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Question 1
Should there be a national policy body that develops national standard of
practice guidelines? If so, is there an existing national body that should be
given this responsibility?
Attendees suggested that existing national bodies such as the Agency for Health Care and Policy Research (AHCPR) and the U.S. Department of Health and Human Services (HHS) - Health Resources and Services Administration (HRSA) should be considered. Others pointed to the National Association of State Boards of Pharmacy and Nurse Anesthetists Association, both of which have developed a model scope. Some questioned the idea of a national body, preferring instead the idea of alliances and partnerships between national professional organizations.
Turning to the composition of the body, some urged the inclusion of national professional certifying organizations, academics, accreditation, and employers. Attendees felt that opposition to the idea would come from states preferring the idea of a national research body rather than an advisory board. Concerns over the effect of federal politics and the way that such a body would be financed were also raised and some stated that a national body should not be congressionally mandated or controlled.
Proposed initial action steps were the exploration of attitudes towards a national rather than a federal approach, and an information gathering/clearinghouse role for the entity as opposed to one that produces guidelines and recommendations.
One group stated that its members expressed considerable interest in some national, objective resource/clearinghouse that would collect information/data regarding scopes of practice. However, there was a lack of consensus over the exact role (information collecting only versus recommendation making) of the entity, and concern was expressed over political involvement at the federal level.
Question 2
If a national body is developed, how should it be structured and financed to
research, develop and publish national standards of practice?
Attendees felt that an obvious model for a national body looking at national standards of practice was the Ontario Health Professions Regulatory Advisory Council. Others pointed to Minnesota where they felt collaborative practice had worked well, and to Louisiana where demonstration projects have been used to provide assurances about the safety of widening scopes. Some felt members of regulatory associations - accrediting bodies, public/consumer representatives, professional organizations, third-party payors and employers should all be represented on any board. It was felt that barriers to the formation of a national body would be the political issues regarding profile and structure, funding, location of experts and the impracticality of having every profession represented. Others felt that a national body would not be appropriate, preferring to concentrate on what was happening at a state level and pointing to the dangers of politicization they felt were inherent in every institution. Still others felt getting agreement from doctors would present the greatest challenge.
Attendees considered the purpose and function of a national body and suggestions as to its role included the following:
Some group members considered that the first steps in establishing a national body should be the exploration of funding ideas and qualities of potential members, and to ensure that guidelines are translated into practice. Others felt that without a federal mandate states would not act, while still others felt that any action must be taken on a voluntary basis. Turning specifically to the qualities required to be an effective member of the national body, it was suggested that objectivity, ability to evaluate information (while not necessarily being a technical expert) and wisdom were paramount. Groups considered how such an entity could be funded and while there was no consensus amongst attendees, ideas included: foundations, a tax levied on individual licensees and professionals, federal funding and a tax on managed health care plans and hospitals.
Question 3
What should be the relationship among state licensing boards, legislatures,
agencies and a national advisory body that develops national scope of practice
guidelines?
Attendees considered that one approach to reaching consensus would be through Model Practice Acts. Turning to proposals for a national advisory body, attendees looked at the example of Kansas which recently incorporated health care groups under one board. The group is advisory and it is seen as a collective body of knowledge versus one interest, and is consulted on that basis by the legislature. Ontario's Health Professions Regulatory Advisory Council was also cited as an example, although some stated that it still has problems with "turf" and control. Others drew attention to the Pennsylvania review process in which a Board proposes changes in law, which are sent to the Secretary and Governor. Following this a legislator is sought to sponsor the bill. Mention was also made of the collaborative efforts among boards taking place in Alabama.
Attendees considered that the national body could be a "broker" for how and what, not who. It was suggested that the body would carry out some or all of the following functions:
Attendees identified potential barriers to change as being whether professions would be willing to reduce their scopes of practice, the system of healthcare and resistance of third-party payers, how the body would be financed, a lack of clarity about who would be responsible for enforcement, and resistance from state legislatures. Others cited a lack of public interest in the debate, inter-board conflicts, and the inability of many boards to lobby. Those in favor of a national body suggested that an initial step would be the formation of a taskforce to compare models of various disciplines and to communicate when practice changes. Others suggested asking professional associations and boards to provide model acts and establishing a way of connecting stakeholders (boards, administrators, consumer groups) on a regular and routine basis.
