Legislative Report s1

Legislative Report February 4, 2012 ORNCC

AORN’s Legislative Priorities:

1. RN as Circulator –for any operative or invasive procedure-actively promotes laws & regulations to ensure the supervisory presence of a Professional RN in the perioperative setting 2. Preserving & protecting the RNFA’s Scope of Practice 3. Supporting workplace safety and patient safety initiatives thereby creating & maintaining a safe environment 4. Advancing positive health care improvements & standardized data collection

State Coordinator: Georgina Centeno Regional Coordinator: Karen Knapp

LOCAL BUSINESS

2012 Legislative Calendar Highlights:

2/24: Last day for bills to be introduced 3/29-4/8: recess 6/1/: Last day to pass bills of House origin 7/7-8/5: summer recess CHECK

The bill to reinstate the BRN was heard on 1/31/2012. Historically, SB 538 was PASSED IN EARLY 90’S THAT REQUIRED EVERY BOARD TO SUNSET.

SB 98 Major Victory for the BRN Bill

BRN Bill was heard and passed on the Assembly floor on 2/2/2012. It was passed to the Senate and has been referred to the Senate Budget Committee. No one spoke up against the bill on the Senate Floor. THE PASSING OF THIS BILL WILL RESTORE THE BRN UNTIL 2016. BOARD OF REGISTERED NURSING MET NOVEMBER 16, 2011

The meeting was long & controversial. There was discussion of the process for taking a School of Nursing from a warning to a closure that will be continued and confirmed at the next meeting. There was an MOU signed for SB 538 which allowed for board to continue basic operations ONLY. The Legislative Committee chaptered AB 1424 that holds the license of about 500 RN’s whose tax debt exceeds $100,000 (Franchise Tax Board of Equalization) SB 100 requires a Medical Board to establish regulatory requirements of the proximity of an MD to a site using laser & light SB 161 Diastat – This bill allows unlicensed personnel to provide Diastat at schools with certain criteria – BILL EXPIRES IN 2017 – The Board would like to work with interested parties to put a plan together to head off any future legislation –

“All the law says is a parent can designate a school employee to give this medication. It is not a provision for a nurse to train non-licensed personnel to administer Diastat. With patience and guidance it is possible for a school district to apply for and obtain funding than can pay for adequate school nursing staff. The BRN declared no one but and RN can lawfully administer Diastat. It’s not a political issue; there is nothing in this bill to change the Nurse Practice Act”

– Tricia Hunter

SB 541 Contracting bill for Department of Consumer Affairs – CHAPTERED- California law that imposes penalties upon institutions that fail to protect the privacy of patient medical records. SB 747 Bill requiring catalog CE courses for LGBT issues – VETOED – likely due to the fact that provision of care for all peoples is already there as part of our Nurse Practice Act SB 943 Military equivalence for education – this bill PASSED “Existing law requires applicants for licensure as a registered nurse to meet certain educational requirements, to have completed specified courses of instruction, and to not be subject to denial of licensure under specified circumstances. Existing law authorizes applicants who have served on active duty in the medical corps in the United States Armed Forces to submit a record of specified training to the board for evaluation in order to satisfy the courses of instruction requirement. Under existing law, if the applicant satisfies the other general licensure requirements and if the board determines that both education and experience establish competency to practice registered nursing, the applicant shall be granted a license upon passing a certain examination.”

Other Bills NOT discussed at the BRN meeting:

SB 122 – (Price) Amended – This bill requires Schools of Nursing to apply for BRN approval to grant degrees & authorizes the BRN to issue cease & desist orders to any Schools of Nursing that have not obtained Board Approval.

SB 554 – Nurse Staffing Ratios– In Senate 4/27/2011 Committee on Health – This bill would ensure that a nurse who is orienting to a given unit would not be counted as staff until he or she demonstrates competency.

