On behalf of the American Association of Colleges of Nursing which represents over 180 collegiate programs of nursing across the country, we strongly urge that professional registered nurses be included in the Professional Standards Review Organizations at the decision-making level. Please contact me if we can provide you with additional information. Sincerely yours, LINDA KAY AMOS, Ph. D., R.N., Chairperson, Governmental Affairs Committee. STATEMENT OF HARRY WEEKS, M.D., PRESIDENT OF THE AMERICAN ASSOCIATION OF PROFESSIONAL STANDARDS REVIEW ORGANIZATIONS I appreciate having the opportunity to testify today on behalf of the American Association of Professional Standards Review Organizations. We are the national organizations which represent the PSROs across the country. We have long supported the basic principles which were embodied in the original Bennett Amendment. We believe that this legislation reaffirms the role of the local physician in determining the care to be provided the individual patient, and the need for a program of true peer review to assure that the highest quality is provided to these patients. We were asked to testify today on the role of the nurse in the PSRO. AAPSRO wants to affirm the position of our members that we recognize the important role that nurses and other non-physician health care practitioners play in PSRO. Nurses play a vital role in the quality and utilization review systems that PSROS have implemented around the country. In addition, many nurses serve in important management positions in many PSROs. We recognize the need to continue to receive input from nurses and other health care disciplines. For this reason, we would support the following legislative measures which would formalize the input of nurses and other health disciplines: (1) at the option of the local PSRO, dentists may be eligible for membership in the PSRO; (2) a position on each PSRO Statewide Advisory Group should be reserved for a nurse; (3) a fifteen person committee composed of representatives of nurses and other health care disciplines should be established to advise the National Professional Standards Review Council on policy issues concerning their involvement in the PSRO program. In addition, in order to assure that this committee has input, that the Chairman of this advisory group be mandated to report to the National Professional Standards Review Council at each of its meetings. We feel that we should continue to explore the role of the nurse in PSRO, and appreciate having had the opportunity to present testimony to this committee today. Hon. DAN ROSTENKOWSKI, AMERICAN COLLEGE OF NURSE-MIDWIVES, Chairman, Subcommittee on Health of the Committee on Ways and Means, DEAR CHAIRMAN ROSTENKOWSKI: The American College of Nurse-Midwives would like to submit this written statement regarding the role of professional registered nurses in Professional Standards Review Organizations, about which your Committee is conducting hearings on September 30, 1977. The American College of Nurse-Midwives feels registered professional nurses. have an important role to play in meeting the health care needs of the nation and therefore should also participate fully in Professional Standards Review Organizations. In situations dealing with obstetrical care, perinatal care, family planning and gynecological screening, certified nurse-midwives should also be included in the P.S.R.O. Thank you for the opportunity to make these comments. Sincerely yours, HELEN V. BURST, C.N.M., M.S., President. STATEMENT OF THE AMERICAN DENTAL ASSOCIATION The American Dental Assicoation appreciates this opportunity to present its: views concerning the role of dentistry in the Professional Standards Review Organization program. This is an issue of continuing concern to the profession and one which the Association hopes soon will be corrected legislatively. As you know the present PSRO law, as contained in Public Law 92-603, requires review of all health care services, including dental services, provided under the Social Security Act health programs At the same time this statute as currently implemented allows only physicians and osteopaths to be participants in the peer review process. Although the law contains permissive language authorizing PSROS to utilize the services of dentists in the review of dental care, this is not a mandatory provision and to the Association's knowledge has not yet been followed by any PSRO. In addition the law prohibits the inclusion of dentists. on the State and National PSR policymaking councils. The PSRO law was enacted to utilize peer review concepts to assure the high quality and necessity of care provided under medicare, medicaid, and the maternal and child health programs. As such it is imperative that a true peer review system be implemented. Under such a system dental services must be reviewed by dentists. It is wholly contrary to any rational understanding of peer review to mandate. the review of dental services without a mandate of equal force that dentists shall conduct this review. In addition such a system must allow for the participation by dentists in policymaking decisions which will affect the dental component of peer review. Allowed to stand, the present provisions of law relating to review of dental services by PSROS will prove a crippling defect to the full acceptance of the law. The artificiality of the present arrangement will become even