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A third reason for inclusion of professional registered nurses in the PSRO Council is that a system of checks and balances is necessary for the efficient operation of any organization. Although physicians certainly represent an important component of health care, they are with the patient for a very small segment of his day. Nursing is present constantly 24 hours a day. Nurses' observations complement the physicians' assessment. Although many hospitals began as physician administered organizations, this is no longer true in most sectors of the country. Today the majority of hospitals are administered by professional management personnel, with nursing and medicine in a triangular arrangement. It would seem this is a sensible model for SPRO. The present PSRO system would seem a retrogressive posture.

Nursing is with the patient 24 hours a day, a cogent argument for inclusion, and nursing education has concentrated on disease processes, client teaching, support, counseling and structuring the patient into the appropriate environment. If the total health care needs of the individual are to be considered these are vital components.

Finally, since nurses have nothing to gain financially from a patient admission, inclusion of a nurse on a Council that looks at hospital health and eventually ambulatory health care practices would seem imperative.

In summary, we support House Bill 3167 for the following reasons:

1. Nurses are doing the actual reviewing and should therefore have professional representation,

2. Nurses have proved their stamina and understanding of the process by interpreting PSRO to physicians,

3. Nursing care is in many cases a determinant of length of stay and nurses are knowledgeable and experienced in the audit process, and finally,

4. Inclusion of the largest group of health care providers guarantees a most important check and balance in the delivery of reasonable and accessible health care for the clients the system is designed to serve.

STATEMENT OF PATSY B. McCLURE

Ms. MCCLURE. I am Patsy B. McClure, president of the Tennessee Nurses' Association, the professional organization of registered nurses in the State of Tennessee. I appreciate the opportunity to present to you some of the problems relative to PSRO in Tennessee.

There are two professional standards review organizations established in Tennessee. Both of these agencies are operating under conditional approval. They are the Tennessee Foundation for Medical Care located in Nashville, serving 83 counties; and the Mid-South Foundation for Medical Care located in Memphis, serving 12 counties. Although the potential flexibility for multiprofessional control of PSRO's is possible according to statutory authority, these Tennessee agencies are totally controlled by physicians. The boards of control are made up of physicians only. Any suggestion of modification of the boards of control to expand the membership to other professionals is met with unequivocal opposition by the medical community in Tennessee.

The Tennessee Foundation for Medical Care has an advisory committee composed of representation of health care professionals and agencies. The members of the advisory committee were nominated by professional and trade associations, and appointed by the all-physician board of control. The Mid-South Foundation for Medical Care is in the process of establishing an advisory committee, and has solicited nominations from the area professional associations. There is only one position for a nurse on either of these advisory committees.

The role and effectiveness of the advisory committees is uncertain at this point. It is impossible, in an advisory status, to determine the impact of the nonphysicians on the functions of the respective PSRO.

It is difficult to perceive how PSRO's, charged with a two-pronged functions of cost containment and quality assurance, can be expected

to be effective since they relate only to the function of the physician in the delivery of patient care services. The review of institutional care, by PSRO ignores the very basic contribution of nursing services to patient care costs and quality. In most instances there would be little reason to admit patients to institutional care if the patient did not have a need for nursing care.

In spite of the exclusion from PSRO, nursing is actively engaging in activities to assure quality patient care in institutional settings. With the aid of voluntary accrediting bodies and nursing organizations, nurses have developed sophisticated methods to set standards for patient care and evaluate the effectiveness of the care rendered.

Within the framework of PSRO, many nurses are employed as review coordinators. Although largely responsible for the functional. review process of PSRO, these nurses have little or no ability to influence the review policies and procedures with which they must do their jobs. They are sometimes put in the position of watching while physicians who have control over PSRO compromise PSRO standards or criteria to fit their own needs.

Public policy, such as that established by the Congress in PSRO, simply perpetuate the noncompetitive physician-dominated health care system. The Congress must recognize the unique contributions of other health care providers to the health care delivery system. Nursing services should be cost accounted specifically to demonstrate to the patient the value of nursing care. Norms of outcomes of nursing care must be recognized and validated to document the quantity and quality of nursing services which patients receive. Reimbursement for nursing services in an institutional setting should be identified specifically within institutional billing and collection processes.

All of those more desirable means for documenting patient care: services delivered by providers other than physicians are stymied by the limitations of PSRO and the restrictive domination of such an important structure as PSRO by one professional group.

The Tennessee Nurses' Association challenges this committee and the Congress to make nursing an integral part of PSRO with both policymaking and functional responsibilities.