ACR 35- Surgical Technologists – adopted by Assembly – to Senate Committee on Rules – This measure would recognize and declare the week of September 18 to 24, 2011, inclusive, as National Surgical Technologist Week in California

AB 1136- Hospital Patient & Health Care worker Injury Protection Act – signed in by Governor on 10/7/2011 – THE ANA PROMOTES SAFE STAFFING – California law advances safe patient handling on October 7, California Governor Jerry Brown signed into law Assembly Bill 1136, “Hospital Patient and Health Care Worker Injury Protection Act”. This law amends the California Occupational Safety and Health Act of 1973 and requires employers to maintain a patient protection and health care worker back and musculoskeletal injury prevention plan which includes “the replacement of manual lifting and transferring of patients with powered patient transfer devices, lifting devices, or lift teams”.

SB-810 -(D-Leno): This bill was passed by the Appropriations Committee and moves to the Senate Floor for a vote. This bill would establish the State Healthcare System by creating a State Healthcare Agency. It makes all residents eligible for specified health care benefits under the System, which would, on a single-payer basis, negotiate for or set fees for health care services provided through the system and pay claims for those services. It creates the Healthcare Policy Board.

December 2011

Governor’s Letter – J. Brown states that the credit rating in California has gone from negative to stable. In his proposed 2012-2013 Budget, he outlines a plan which would impose a temporary tax for 5 years, increase local taxes by ½ % & ensures those temporary taxes would be designated to Education & Public Safety. The impact on Nursing in State Hospitals may be adversely affected around staffing ratios.

BRN Forecast of the RN workforce in California was issued. Overall it remains difficult to predict the needs and availability of RN’s but certainly the efforts to promote and provide RN’s will continue.

January 2012

In 14 California hospitals: $850,000 in fines for failing to follow procedures in surgery that left an item and required a second surgery; for not having safe medication procedures; for failing to follow medication procedures; for failing to follow surgical procedures; many for failure to have safe patient care procedures.

Governor Jerry Brown announced the appointments of the Department of Consumer Affairs: Denise Brown (D), Awet Kidane (D) & Reichel Everhart (D).

OTHER NOTEWORTHY NEWS

CMS Hospital Engagement Networks Publish Date: 1/18/2012

As part of its Partnership for Patients program, CMS has engaged 26 Hospital Engagement Networks (HENs) to design and conduct various types of training events and sessions for hospitals. The education sessions will be designed to achieve reductions in 10 core events:

• Adverse drug events • Catheter-associated urinary tract infections (CAUTI) • Central line-associated blood stream infections (CLABSI) • Injuries from falls and immobility • Obstetrical adverse events • Pressure ulcers • Surgical site infections • Venous thromboembolism • Ventilator-associated pneumonia • Preventable readmissions

Check for Your Colleagues – CMS Innovation Advisors Publish Date: 1/18/2012

On January 3, 2012, the Centers for Medicare & Medicaid Services (CMS) announced the first group of Innovation Advisors. 73 individuals from 23 states and the District of Columbia have been selected to work with the CMS Innovation Center to test new models of care delivery in their own organizations and communities. Innovation Advisors will also create partnerships to find new ideas that work and then share them regionally and across the United States.

CMS’s Innovation Center was created by the Affordable Care Act to test new models of health care delivery and payment. As part of its mission, the Innovation Center also seeks to offer technical support to providers to improve the coordination of care, and share lessons learned and best practices widely throughout the healthcare system. This first group of Innovation Advisors was selected through a competitive process and includes clinicians, allied health professionals, health administrators, and others. More information about the Innovation Advisors program is available on the CMS website.

Check Your Area - CMS Names Pioneer ACOs Publish Date: 1/18/2012 Established by the Affordable Care Act, the Medicare Shared Savings Program provides incentives for Accountable Care Organizations (ACOs) that meet standards for quality performance and reduce costs while putting patients first. Final rules for ACOs were published on November 2, 2011.

Now, the Centers for Medicare & Medicaid Services (CMS) is testing an alternative ACO model, the Pioneer ACO Model. The Pioneer ACO Model is designed to support organizations with experience in operating as an ACO. The Pioneer ACO Model will test a shared savings and shared losses arrangement with higher levels of risk and reward for the participating ACOs than the Shared Savings Program outlined in the November 2011 rules.

