Scope of Practice Discussion - PowerPoint Presentation

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Scope of Practice Discussion

Mary Jo Williams, RN, MBA

Managing Director

TPMG

Presentation to:

Residency Elective in Health

Policy

CONFIDENTIAL

Staffing physician offices in TPMG

Physician office practice is supported by:Clinicians who assist the MD with patient care – NPs, PAs, RNs, clinical pharmacistsSupport staff who assist the MD with routine care tasks and administrative clerical functions and panel management – receptionists, medical assistants.

Regional and local support services – population management reports, outreach and inreach, Medicare diagnosis refresh, nursing practice expertise, etc.

Referral and diagnostic services – imaging, lab, cardiac studies, PT, Behavioral Health, etc.Referral and consultative MD servicesFocus today: Scope of practice of the clinicians who assist the MD with patient care

RN Education

In California, RNs may graduate with an Associate’s degree from a community college or with a Bachelor of Science degree, as the entry to practice. App. 65% of RNs currently employed with KP have a Bachelor’s degree

A new type of program – ABSN and MEPN –has recently been developed to allow students with a Bachelor’s degree in a related field to complete a nursing program in one year.RNs may pursue advanced

academic degrees – MSN or PhD -if they are interested in administration, teaching, etc.The entry level RN degree is required to purse advanced practice degrees such as the Certified Nurse Midwife, Certified Registered Nurse Anesthetist, Nurse Practitioner, or Clinical Nurse Specialist. The new degree conferred is a Clinical Doctorate in Nursing Practice (DNP).Nurse Practitioners may also pursue advanced degrees that allow them to specialize in specific areas of specialty, such as geriatrics, pediatrics, or acute care.

Program Overview

The program prepares students to work as registered nurses. Upon completion, thegraduate will receive an Associate Degree in Nursing. The graduate is entitled to take the

California State Board of Registered Nursing licensing exam.

The program offers a series of courses that combine academic classes on campus, skillspractice in the nursing skills laboratory, and patient care experience in various hospitalsand facilities in the San Francisco area. More InformationBureau of Labor Statistics on Registered NursingCalifornia Board of Registered NursingNCLEX Passing Rates

SFSU Roadmap for CCSF Registered Nursing ProgramMission StatementThe purpose of City College of San Francisco Registered Nursing Program is to recruit,counsel and prepare qualified people in the San Francisco Bay Area to functioneffectively at an entry level registered nursing position.

UC Davis Health School of Medicine

Betty Irene Moore School of Nursing at UC Davis

Innovation in educational approaches and learning methodsEducational programs at the Betty Irene Moore School of Nursing place an emphasis on problem solving, independent thinking and individual accountability to empower students to fulfill their learning needs and prepare them to lead in health care. Faculty and students work together to create environments that promote leadership, inter-professional education, transformative research and cultural inclusiveness. Through innovative teaching and learning approaches that address a variety of learning styles, professors actively engage students.

Whether it’s future researchers and nursing faculty looking to advance their careers or nurses, nurse practitioners and physician assistants seeking greater clinical knowledge, all students at the School of Nursing benefit from professors with diverse interests who create learning environments that empower them to be agents of health care change. Many courses use the flipped classroom style of learning where students work in a way that fits their learning style to review content and come to class prepared to engage in meaningful discussions around a topic. Technology allows students to maximize learning time by completing coursework before coming to class. The elimination of lecture-style instruction engages students in a two-way flow of information.

Stanford School of Medicine: MASTER OF SCIENCE IN PHYSICIAN ASSISTANT STUDIES

Creating Exceptional Clinical PAs and Future PA Leaders

The Stanford School of Medicine Master of Science Degree in PA Studies program seeks to develop highly skilled clinical PAs and inspire PA students to become PA leaders through work in scholarly concentrations, including community health, clinical research, health services and policy research, and medical education.  During the 30-month program, students will be educated by exceptional Stanford clinical faculty, will immerse themselves in scholarly concentrations to build leadership skills, and will experience clinical practice in a world-class healthcare infrastructure.

