The Texas Nurses' Association believes the current PSRO laws have failed to provide for appropriate involvement and decisionmaking on the part of the registered nurse.

1. Nursing is the largest professional group within the health field of Texas. Statewide Texas houses 45,000 professional nurses and, nationally, 900,000 nurses actively practice. This large and important force must be allowed to practice and evaluate their own service. As is true of any profession, nursing commands a body of specialized knowledge. Nurses should be allowed not only to practice within that body of knowledge, but also use it as a yardstick by which to measure what care the patient/client receives.

2. Nursing is confident of its level of expertise in quality assurance. Our profession has a code of ethics, standards, and certification that are forerunners in health care. Nursing has demonstrated its responsibility to the public through open forums on the profession.

3. The nursing profession can document how and where nursing care can impact the patient. The medical profession can do this also. The end-product, the patient, should have the colleagues who jointly deliver his care and jointly evaluate his care.

Ms. KEYS. Might I remind the witnesses to speak into the mike? It is a little difficult sometimes to hear in this large room.

STATEMENT OF ROBERTA THIRY

Dr. THIRY. My name is Roberta Thiry. I am president of the Kansas State Nurses' Association. Thank you for the opportunity to present testimony on behalf of H.R. 3167, providing for nursing involvement in the realm of decisionmaking of the Professional Standards Review Organizations.

Kansas was designated as a PSRO area in 1974. The Kansas Medical Foundation had a planning contract for approximately 2 years before being designated a conditional PSRO in the spring of 1977. Over the past 2 years the State's nurses association has made regular requests of the Kansas Medical Foundation to be apprised of progress in structuring the PSRO. In addition, a list of several nurses qualified to serve on the advisory group or in other areas of the PSRO was submitted. These efforts have met with little or no response.

Kansas nurses have been involved in quality assurance activities for some time. However, their efforts have increased markedly since 1974. Examples of efforts are: (1) Presentation of programs on implementation of American Nurses Association's standards of practice, nursing audits, peer review, and other aspects of quality assurance at many workshops and conventions; (2) a position paper on PSRO was approved by the board of Kansas State Nurses Association in July 1977; (3) past basic courses are offered on quality assurance for nurses at both Wichita State University and the University of Kansas; (4) hospitals and other health agencies have developed quality assurance programs in response to professional concerns, consumer requests and accreditation requirements.

Many nurses serve as coordinators for the development and implementation of such programs. Nurses from all areas of clinical practice have been involved in setting standards for patient care and identifying outcome or process criteria for judging the quality of care. At present

nursing staffs are developing the mechanisms for peer review. As you can see, there is considerable expertise being developed among nurses practicing in Kansas. In addition, nurses are often employed to implement utilization review and other aspects of quality assurance for physicians.

Nurses would not presume to judge all aspects of medical care, but they certainly are qualified to review many areas of health care and, in particular, the care given by nurses.

Nursing assumes a major role in health care due partially to the numbers of nurses, but also due to their unique contacts with clients and their interrelationships with physicians and other health care providers. Nurses are legally accountable for their practice even though some portion of it may be delegated by physicians.

There appears to be a trend to provide third-party payment to properly credentialed nurses functioning in expanded roles. Preventive and maintenance aspects of health care are becoming more and more the responsibility of nurses as is the management of uncomplicated, chronic disease. There is no mechanism within the existing structure to allow for review of health care not generated by the physician. Are these major areas of health care to be exempt from quality assurance requirements (PSRO)?

Nurses have generally been supportive of the concepts of peer review and quality assurance. The current programs for quality assurance are highly dependent on nursing. The one thing that is missing is the opportunity for nurses to participate in policy development and decisionmaking at the State and national levels. There is no guarantee under the present law that nurses will be represented on the advisory groups, or be among the nonprofessionals appointed to the councils.

Public Law 92-603 provides for physician control of PSRO policy. This format negates any type of check and balance within the health care system. Recognition must be given to nurses and other health care providers as they assume professional obligations to the public. It is appropriate that nurses review nursing practice and judge its quality at the implementation level of the PSRO. It is also imperative that nurses be included in policymaking bodies to share their expertise and to represent the nursing profession's contribution to health

care.