clearer and more crippling as ambulatory services are given closer attention. We believe. it is in everyone's best interest to rectify the matter now. Dentists are professional providers of primary oral health care and are duly licensed in every State and jurisdiction in the Nation to provide such care. Under medicare dentists are the only nonphysician health professionals granted independent authority to certify hospital admissions. There are, today, over 100,000 members of the profession engaged in the private. practice of dentistry. More than 100 million people annually seek their services. According to the most recent estimates released by the Social Security Administration, some $8.6 billion was expended during 1976 for dentists' services. Of this total, the same source estimates that some $469 million was public expenditures, much of it under Titles V, XVIII, or XIX of the Social Security Act, all of which is now or will be subject to PSRO review. These basic characteristics of dental practice-independent licensure, provision of primary care, 100 million patient visits and large-scale expenditures-are fundamentally identical to those of physicians. No health occupation other than these two has this combination of characteristics. Further, dentists are actively engaged today in providing care within hospitals. and other institutional settings, care which is currently subject to PSRO review. According to figures compiled by the American Hospital Association, more than 3,000 hospitals today have organized dental services either free-standing or as sections within departments of surgery. Data available through the American Dental Association's Council on Hospital Dental Services indicate that some 3 percent of the total admissions to hospitals today are for dentally related services. More than 15,000 dentists regularly admit patients to hospitals. We have, over recent months, made a number of efforts to obtain additional, independent verification of the procedures performed within hospital settings by dentists. The Commission on Professional and Hospital Activities estimates that nearly 5 percent of hospital admissions for the 2,700 hospitals participating in the Commission's program were for dental or oral surgical procedures. The National Center for Health Statistics' Division of Health Resources Utilization Statistics Branch estimates that more than 550,000 operations were performed in hospitals by dentists in 1974. The American Society of Oral Surgeons has made available to the National Center lists of the procedures dentists are licensed to perform and of the diagnoses in which the dentist might play a primary role. The Center indicated that there were about 1.1 million first-listed diagnoses under which the dentist might provide. treatment and some 2.2 million conditions in the treatment of which a dentist might be involved. The Accreditation Manual for Hospitals issued by the Joint Commission on Accreditation of Hospitals states that medical staff membership shall be limited to individuals who are fully licensed to practice medicine and, in addition, to licensed dentists. The Joint Commission defines an organized medical staff as a formal organization of physicians and dentists with the delegated responsibility and authority to maintain proper standards of care. Its manual stipulates that dentists who are members of the medical staff may admit and discharge patients. These, then, are a selection of the various facts and judgments attributable to non-dental organizations. Without question, they fully support the position enunciated in the opening paragraphs of this statement. The history of activity by the dental profession with regard to participation in the PSRO process is longstanding. We will not burden you with all of its details but will note that in the most recent activity the Association and the American Society of Oral Surgeons appeared jointly before the National PSR Council to request the support of the Council for appropriate changes in the PSRO law. This effort resulted in a Council action recognizing the distinctions between dentistry and the other health professions and recommending that the Department support an amendment to the PSRO law that would enable local PSROS to offer membership to dentists. At present this recommendation is awaiting Departmental action by the Secretary of Health, Education and Welfare. While cognizant of, and sympathetic to, the complexities and controversies involved with the implementation of the Professional Standards Review law, the Association believes the time has arrived for Congress to enact the necessary changes to fulfill the mandate of this peer review program. In light of the nature and extent of dental services now subject to PSRO review because they are provided in institutional settings, and the much greater amount of dental services which will be subject to review when the program is expanded to include review of ambulatory services, we recommend that legislation be enacted to provide the following: 1. Immediate National and State PSRO Advisory Council membership for dentists. 2. Immediate full participation for dentists who are hospital medical staff members and who have independent hospital admitting privileges with regard to the review of dental services provided in institutional settings. 