aorn's response to the pew taskforce on health care workforce regulation

FEBRUARY 1997, VOL 65, NO 2 P E W C O M M I S S I O N R E P O R T

AORN’s response to the Pew Taskforce on Health Care Workforce Regulation

he Association of Operating Room Nurses (AOIZN) respectfully submits the following T response to the Pew Health Professions Com-

mission Taskforce on Health Care Workforce Regu- lation report, with the belief that this input will be seriously considered in future deliberations of the Taskforce. AOFW f m l y contends that what is good for health care professions and consumers is good for society. AORN submits these comments in that spirit.

PRlNClPLESNlSlON

ORN enthusiastically supports the set of princi- A ples and vision upon which the Pew Health Professions Commission Taskforce on Health Care Workforce Regulation bases its recommendations for regulation of the health care workforce of the future. This report is submitted in cooperation with the National Certification Board:Perioperative Nursing, Inc (NCB:PNI), an independent not-for-profit certify- ing body that has, to date, certified more than 30,000 perioperative nurses. It has a collegial, collaborative relationship with AORN, and it supports A0R”s response to the Taskforce’s report, with specific additional comments related to recommendations one and seven.

AORN is the professional association of perioperative nurses, representing 46,000 members who are RNs specializing in care of patients undergoing operative and other invasive procedures. AORN has been the premier professional association for perioperative nurses (OR nurses) in this country since 1949. As such, it has provided continuing education, represen- tation, and standards for quality patient care.

A0R”s standards and recommended practices aim to promote optimum patient outcomes from the surgical experience. As professionals, perioperative nurses have a “social contract with society that acknowledges professional rights and responsibilities as well as mechanisms for public accountability.”’ AORN believes that perioperative nurses have a moral obligation to live by the fist two principles identified by the Taskforce (ie, promoting effective health outcomes, protecting the public from harm).

AORN encourages the development of methods to measure a health professional board’s accountability to the public. It is imperative that regulatory bodies know good practice from unsafe practice. Quality practice demands collaboration among health care professions and the development of unique bodies of knowledge from each discipline. Furthermore, AORN believes that boards should have protection from organized groups and systems that have conflicts of interest with board action.

AORN respects the right of consumers to choose health care providers and recognizes the need for consumers to have information about safe options in the surgical arena. At present, consumers’ ability to choose is hampered by reimbursement plans and policies, gag rules, and interdisciplinary turf battles among providers.

AORN joins the Taskforce in encouraging a flexible system that would facilitate more effective working relationships among competent health care providers throughout this country, without regard to regional attributes. Consumers deserve the same options for quality health care providers, whether they live in urban or rural areas of this country. Geo- graphic mobility of providers and a reformed regulatory system could do much to make this a reality.

AORN looks forward to working with the regulatory bodies of the future to ensure the vision of a standardized, accountable, flexible, effective, and efficient system that will safeguard the public’s optimum health, safety, and welfare.

AORNS RESPONSE TO THE PEW RECOMMENDATIONS

A sions Commission Taskforce’s 10 recommendations are listed in Table 1. Specific comments about each recommendation follow.

ized and understandable language for health professions regulation and its functions to clearly describe them for consumers, provider organizations, businesses, and the professions.

0 R ” s responses to the Pew Health Profes-

Recommendution #1. States should use standard-

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FEBRUARY 1997, VOL 65. NO 2 P E W C O M M I S S I O N R E P O R T

Issues and recommendation for reform. AORN supports standardized and understandable language for health profession regulation, believing that standardized terminology will make the regulatory process more understandable and accessible to health professionals, health providers, businesses, and consumers. Consistency of language also serves to protect the public, because the granting of a “title” or a “credential” will be based on documented, nationally standardized criteria.

Any body convened for the purpose of codifying terms and language will want to consider the implications of what title changes will do to the public’s con- fidence in, and uriderstanding of, the health care professional’s established abilities and Competencies. Standardizing terms such as supervision and delegu- tion can clarify one care provider’s role in relation to other care providers. The term udvunced practice nurse should be defined consistently to enable consumers to expect the same level of competency when they cross state boundaries.