In December 2011, CMS announced 32 Pioneer ACOs, chosen for their experience in offering coordinated, patient-centered care in ACOs and ACO- like arrangements

AORN comments on CMS’ Conditions of Participation in an effort to have the Center for Medicare & Medicaid Services (CMS) look to future improvements in the Conditions of Participation, AORN submitted comments on December 19 regarding proposed reforms of outdated or unnecessary Hospital Conditions of Participation. The proposed rule of CMS would revise the requirements that hospitals and critical access hospitals (CAHs) must meet to participate in the Medicare and Medicaid programs. These proposed changes are an integral part of AORN’s ongoing efforts to reduce procedural burdens on providers.

To assure medical and clinical staff improvement, AORN recommended consideration of competency standards addressing the evaluation of continued competency of performance. And because nurses are responsible for many of the compliance and documentation requirements attendant to patient care, AORN applauded the agency’s commitment to reducing unnecessary regulatory burdens on hospitals while continuing to focus on maintaining important safety measures and quality of care protections for hospital patients.

AORN also praised CMS because the proposed rule reflects many of the positive changes for nursing recommended in the IOM’s recently released report, Future of Nursing: Leading Change, Advancing Health. The proposed rule preserves patient safeguards in the Conditions of Participation that are important to perioperative registered nurses, including the traditional and current role of nursing in providing direct patient care and supervising allied health care providers who perform delegated nursing functions.

In its comments, AORN supported CMS’s proposal to clarify that a hospital may grant privileges to both physicians and non-physicians to practice within their state scope of practice, regardless of whether they are also appointed to the hospital’s medical staff. AORN’s comments specifically highlighted that many RNFA’s are privileged to perform first assistant at surgery services in Medicare-participating hospitals.

Many of the perioperative-specific issues highlighted from the AORN comments were also included in the comments to CMS from the American Nurses Association, the Nursing Community, and the Nursing Alliance for Quality Care.

Pennsylvania Title “Nurse” Protection on December 6, 2011 the Pennsylvania House of Representatives unanimously passed House Bills 469 and 470, regarding Title “Nurse” Protection. These bills reserve the title “nurse” for only those who meet the legal and educational standards set forth for nurses. Current law prohibits any person from using the title “Registered Nurse” or “Licensed Practical Nurse” unless licensed as such by the Pennsylvania State Board of Nursing. However the use of the title “nurse” is not currently protected, which allows for the possibility of unlicensed individuals to mislead the public. Passage of these bills will also help to ensure the public is consulting with professionals that are required to adhere to professional codes of practice and ethics.

H469 and 470 are now headed to the State Senate Consumer Affairs and Professional Licensure committee. Please take an opportunity to review the bill’s talking points and contact your State Senator either by phone, letter, or in person. Also please contact your State Representative and thank them for protecting the title “nurse.” Deadline looms for ASCs to use safe surgical checklists

The deadline is fast approaching for ambulatory surgery centers to use safe surgical checklists. The Centers for Medicare and Medicaid Services expects ASCs and hospital outpatient surgery centers to use the checklists for all of 2012, starting on January 1. Further, CMS wants ASCs to report on whether or not they’ve used the checklists as part of a broader Medicare quality reporting initiative.

Although downloading and modifying a checklist takes just minutes, communicating the need for its use and changing staff behavior can take months, OR experts warn. Therefore, if a facility hasn’t started implementing a safe surgical checklist, it’s time to get moving.

Why Safe Surgical Checklists?

Safe surgical checklists – also known as surgical safety checklists - save lives, reduce medical errors and lessen the number of post-surgical complications. Developed by the World Health Organization (WHO) and adapted by AORN for the OR, checklists have been widely used in hospitals since 2008. Some ASCs have also been using checklists, but this new Medicare rule will accelerate adoption industry-wide.

A checklist identifies three distinct phases of an operation, each corresponding to the perioperative workflow. They are:

• before the induction of anesthesia (“sign in”); • before the skin incision or start of an invasive procedure (“time out”); and • before the patient leaves the operating room (“sign out”). In each phase, a checklist coordinator – usually the circulating nurse – confirms that the surgical team has completed the listed tasks before continuing with the procedure. Some checklists also include a ‘pre- operative’ phase for gathering information.

