In addition, for at least 5 consecutive years, the American Nurses' Association and its constituent State nurses associations have actively promoted nursing audit, peer review, and quality assurance mechanisms.

For your information, examples of such activities in New York State are included in attachment A.

There are 17 PSRO's in New York State. We have not a single nurse on an advisory council or on the State governing council. We have not one single nurse in a voting capacity at the policy and planning level.

I think that is entirely regrettable.

We have many nurses, at least 52 in staff capacities, so we are in the process of data collection, evaluation, but only under the guidelines established by another profession.

We feel this just cannot continue.

It is clear that the particular expertise of nurses is recognized, sought after, and utilized in PSRO staff activities in New York State. It is equally clear that the nursing community and individual nurses in the State understand and seek the responsibility for participation in professional standards review.

However, it is abundantly evident that acceptance of nurses on PSRO decisionmaking and governing bodies is grossly lacking.

As is often the case, practice once again appears to have preceded law.

We cannot leave this up to chance. We are asking that it be mandated and explicitly required.

Experience to date in New York State demonstrates that nursing involvement in PSRO's is indeed both necessary and feasible.

However, we now need the help of Congress to assure the public that nursing involvement in PSRO's will also be both complete and permanent.

In closing, I wish to reiterate our appreciation for the opportunity to make our views known to you and to publicly encourage prompt enactment of H.R. 3167.

I would be pleased to respond to any questions or comments you may have.

[The prepared statement follows:]

STATEMENT OF THE NEW YORK STATE NURSES ASSOCIATION, PRESENTED BY VIRGINIA L. BARKER, ED. D., R.N., PRESIDENT

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.

The purpose of the law which created Professional Standards Review Organizations-i.e., "to assure . that the services for which payment may be made under the Social Security Act will conform to appropriate professional standards of health care "-is beyond reproach. However, the mechanism created to achieve that purpose is highly inappropriate and ineffective.

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 service 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 PSROS not only as staff to statewide and area PSROS 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. In addition, for at least five consecutive years, the American Nurses' Association and its constituent state nurses associations have actively promoted nursing audit, peer review and quality assurance mechanisms. For your information examples of such activities in New York State are included in Attachment A.

Perhaps the most compelling evidence of the need for nurses to be involved in PSROS is the extent of their involvement at the present time. In seventeen PSRO areas in New York State, at least fifty-two registered professional nurses are serving in PSRO staff capacities. Positions held by nurses include these titles: Project Director; Director of Reviews; Director of Hospital Review; Director, Hospital Review Division; Program Coordinator; Assistant Director and Review Coordinator; Program Supervisor; Director of Professional Service; and Senior Review Coordinator. Nurses have been nominated for these positions in a variety of ways-by District Nurses Associations, by the New York State Nurses Association, by colleagues in nursing and other health care disciplines. The statewide planning council is in the process of being constituted. The New York State Nurses Association has been assured that names of nursing representatives will be considered as nominees for membership on the council. In addition, in individual areas where advisory councils are not yet operational, the nursing community continues to seek representation. Also, at the federal level the position of Program Coordinator in the DHEW Region II (New York, New Jersey, Puerto Rico and the Virgin Islands) PSRO Program is held by a professional nurse.

It is clear that the particular expertise of nurses is recognized, sought after and utilized in PSRO staff activities in New York State. It is equally clear that the nursing community and individual nurses in the state understand and seek the responsibility for participation in professional standards review. However, it is abundantly evident that acceptance of nurses on PSRO decision-making and governing bodies is grossly lacking.

As is often the case, practice once again appears to have preceded law. Absent the legal requirement, health care providers have acknowledged that delivery and monitoring of health care services are collaborative activities and they have established collaborative review mechanisms. Emergence of these mechanisms on a voluntary basis is laudable, but protection of public interest can no longer be left to chance. The law which mandates review of standards of health care must do more than simply encourage involvement of the major providers-it must explicitly require it. Experience to date in New York State demonstrates that nursing involvement in PSRO's is indeed both necessary and feasible. However, we now need the help of Congress to assure the public that nursing involvement in PSROS will also be both complete and permanent.

In closing, I wish to reiterate our appreciation for the opportunity to make our views known to you and to publicly encourage prompt enactment of H.R. 3167. I would be pleased to respond to any questions or comments you may have.