Poky options for state considerutiof?. As noted, inconsistent terminology has hampered not only consumers’ understanding of the regulatory process, but also health professionals’ access to employment. Mutual recognition by states or employers, based on standardized criteria, can enhance consumers’ access to competent, quality care. A practical difficulty in standardizing terminology with implications for consumer understanding of the regulatory process lies in the terms licensure and registration as applied to nurses. Although nurses are licensed, the term registered nurse is ingrained in society; changing the title would create unnecessary confusion in consumers’ minds. It also could give consumers the inaccurate impression of the level of education and skill of licensed practical (LPNs) (or vocational) nurses as compared to RNs. The competencies of LPNs and RNs are not comparable, and to imply that they are potentially could deprive the public of the care provided by RNs who are more rigor- ously prepared.

AORN, in cooperation with NCB:PNI, supports reserving the term certz$cution for voluntary sector programs that attest to the competency of individual health professionals. The NCB:PNI is accredited with the American Board of Nursing Specialties,

which was incorporated in 1991 with the goal of serving as an advocate for consumer protection. The American Board of Nursing Specialties established and maintains 12 standards for professional specialty nursing certification and increases consumers’ aware- ness of the meaning and value of specialty nursing certification.

Perioperative nurses who wish to earn the CNOR certification designation undergo a rigorous certification process through the NCB:PNI, which requires a minimum number of practice hours, peer evaluation, and an examination. Recertification, which is required every five years, can be achieved by retak- ing the examination or by accruing 150 hours of approved continuing education. An additional certification process (ie, CRNFA) for registered nurse fust assistants exists with additional criteria. Especially in light of today’s focus on managed care in health care delivery, competency measurements should include the critical thinking skills of practitioners, rather than focusing solely on the tasks of a given role.

The state boards of nursing, by joining together in presenting one entrance examination for professional licensure, have gained expettise in licensing examinations and procedures. Consequently, the individual specialty nursing organizations and their sister certi- fying bodies have gained expertise in developing voluntary programs for recognizing advanced knowledge in the various nursing specialties. To expect the states to duplicate this process would be inefficient and expensive, without added value.

Table 1 AORN’S RESPONSE TO THE P M I REPORT RECOMMENDATIONS

Recommendation #1

Recommendation #2.

Recommendation #3. Recommendation #4.

Recommendation #5.

Recommendation #6.

Recommendation #7.

Recommendation #8.

Recommendation #9.

Recommendation #lo.

AORN supports this recommendation, with reservations as described in the text.


AORN supports this recommendation. AORN submits reservations to this recommendation as described in the text.



AORN supports this recommendation.

AORN supports this recommendation. AORN supports this recommendation.


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Recommendmion #2: States should standardize entry-to-practice requirements and limit them to competence assessments for health professions to facilitate the physical and professional mobility of health professions.

Issue and recommendation for reform. AORN supports standardization of entry-into-practice requirements for health professions while urging caution on limiting those requirements to narrow clinical competency assessments instead of the broader conviction that requirements should include assessment of such critical factors as clinical judgment, clinical acumen, responsibility and accountability, ethical behavior, crisis management, and adaptability. A standard entry requirement would foster greater accountability to the public. It also would form the basis for more effective implementation of established technologies, such as those associated with out-of-state organ procurement, and newer technologies, such as telemedicine and telecommunication. The waivers allowed in Col- orado, Maine, and South Carolina for the medical treatment of Olympic athletes, campers, and low- income patients, respectively, are sensible as well as protective of the public good.

dardizing entry requirements in some professions on the basis of competence, greater progress can be made. Professional associations do have considerable control of practice privileges based on specialized, demonstrated competencies, but they do not address the entry requirements and they are not accountable to the public. Even so, to remove professional groups from determining competency in their areas of expertise would not enhance patient safety. The example noted in the Taskforce’s report (ie, describing the Federal Aviation Administration’s requirement that pilots be tested for specific competency to fly particular planes) could not be achieved solely by a board composed of consumers, flight attendants, and pilots. The flying public’s safety demands that only competent pilots determine another pilot’s competence, and so it should be with health professions’ duty to ensure the safety of health care consumers. The example also can be extended to demonstrate that airline com- panies should not control the establishment of criteria for pilot competency. Such “institutional licensure” could be readily abused by individuals or organizations looking for the least expensive “pilot” (or health care worker).