3. A provision mandating that before PSRO authority can be expanded to include review of ambulatory services there be provisions for inclusion of dentists in this review process with regard to dental services provided in noninstitutional settings. The PSRO program is of major significance to the success of the Social Security Act Health programs. It cannot work with respect to covered dental services unless dentists are permitted to participate in it. There is an immediate need for dental participation in the review of dental services now being provided in institutional settings. There will be an equally imperative need for dental participation in review of other services as they are made subject to review. The Association requests your support for amendments to the PSRO law to accomplish these goals in the manner outlined above. Thank you for this opportunity to present the Association's views on this very important issue. The assistance of the ADA in drafting appropriate amendments to the PSRO law is offered to you and your staff. STATEMENT OF THE AMERICAN HOSPITAL ASSOCIATION The American Hospital Association represents more than 6,500 member institutions, including most of the hospitals in the country, extended and long-term care institutions, mental health facilities, and hospital schools of nursing, and over 25,000 personal members of whom over 2,000 are nursing service administrators. The American Hospital Association welcomes the opportunity to present the views of the Association on H.R. 3167, a bill to grant registered nurses a role in Professional Standards Review Organizations (PŠROs). The Association has been asked to address the broader issue of non-physician involvement in PSROS and we shall therefore address this broad subject before making specific comments on the proposed legislation. Involvement of nonphysician health professionals in PSROs and quality assurance programs In previous testimony before the Subcommittee on Oversight of the House Committee on Ways and Means, AHA expressed concern that the development and implementation of peer review systems for non-physician health care professionals could substantially raise overall health costs at a time when hospitals and government were making every effort to contain such costs. AHA further expressed concern about the number of professional groups initiating peer review activities outside the institution under the auspices of area PSROS and that areawide or nationally developed criteria and treatment objectives developed by individual peer groups might not be suited to the organizational pattern of hospitals. Externally imposed criteria and standards could cause a significant increase in the cost of patient care without necessarily assuring improvement in the quality of the care delivered or without having a positive impact on health care costs, through cost savings that could result from this activity. Such programs might also undermine the effective management of institutions because of a lack of coordination. The possible results outlined above have led AHA to oppose in principle the concept of separately developed criteria and objectives by a multiplicity of health professionals, each reviewing their own discipline, since the twin aims of PSRO legislation, namely cost containment and quality assurance, would not be achieved under these conditions. In accordance with these views, AHA believes that non-physician health professionals should establish standards for their professions and apply those standards in an interdisciplinary fashion to a single quality assurance process within the individual institution. In conjunction with these recommendations on the quality assurance activities of PSRO programs in institutions, the AHA has further urged that the Bureau of Quality Assurance ((BQA) and Joint Commission on Accreditation of Hospitals (JCAH) continue joint efforts to coordinate review requirements so that a single interdisciplinary hospital review system can meet the various requirements placed upon it by these and other agencies, provided the objectives of the review requirements to improve the quality of health services are not compromised by efforts to reduce costs. Currently, JCAH standards require a hospital to demonstrate that the quality of care provided to all patients is consistently optimal by continuously evaluating it through reliable and valid measures. The interpretation of this standard states that the quality of patient care shall be evaluated by members of the medical and other professional staffs directly responsible for patient care. The interpretation also states that specific criteria for the measurement of care must be established by non-physician health care professionals for evaluation of those aspects of patient care that they provide. The critical role of nursing in quality assurance programs and its potential contribution to cost containment efforts Hospitals are the largest employer group of professional registered nurses. There are currently over 525,000 RNs in hospital employment and nursing services comprise the greatest percentage (between 40-60 percent) of the total human resources expenditures in the operating budget of the institution. The HEW publication Nurse Staffing Methodology: A Review and Critique of Selected Literature documents many studies focused on nursing services which attempted to control costs without jeopardizing the quality of care. At a time when cost containment efforts are more pressing than ever before, nursing