STATEMENT OF SANDRA BYERS

Ms. BYERS. I am Sandra Byers, representing the Ohio Nurses' Association, and I am chairman of the Professional Nursing Practices Committee for Mid-Ohio District. I am director of medical nursing for Riverside Hospital at Columbus.

The professional registered nurse has a unique contribution to make as a member of the professional standards review organization. Her voice must be heard in the planning and her influence felt in the implementation of an efficient and economical quality health care delivery system for the citizens of this country.

Health care which promotes positive results for the consumer and is accessible and affordable demonstrates our beliefs that health care is a "right." What is the quality of health care? Who is delivering the services? What is the process by which the outcome of that service is being monitored, corrected, and improved? Is the consumer's physical, mental, and social well-being the focal point around which revolves an effective, efficient health care delivery system?

Professional standards review sets forth measurable criteria of the quality of health care delivered and applies to all professional health care providers. An approach dominated by one profession can only continue to sustain interprofessional rivalry which can result in patient dissatisfaction, misuse of the services, and ineffective use of human

resources.

The physician does not deliver all the service. The professional registered nurse is an accountable health care provider who is right now at the vital center of this issue. Professional registered nurses want to be involved with the policymaking bodies dealing with health care, not medical care.

The colleague relationship between physicians and nurses must be emphasized to facilitate the work of both professionals and to allow the consumer to utilize the expertise of either effectively. Without her expertise, professional standards review would not be implemented. to the extent that it is.

Why? In order for PSR to be effective and economical, a knowledgeable, humanistic, professional health care provider must be where the action is 24 hours a day, 7 days a week. The action occurs where the consumer has need for or contact with the health care system. At this point the professional registered nurse, in a wide variety of settingsschools, industry, community health centers, hospitals, and physician offices can utilize her education and experience to intervene in assisting the patient toward a positive outcome. Efficient use of human and material resources at this time produces quality care.

The professional registered nurse is an objective and consistent evaluator utilizing the PSRO guidelines so that the services being paid for are, in fact, the ones the patient has received. The nurse is the one person qualified to know when the human variables warrant the expertise of the physician or if they are, in fact, within normal boundaries.

In the State of Ohio registered professional nurses function as review coordinators, primarily in hospital settings. They are the backbone of the professional standards review system. Approximately 350 professional registered nurses are making the decisions based on PSRO guidelines which dictate the quality of health care. They decide what records go to the physician reviewer. They know quickly what information to look for in the record and where to indicate appropriateness of length of stay and level of care. As a professional the nurse maintains the confidentiality required.

Registered professional nurses are the program coordinators for five areas in Ohio. Two areas have advisory panels with professional registered nurses serving as voting members. The advisory panels direct the PSRO boards' activities. The PSRO committee in acute care hospitals tend to have professional registered nurses, and other health care providers on the committee as voting members.

The almost 1 million nurses in active practice in this country can positively influence the objectives of Professional Standards Review Organization if they have a legally established role in its functioning. [The prepared statement follows:]

STATEMENT OF SANDRA R. BYERS, R.N., M.S., REPRESENTING THE OHIO NURSES'

ASSOCIATION

The Professional Registered Nurse has a unique contribution to make as a member of the Professional Standards Review Organization. Her voice must be

heard in the planning and her influence felt in the implementation of an efficient and economical quality health care delivery system for the citizens of this country. Health care which promotes positive results for the consumer and is accessible and affordable demonstrates our beliefs that health care is a "right." What is the quality of health care? Who is delivering the services? What is the process by which the outcome of that service is being monitored, corrected, and improved? Is the consumer's physical, mental and social well being the focal point around which revolves an effective, efficient Health Care Delivery System?

Professional Standards Review sets forth measureable criteria of the quality of health care delivered and applies to all professional health are providers. An approach dominated by one profession can only continue to sustain interprofessional rivalry which can result in patient dissatisfaction, misuse of the services and ineffective use of human resources. The physician does not deliver all the service. The professional registered nurse is an accountable health care provider who is right now, at the vital center of this issue. Professional registered nurses want to be involved with the policy making bodies dealing with Health Care, not Medical Care. The colleague relationship between physicians and nurses must be emphasized to facilitate the work of both professionals and to allow the consumer to utilize the expertise of either effectively. Without her expertise Professional Standards Review would not be implemented to the extent that it is. Why? In order for PSR to be effective and economical a knowledgeable, humanistic, professional health care provider must be where the action is-24 hours a day, 7 days a week. The action occurs where the consumer has need for or contact with the health care system. At this point, the professional registered nurse, in a wide variety of settings-schools, industry, community health centers, hospitals, and physician offices can utilize her education and experience to intervene in assisting the patient toward a positive outcome. Efficient use of human and material resources at this time produces quality care.

