BILL ANALYSIS                                                                                                                                                                                                    

                                                                  SB 294
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          Date of Hearing:   June 30, 2009

                                 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,  


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            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  

             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  


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          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  

          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,  


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          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  


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          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.


          California Association of Nurse Practitioners (sponsor)
          American Federation of State, County and Municipal  
          California Association of Nurse Anesthetists
            United Nurses Associations of California/Union of Health Care  

          None on file.

           Analysis Prepared by  :    Ross Warren / B. & P. / (916) 319-3301