Safe surgical checklists dramatically reduced death rate from 1.5 percent to 0.8 percent and incidence of inpatient complications from 11 percent to 7 percent when implemented in eight hospitals worldwide, according to research published in 2009 in the New England Journal of Medicine.

Although similar studies have not been conducted in ASCs, checklists can still prove valuable.

“They ease the burden of relying on your memory, because everything you need is right there,” said AORN Manager of Ambulatory Products Jan Davidson, MSN, RN. “Teamwork and communication improve when everyone in the room stops what they are doing and focuses on the patient.”

Adds former AORN board member and President of Genessee Associates, an ASC consulting firm, Beverly Kirchner, BSN, CNOR, CASC: “Miscommunication is the number one cause of medical errors.”

In the ambulatory setting, surgical checklists may prove most helpful in reducing “wrong-site, wrong-side, wrong-patient” errors. Checklists also ensure that the correct, sterile equipment is on hand before anesthesia.

How to Implement a Checklist

First, review your facility’s caseloads to identify the range of different type of cases handled.

Second, download the WHO or AORN safe surgical checklists. “Consider what you want to add or adapt but aim to keep the checklist as standardized as possible,” says Ann Purvis, BSN, CNOR, administrator, patient care services, at SurgiCenter of Eastern Carolina LLC.

“I don’t think WHO meant for this to be a tool exactly as they wrote it,” Davidson says, “but to provide you with a tool you can modify for your needs, so it works for you all the time. You can always assess the checklist 30 or 60 days after implementation and revamp it.”

If you need help, AORN staff are available to help modify your checklist.

Third, get buy-in from all members of the surgical team, including your surgeons and anesthesia providers. Present the checklist as a tool to promote safe patient care.

Fourth, educate staff; audit for compliance; and when there are mistakes, re- educate.

“Surgery centers can expect failures when they first start to use this,” Davidson says. Learn from them and move on. Don’t change policies and procedures for an isolated incident but rather use glitches as an opportunity to improve your processes.

What We Know, What We Don’t

CMS’ final rule provides partial, but not complete guidance on how ASCs will be required to implement and report the safe surgical checklist. We know that:

• ASCs can use any checklist as long as it contains the three distinct interoperative phases previously mentioned. • The safe surgical checklist is not required to be part of patients’ permanent paper or electronic medical record. Still, OR experts believe it should be. “The best practice would be to integrate it into the paper or electronic medical record,” says Kirchner. “I mean, really and truly, why not?” • ASCs must report data for all patients, not just Medicare patients. • ASCs must report whether or not they used a checklist in the calendar year of 2012 to Quality Net anytime between July 1, 2013 and August 15, 2013. • CMS will adjust payments beginning in 2012 based on this new reporting requirement. • CMS is expected to publicly report whether the ASC uses a checklist or not. It’s not yet clear:

• What exactly ASCs will be required to report and how that will overlap with Medicare surveyor expectations. Will CMS ask if checklists were used throughout 2012, calling for a simple yes/no answer? Will CMS surveyors ask ASCs to produce patient records that show the checklist was used since 2012? • Whether CMS will tie checklist use to payments after 2015. Kirchner, who participates in AORN’s ASC task force, says this reporting requirement is just the beginning. In the future, CMS may ask ASCs to report outcomes and other quality data tied to checklist.

“We will be reporting more data and better data,” she says. “It will evolve into something more.” AORN joins Nursing Community on provider-neutral language issueIn early November, AORN signed on to a letter to the Secretary of the U.S. Department of Health and Human Services asking Secretary Kathleen Sebelius to remain mindful of the continued need to move away from use of physician-centric language by federal officials within HHS. The letter was signed by 44 members of the Nursing Community, a forum for national professional nursing organizations to build consensus and advocate for a wide spectrum of healthcare and nursing issues.

