BILL ANALYSIS Ó
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|Hearing Date:August 30 , 2012 |Bill No:SB |
| |122 |
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SENATE COMMITTEE ON BUSINESS, PROFESSIONS
AND ECONOMIC DEVELOPMENT
Senator Curren D. Price, Jr., Chair
Bill No: SB 122Author:Price
As Amended:August 20, 2012 Fiscal:Yes
SUBJECT: Healing arts.
SUMMARY: Makes changes to the requirements for approval of a school
of nursing by the Board of Registered Nursing (BRN) and the licensing
for physicians by the Medical Board of California (MBC) who have
attended foreign medical schools.
NOTE : This bill is a rewrite of this measure as it left the Senate
and has been referred to this Committee pursuant to Rule 29.10 (d)
for consideration. The Committee may by a vote of the majority
either (1) hold the bill, or (2) return the bill to the Senate floor
for consideration of the bill as amended in the Assembly.
Existing law, the Business and Professions Code (BPC):
1) Provides for the regulation of various health professions by
regulatory boards within the Department of Consumer Affairs
(DCA).
2) Establishes the Nursing Practice Act which provides for the
certification and regulation of registered nurses, nurse
practitioners and advanced practice nurses by the BRN within
the DCA.
3) Specifies that an approved school of nursing is one that has been
approved by the BRN, outlines the course of instruction approved by
the BRN including: 1) the course of instruction be at least two
academic years, 2) is affiliated or conducted in connection with
one or more hospitals, and 3) is an institution of higher education
or is affiliated with an institution of higher education. (BPC §
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2786 (a))
4) Defines "institution of higher education" as community colleges
offering an associate of arts or associate of science degree and
private postsecondary institutions offering an associate of arts or
associate of science degree. (BPC § 2786 (a))
5) Requires that a school of nursing that is not an "institution of
higher education, "as defined, shall make an agreement with an
institution of higher education in the same general location to
grant an associate of arts or associate of science degree to
individuals who graduate from the school of nursing or to grant a
baccalaureate degree with successful completion of an additional
course of study as approved by the BRN and the institution. (BPC §
2786 (a))
6) Provides that the BRN shall determine by regulation the required
subjects of instruction in an approved school of nursing and the
amount of clinical experience necessary.
(BPC § 2786 (b))
7) Specifies that it shall be the duty of the BRN, through its
executive officer, to inspect all schools of nursing in this state
at such times as the BRN shall deem necessary, and if it is found
that a school is not maintaining the standard(s) required by the
BRN, then the BRN may request the defects to be corrected, and if
not corrected then the BRN may remove them from the approved list.
(BPC § 2788)
8) Provides that it is unlawful for anyone to conduct a school of
nursing unless the school has been approved as an accredited school
by the BRN, or is exempt as specified.
(BPC §§ 2789, 2798)
9) The Medical Practice Act provides for licensing and regulation of
physicians and surgeons by the MBC. (BPC § 2000)
10)Requires an applicant for a license as a physician or a surgeon to
complete specified medical curriculums, clinical instruction
programs and training programs. (BPC § 2080 et seq.)