ATTACHMENT A

THE NEW YORK STATE NURSES ASSOCIATION'S INVOLVEMENT WITH PSRO

I. Activities of NYSNA Re Promotion of Public Law 92-603 Professional Standards Review Organization (non-inclusive)

Developed and widely disseminated to New York State's nursing community and other states Guidelines Basic to Establishing a Peer Review System;

Developed Policies and Procedures Governing Violations of the Code for Nurses; Developed a Form for Reporting Alleged Violations of the Code for Nurses; Compiled Operational Definitions in Evaluating Allegations of Professional Misconduct in Nursing;

Developed Position Statement Re Role of the Nursing Practitioner in Professional Standards Review Organizations;

Compiled and Disseminated, to all District Nurses' Associations and various educational facilities, Information Sheets Re PSRO with a Map Designating Geographical Interrelationships between NYSNA and DHEW Region II, N. Y.S. PSRO Regional Areas, November 1974. PSRO Updates, January 1975, April 1975, July 1975, October 1975, December 1975, September 1977;

Assisted the Nursing Profession with Implementation of the Standards of Nursing Practice and Services;

Developed a Quality Assurance Model for Nursing.

II. Program Activities

NYSNA sponsored the following programs:

NYSNA Convention Program, "Are Professional Nurses Ready for a Quality Assurance Program?" Lake Placid, N. Y., October 12, 1974, Norma Lang, Ph. D., R.N.;

NYSNA-Convention Program "PSRO-Call to Accountability," Syracuse, N. Y., October 8, 1975, Sharon L. Davidson, M. Ed., R.N.;

NYSNA-Council on Nursing Practice "Implementing the Legal Definition of Nursing Practice," Five Regional Workshops, May 4, 1974 through May 22, 1974;

NYSNA-Council on Nursing Practice-"Coping with Quality Assurance-A Nursing Model," Six Regional Workshops, March 4, 1975 through April 10, 1975; NYSNA Council on Nursing Practice "Quality Assurance Workshop: A Nursing Model," Albany, N. Y., June 24, 1976;

NYSNA Councils, Conference and Specialty Groups-"Leadership Workshop: Implementation of ANA Standards of Nursing Practice and Services," Albany, N. Y., September 15-16, 1977;

NYSNA Council on Ethical Practice "The Professional Umbrella: Accountability," Albany, N. Y., April 25, 1975;

NYSNA "Special Meeting of Nurses Employed in Department of Mental Hygiene Facilities," Albany, Ñ. Y., April 1, 1976.

III. Activities of Representatives of NYSNA Re Presenting Conferences and Participating in District and State Nurses' Association Programs

"Zeroing In on Standards of Practice and Ethics," NYSNA Gerontological Nursing Practice Conference Group, Albany, N. Y., March 1973;

"Standards of Nursing Practice and Services and Education are for the BirdsSeagulls That Is-Not Canaries," NYSNA District 1, May 16, 1973;

One State's (N. Y.) Progress in Peer Review," New Hampshire Nurses' Association, October 1973;

"Professional Controls and Self Regulation-Recommended Tool Peer Review," Buffalo Telephone Network, SUNY Buffalo, February 12, 1974;

"Be Futuristic-Evaluate Effectively: Peer Review," SUNY Buffalo, April 1974;

"Standards +Peer Review=QAP; Peer Review Progress-Not Provocation," Pennsylvania Council on Nursing Practice Conference, Harrisburg, Pa., September 6, 1974;

"State of the Ark—Standards of Nursing Practice," Buffalo General Hospital, February 4, 1975; "Professional Control-Self Regulation, Recommended Tools, NYSNA District 3, May 15, 1975;

"What You Ought to Know About Peer Review," NYSNA District 9, February 5, 1976;

"Quality Assurance: One State's (N.Y.) Progress in Peer Review," NYSNA District 13, April 14, 1976;

Professionally Speaking: Quality Assurance-Peer Review," N.Y.S. Dept. of Civil Services, Nursing Staff, Albany, N. Y., July 9, 1977.

IV. NYSNA Publications

Brown, Grace, et al. "Implementing the Definition of Nursing Practice," The Journal of the New York State Nurses Association, 6(1):6-33, March 1975. Davidson, Sharon L. "PSRO-Call to Accountability," NYSNA Convention Program, Syracuse, N. Y., Oct. 8, 1975, tape available.

Lang, Norma. "Are Professional Nurses Ready for a Quality Assurance Program?" The Journal of the New York State Nurses Association, 5(4):24–32, Convention Papers 1974.

New York State Nurses Association. "Report of the Task Force to Study the Nursing Home Situation," The Journal of the New York State Nurses Association, 6(3):21-7, November 1975.

V. Conferences Attended by NYSNA Representatives

ANA-AHA Joint Sponsored Workshop "Quality Assurance for Nursing," Kansas City, Mo., Oct. 29-31, 1973;

ANA-Peer Review and Implementation of Standards of Nursing Practice, Kansas City, Mo., June 29-30, 1975;

ANA-Invitational Workshop Re Quality Assurance, Tucson, Ariz., Dec. 10–11,

1975;

ANA-Leadership Workshop, Quality Assurance: "Implementation of Standards of Nursing Practice," Hartford, Conn., Mar. 23–25, 1976;

DHEW-Peer Review Research, Bethesda, Md., Feb. 26, 1976;

JCAH-Seminar on Utilization Review, Hauppauge, N. Y., Apr. 29, 1976.

