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calling for some alternative proposals is sufficient evidence of their interest in inclusion of nurses in PSRO's?

Ms. GUY. I would say we are disappointed in the testimony. We are pleased with the interest, but we would prefer some action.

Ms. KEYS. The administration yesterday was prepared to testify in a very different fashion and offer the support of the administration for inclusion of at least one nurse on State advisory councils and three health professionals other than physicians on the national council, at least of which one would be a nurse.

Do you have any idea why their attitude changed?

Ms. HOLLERAN. No; we were quite surprised this morning.

Ms. KEYS. I certainly know the feeling.

I would like to ask one more question raised in debate. A great many people seem to fear that if local PSRO's were opened to nurse membership, the tremendous number of persons in the nursing profession would result in an imbalance in voting strength.

Could you speak to that? Is this a legitimate fear?

Ms. GUY. I would say it is not a legitimate fear. I think that in my experience it is a better understanding within nursing of what constitutes the perimeters of nursing practice. We do not have the philosophy, as I think some physicians do, that medicine encompasses all practices, so I think our interest is confined to those potential elements of care which only nurses can provide and that would be our area of interest and concern.

Ms. KEYS. How do you feel about the suggestion that was made that if nurses were included on the National Advisory Board, they would not vote on matters which affected only physicians?

Ms. GUY. I would say if the concern of the National Council is health care, then all members of the Board would have that as their concern and would have voting authority in that area. I do not see the National Health Advisory Council serving a purpose if it is compartmentalized into specific services related to the disciplines.

It is my understanding that Congress wants to look at health care, costs and quality, and therefore I think that members would sit as colleagues on that Board.

Ms. KEYS. I thank you, Ms. Guy and Ms. Zimmer and Ms. Holleran. Now I will ask Mr. Tranbarger to begin the panel.

Dr. WHITE. I am sorry, would you allow us to change the speaking

order?

Ms. KEYS. Proceed as you wish.

STATEMENT OF CHARLES WHITE, PH. D.

Dr. WHITE. I am Charles White, executive director, California Nurses Association. Personnel is, of course, the largest cost center in a hospital. Nursing service is the largest single component of that cost center, and the largest portion of the medicare-medicaid, "Medi-Cal" reimbursements is for nursing service. In California nurses are not participating as envisioned in this resolution. They function at task rather than policy levels, as we have heard all morning.

We have heard urging by the administration to participate, and people are doing that at all levels. Nurses have been trained, such as in California, by the expenditure of almost $1 million of regional medical program funds for medical audits, nursing audit workshops, et cetera.

So nurses are very expert, and they have responsibilities but no authority. Our association feels that nurses are frequently regarded in these review activities as a uniformed secretary. In the past it might have been considered that nurses were only interested in bread-andbutter issues concerning themselves, that they had no knowledge of larger health care issues such as planning, health resources development, regulation, cost control; that they might not have had an overview of the health delivery system or the medical-political system in which it operates.

If that was ever true, it is certainly no longer a reality in California. I bring you the experience of our State this morning, closing with the comment that what we seem to be hearing is a status quo argument and the language typically used all the way through history by one group that wants to exclude another.

Each of us has prepared a written statement. You will receive those, but each person in the speaking order will deliver an abbreviated

statement.

[The prepared statement follows:]

STATEMENT OF CHARLES H. WHITE, PH. D., EXECUTIVE DIRECTOR, CALIFORNIA NURSES' ASSOCIATION

Good morning. My name is Charles H. White, Ph. D., executive director, California Nurses' Association, and I bring you greetings from that organization of 17,207 health professionals dedicated to the care of their patients. My experience in PSRO related activities includes 10 years of service in regional medical programs which funded, in California, nearly $1 million of training workshops and other educational activities related to medical care evaluation, patient care audit, nursing audit, medical records usage; and later, as associate executive director of Health Systems Management Corporation, which was the contractor for PSRO training workshops during 1976-77.

The development of PSRO's in California has followed a natural course of human events where some have matured quickly and easily, some have plodded forward with curable flaws, and others have been born with difficulty. A total of 26 review areas were designated in California; of that number, 15 organizations were called conditional in August 1977 by the United Foundations for Medical Care which is the PSRO Support Center in California. Nine other groups can be described as funded for planning, while the final two are currently incorporated but not funded.

If there is merit in showing any sort of trend, ten of the fifteen conditional review organizations are north of the Tehachapi Mountains which is the traditional dividing line between northern and southern California. A recent survey of those existing organizations, which are operational and are conducting reviews, shows that nurses are not participating in the manner envisioned by H.R. 3167. Available data show that:

Only one nurse is a member of any PSRO governing body.

That person is male, and was elected to one of four nonphysician seats on his board as a patient advocate (his job description title) rather than as a nurse. All other governing bodies are composed exclusively of physicians.

An Advisory Committee for California has not yet been formed, but
A seat will "probably" be set aside for a representative of nursing.

