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UWHC,UWMF,

Policies,Administrative,UWHC,Department Specific,Nursing Administrative,Personnel

Nursing Clinical Advancement Program (NCAP) (4.65)

Nursing Clinical Advancement Program (NCAP) (4.65) - Policies, Administrative, UWHC, Department Specific, Nursing Administrative, Personnel

4.65

POLICY & PROCEDURE





Effective Date:
3/1/2015

Administrative Manual
Nursing Manual
 Other _______________

Policy #:
4.65

 Original
 Revision

Page 1
Of 6

Title: Nursing Clinical Advancement
Program (NCAP)


I. PURPOSE

To outline the University of Wisconsin Hospital and Clinics (UWHC) Department of Nursing
and Patient Care Services’ program for advancement and recognition of the professional nurse,
the Nursing Clinical Advancement Program (NCAP).

DEFINITIONS

a. Direct care nurse:
i. Nurses that practice in direct patient care and are listed in the document,
“Nursing Titles Eligible for the Nursing Clinical Advancement Program.”
b. Non-direct care nurse:
i. Nurses that do not practice in direct patient care. Examples include, Nurse
Managers, Clinical Nurse Specialist, Nursing Education Specialist, and
Nursing Informatics Specialist.


II. POLICY STATEMENT

The Department of Nursing and Patient Care Services will maintain a system to reward
nurses by recognizing them for their achievements and contributions to patients, families, the
organization, and the profession of nursing. The structured framework includes three domains
(Clinical Nursing Practice, Clinical Nursing Leadership, Clinical Nursing Scholarship)
defined by behavioral criteria that advance across four levels. The four levels are assigned as
follows:
ξ Advanced Beginner - Nurse Residents and ADN New to Practice Nurses
ξ Competent - the minimum expectation for nurses, includes experienced new hires
ξ Proficient - voluntary and an application is required
ξ Expert - voluntary and an application is required


III. PROCEDURE

a. Eligibility

POLICY & PROCEDURE





Effective Date:
3/1/2015

Administrative Manual
Nursing Manual
 Other _______________

Policy #:
4.65

 Original
 Revision

Page 2
Of 6

Title: Nursing Clinical Advancement
Program (NCAP)


i. To be eligible for the Nursing Clinical Advancement Program an applicant
will meet the following:
1. Received an overall rating of a 3 or higher on their most recent
performance evaluation
2. Have passed probation
3. Have no active discipline
4. Job Title is listed in the document, “Nursing Titles Eligible for the
Nursing Clinical Advancement Program”
b. The instructions, supporting documentation and contact information for application
will be available on U-Connect.
c. The tools used to demonstrate that an applicant has met the required criteria are as
follows:
i. Application: Applicants submit an “Intent to Apply” form including a
proposed date for portfolio submission per the deadlines outlined in Figure 1
(Nursing Clinical Advancement Program Calendar).
1. Manager Endorsement - Managers retain the right to determine
when an employee is eligible to submit an application for
advancement. If a manager determines that an employee is
ineligible for endorsement he/she will submit his or her specific
rationale to the employee in writing. Manager denials will not be
subject to the appeals policy.
ii. Portfolio - A portfolio is submitted by the proposed date for document
submission as indicated by the applicant on their “Intent to Apply” form and
meets all eligibility criteria. The required components for a portfolio include:
1. Application Form
2. Resume
3. Three (3) letters of recommendation. Letters will be written by an
individual who is able to speak to the applicant’s practice within 12
months from the date the applicant submitted his/her current intent to
apply. Letters are dated and signed and the date falls after the date of
the most current intent to apply. Writer may not be a patient, patient’s
family member, personal family member, or personal acquaintance.
4. Five (5) medical record numbers of patients cared for within 12
months from the date of the current Intent to Apply including day,
month, and year of encounter.

POLICY & PROCEDURE





Effective Date:
3/1/2015

Administrative Manual
Nursing Manual
 Other _______________

Policy #:
4.65

 Original
 Revision

Page 3
Of 6

Title: Nursing Clinical Advancement
Program (NCAP)


4. Clinical narratives. Including date(s) of care (Minimally Month and
Year), that fall within 12 months from the date of the current Intent to
Apply
5. Scoring Tool indicating the source of evidence that addresses each
criterion.
6. Additional non-required items, relevant to criteria, may be included in
the portfolio submission. All items include the date the activity
occurred (minimally Month and Year) and the date falls within 12
months from the date of the current Intent to Apply.
iii. Chart review – the review team will review charting of the applicant
iv. Interview - If the required number of criteria is not met with the portfolio
review, the Review Team will invite the applicant to come in for an interview
to give the applicant the opportunity to address unmet criteria.
v. Review and scoring - A Review Team will be selected for each applicant
review. Reviewers will be comprised of:
1. Members of the Nursing Advancement Council
2. Direct-care nurses that have advanced to the Proficient or Expert level
may review same level applications
3. Non-direct care nurses who are not members of the Nursing
Advancement Council who have received training in the NCAP
review process.
vi. An applicant may review the Council membership on the NCAP U-Connect
website in advance of the review process. The applicant may request that a
Council member be excluded as a member of the review team if there is a
family or financial conflict of interest. The request will be reviewed by the
Program Specialist. A Review Team member that has a family or financial
conflict of interest with an applicant will recuse herself/himself from the
Review Team process.
vii. Review team members will:
1. Individually review and score written application materials
2. Meet as a team to consensus score written application material
3. As a team, un-blind applicants and review charting.
viii. Technical Experts – The Review Team may choose to consult with a
Technical Expert from outside the Review Team or Nursing Advancement