Policy OptiOnS for state consideration. AORN SUP- ports policy options that advocate uniform entry-into- practice standards, mutual recognition of licensure across state lines, and competency examinations that relate diectly and demonstrably to the required knowledge and skills necessary for safe and contem-

Although some progress has been made in stan-

porary practice. To ensure the public’s safety, we believe that the scope of nursing practice should be the same in each state, and we, therefore, advocate a uniform state practice act for nursing. AORN is wary of the term minimum in today’s rapidly changing cost-driven health care delivery environment where we witness inappropriate downward substitution of professional caregivers with lay people deemed competent to deliver care merely to save money. We urge caution in determining minimum requirements for the health care workforce of the twenty-fist century.

Although we recognize the value of alternative pathways to satisfy entry-into-practice requirements in some professions, we do not want to return to the days of on-the-job-training as the acceptable alternative. How will these alternative pathways affect consumer safety? How and by whom will certain experiences be determined as equivalent to one another? Will experiences of rural practitioners be evaluated the same as those of practitioners in urban teaching hospitals? AORN believes any further discussion of alternative pathways must be based on valid, scientific data when such data exist.

Recommendut/on #3: States should base practice acts on demonstrated initial and continuing competence. This process must allow and expect different professions to share overlapping scopes of practice. States should explore pathways to allow all professionals to provide services to the full extent of their current knowledge, training, experience, and skills.

Issue and recommendation for reform. With the increased mobility of health care providers between and among states-along with the growth of telemedicine and other forms of technologically-based communication, consultation, and intervention-xisting barriers to the full use of competent health professionals impedes consumers’ access to quality health care.

At issue is the definition of competence, which admittedly has led to a number of turf issues among health care professions. The complexity of many health care interventions (eg, surgery in particular) has led to a disproportionate focus on the tasks involved in delivery of that care. Measuring the competent performance of tasks is relatively easy, but it does not capture the cognitive processes required to provide that care safely and effectively. Surgeons are not merely technicians: they must diagnose, judge, plan, and evaluate their interventions. Likewise, perioperative registered nurses must employ problem- solving skills throughout the perioperative period (ie, immediately before, during, and after the surgical intervention). For example, the professional perioperative nurse assesses and plans care so that the patient is protected against the inherent risks of electrical

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hazards and chemical agents. He or she must know when it is necessary to have a cardiac defibrillator ready for immediate use, not merely possess the competency to push the button. The nurse must possess knowledge and apply the appropriate skill when the patient has a previously implanted device (eg, hip prosthesis, pacemaker) and the surgeon is planning to use an electrosurgical device. The professional judgment involved, although critical to patient welfare, is not always readily apparent when discussing elimina- tion of what might at first appear to be barriers to practice.

Policy options for state consideration. Competence based on knowledge, training, experience, and skills should be considered regardless of geography (eg, between states, between rural and metropolitan areas). Unnecessary restrictions limit consumers’ access to care and professionals’ ability to provide care that they are licensed to provide. Unnecessary restrictions should be eliminated.

Until recently, AORN members in the state of New Jersey experienced unnecessary restrictions with respect to the use of RNs acting as first assistants during surgery. They still face barriers in California due to Title 22, which mandates that three surgeons be present for all cardiac surgery procedures.

Boards of nursing in all 50 states currently interpret their nurse practice acts to include RN fist assisting, but the aforementioned states had, or continue to have, contradictory regulations.

The education and training of RN first assistants (RNFAs) has been established firmly in guidelines and recommendations promoted by AORN, and W A S currently practice in all 50 states. It is not unusual to find, in one hospital, physicians, RNFAs, and physician assistants successfully and safely alter- nating in the role of fist assistant. This represents one option that is consistent with the Taskforce’s recommended policy option of eliminating exclusivity in the provision of competent, effective, accessible care.

Recommendation #4: States should redesign health professional boards and their functions to reflect the interdisciplinary and public accountability demands of the changing health care delivery system.

of consumerism and patients’ rights, along with the public’s increased level of sophisticated knowledge about health care, should serve to promote greater inclusion of public representatives on health professional boards. Challenges to effective public participation can be met with a selection process that is open, fair, and equitable; that clearly describes members’ roles and responsibilities; and that promotes a training program that addresses not only rules and regulations, but also professional practice issues

Issues and recommendation for reform. The impact

unique to the profession, as well as those overlapping other professional boundaries.