Nurses are very active in the review process, however, as

Nurse coordinators who fulfill the necessary facilitating and clerical functions. Several conditional PSRO's have a salaried supervising nurse coordinator, while Most delegated hospitals have nurse coordinators in their employ.

Several PSRO's conduct training for nurse coordinators whether they are staff of the review organization or hospitals

Nurses are frequently-used members of review panels or committees and their skill and experience is prized by some hospitals.

Places for nurses have been designated on the Advisory Committee of the PSRO which appears to be farthest advanced in use of nurses as well as on the Education and Training Committee, Review Planning Committee, and the Non-Physician Review Committee.

Frequently, nurses appear in the role of first line of review, with the ability to make any review decision except that of denial that medical reason exists for admission to the hospital.

In summary, the data shows that nurses are omni-present in the review process at task rather than policy levels. All review committees in all hospitals covered by this survey are composed exclusively of physicians but nurses are called in to participate. All seats on all govering bodies are filled by physicians or businessmen (where non-physician seats are available) except for the single case cited above. Review data developed so far shows the need for more elaborate and more specific audits and greater depth in examining the total impact on patients. Certainly, the examination of this impact must involve nurses, since they are closer to the actual scene of the delivery of care and health services at all levels. Nurses in California have developed a strong sense of the potential offered by patient review, evaluation and audit. Many individual nurses are expert in the process and have served as instructors in training programs such as those sponsored by RMP. Others are presently participating in actual reviews conducted by their community hospitals. Yet, their authorities are not commensurate with their responsibilities and the initial tendency equals a highly-skilled professional nurse as a uniformed secretary.

Nurses in California are skilled, trained, and ready to assume more appropriate roles, the California Nurses' Association can provide the names of many individuals who want to be included; who want to serve in policymaking roles as members of governing bodies; who are experienced and ready for these responsibilities, and who are, in many cases, the most knowledgeable health care providers about the review process. In the past, it may have appeared that nurses were only interested in bread and butter issues for themselves, that they had no knowledge in large health care issues of planning, resources development, regulation and cost control. It may have appeared that they did not possess an overview of the health care delivery system and the medical/political systems in which it operated. Whether or not those appearances and assumptions were ever true, they are no longer a reality in California. CNA is ready to respond to those matters of public concern which are appropriate as concerned citizens and knowledgeable health professionals who care.

We urge you to move this legislation so that it might be marked up in this session of the Congress. Thank you for this opportunity to express our views. Ms. KEYS. Thank you, Dr. White, and those statements will all be included in the record.

I would ask that each of you proceed and identify yourselves as you begin.

STATEMENT OF JUDY ZOELLNER

Ms. ZOELLNER. I am Judy Zoellner, speaking for Illinois. I am in charge of continuing education at the Department of Nursing, Evanston Hospital, Evanston, Ill., and I am speaking for Marian Frerichs, president of the Illinois Nurses' Association. In its present form we look at all title XVIII and title XIX patients and in Illinois we are extending it to looking at the private insurance carriers, too, in the very near future.

Almost all reviewers looking at the charts and nurses were chosen to be reviewers for a number of reasons, the best of which is they are an intelligent, informed group of individuals who understand the process of hospitalization, who understand the language that is necessary. It is interesting that one of the major parts of their unwritten job description is education of the physicians.

As all of you are probably aware, the physicians were not overly enthusiastic about PSRO when it began. The fact that for the largest part they have learned to live with it and the compliance of the physician group has been as good as it is, I think, is very much due to the PSRO reviewers' tact and skill and patience in interpreting to the physicians just exactly what PSRO is, how it works and how to live within its limits.

For many physicians it is the first intimate contact with Government regulations as it affects their private practice. The compliance is largely due to the skill of the PSRO nurses. It is interesting that in a democracy that the individuals who do the teaching and interpretation and the day-to-day work are not represented on the national level or, for the most part, the State level and that is my first argument for inclusion of the nurses on the PSRO Council is they are, in fact, doing the work and educating the physicians so that the physicians' understanding is increased.

The Chicago Foundation is our PSRO in the area that I live in. Although the Illinois Nurses' Association has been in recent contact verbally and written to include nurses at the council level, this has not happened. The Chicago Foundation and other foundations in similar areas are quick to tell you they do have nurses, but the nurses are in a staff position. They are PSRO reviewers and going to be used for the nondelegated hospitals. They are not in a decisionmaking area. The second reason for including PSRO at the national level is something that has been mentioned previously and I am not going to belabor the point, but that nurses really do make a difference in whether the patient leaves the hospital on time. That is not necessarily true for the healthy 30-year-old who has the hernia taken care of, but the title XVIII and title XIX patients are usually older, quite frequently debilitated, and the most skilled medical care is not going to save the patients if the nursing care is not as skilled.

If he is to leave the hospital at the maximum possible for rehabilitation care, he needs skilled nursing care, and that is one of the reasons he is hospitalized. The nurses are skilled in looking at this care. Both at the national and local levels they have been auditing the process and outcomes of health care.