should be included in any mechanism to control cost and safeguard the quality of care. All health care practitioners should face greater accountability but those whose professional duties include the care of all patients at all times during their institutional confinement should plainly be held more accountable for control of cost. PSROS' mandate to contain costs and to assure quality through the process of professional peer review logically requires a collaborative interdisciplinary effort if the mechanism is to succeed at a local level. The activities of nurses and other health providers have been subject to PSRO review but they have been excluded by law from the highest policymaking body and not mandated as participants in policy-making bodies at any level. Once a physician has admitted a patient and written the medical orders following his assessment of the patient's condition, many decisions which determine the quality and cost of that patient's hospitalization rest with the professional registered nurse. The nurse not only carries out the physician's orders but develops a nursing care plan based on data gathered from the patient, physician, family or other significant sources. The effective implementation of this plan impacts on the length of stay of the patient and after the patient is discharged on the likelihood of his readmission. The medical care plan does not stand alone; it is augmented by the nursing care plan in a collaborative practice between the physician and the nurse. By virtue of the combination of professional knowledge and the universal role in direct patient care-24 hours a day-the nurse has become a key coordinator of patient care within the institution. It is the nurse who alerts the physician to conditions requiring attention during the physician's absences from the bedside, and through assessment skills the nurse may anticipate needs for supportive services (such as respiratory therapy, physical therapy, etc.) and prevent costly complications. Statistics show that many referrals for supportive services are initiated by professional registered nurses who are with the patient more than any other professional. Recommended response to the Keys bill, H.R. 3167 AHA has considered the issues of non-physician peer review and has recommended caution in approaching expansion of the National Professional Standards Review Council. This caution is based on the perception that PSROS are still in an evolutionary phase and that physician support for the entire PSRO concept is not sufficiently strong to withstand major changes in the current structures. AHA supports the continuing evaluation of all levels of the PSRO program including a structured system to review patient care. An interdisciplinary review methodology should be developed, including health care practitioners other than physicians. AHA and other professional organizations would be pleased to cooperate with the Department of Health, Education, and Welfare to develop such a system. When developed, consideration of legislative action to assure appropriate policy and program involvement for such professionals can be considered. While recognizing the important role of nurses, the AHA believes that enactment of H.R. 3167 would be premature. Rather, the amendment to the PSRO authority embodied in the bill should be considered in a broader context which would also include the involvement of other non-physician health care professionals. THE AMERICAN OCCUPATIONAL THERAPY ASSOCIATION, INC., Hon. DANIEL ROSTENKOWSKI, DEAR MR. CHAIRMAN: On behalf of the American Occupational Therapy Association, I would like to take this opportunity to submit comments for the record in conjunction with the Subcommittee's hearing on the role of professional registered nurses in Professional Standards Review Organizations. As health professionals with a deep commitment to the goals of the PSRO program, we are seriously concerned with the law's failure to mandate participation of all health practitioners in achieving these goals. Formed in 1917, the Association now represents over 23,000 active members, including registered occupational therapists, certified occupational therapy assistants, and students of occupational therapy. Occupational therapists provide services to those individuals whose ability to cope with the tasks of living are threatened or impaired by developmental deficits, the aging process, poverty and cultural differences, physical injury or illness, or psychological and social disability. Occupational therapy practitioners provide services in many settings, including hospitals, skilled nursing facilities, outpatient clinics, and in home health settings. For most of the past 10 years, occupational therapists have been actively engaged in formal peer review activities. At the national level the Association has promoted the development of criteria to evaluate quality practice and stressed the need for occupational therapists to become knowledgeable in peer review procedures and evaluative collaboration with other health professionals. Extensive training programs have been developed for Association members, and in recent years the California Medical Association's "Training for Trainers" presentation has been used to prepare workshop leaders on the state level. All of the educational activities have been coordinated with local occupational therapy associations in the 50 states and Puerto Rico. |