The professional registered nurse understands medical terminology and can interpret physicians orders to patient as well as other members of the health team. The nurse records and reports signs and symptoms of the patients progress and seeks out the right kind of professional assistance at the right time, thus helping to eliminate complications of treatment or medications, which might necessitate further health care services. The nurse has ability to direct and coordinate health care services, reduces fragmentation of health care. The nurse is sensitive to the responses of the individual or family, to the services received thus being the link for redirection and reassessment. The professional registered nurse is an objective and consistent evaluator utilizing the PSRO guidelines so that the services being paid for are in fact the ones the patient has received. The nurse is the one person qualified to know when the human variables warrant the expertise of the physician or if they are in fact within normal boundaries.

In the State of Ohio, Registered Professional Nurses function as review coordinators, primarily in hospital settings. They are the backbone of the Professional Standards Review System. Approximately 350 professional registered nurses are making the decisions based on PSRO guidelines which dictate the quality of Health Care. They decide what records go to the physician reviewer. They know, quickly what information to look for in the record and where to indicate appropriateness of length of stay and level of care. As a professional, the nurse maintains the confidentiality required.

Registered professional nurses are the program coordinators for five (5) areas in Ohio. Two areas have advisory panels with professsional registered nurses serving as voting members. The advisory panels direct the PSRO Boards activities. The PSRO Committee in acute care hospitals tend to have Professional Registered Nurses, and other health care providers on the committee as voting members.

The almost one million nurses in active practice in this country can positively influence the objectives of Professional Standards Review Organization if they have a legally established role in its functioning.

STATEMENT OF RUTH STEWART

Ms. STEWART. I am Ruth Stewart, president of the Texas Nurses' Association. I am very pleased to be here with the subcommittee today. The Texas Nurses' Association is the official organization of professional nurses in Texas, representing approximately 6,500 registered nurses across the State. The Texas Nurses' Association is pleased to be able to speak in support of Congresswoman Keys'

bill supporting the inclusion of registered nurses in PSRO policymaking bodies.

Nurses in Texas have had a long and patient wait for PSRO designation. Since 1973 the Texas Nurses' Association has sent one or two registered nurse members to each meeting of TIMA, the Texas Institute of Medical Assessment, the planning body for Texas' proposed single-State PSRO.

Nurses along with other health professionals such as dieticians and psychologists have monitored board meetings and participated in task forces. In December of 1976 TNA nurses' representatives approached the planning body of TIMA and requested that a more formal advisory council for the PSRO be organized. At that time the Texas Nurses' Association volunteered to begin work on advisory council bylaws according to PSRO transmittal notices.

In January of 1977 the Texas Nurses' Association wrote a formal proposal letter to the president of TIMA and outlined those areas where we felt nursing could best offer input. I will outline the highlights of that letter for you:

1. We requested that Texas Nurses' Association-designated nurse be included on the governing body of TIMA.

2. We voiced our interest again in nurses serving on the advisory council and again volunteered to initiate the drawing up of bylaws. 3. We showed samples of the outcome criteria TNA had developed for review of nursing care.

4. We requested the right to develop the mechanisms to be used for review of nursing care.

5. We volunteered expanding our current continuing education system for identifying nursing knowledge deficits found on chart review.

6. We encouraged nursing involvement with hospital review committee activities.

7. We requested assurance from TIMA that nursing alone would be eligible to vote on issues relating to nursing practice.

8. Foremost, TNA requested that TIMA establish a schedule for the implementation of health care review of nonphysician health care practitioners.

Texas, to date, does not have a designated PSRO. The Texas Nurses' Association is waiting to implement these projects as soon as possible within the organizational structure of TIMA.

The Texas Nurses' Association and its members have contributed expertise, finance, and time to the preparation and initiation phase of PSROs.

1. Our association developed in 1975, with assistance of documents from ANA, a workshop on PSRO law and the nurse's role in quality assurance. The workshop was presented in 14 different areas of the State in an attempt to disseminate vital information on this new law to the nurses of Texas.

2. In 1976 TNA held an invitational conference for 85 nurses with clinical expertise to develop 80 sets of outcome criteria for the measurement of quality care. This was done at a cost of $2,500 as a professional commitment to assist nurses in local areas to review their care. 3. TNA staff and councils have served as consultants to other nursing groups, other health professionals, and State health agencies on quality assurance programs.

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