Staff nurses in our hospitals and throughout the Chicago area have been doing_audits for a long time. They have become very sophisticated, and I think the expertise they bring would provide the Government and the clients with a substantial body of knowledge..

The third reason for including nurses in PSRO's is to provide a system of checks and balances for a system that is to our eyes somewhat out of balance. Most hospitals began or were begun by physicians. Almost all hospitals that I know anything about are now run by a triangular arrangement with physicians, nursing and hospital administration, professional business people managing to run the hospital. To eliminate nursing from PSRO would seem a step backward in time rather than a step forward.

Finally, nurses have nothing to gain financially from the admission of a patient to a hospital, and that provides another important check and balance on a system that is looking at how costs are and how we can control them.

In summary, I would like to offer support for 3167 for the following reasons: The nurses are doing the actual reviewing and should therefore have professional representation, nurses improve their stamina and understanding of the process by interpreting PSRO to the physicians, nursing care is for many reasons a determinant of the lengths of stay and nurses are experienced and knowledgeable in the audit. process, and the inclusion of the largest group of health care providers provides the most important check and balance in the delivery and accessible health care for the system it is designed to serve. [The prepared statement follows:]

STATEMENT OF JUDITH Zoellner ON BEHALF OF THE ILLINOIS NURSES'

ASSOCIATION

I am Judith Zoellner, Coordinator for Continuing Education, Department of Nursing, Evanston Hospital, Evanston, Illinois, representing Marian Frerichs, President of the Illinois Nurses' Association, I have come to discuss the need for the changes which Mrs. Keys' bill, H.R. 3167, proposes.

PSRO in its present form provides for a review of all Title XVIII-XIX paid patients in the hospital. The review process will soon cover private insurance patients and will eventually be extended to ambulatory settings. Illinois has two conditional PSRO's, and it is anticipated a third will have conditional status in the near future. Most of the Illinois hospitals have chosen to do a delegated review. That is, the reviewers or coordinators are employed by the hospital, but their salaries are supplied by the Federal Government. Almost all of the reviewers are RN's; the remainder are, for the most part, medical librarians. The reviewers are nurses for a number of reasons, but the most significant rationale for choosing intelligent, well-informed nurses as reivewers is that they understand hospitalization, the language, and the process. The reviewers perusing all medical charts within 48 hours of admission must certify the admission as valid according to the regional criteria, and establish a reasonable length of stay. Professional judgment is mandatory on what often turns out to be a firing line.

For example, the physician admits a 66-year-old man for a hernia and neglects to note that he has significant medical problems. He relies on the nurse reviewer to note that the patient is taking medication for heart disease and will probably need to be coded for "multiple problems." Physicians who by and large were not supportive of PSRO have learned to live with it. To a major extent this is due to the efforts of the PSRO reviewers. PSRO reviewers' unwritten job description has included: educating the physician; interpreting PSRO legislation, elucidating what constitutes valid criteria for admission and justification for extension of stay. I must add, that since this education has not been "easy medicine" for the physician to take, the presence of the constraints have been difficult for the physician and troublesome for the nurse to present. The relative good compliance of the physician group, coping with what has been, for many, their first intimate contact with government regulations, is a tribute to the PSRO reviewers' tact, patience and teaching skill. The first reason then, for inclusion of nurses in the PSRO Council is that the individuals who are actually doing the work, and making the system go should have professional representation at the top. When nursing is not represented professionally at the national level, few, if any, of the local and state-delegated organizations are willing to include professional nursing representation. Illinois has no representative. The Chicago Foundation is a case in point. The Chicago Foundation for Medical Care is the delegated PSRO organization for the Chicago area. There is open communication between the Chicago Foundation and the Illinois Nurses' Association. The INA has made several requests to the Chicago Foundation for representation on the local Council. Although there is no state of federal prohibition against nurses serving on the local Council level, the fact is that nursing is not represented-only physicians are on the Council.

It seems counterproductive to most believers in the democratic process, that individuals who are considered sufficiently competent to make decisions on patient admission and discharges on a day-to-day basis and who are considered to have professional expertise to do appropriate professional consultation and work with a wide range of physicians, do not have professional representation at the policy making level.

The second reason for including professional registered nurses at the national level is an extention of the first one. Although physicians in most settings are the primary admitters and dischargers, it is the nursing care the patient receives in the institution which can determine, to a great extent, his being discharged on time without complications (or to put it more bluntly, which can determine his survival). Although this is not true for all patients, such as a healthy 35 year old male admitted for a hernia repair, it is true for the patient with multiple health problems and many Medicare patients are included in that group. A skilled surgeon may perform near miraculous surgery on a debilitated, critically ill patient; unless the nursing care is equally skilled the patient can suffer complications that prolong his hospitalization and cost a great deal of money. Nursing views the process of auditing nursing care very seriously at both the local and national level. As a group nurses have substantial experience in looking at the process and outcomes of nursing care for the hospitalized patient. Professional representation in the PSRO National Council, and at the local level, would provide the government, and the client, with a substantial body of knowledge.

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