NPs and PAs – side by side comparison

NPs:Union employees in KPNo defined SOP in California lawDefined as Allied Health Professional under Kaiser Foundation Hospital by-laws

“Standardized Procedure” is the mechanism for delegation of work from MD to NP; defines the scope of practice for the NP in the particular departmentMD co-signature requirements as required by Ca state law and certain payorsRN degree required to apply to a NP programMaster’s degree in Nursing; completion of education allows RN to “hold themselves out” as a NP; NP must pass one of 4 national certification exams; typical educational concentration in primary care

Perceived to be a more independent practice, grounded in nursing principlesPAs:Exempt employees in KPDefined SOP in California lawDefined as Allied Health Professional under Kaiser Foundation Hospital by-laws“Delegation of Services” is the mechanism to define the delegation of work from MD to PA; defines the scope of practice for the PA working with a specific MD or group of MDsMD co-signatures required under certain circumstances and as required by Ca state law and certain payors Master’s degree; must pass certification exam to be licensed as a PA-C; educational preparation includes primary and specialty care

Perceived to be more of a dependent practice, with direct link to the supervising MD; supervising MD name entered on all chart entries

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What defines NP and PA scope of practice?

State boards - Physician Assistant Board and Board of Registered Nursingdefine the minimum requirements for educational preparation of students. Educational programs must be approved by the boards, as well as being accredited.Interpret questions about practiceExample: Nursing practice information, advisories, and guidelines are provided by the BRN to ensure ongoing communication of competency standards to consumers, registered nurses, advanced practice nurses, employers, educators, and other regulators. As the scope of nursing practice changes and grows, so does this information.

State regulations

California Business and Professions CodeCalifornia Code of Regulations Compilations of Regulations:NP: The Nursing Practice Act (NPA) is the body of California law that mandates the Board to set out the scope of practice and responsibilities for RNs. The NPA is located in the California Business and Professions Code starting with Section 2700. Regulations which specify the implementation of the law appear in the California Code of Regulations.

The NPA is updated annually and is published by LexisNexis in conjunction with the Board. To purchase the latest edition of the NPA, please visit the LexisNexis Store.PA:

Test Your Knowledge of PA Laws and RegulationsYour knowledge of the PA laws and regulations is important. The Board has developed a new anonymous online 10 question examination to test your knowledge!Try it now - it only takes a few minutes and you will find out if you're up-to-date on your knowledge of the PA Laws!Just a reminder, you may view the complete booklet of PA laws and regulations by clicking here.

What defines NP and PA scope of practice?Medicare Reimbursement rules

Example: Coverage Criteria for PAs These coverage criteria apply: You are legally authorized and qualified to furnish the services in the State where you perform such services Services are not otherwise precluded due to a statutory exclusion, and the services must be reasonable and necessary[1] Services are the type considered physician’s services if furnished by a medical doctor or a doctor of osteopathy

Services are performed by an individual who meets all PA qualifications Services are performed under the general supervision of a medical doctor or a doctor of osteopathy The physician supervisor or designee need not be physically present when a service is being furnished and can be contacted by telephone unless State law or regulations require otherwise Assistant-at-surgery services furnished by a PA may be covered KP Policies, Standardized Procedures, Delegation of Services Agreements

Example: Removal of Tissue and Severing of Tissue - Nurse Practitioner Standardized Procedure for Procedures Involving Severing TissueThis Standardized Procedure (SP) is used only for those nurse practitioners who perform procedures that may require severing and/or removing tissue as indicated in this SP as a part of their practice. (Reference California Board of Registered Nursing Title 16 CCR sections 1472 and 1474.) 

What influences NP and PA scope of practice?

Professional OrganizationsExample: California Association For Nurse Practitioners - Power in PracticeSince its establishment in 1977, the California Association for Nurse Practitioners has provided a forum and unifying voice for nurse practitioners statewide, often joining forces with other state and national organizations, to advance the profession and bridge health care needs. As the one advocate solely dedicated to nurse practitioners in California, it works for the advancement and recognition of its constituents. As a conduit of information, it fosters the dissemination of ideas, advice and standards of practice. As a network of professionals, it brings nurse practitioners together to enhance their collective potential. In California’s dynamic health care environment, CANP is a powerful agent of change and upholder of professional standards, for the benefit of all nurse practitioners.

