BILL ANALYSIS SB 294 Page 1 Date of Hearing: June 30, 2009 ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS Mary Hayashi, Chair SB 294 (Negrete McLeod) - As Amended: June 8, 2009 SENATE VOTE : 25-11 SUBJECT : Nurse practitioners. SUMMARY : Expands the authorized functions that may be performed by nurse practitioners (NP) practicing under standard procedures. Specifically, this bill : 1)Expands the authorized functions that may be performed by an NP practicing under standardized procedures to include: a) Ordering durable medical equipment, subject to any limitations set forth in the standardized procedures. Specifies that this authority does not limit the ability of a third-party payor to require prior approval; b) Certifying disability, as specified, after performance of a physical examination by the NP and collaboration with a physician and surgeon; and, c) Approving, signing, modifying or adding to a plan of treatment or plan of care for individuals receiving home health services or personal care services after consultation with the treating physician and surgeon. 2)Prohibits this bill from being construed to affect the validity of any standard procedures and protocols in effect prior to the enactment of this bill or those adopted subsequent to the enactment of this bill. 3)Makes legislative findings and declarations. EXISTING LAW : 1)Establishes the Nursing Practice Act which provides for the certification and regulation of nurses, NPs and nurse-midwives by the Board of Registered Nursing (BRN) and requires the BRN to establish categories and standards for nurse practitioners in consultation with specified health care practitioners, SB 294 Page 2 including physicians and surgeons. 2)Defines the practice of nursing as those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems, and that require a substantial amount of scientific knowledge or technical skill, as specified. 3)Defines standardized procedures to mean either of the following: a) Policies and protocols developed by a licensed health facility, as defined, through collaboration among administrators and health professionals including physicians and nurses; or, b) Policies and protocols developed through collaboration among administrators and health professionals, including physicians and nurses, by an organized health care system which is not a licensed health facility, and specifies that the policies and protocols shall be subject to any guidelines for standardized procedures that the Medical Board of California (MBC) and the BRN may jointly promulgate. If promulgated, the guidelines shall be administered by the BRN. 4)Authorizes NPs to furnish or order drugs under certain conditions, pursuant to standardized procedures or protocols and under the supervision of a physician and surgeon. FISCAL EFFECT : Unknown COMMENTS : Purpose of this bill . According to the author's office, "Nurse practitioners (NPs) are licensed registered nurses who perform their duties under standardized procedures which are developed by the physicians and facilities they work with/in. These duties are not delineated within the Business and Professions Code but instead the standardized procedure is the governing document. As a result, there are very diverse standardized procedures in use. In some instances, third party payers, health facility administrators, and others question what duties a nurse practitioner may perform because they do not want to SB 294 Page 3 review individual standardized procedures. Thus, SB 294 would codify a few minimum duties to make it clear that NPs may perform these duties if their standardized procedure permits them to." Background . Current regulations define a NP as a registered nurse who possesses additional preparation and skills in physical diagnosis, psychosocial assessment, and management of health-illness needs in primary health care, and who has been prepared by a program that conforms to BRN standards, as specified. The Nursing Practice Act delineates nurse's scope of practice, which includes: direct and indirect patient care services that ensure the safety, comfort, personal hygiene, and protection of a patient; the performance of disease prevention and restorative measures; direct and indirect patient care services, including, the administration of medications and therapeutic agents necessary to implement treatment, disease prevention, or rehabilitation regimen ordered by a physician, dentist, podiatrist and clinical psychologist; the performance of skin tests, immunization techniques, and the withdrawal of blood from veins and arteries; observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition, and determining whether the signs, symptoms, reaction, behaviors, or general appearance exhibit abnormal characteristics; and implementation, based on observed abnormalities, of appropriate reporting, referral, standardized procedure, changes in treatment regimen in accordance with standardized procedures, or the initiation of emergency procedures. Standardized procedures are the legal mechanism for RNs and NPs to perform functions which otherwise would be considered the practice of medicine and which would be within the scope of practice of a physician and surgeon. Standardized procedures and protocols are policies and protocols developed by a health facility or organized health care system, and developed through collaboration with the administration, physicians and nurses. They must include a written description of the method used in developing and approving them. Each standardized procedure must: (1) be in writing and signed by authorized personnel in the organized health care system; (2) specify which standardized procedure functions registered nurses may perform and under what circumstances; (3) state any specific requirements which are to be followed by registered nurses in performing particular standardized procedure functions; (4) specify any experience, SB 294 Page 4 training, and/or education requirements for performance of standardized procedure functions; (5) establish a method for initial and continuing evaluation of the competence of those registered nurses authorized to perform standardized procedure functions; (6) provide for a method of maintaining a written record of those persons authorized to perform standardized procedure functions; (7) specify the scope of supervision required for performance of standardized procedure functions, such as telephone contact with the physician; (8) set forth any specialized circumstances under which the registered nurse is to immediately communicate with a patient's physician concerning the patient's condition; (9) state the limitations on settings in which standardized procedure functions may be performed; (10) specify patient record-keeping requirements; and, (11) provide for a method of periodic review of the standardized procedures. If a registered nurse or NP undertakes a procedure without the competence to do so, such an act may constitute gross negligence and be subject to discipline by the BRN. Suggested amendment : The committee may wish to recommend an amendment to delete the phrase, "Notwithstanding any other provision of law," because it is unnecessary and duplicative of other provisions of the bill stating that it's provisions are in addition to other functions performed under standard procedures authorized under existing law. Previous legislation . AB 1436 (Hernandez) of 2008, defines the scope of practice of NPs and authorizes a NP to provide comprehensive health care services, as specified. This bill was heard in this Committee but was not voted on. SB 809 (Ashburn) of 2007, defines the scope of practice of nurse practitioners and authorizes nurse practitioners to perform specified acts. This bill was never heard and died in this Committee pursuant to Joint Rule 56. AB 1643 (Niello) of 2007, would repeal the prohibition against a physician and surgeon supervising more than four NPs at one time for purposes of furnishing or ordering drugs or devices. This bill was never heard and died in the Assembly Committee on Business and Professions. AB X1 1 (Nunez) of 2008, would among other things, establish a SB 294 Page 5 nine-member Task Force on Nurse Practitioner Scope of Practice (Task Force), with specified membership, to develop a recommended scope of practice for NPs by June 30, 2009, and would require the Director of Consumer Affairs to promulgate regulations, consistent with existing law, that adopt the Task Force's recommended scope of practice by July 1, 2012. ABX1 1 failed passage in the Senate Health Committee. AB 2226 (Spitzer) Chapter 344, Statutes of 2004, requires on and after January 1, 2008, an applicant for initial qualification or certification as a NP to meet specified requirements including possessing a master's degree in nursing, a master's degree in a clinical field related to nursing or graduate degree in nursing and completion of a NP program approved by the BRN. AB 2560 (Montanez) Chapter 205, Statutes of 2004, authorized a NP to furnish drugs or devices whenever it is consistent with their educational preparation or clinical competency. REGISTERED SUPPORT / OPPOSITION : Support California Association of Nurse Practitioners (sponsor) American Federation of State, County and Municipal Employees California Association of Nurse Anesthetists United Nurses Associations of California/Union of Health Care Professionals Opposition None on file. Analysis Prepared by : Ross Warren / B. & P. / (916) 319-3301