ORNAC Notice: These guidelines are currently under review by the Education Committee and may be subject to change without notice.


Title Perioperative Education Programs
Program Review and Approval Process
Download/Print Version
Number 400
Source Executive & Board; Perioperative Education Committee
Date Revised January 2011
Date Effective 1988

Perioperative Programs for Registered Nurses
Program Review and Approval Process: Guidelines for Self-Assessment

  • Accountability for co-ordination of the Approval Process for Perioperative Education Programs for Registered Nurses lies with the Perioperative Education Committee.
  • Programs shall notify the Chair of the Perioperative Education Committee of their intent to apply for ORNAC Approval at least three months in advance. The Chair shall then arrange for the review process.
  • The approval process shall be strictly confidential, and information will not be communicated regarding applications. The Committee’s reports to the ORNAC Board will indicate the number of applications, reviewers, etc. but will not divulge confidential details. If External reviewers are required they will sign a confidentiality agreement with ORNAC.
  • Programs which apply for ORNAC Approval may be requested to provide individuals to participate in external reviews of other programs, subject to ORNAC confidentiality agreement. Applications will follow the format outlined in the Approval Process.


  1. ORNAC’s Approval Process for Perioperative Education Programs is available only for those educational programs offering education for Registered Nurses. Programs offering the same education to other health care providers or to both Registered Nurses and others within the same program will NOT be evaluated or approved by ORNAC.
  2. Approval Status

    2.1 Full Approval
    A program is granted unqualified approval by ORNAC for three (3) years. Suggestions may be included by the reviewers for consideration by the Program, but the approval status is not dependent upon implementation of these suggestions.

    2.2 Conditional Approval
    A program is granted conditional approval, based on the results of the assessment. The conditions may be removed by ORNAC, with full approval status subsequently granted, upon:

    • Implementation of the major recommendations set forth in the conditional approval; and,
    • Submission of a written report, within the time-frame specified by the reviewers, (maximum 6 months) outlining actions taken on the recommendations.

    A decision regarding the removal of conditions remains the discretion of the Committee and reviewer

    2.3 New Program Approval
    A new program may be granted either full or conditional approval, with provision for a review of approval status following the graduation of the first class.

    2.4 Approval Denied
    A program may be denied approval by ORNAC when:

    • The program has failed to present sufficient evidence that the criteria have been met.
    • The program has not taken action to address recommendations in the time-frames outlined in an award of Conditional Approval.
  3. Application Format
    The same application format is used both for original applications, and for applications for renewal of approval.
  4. Application and Other Fees
    A non-refundable application fee (payable to ORNAC) must accompany the application. The application fees shall be received by ORNAC prior to approval review being initiated or approval granted. The fee structure is established by the ORNAC Board.

    Website fees (as established by ORNAC) shall accompany each request for changes to Program information on the ORNAC website during the 3-year approval period. All requests for changes to information on the ORNAC website shall go through the Chair, Perioperative Education Committee.
  5. Appeal Process
    A program may appeal the decision of the review process. Such appeals are to be made in writing to the Chair of the Perioperative Education Committee within one (1) month of receipt of the decision. The Chair has the discretion to appoint a second review of the documents as submitted.

    Results of the Appeal process are final.
  6. Perioperative Education Programs for registered nurses that achieve "ORNAC Approved" status may indicate that status on their promotional materials only for the period covered by the approval, and only in the format as indicated by ORNAC in the letter of Approval. A certificate from ORNAC (suitable for framing) indicating approval status and time-frame for the approval will be provided to the educational provider. This is suitable for display in clinical settings, etc.
  7. ORNAC will maintain a current list of approved Perioperative Education Programs for registered nurses on its website. This list shall indicate program information, the educational provider, contact information and approval status.
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