If it is not feasible for nurses to be included in the decisionmaking levels of the present structure, then nursing should have a separate quality assurance system equivalent to the PSRO established for physicians. I strongly believe that one profession should not be made subservient to another by Federal law when much of each health profession's practice is independent of or complementary to the other.

[The prepared statement follows:]

STATEMENT OF THE KANSAS STATE NURSES' ASSOCIATION

As a profession, nursing has been committed to quality of health care and has assumed responsibility for monitoring its own practice. Historically, accountability has been evidenced through the State Board Test Pool exam, participation in voluntary accreditation programs, and the development of a systematic approach to nursing through the nursing process. More recently in Kansas, nursing has implemented quality assurance programs based on standards of practice and utilization of the nursing audit. With this background, nursing is prepared to participate in the Professional Standards Review Organization (PSRO) activities:

as defined in Public Law 92-603; the 1972 amendments to the Social Security Act, on October 30, 1972.

"The legislation provided for the creation of Professional Standards Review Organizations, which would involve local practicing physicians in the ongoing review and evaluation of heatlh care services covered under Medicare (Title XVIII), Medicaid (Title XIX), and the Maternal and Child Health Programs (Title V). Such organizations were envisioned to provide the 'means by which the concepts that health professionals are the most appropriate individuals to evaluate the quality of medical service and that effective peer reveiw at the local level is the soundest method for assuring the appropriate use of health care resources and facilities.'"

The nursing profession is responsible for defining and interpreting that which constitutes the contribution of nursing within the total health care system. However, current legislation (P.L. 92-603) which provides the structure for PSRO has failed to clearly provide for appropriate involvement in decisionmaking on the part of health professionals other than physicians.

Therefore, the major purpose for the effort to include nurses in P.L. 92-603 is to provide the statutory base for the exercise of their responsibility for providing quality nursing care as reflected in the ANA Standards of Practice. These standards were developed by nurses and serve both to guide and to evaluate practice. In conjunction, efficiency and cost control must be taken into account. The appropriate involvement of the registered nurse in PSRO requires that registered nurses make decisions at all levels on issues relating to the practice of nursing. In order to permit this level of involvement efforts to bring about changes in the PSRO structure will be continued. In the interim, nurses will continue to promote quality assurance programs which will complement the activities of the PSRO. Successful involvement of nursing in quality assurance requires action by both the profession and the individual nurse. The profession has assumed responsibility for establishing professional standards of care and guidelines for implementation. The individual nurse must obtain the knowledge and skills necessary to adapt the criteria, standards, and norms for his/her particular geographic area and client/patient population.

The essence of a quality assurance program is the process of peer review. Peer review is the process by which registered nurses actively engaged in the practice of nursing appraise the quality of nursing care in a given situation in accordance with established standards of practice. This includes both the appraisal of nursing care delivered by a group of nurses in a given setting and the appraisal of nursing practiced by individual practitioners. This is the hallmark of professionalism and it is through this mechanism that the profession is held accountable to society.

STATEMENT OF RUSSELL TRANBARGER

Mr. TRANBARGER. My name is Russell Tranbarger. I am a registered nurse employed as a nursing service administrator at Moore Memorial Hospital, Pinehurst, N.C. In that capacity I have been an active member of the Medical Audit Committee of our hospital. I have participated in our retrospective patient care audits, utilization reviews and observed the development of physician involvement in PSRO. I also serve as president-elect of the North Carolina Nurses' Association. I represent the 3,400 actively involved members of that association.

PSRO activities in North Carolina are still in the early stages of development. Our State is divided into eight PSRO areas. One area PSRO is operational and at least two others are conditionally approved and expect to be operational within the next few months. Conseqently there is no advisory council in North Carolina at this time, nor have any local committees been appointed. Thus, no nurses are formally involved in other than staff positions at this time.

The North Carolina Nurses' Association tries to act to shape the future rather than reacting to the future shaped by others. We have attempted to assume leadership responsibilities for educating the

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registered nurses in North Carolina and to facilitate the application of their expertise to solving the health care problems of our citizens. We have made significant efforts in developing working relationships with physicians and other health care professionals. For instance, the recommendations of the National Commission for the Study of Nursing and Nursing Education were published in 1970.