AORN supports enhanced interdisciplinary communication among professional boards. Collaborative efforts between and among boards may be an appropriate initial step to identify the differences and simi- larities that do exist. Creation of interdisciplinary oversight boards, without the intermediate step of collaborative investigational efforts, may create even more difficult turf battles, as groups position them- selves within an integrated system. As cited in the report, the Virginia Board of Health Professions is an example of this intermediate approach that can serve as a template for future professional boards.

Policy options for state consideration. The ultimate aim of consolidated boards is to serve the best interests of the public. Given the complex nature of physicians’ and nurses’ professional practice, what public safeguards exist if practice decisions are placed in the hands of nonprofessionals who might comprise the majority of board members, as suggested? In addition, although public participation is important, the financial implications, as well as confidentiality and privacy issues of including the public in regulatory boards, are immense.

is well known that legislative staff members wield considerable power and influence in policy formation. Regulatory board staff members also would have to be selected carefully, if the public is to be protected from special interests. Consolidating boards to reflect specific health service areas is consistent with promoting greater continuity of care. In any multidisciplinary group, however, there are frequent attempts by some to exert greater control over others. If the focus of health care is actually disease care, physicians could claim a role as “most equal among equals.” If, on the other hand, emphasis is placed on health promotion or disease prevention, physicians would have less claim to be the driving force on regulatory bodies, because those areas do not reflect the core competencies of medicine. These distinctions between disease and health are more than mere semantics. Although society requires professional intervention related to both realms of disease and health, the consequences of promoting one over the other can be far-reaching.

sumers to assist them in obtaining the information necessary to make decisions about practitioners and to improve the board’s public accountability.

issue and recommendation for reform. AORN supports consumers’ access to appropriate information about their health care providers within the principles outlined in the Right to Privacy Act2 and the Patient’s

What would be the role of board staff members? It

Recornmendation #5: Boards should educate con-

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Bill of Rights.3 Standardization across all 50 states would alleviate the bureaucratic red tape that baffles consumers, as well as protect health care workers from unnecessary harassment. AORN shares the con- cern that information should be given to the public regarding health care professionals’ records of malpractice suits, settlement figures, and disciplinary actions imposed for specified offenses. In some instances, malpractice settlements are reached without finding actual fault by any one individual and never go to court for settlement.

How to assist consumers in obtaining information about the practitioners who provide nursing services is a difficult and troubling question. The umbrella of nursing services is large and loosely defined. Boards of nursing have various levels of jurisdiction over those persons who provide, or assist in the provision of, nursing services. The nursing community already is grappling with the very difficult issue of the use and regulation of unlicensed assistive personnel (UAP) in the continuum of “nursing” care. Services, settings, educational preparedness, and nursing involvement in UAP utilization present potential gaps in consumer protection within the current system. Adequate information regarding UAP education, competencies, and authority is unavailable to consumers. Standardized educational, experiential, and minimum competency standards for UAP are lack- ing, making it very difficult for nurses to assess UAP qualifications and knowledge with any level of confi- dence in delegating patient care activities. Authority for UAP regulation by boards of nursing or any other oversight entity often is nonexistent.

Policy options for sfufe considerufion. AORN agrees that consumers should be well informed and has launched a consumer education campaign. The role of boards in assisting consumers to obtain information about individual practitioners, however, is not one we are able to support without an analysis and evaluation of various methodologies to achieve this goal.

aimed at consumer education. These include: consumer brochures detailing the disciplinary process, brochures informing consumers of their rights, consumer forums regarding board regulatory functions, and public presentations. AORN recommends the implementation of a wide variety of educational activities and development of educational materials as a more viable policy option for consumer education. In addition, AORN strongly urges the Taskforce to tackle the pressing question of identlfying regulatory and enforcement options for educational and experiential competency standards and for oversight authority of UAP.