Example: Institute of Medicine

The Institute of Medicine recently released a report on the progress achieved to date on the recommendations set forth by the IOM’s 2010 report The Future of Nursing: Leading Change, Advancing Health. The Campaign for Action, a nursing initiative developed by the Robert Wood Johnson Foundation and AARP, has worked with nurses nationwide since 2010 to advance the IOM recommendations.In the progress report released Dec. 4, the IOM committee gave specific recommendations in the areas of removing barriers to practice and care; transforming education; collaborating and leading; promoting diversity; and improving data. In conclusion, the committee said, “no single profession, working alone, can meet the complex needs of patients and communities. Nurses should continue to develop skills and competencies in leadership and innovation and collaborate with other professionals in healthcare delivery and health system redesign. To continue progress on the implementation of The Future of Nursing recommendations and to effect change in an evolving healthcare landscape, the nursing community, including the campaign, must build and strengthen coalitions with stakeholders both within and outside of nursing.”

What influences NP and PA scope of practice?

Professional OrganizationsExample: California Academy of Family PhysiciansThe Family Physicians Political Action Committee (FP-PAC) is a bipartisan group dedicated to helping pro-family medicine candidates win election to public office and educating current legislators on the importance of family medicine. FP-PAC is the ONLY political organization whose sole mission is to promote family physicians and family medicine. We are the voice of family medicine in California

.Example: California Medical AssociationWorking to protect patientsCalifornia law fosters a team approach to medicine in which doctors collaborate with physician assistants, nurses and others. However, this longstanding and highly successful model of providing physician-led, patient-centric care is in jeopardy. Some health care providers are seeking to expand their scope of practice – to treat patients for medical conditions that were not part of their training. They argue for taking on this greater role by saying it will enhance patient access to care and reduce health care costs.

Mid-level practitioners and other allied health professionals play a significant role in health care, but patients must not substitute them for physicians. A patient's care should begin with a primary care physician, who can most ably advise a patient on what care he or she needs. Simply expanding the scope of practice of practitioners, without expanded training or education, can mean lowering the standard of care for patients. It is imperative that the drive for "access" does not translate into a second tier of health care, one that offers convenience and lower cost in exchange for poorer quality and reduced patient safety. All Californians deserve a health care system that protects their safety and standard of care.

Full Practice States for NPs

Scope of practice guidelines for advanced nursing professions vary by state. Currently, 21 states and the District of Columbia have approved "full practice“ status for Nurse Practitioners, a provision that allows them to assess, diagnose, interpret diagnostic tests, and prescribe medications independently.According to 

Kaiser Health News External link , Alaska, New Hampshire, Oregon, and Washington were the first states to offer expanded scope of practice in the 1980s; more rural states, mainly those with physician shortages, followed in the 1990s.In 2010, full practice status became the recommended model by the Institute of Medicine and the National Council for State Boards of Nursing. Not all states, however, are on board with the measure; 29 continue to mandate reduced or restricted practice regulations for Nurse Practitioners. While the practice guidelines for both of these levels are slightly different depending on location, all require NPs to have either a signed collaboration agreement with a physician or direct oversight from a physician. Not all states require the physician to be physically present or even in the same building with the NP during patient care, but he or she should be available by phone or email.

Stories to share

Full Practice Legislation - NPs Power of CMA and FP-PAC to defeat billsFluoroscopy licensure, supervision requirements – PAsPower of CMA, other lobby groups, to reduce the supervision requirements and allow PAs to obtain fluoroscopy certificationSupervision and furnishing requirements – CRNAs

CRNAs have more autonomy in other states. In California, their orders/plan of care require concurrence by a MD and authorization for the anesthetic agents. Major players: CSAMedical OptometryKP specific issue: TPMG wants Optometrists to work to the “top of license” allowed by law and consistent with educational preparation. Requires negotiation with labor union, who wants additional pay and more relaxed rules about scope of work.