Within 2 years North Carolina had a functioning joint practice committee composed of six physician members appointed by the North Carolina Medical Society and six nurses appointed by the North Carolina Nurses' Association. It has functioned in the area of practice concerns related to the interaction of medical and nursing practice. It has already phblished several task force reports on the role of the nurse in extended practice such as the family nurse practitioner, the mental health clinician, et cetera.

In 1974 the North Carolina Nurses' Association and the North Carolina Hospital Association jointly sponsored workships throughout North Carolina on the Joint Commission on Accreditation of Hospital Standards on retrospective audits of nursing care. Programs on implementing standards of practice as developed by the American Nurses' Association have been presented in our area and were well attended by nurses in our State.

We have also made considerable strides toward educating the nurses in North Carolina about quality assurance and PSRO. Duke University Hospital has a well-established quality assurance program in nursing that has been in existence at least 3 years. The nurses from that program have presented lectures and workshops to nurses in North Carolina.

At least one baccalaureate program in nursing in North Carolina (UNC-Greensboro) has added aspects of the criteria for quality assurance in PSRO, using the American Nurses' Association PSRŎ model, to its curriculum. The newly graduated nurses are entering practice now with real knowldege of quality assurance.

A subcommittee on PSRO was established by Commission on Practice of the North Carolina Nurses' Association in 1977. The chairperson of that subcommittee has an impressive background in quality assurance and previously was the staff person of the American Nurses' Association quality assurance program. One committee member is employed as a supervisor of utilization review coordinators of an area PSRO. The committee has sent letters to all area PSRO's in North Carolina, offering their support, cooperation, or assistance in any way of benefit to the area PSRO's.

An article was published in the Tar Heel Nurse of July 1977, on "PSRO, the Legislation (Public Law 92-603), Its Purpose, How It Is to Function." This issue went to all members of NCNA and was intended to heighten their awareness and educate them in a positive

manner.

A resolution has been drafted and will be presented to the House of Delegates of the North Carolina Nurses' Association next month. It provides for identifying qualified nurses in each of the eight PSRO areas willing to serve on advisory groups, PSRO boards, and committees, and also provides for communicating this information to appropriate State and Federal representatives, and finally provides a mechanism for keeping the list of names current.

We have also attempted to identify all nursing specialty groups of nurses organized in North Carolina such as the Emergency Department Nurses' Association, the North Carolina League for Nursing, et cetera. A meeting is scheduled later this year between the officers of the North Carolina Nurses' Association and two representatives of each organized specialty group. We hope to identify areas of mutual concern and develop strategies for combined action to meet those needs.

I believe these examples illustrate the expertise of nurses in North Carolina, their willingness to be involved, to share their knowledge with others, and their ability to work with physicians and other health care workers to improve the delivery of health care to the people of North Carolina.

Health care is composed of the medical care component plus the nursing care component plus the allied health component. Public Law 92-603 provided for physician involvement in quality assurance. House bill 3167 will provide for the nursing involvement. As the largest group of health care professionals and particularly as the group involved with patients around the clock, 7 days a week, we feel we have considerable knowledge to share with others, and we desire the opportunity to do so.

STATEMENT OF VIRGINIA BARKER

Dr. BARKER. I am Virginia Barker, president of the New York State Nurses' Association.

On behalf of the 180,000 registered professional nurses in that State, I extend appreciation to the subcommittee for the opportunity to present our strong support of H.R. 3167.

Although the law seeks to assure standards in health care delivery, it confers almost exclusive authority upon members of only one health discipline, doctors of medicine and osteopathy.

It has long been recognized that health care is not synonymous with medical care. It has also been recognized that physicians, their expertise and authority in medical practice notwithstanding, are not qualified by education or experience to monitor the services of other health care disciplines.

Conferring such authority upon physicians jeopardizes rather than protects standards of health care.

The volume of nursing care services provided under the aegis of the Social Security Act and the numbers of nurses engaged in those services stagger the imagination.

These facts alone justify and mandate inclusion of registered professional nurses in PSRO's not only as staff to statewide and area PSRO's, but also as active participants, with voting privileges, on governing bodies, advisory councils, and policy and planning committees.

Beyond this, the profession and its practitioners have clearly demonstrated their capacity and accountability for quality assurance. Standards of nursing practice have been articulated by the American Nurses' Association and widely disseminated throughout the nursing community.

These standards are utilized not only by nursing practitioners themselves, but also by regulatory and accrediting bodies charged with protection of public interest.