Several states have implemented various strategies

Consumer protection, which is the historic and current mission of boards of nursing, demands some regulation and methods for addressing inquiries and complaints concerning UAP. It is AORN’s intent, in urging this as a Commission consideration, to foster data collection that can be used in a collaborative effort with consumers, other regulatory agencies, and providers to increase access to and delivery of quality

Recommefldulkm #6: Boards should cooperate with other public and private organizations in collect- ing data on regulated health professions to support effective workforce planning.

ports and encourages regulatory involvement in the collection of health care worker data, although it believes state-based data collection has severe limita- tions in an environment of professional mobility and telemedicine technology. Consensus exists that standardized data collection systems are necessary. Stan- dards, however, vary from state to state.

Professional boards are excellent sources of information for nurse employment, multidisciplinary health employment, and projected shortfalls and overages. Data also are collected for the purposes of licensure. It is more difficult, however, for these same boards to collect accurate outcome data for the con- stantly changing workplaces of health care professionals. Departments of health collect demographic data on health care providers, but the lack of standard terminology makes much of the data useless for com- parison among the 50 states.

The National Council of State Boards of Nursing (NCSBN) currently cooperates with the Division of Nursing, Health Resources and Services Administra- tion, in the National Institutes of Health, to provide data that the Division of Nursing uses as one basis for its annual report on workforce projections to Con- gress. The NCSBN also is in the process of complet- ing and implementing the Nurse Information System, which will provide unduplicated counts and demographic information about nurses in the United States.

AORN wishes to emphasize that determination of regulation of health care providers by others may affect scope of practice. Who knows enough about other disciplines to ensure appropriate regulation? The nursing role as patient advocate may be restrict- ed, based on the Pew Commission’s comments that all health care providers are patient advocates. Fre- quently, there are differences of opinion regarding surgeons’ stances to “save a life” versus a patient’s best interest. Who determines quality of patient care and how will this be defined? Will legislation, such as HR 3355, “The Patient Safety Act,” define patient safety, or will there be outcome measurements? As

Care.

Issue and recommendation for reform. AORN sup-

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attention continues to focus on cost containment, will consumers demand the lowest-cost providers without the knowledge and education appropriate for the scope of work required? Will state boards regulate and license the practice of all categories of health care workers? Under whose direction will they be regulated? At the writing of this document, Pennsyl- vania was considering legislation to determine how educational requirements are to be established and maintained for these personnel.

licensed, what means exist to determine continued competence in areas of practice? Are mechanisms in place to ensure consistency in specialty licensure across the nation?

ports approaches similar to those being undertaken by the NCSBN. If such efforts are to be meaningful, barriers to successful cooperative efforts in data collection supporting effective workforce planning need to be identified and overcome. To develop sufficient and useful data, resources must be accumulated (eg, computers, database programs, data entry personnel) and integrated across all professions. AORN supports standardized language in data collection in all health care disciplines.

Laws and policies that relate to privacy and confidentiality must be managed to allow data sharing. After data are collected, the risk of being “analysis poor” must then be overcome. Data analysts, who can manipulate and interpret bias-neutral data to achieve workforce projections, will be required. Questions of who will pay for such an endeavor and how the health professions community will promote the rapid and accurate exchange and interpretation of data, remain to be answered.

Recommendufion #7: States should require each board to develop, implement, and evaluate continuing education requirements to assure the continuing competence of regulated health care professionals.

lssue und fecommendution for reform. Nursing, especially the specialty of perioperative nursing, has contended with the rapid development of technologic and scientific advances as one of the greatest challenges to ensuring competence in the provision of nursing care. The competent use of technology involves not only the understanding of equipment, but also the decision-making and critical thinking skills needed to use equipment effectively, safely, and appropriately. Standards for professional nursing provide accountability for continuing competence as a requisite to professional practice. A significant problem for all professional boards is the specializa- tion that occurs among practitioners and the different expectations applied to novices as they mature into

For those professionals who are currently

Policy options for stute considerotion. AORN sup-

experts in a given practice. Fundamental questions related to assessing competence include: Which kind of competence should be assessed? At what level of expectation for competence should the generalist and the specialist be assessed? How are the application of howledge, psychomotor skills, and affective domains to be assessed, and by whom?