Question 4
What methods/processes might be used for standards of practice decision-making
that are less political and use empirical evidence? Who should participate in
this?
Some suggested the experiences in federal settings (such as VA hospitals) could be used as an example, as could the "socialization" process in medical school (as used in Colorado) where students are exposed to interdisciplinary modules. In Louisiana physicians were made responsible for Advanced Practice Nurses under demonstration projects and reported errors. Others present said consideration should be given to setting up a dialogue between states and agencies with existing models. For example in Iowa a body is set up when scopes disputes arise which prepares reports for the legislature. Minnesota has a model that requires that feasibility and accessibility studies are conducted before the legislature will consider changes. In Kansas the Health Occupations Credentialing Act has protocols, criteria, and is date driven. Some attendees stated that change should start at a state level before a national level is contemplated, while others felt the Federal Government should mandate demonstration projects, taking care to lay out effective models and outcome measures.
Question 5
Should guidelines be developed for establishing national scopes of practice? If
so, who should participate?
Some attendees felt that standardized minimum requirements need to be established prior to the publication of guidelines. Others were concerned about who would oversee this project. They stated that it cannot be profession(s) specific, rather that it needs a neutral body. Others feared that developing a national scope would take such a long time that it might lag behind practice evolution and appear outdated.
Question 6
While waiting for a national body, should states allow demonstrations/
experimental projects for professionals to perform beyond scopes of practice?
How can States build protections into demonstrations?
Some present remarked that experimental projects are currently going on in California, and that data collection is required. Others noted a proposed Ohio law giving nurse practitioners prescriptive authority for demonstrating for which a report is pending. Still others pointed to Washington State where nurses are delegated the administration of medications and some administrative duties.
Those present felt that the political will of legislatures might be the biggest barrier to change. Other barriers were felt to be the safeguards that would necessarily need to be built into the experiments, as well as questions about the level of training, the lack of data regarding mental health and the perception that a demonstration project could be considered a danger to the public. It was felt that there was a danger that evidence would be perceived as being anecdotal. There were also concerns expressed that the lack of nationwide uniformity would work against changes to scopes of practice. For changes to take place institutions, regulators, academic payors, would all need to communicate and there was a feeling on behalf of some that the current systems are out of step with one another.
Some suggested examining what is happening in non-regulated or lightly regulated professions. It was felt that initial action steps would be to set up studies under supervision, secure demonstration projects or find existing ones and collect models for states to adopt. Others suggested the exploration of the development of human research protocols, examining the need for clinical training required for professions seeking expansion before involving them in the demonstration project. The establishment of an internet web site with scopes of practice and demonstration projects was also suggested as was looking at the least restrictive states for ideas about process, breaking down barriers, outcomes, and the level of compelling evidence that has been generated. It was also stated that an ongoing systematic approach would be needed to independently determine who needs to be regulated. Some felt that existing sunset/sunrise provisions could be used for this purpose.
Some attendees felt that the following questions needed to be answered before the initiative could be further considered: how do we distinguish cognitive knowledge from task? How could scopes of practice be agreed that recognize that tasks will change?
Turning specifically to the demonstration process, attendees felt it would be important to carefully structure the body, giving it proper authority, appropriate time lines, and safeguards (such as legal exemption, human subject research procedures (informed consent), supervision/oversight of project). It was also suggested that the benefit to both public and profession must be clearly articulated. Furthermore the clinical training of professionals must be sufficient to be involved with these experiments.
Turning to initial action steps, attendees felt that a search should be performed for a clearinghouse of information. It is also vital to establish whether states are interested in such an initiative. Some were concerned that any national advisory body would have the same political control issues of power, history and money. Attendees were split on whether a national body should make recommendations or whether it should be limited to providing clearinghouse information.
Turning to specific responsibilities for a national body, attendees felt it would difficult to test cognitive skills. Potential difficulties also could be the weighting given to different parts of examinations, e.g. practical exam versus written exams. Some also mentioned the importance of recognizing the overlaps of scopes, for example a number of professions administer drugs.