The Nursing Community represents the interests of registered nurses who practice in all roles and settings, including APRNs and NPs, clinical nurse specialists, certified nurse midwives, and CRNAs. The letter calls upon HHS and its many agencies, including CMS, to use provider-neutral language to acknowledge the significant contributions of the wide array of professionals (including RNs) meeting the health needs of our nation. Continued discretionary use of the term “physician” to loosely describe all types of providers reflects a bias. By signing on to this letter, AORN joins the Nursing Community in asking HHS to appropriately refer to clinicians and providers when physician is not the specific reference needed in national health care regulations and other publications.

The Board of Registered Nursing (BRN) was sunset when the Governor vetoed SB 538 Price. I am asking your help to reinstate the BRN as quickly as the process allows so services are not disrupted.

The Governor's office has assured us that they will sign a bill that is a renewal of the BRN as soon as it can be put on their desk. We understand that this bill will take a 2/3 vote.

I ask your support in getting a bill through the process as quickly as possible that meets the Governor's request.

Thank you for your support and help!

New Jersey Governor Conditionally Vetoes Surgical Technologist Bill Publish Date: 11/15/2011

New Jersey Governor Chris Christie returned a surgical technologist education and certification bill back to the legislature without his signature last week, citing concerns that the bill would limit the pool of candidates eligible for employment as a surgical technologist.

The New Jersey legislature had passed Assembly bill 3946 and sent it to Governor Christie for signature on June 29, 2011. As written, the bill would require education and certification of all surgical technologists, including specifically (a) successful completion of a nationally accredited educational program for surgical technologists, and (b) the certified surgical technologist credential administered by the National Board of Surgical Technology and Surgical Assisting or other nationally accredited credentialing organization.

In his Veto memo, Governor Christie acknowledged that surgical technologists are important members of the surgical team and that the bill represents a positive step forward in increasing patient safety and ensuring that high-quality health care is delivered in New Jersey. However, Christie expressed concern that, as drafted, the bill would limit the pool of candidates eligible for employment as a surgical technologist to only those who possess a specific credential. Christie recommended revising the bill to eliminate this limitation.

A conditional veto allows the governor to recommend amendments to the legislature. Under Christie’s proposal, in order to be eligible for employment, surgical technologists would need to have either (a) completed a nationally or regionally accredited educational program for surgical technologists, or (b) hold and maintain a certified surgical technologist credential administered by the National Board of Surgical Technology and Surgical Assisting or another nationally recognized credentialing organization.

The legislature has until January 15, 2012 to act on this bill or the bill dies. AORN was supportive of the certification and education aspects of this bill but had asked Governor Christie’s office for an amendment naming the New Jersey Board of Nursing as the regulatory agency responsible for implementing and enforcing the bill. AORN will continue to work with our legislative State Coordinator and our lobbying firm in hopes of accomplishing AORN’s purpose of achieving education and certification requirements for surgical technologists while at the same time preserving the supervisory role of nursing over delegated nursing functions in the operating room. “Our continued hope in New Jersey is that we can work collaboratively with the surgical technologists and interested stakeholders to assure patient safety in New Jersey health care facilities,” commented Dianna McCorkle, BSN RN CNOR, AORN State Legislative Coordinator for New Jersey. “We support education and certification requirements for surgical technologists and would like to work with our health care colleagues in the state to include nursing supervision language in this bill in accordance with AORN policy.”

California Law Advances Safe Patient Handling Publish Date: 10/26/2011

On October 7, California Governor Jerry Brown signed into law Assembly Bill 1136, “Hospital Patient and Health Care Worker Injury Protection Act”. This law amends the California Occupational Safety and Health Act of 1973 and requires employers to maintain a patient protection and health care worker back and musculoskeletal injury prevention plan which includes “the replacement of manual lifting and transferring of patients with powered patient transfer devices, lifting devices, or lift teams”. AORN supports legislative and regulatory initiatives that create and maintain a safe perioperative work environment that promotes safe patient care. Particular focus on safe patient handling can be found in AORN’s Safe Patient Handling and Movement Tool Kit, which was designed to educate perioperative nurses in the safe way to move patients and equipment to prevent musculoskeletal injuries. This Tool Kit was based on the AORN guidance statement, “Safe Patient Handling and Movement in the Perioperative Setting” which can be found in Perioperative Standards and Recommended Practices.