Policy option for stute considerution. AORN and NCB:PNI support the policy option that would require health professionals to demonstrate competence periodically through appropriate testing mechanisms. Furthermore, we support cooperation between private sector organizations and state regulatory bodies in expanding on existing methods. As modern technology tools become more available and less expensive, the private sector organizations will forge ahead and use virtual-reality testing tools to measure skills and cognitive abilities required by individual practitioners of the twenty-first century.

AORN is very interested in multipath models to competency demonstration, which could include ongoing continuing education, matriculation in next- step nursing degree programs, portfolio development, certification, and appropriate competency assessment methods, such as clinical simulation testing (eg, case studies, clinical exemplars). Although we are interested in empirically valid methods to document and evaluate competence, we also recognize the importance of funding to successfully meet a challenge of this magnitude.

Recommendufion #8: States should maintain a fair, cost-effective, and uniform disciplinary process to exclude incompetent practitioners to protect and promote the public’s health.

ports this recommendation and urges the state boards to become more involved in educating consumers about the complaint process taken against health care practitioners who, like the example in the Taskforce’s report, clearly are undeserving of the public’s trust. AORN urges a system in which states can share data so that incompetent practitioners cannot merely move to another state and continue the same practice pat- terns in a new location. AORN also supports appropriate alternative mechanisms for discipline.

Perhaps one contributing factor to the lack of data submitted to the National Practitioner Data Bank is the lack of knowledge on the part of health care professionals about procedures for reporting other health care professionals for misconduct or incompetence. How does a physical therapist report a surgeon who appears to be recommending unnecessary surgery without some fear of sanctions on hisher own practice? Could a midwife report a gynecologic physician for improper behavior without fear of reprisal?

lssue and recommendution for reform. AORN SUP-

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Policy options for state considerution. AORN supports disciplinary processes for all health professions, whether the members of those professions are licensed, certified, registered, or “none of the above.” This would require clearly delineated lines of authority under specific scopes of practice and licensure. Nevertheless, it is imperative that such a system be developed as soon as possible and that we not wait for the more complicated issue of standardizing terms to be solved. AORN supports clear communication of the disciplinary process to the public and urges standardization of the same across all states.

Recommendution #9: States should develop evaluation tools that assess the objectives, successes, and shortcomings of their regulatory systems and bodies to best protect and promote the public’s health.

ports the need for evaluation tools to assess the outcomes of the regulatory system in each state but questions if it is possible for each state to monitor itself. AORN supports the development of a model health care professional regulatory board that could be used or modified to meet specific state needs. AORN considers that the professions often use the sunset review process as an opportunity to further the interests of the profession, not necessarily to protect the public. It should be kept in mind that information given to legislators during the sunset review process relies heavily on information generated by board members and board staff members. Wholly independent external assessment is labor intensive and costly to conduct.

Policy options for state considerution. Regulatory bodies should make reports of internal and external quality reviews accessible to the public in a clear, consumer-friendly manner. AORN recommends some standardization of the review process that includes an interdisciplinary approach with considerable consumer input. The criteria for sunset review, established by the Arizona Auditor General, as identified in the Taskforce report, could be used as a guide- line for developing sunset standards for all professional boards to evaluate regulatory performance effectively.

Recommendation # 10: States should understand the links, overlaps, and conflicts among their health care workforce regulatory systems and other systems which affect the education, regulation, and practice of health care practitioners and work to develop partnerships to streamline regulatory structures and processes.

Issue and recommendation for reform. AORN sup-

Issue and recommendation for reform. State regulatory bodies vary in so many ways that it is virtually impossible for them to understand each other, much less understand the effect of other systems on education and practice of health care practitioners. All this contributes to the confusion and barriers set up for health care professionals who practice in more than one jurisdiction. In some states, regulatory boards or agencies oversee individuals; in others, they oversee facilities. At least the basic structure should be standardized to reduce consumers’ and professionals’ confusion and to enhance continuity and collaboration among systems.

AORN supports the position of the NCSBN in advocating that some entity needs to “look beyond the trees (ie, individual agencies) to view the forest (ie, the entire regulatory system) as a ~ h o l e . ” ~ Although the Taskforce states that a comprehensive delineation of relationships between and among all regulatory bodies and professions of all 50 states is beyond its scope, such an analysis is sorely needed if the principles and the vision are to be realized.