POLICY & PROCEDURE





Effective Date:
3/1/2015

Administrative Manual
Nursing Manual
 Other _______________

Policy #:
4.65

 Original
 Revision

Page 4
Of 6

Title: Nursing Clinical Advancement
Program (NCAP)


Council to assist in practice evaluation for a given area of clinical
specialization.
1. An applicant will be able to provide a list of technical experts for the
Review Team to consider.
2. The Review Team may select an individual that the applicant does
not include on his/her list.
3. A Technical Expert is defined as an individual who is widely
recognized as a reliable source of knowledge, technique, or skill
whose judgment is accorded authority and status by their peers.
4. Technical Experts have prolonged or intense experience through
clinical practice or clinical practice and education in a particular field.
ix. Interview Process
1. A report of deficiencies will be provided to the applicant at least two
(2) weeks prior to the interview to provide the opportunity to
readdress criteria.
2. Interview by Review Team, if necessary.
3. Consensus scoring by the Review Team.
4. Preparation of results by the Review Team for presentation to
Nursing Advancement Council.
x. Presentation of findings to the Nursing Advancement Council by Review
Team.
1. Council Vote
d. Applicants must meet a minimum of 90% of the criteria on the scoring tool to
achieve advancement.
e. Notification of results to applicant will be provided in a letter from the Nursing
Advancement Council.
i. If approved, applicant will receive a congratulatory letter and certificate from
the Senior Vice President, Patient Care Services, Chief Nursing Officer; and
Vice President, Development, Nursing and Patient Care Services and a
monetary bonus. Proficient nurses will receive a $1,500 annual lump sum
bonus prorated based on FTE for three years (at which time they will need to
reapply). Expert nurses will receive a $2,500 annual lump sum bonus
prorated based on FTE for three years (at which time they will need to
reapply). Bonuses will be paid annually, on the quarter directly following

POLICY & PROCEDURE





Effective Date:
3/1/2015

Administrative Manual
Nursing Manual
 Other _______________

Policy #:
4.65

 Original
 Revision

Page 5
Of 6

Title: Nursing Clinical Advancement
Program (NCAP)


designation and will be pro-rated based on the employee’s FTE at time of
payment.
ii. If denied, a report will be provided to the applicant with opportunity to
discuss findings with the Program Specialist. The applicant may re-apply in
six months
f. Evaluation of applicant material will be done quarterly (Refer to Figure 1 “Nursing
Clinical Advancement Program Calendar” for deadlines).
g. Nursing Advancement Council Members and Review Team members will be in pay
status when conducting Council or Review Team work. Applicants will be in pay
status for interviews, additional time spent as a part of the application process (e.g.
building portfolio, attending NCAP educational offerings) will be done on the
applicant’s own time.
h. Maintenance
i. Following the processes outlined in this policy, reapplication is required
every three years after initial designation. Transfer to a different area/unit
does not change the reapplication timeline.
ii. Submission of Intent to Apply form at least six to nine months prior to the
three year anniversary date and portfolio at least three months prior to the
three year anniversary date are required to avoid a lapse in designation status.
If designation lapses, an applicant’s status will be at the Competent Level.
iii. Applicants at the Proficient Level that re-apply at the Proficient or Expert
Level and do not maintain an advanced designation status will be considered
Competent.
iv. Applicants at the Expert Level that re-apply at the Expert Level and do not
maintain Expert designation status will have one additional opportunity to
apply for the Expert level. Applicants will need to wait three months and no
more than 6 months to submit a new Intent to Apply form for the Expert
Level. Applicants will be at the Competent Level during this time. Nurses at
the Expert Level that do not re-designate will be at the Competent Level.
v. NCAP designees who receive discipline at the level of a suspension and/or
placed on a performance improvement plan will lose their designation as a
Proficient or Expert Nurse.
vi. An employee who voluntary terminates employment and returns to
employment within one year will not have their advancement designation

POLICY & PROCEDURE





Effective Date:
3/1/2015

Administrative Manual
Nursing Manual
 Other _______________

Policy #:
4.65

 Original
 Revision

Page 6
Of 6

Title: Nursing Clinical Advancement
Program (NCAP)


affected, nor will it change the reapplication timeline. Employees rehired
after one year will be considered at the Competent level.
vii. Promotions, voluntary demotions, transfers, restructuring or recall from
layoff to an NCAP eligible title will not affect NCAP designation.


Figure 1: Nursing Clinical Advancement Program Calendar
Intent to Apply form due
between:
Submit portfolio
by:
Interview will be
scheduled in:
You will be notified
of the Nursing
Advancement
Council’s decision
by:
February 2 – May 1 August 1 October November 1
May 2 – August 1 November 1 January February 1
August 2 – November 1 February 1 April May 1
November 2 – February 1 May 1 July August 1


IV. REVIEWED BY:

a. Director, Compensation & Benefits
b. HR Consultant
c. Nursing Program Specialist, Professional Practice
d. Director, Medical Nursing
e. VP Development, Nursing & Patient Care Services
f. Nursing Administrative Policy & Procedure Committee



SIGNED BY:

Beth Houlahan, MSN, RN, CENP
Senior Vice President and Chief Nursing Officer