VI. Testimony presented by NYSNA representatives

Sward, Kathleen. "Statement of The New York State Nurses Association on Proposed Revisions of Regents' Rules Defining Unprofessional Conduct in the Practice of the Professions Licensed or Certified Under Title VIII of the Education Law," Albany, N. Y., Jan. 13, 1977.

Welch, Cathryne A. "Statement of The New York State Nurses Association on Proposed Revisions of the Rules of the Board of Regents' Defining Unprofessional Conduct in the Practice of the Professions Licensed or Certified Under Title VIII of the Education Law," Albany, N. Y., May 10, 1977.

STATEMENT OF CLAIRE O'NEIL

Ms. O'NEIL. I am Claire O'Neil, president of the Connecticut Nurses' Association.

I am also the director of nursing at the University of Connecticut Health Center.

I am pleased to have this opportunity to speak today.

In speaking in support of the amendments recommended by the Keys' bill, I would like to take this opportunity to review the activity of Connecticut nurses in professional standards review organizations programs, PSRO's.

Our State has four area PSRO's and one State advisory council. The four area PSRO's have been active for some time. The first meeting of the State advisory council was held this spring.

I will speak in detail on the activities of one of the area groups, Hartford County PSRO.

the

Initiated under the aegis of the Hartford County Medical Society, it has been active in the development of the utilization review, criteria setting, and delegation programs for nine hospitals in the area. At this date, all hospitals have delegated status.

Until last night, I didn't realize I was a part of a rather small group because I am an elected member of the Hartford County Board of PSRO directors and have been since October 1975.

Initially elected for a 1-year term, I was reelected for a 2-year term in 1976.

Recommended by the nominating committee, I was elected by the voting body of the Hartford County Medical Society.

I am one of six nonphysicians on the board. At present, I am the only clinically oriented nonphysician member.

Professional nurses are the other primary persons involved in client care.

With the physicians, we provide scope and continuity of care. The nursing profession is committed to the establishment of peer review systems that are outcome-oriented.

As providers of nursing care services, we can and want to be held accountable by consumers for the effective and efficient utilization of these services.

At my election to the HC-PSRO board of directors, I acted in an advisory capacity to the physician-members.

Working with my nonphysician colleagues, we brought to the physicians other prospectives of health care as they developed-peer review, hospital admission, and delegation criteria.

As they developed peer review mechansims, it became obvious that more than medical practice had to be reviewed. I was able to advise them that any peer review system that evaluates quality and cost of health care must include all health professionals.

It is appropriate that each profession develop its own mechanism for peer review, develop it, of course, in cooperation with and interdependently with physicians but not under the umbrella of "medical"

care.

In July 1976 it became evident that there was a need for the development of a nonphysician health care practitioner advisory group.

As a representative of the board of directors, I acted as the chairman of the task force to study this question. In May 1977, the board approved the recommended guidelines for the appointment, duties and responsibilities of this nonphysiciau advisory group. I list for your information the duties and functions.

As this new year of activity begins, the HC-PSRO has broadened its perspective and is developing a plan for the review of long-term care. The appointment of a long-term care committee of 26 includes 3 registered nurses. This committee will have as a major focus the development of admissions and continued stay review criteria in which services of health care practitioners other than physicians will contribute significantly to the justification for admission and continued care. I believe nurses in Connecticut and the Nation want to be included on boards of directors of PSRO's. They are comfortable with the peer review process and are committed to a program of accountability for their services.

I believe the contributions that have been and are being made by registered nurses to peer review activities is enhanced as they are involved at decisionmaking levels at the State and county levels.

It is not appropriate then that that involvement occur at the Federal level.

Thank you for your attention.
[The prepared statement follows:]

STATEMENT OF CLAIRE E. O'NEIL, PRESIDENT, CONNECTICUT NURSES

ASSOCIATION

I am Claire O'Neil, president of the Connecticut Nurses Association. I am pleased to have the opportunity to meet with you today to discuss "a bill to amend part B of title XI of the Social Security Act to assure appropriate participation by professional registered nurses in the peer review and related activities authorized thereunder." (HB 3167)

In speaking in support of the amendments recommended by the Key's bill, I would like to take this opportunity to review the activity of Connecticut nurses in professional standards review organization programs (PSRO's). Our State has four area PSRO's and one State advisory council. The four area PSRO's have been active for some time. The first meeting of the State advisory council was held this spring.

I will speak in detail on the activities of one of the area groups-the Hartford County PSRO. Initiated under the aegis of the Hartford County Medical Society, it has been active in the development of the utilization review, criteria setting and delegation programs for nine hospitals in the area. At this date, all hospitals have delegated status. I have been an elected member of the Hartford County