The issue of reimbursement and its relationship to public policy licensing decisions is not to be taken lightly in today’s environment. It is interesting to note that many of the problems inherent in a diverse state- based regulatory system can be traced to barriers imposed upon both consumers and health care professionals by the reimbursement system. Currently, insurers are effectively inhibiting access to health care through their reimbursement policies.

Our health care values are reflected in what we reimburse. (See previous comments in “Principles/ Vision” at the beginning of this article.) If we are to embrace the promotion of wellness and disease prevention, then those professionals who have expertise in these areas (eg, nutritionists, educators, physical therapists, public health providers, as well as nurses and physicians) should be recognized and reimbursed accordingly for their expertise.

AORN has a special interest in this area, because one of the subgroups of perioperative nurses- RNFAs-provides cost-effective health care services. These services include not only the ability to provide demonstrated competence to assist at surgery, but also the important functions of preparing patients for surgery and enhancing their return to functional status by teaching them about the impact of surgery and the implications of specific procedures. Examples include the need for regular follow-up in patients who require chronic anticoagulation therapy after implantation of

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prosthetic/mechanical heart valves and patients who require immunosuppression medication after receiving transplanted organs. Despite the demonstrated cost- savings to hospitals that use them, RNFAs are not reimbursed by Medicare and are inequitably reimbursed by other third-party payers.

tutions by the profession, not consumers. One of the marks of a profession is the ability to set educational standards by which novice practitioners are taught and socialized into the profession. To relegate this important function predominately to those who are not in the profession would be a societal injustice. If the Taskforce is concerned about undue self-interest, AORN suggests an oversight body, with active consumer input, to ensure ethical behavior rather than sweeping the accreditation system under the public’s collective rug.

AORN recognizes the role of the American Nurses Association (ANA) in defining the scope of practice for the profession of nursing. In turn, ANA recognizes AORN as the professional association that defines perioperative nursing. In a pluralistic political system, there is no conflict of interest in an association advocating for its members. That is the purpose of voluntary associations in a democratic society. In fact, pluralism assumes that the best interest of the citizen is ensured by the political debate and compromise of various interest groups in a public forum. One can observe the increased activ- ity in association formation in the former Eastern- bloc countries to realize that the human need for collective action is in large part met by associations in a democracy.

As the Taskforce report illustrates, the “fox guard- ing the hen house” problem is one that permeates not only associations but state regulatory bodies as well. Including consumer members in the regulatory process can help alleviate this problem. A system of education and support for consumer members of regulatory bodies is critical to enable them to participate fully as consumer advocates for quality health care delivery. This needs to be addressed by any reform measures instituted for the public good.

ports the need for a national level study, with state input, to determine areas for immediate, short-term, and long-term reform. AORN supports a study of best practices in facility regulation, especially as it relates to monopolies under the managed care umbrella.

AORN supports accreditation of educational insti-

Policy options for state consideration. AORN sup-

REGULATORY REFORM BARRIERS AND OPPORTUNITIES

arriers to health care workforce reform in this B country are the current reimbursement system, the state-based regulatory system, the lack of universal health care for all Americans, and the reliance on the medical model for health care delivery.

The current system of regulating and governing the health care workforce is complex and fragment- ed, with overlapping lines of authority responding to inconsistent, poorly defined evaluation mechanisms. AORN f m l y believes that a major barrier to health care reform is the current reimbursement system, which is dominated by the insurance industry. Reimbursement not only affects consumers’ choices of health care professionals, but also has a strong link to accreditation of institutions and licensure and certification of individuals. Policymakers who have authority in regulating the insurance industry should be challenged to consider seriously evaluating and reforming the current system of third-party reimbursement for health care services.

The current state-based regulatory system limits the mobility of health care professionals. Efforts need to be increased to standardize language used in health professions regulation. As language becomes standardized, it will become easier for regulatory bodies to recognize good practice from bad practice and to translate this into understandable and appropriate mechanisms for regulating the health care disciplines and safeguarding the public interest.

In the absence of federal health care reform, states remain the laboratories to solve the thorny issues facing health care delivery in this country. The number of uninsured or underinsured in this country is increasing yearly. Although the Ameri- can people support a single-payer system of health care, employer-based health care insurance is a major obstacle to implementing universal, afford- able, and accessible health care in this country.

