NK2a and b. Remember NK2 studies must be a different study than presented in NK1.

Q - For our nursing research can we use the same study for NK2 as we use for NK1? (FAQ April 2019, updated February 2020)

No. The applicant organization must use a different study for NK2 than is used for NK1.
The study used for NK2 must be disseminated within the 48-month application timeframe. The same study can be used in NK2a and NK2b to demonstrate dissemination.
If the study used in NK2 is completed prior to the 48-month application timeframe, it does not need to be included on the research table.

NK3a/3b

Q - What does “organization” mean for NK3a and NK3b? Could this mean any one unit? Or does the new or revised practice need to take place on more than one nursing unit? Could this be anywhere within the organization? (updated September 2019)
The examples provided for NK3a and NK3b, may be at the organization-level, division-level or the unit-level.

NK6EO

Q - Two examples are required. If I do not have any ambulatory care settings how do I respond? (September 2019)
Two examples must be submitted. If there is not an ambulatory setting, both may be from inpatient settings.

NK7EO

Q - Two examples are required. If I do not have any ambulatory care settings how do I respond? (Updated September 2019)
Two examples must be submitted for NK7EOa. If there is not an ambulatory setting, both may be from inpatient settings.

NK7EOb

Q - NK7EOb is written different than the other sources where ambulatory is an option. Is this intentional? (June 2020)
This is intentional. NK7EOb must be from an ambulatory setting, while NK7EOa can be from an inpatient or an ambulatory setting.

Site Visit

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Q - What does “determining enculturation at Site Visit” mean? (June 2020)
Enculturation is defined in the 2019 Magnet Application Manual Glossary on pg. 149. Additionally, Appendix F, pg. 85, explains that the site visit is “…arranged to validate, verify, and amplify compliance and enculturation of the Magnet components.” Various elements of each of the Magnet Components, including Source of Evidence (SOE) examples, may be reviewed and validated during the Site Visit to ensure that the characteristics and process by which the values of Magnet are evident throughout the organization.

During the site visit meetings and unit visits, the Appraisers will explore enculturation of Source of Evidence examples presented in the documentation as well as inquire about the enculturation of the SOE examples that were not included in the documentation; in particular those SOEs for which options were not included in the submitted documentation (i.e.TL TL6, TL7, TL9EO, SE9, EP11).

NOTE: If evidence for enculturation is not found for any SOE example, the potential exists that the SOE example will be scored deficient in the Site Visit phase.

During the Site Visit, Appraisers will:

Validate and verify what has been presented in the documentation for evaluation
Verify the accuracy of data presented for SE4EO, SE6EO, EP2EO, EP18EO, EP19EO, EP20EO, and EP21EO
Review personnel records to validate nurse leader education eligibility requirements are sustained.
Review records to validate use of periodic formal performance review that includes self-appraisal and peer feedback process, demonstrating a plan for professional development for all levels of nursing (EP11)

2019 Magnet® Application Manual Updates and FAQs