With the greater understanding of the importance of good nutrition, stress reduction, exercise, and pre- ventive health care, it is time to reexamine the medical model of health care deliveIy that focuses on cur- ing people afflicted with disease and illness. As the population ages, this prevention model will be critical in serving the needs of the population as a whole, as the large baby-boom population commands more of the health care dollar. Successful adoption of the prevention model of health care should greatly reduce

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the cost of health care, and it will shift the focus on the roles of health care providers as less invasive skills are needed in health care delivery.

As the demand grows for health care, the need for collaboration and full utilization of health care service providers is essential. Until now, the debate has been dominated by physicians. With the growing number of RNs, nurse practitioners, physician assistants, and trained allied health professionals, it is essential that all providers sit at the same table during the health care debate. Lf this society is to reach its goal of universal health coverage, all qualified health professionals will need to coordinate their efforts to serve the needs of the population. Now is the time to develop an umbrella structure for the regulation of the health care workforce of the twenty- fust century-a workforce that is cost-effective, driven by quality of care, and responsive to the needs of consumers. AORN reinforces the need for professional associations to conduct research that supports standards of practice to help define the roles of physicians, RNs, and assistive personnel in health care delivery. With the historical experience of the nursing profession as managers of patients’ health care experiences, RNs are positioned naturally to be leaders in the development of partnerships to streamline regulatory structures and processes.

LINDA K. GROAH RN. MS, CNOR, CNAA

PRESIDENT

JANE C. ROTHROCK RN, DNSc, CNOR

CHAIR, PROFESSIONAL PRACTICE ISSUES PROJECT TEAM

PATRICIA C. SEIFERT RN, MSN, CNOR, CRNFA

MEMBER, BOARD OF DIRECTORS

PAT NIESSNER PALMER RN, MS, MNM

DEPUN EXECUTIVE DIRECTOR

CANDACE 1. ROMIG HEALTH WLICV ANALYSTILEGISLATIVE PROORAM COORDINATOR

The authors acknowledge the contributions of the following individuals, commiW, chap&, and orgonizotion to fhis reporf: Post Presidents Joan S. Koehler, RN, and Ruth E. Vaiden, RN, CNOR, CRNFh AORN members Tess M. Pope, RN, CNOR, and Barbara A. TrMer, RN, CNOR Lqislative Committee; National Committee on Education; Nursing Practiices Committee; Nursing Research Com- miitee; Recommended Practices Committee; AORN of Santiam River of Orqon; and the Nationol Cettificotion B0ard:Perioperative Nursing, Inc.

NOTES 1. American Nurses Association,

Nursing’s Social Policy Statement (Washington, DC: American Nurses Association, 1995); American Nurs- es Association, Code for Nurses with Interpretive Statements (Kansas City, Mo: American Nurses Associ- ation, 1985); Association of Operat- ing Room Nurses, Inc, “ANA Code for Nurses with Interpretive State-

ments-Explications for perioperative nursing,’’ in AORN Standards and Recommended Practices (Den- ver: Association of Operating Room Nurses, Inc, 1996) 33-50.

2. Freedom of Information and Protection of Privacy Act, as amended, 5 USC 552, and 5 USC 301.

3. American Hospital Associa- tion, A Patient’s Bill of Rights

(Chicago: American Hospital Asso- ciation, 1992) catalog no 157759.

4. National Council of State Boards of Nursing, Inc, “National Council of State Boards of Nursing response to the Pew Taskforce principles and vision for health care workforce regulation,” in 1996 Book of Reports (Chicago: National Council of State Boards of Nursing, Inc, 1996) 17.

Submit Questions about the Pew Commission Reports At the General Session on Monday, April 7, a panel of experts will debate the issues identified in the three reports released by the Pew Health Professions Commission. A question-and-answer session will follow the presentation. AORN members are encour-

aged to submit questions for this discussion. Fax questions about the reports and recommendations to the Center for Perioperative Education, Attn: Sue Hardin, at (303) 338-4841 or (303) 755-5494, no later than March 1, 1997.

216 AORN JOURNAL

aorn's response to the pew taskforce on health care workforce regulation

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