11)Authorizes the MBC to determine whether materials submitted as
proof of completing requisite medical education and training by
applicants for a physician and surgeon certificate meet those
requirements. (BPC § 2080)
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12)Provides that the Division of Licensing of the MBC may approve
every Ýmedical] school which substantially complies with the
requirements, as specified, for resident courses of professional
instruction and graduates of medical schools approved shall be
deemed to meet all the minimum curriculum requirements, as
specified. (BPC § 2084)
13)Provides that a graduate of an approved medical school located in
the U.S. or Canada who has graduated from a special medical school
program that does not substantially meet the minimum curriculum
requirements, as specified, may be approved by the Division of
Licensing if the division determines that the applicant has
otherwise received adequate instruction in the appropriate subject
areas, as specified. (BPC § 2085)
14)Requires clinical instruction in subject areas and for a minimum
number of weeks, as specified. (BPC § 2089.5)
15)Requires that before a physician's and surgeon's license may be
issued, an applicant for the license must show that he or she has
satisfactorily completed at least one year of postgraduate
training. (BPC § 2096)
16)Requires that an applicant whose professional instruction was
acquired in a country other than the U.S. or Canada shall provide
evidence satisfactory to the MBC that they have met all of the
requirements of professional instruction and training equivalent to
that required of applicants who received their education and
training in the U.S. or Canada. (BPC § 2102)
17)Provides that nothing prohibits the MBC from disapproving a foreign
medical school or from denying an application of an applicant for
licensure if, in the opinion of the MBC, the professional
instruction received by the applicant is not equivalent to that
required U.S. or Canadian medical schools. (BPC 2102 (e))
Existing law, the Education Code (EC):
1)Establishes the Bureau of Private Postsecondary Education (BPPE)
within the Department of Consumer Affairs (DCA) and provides for
Bureau oversight and regulation of California private postsecondary
institutions pursuant to the Private Postsecondary Education Act of
2009 (PPE Act), including a school of nursing that is not accredited
by accrediting agencies affiliated with the Western Association of
Schools and Colleges (WASC) or regional accrediting agencies
recognized by the United States Department of Education. (EC §
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94820)
2)Establishes numerous unfair business practices for institutions
covered by the PPE Act, including prohibiting an institution from
promising employment or otherwise overstating the availability of
jobs or making untrue or misleading statements regarding student
completion, placement or expected salary rates. (EC § 94897)
3)Sets forth certain disclosure requirements pertaining to completion,
placement, licensure, and earning potential. (EC § 94910)
This bill:
1) Subjects a school of nursing or a new nursing program seeking
approval by the BRN to the following fee schedule:
a) A fee of $5,000 for approval of a nursing program.
b) A fee of $3,500 for continuing approval of a nursing
program established after January 1, 2013.
c) A fee of $500 for processing authorization of a
substantive change to an approval of a school of nursing.
2) Deletes provisions requiring a school of nursing that is not
affiliated with an institution of higher education to make an
agreement with such an institution for purposes of awarding nursing
degrees and instead authorizes the BRN to grant approval to these
institutions to grant nursing degrees.
3) Requires the BRN to issue a cease and desist order to a school of
nursing not approved by the BRN and to notify the Bureau for
Private Postsecondary Education (Bureau) and the Attorney General
of such a school. Makes it unprofessional conduct for any
registered nurse (RN) to violate or attempt to violate or to assist
or abet the violation of this provision.
4) Requires meetings of the BRN to be held in northern and southern
California.
5) Requires the BRN to have a memorandum of understanding with the
Bureau to delineate the powers of the BRN and the Bureau as related
to schools of nursing and the powers of the Bureau to protect the
interest of students attending institutions governed by the PPE
Act.
6) Authorizes the MBC to determine that an applicant is eligible for a
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physician and surgeon's certificate if they attended a foreign
medical school that is not recognized or has been previously
disapproved by the Board if the applicant meets the following
requirements and authorizes the Board to adopt regulations, as
specified, for implementing this authority:
a) Successfully completed a resident course of medical
education leading to a degree of medical doctor equivalent
to that specified under current law, as specified;
b) Holds an unlimited and unrestricted license as a
physician and surgeon in another state or federal territory
and continuously practiced for at least 10 years, as
specified, if the applicant acquired any of his or her
education from an unrecognized foreign medical school;
c) Holds an unlimited and unrestricted license as a
physician and surgeon in another state or federal territory
and continuously practiced for at least 20 years, as
specified, if the applicant acquired any of his or her
education from a foreign medical school previously
disapproved by the Board;
d) Is certified by a specialty board that is a member
of the American Board of Medical Specialties;
e) Successfully passed specified examinations for
licensure as a physician and surgeon;
f) Has not been the subject of a disciplinary action by
a medical licensing authority or of adverse judgments or
settlements, as specified;
g) Successfully completed three years of approved
postgraduate training, as specified;
h) Is not subject to denial of licensure, as specified;
i) Has not held a healing arts license and been the
subject of disciplinary action by a healing arts board by
any state or federal territory.
7) Prohibits specified persons from seeking licensure pursuant to Item
# 6) above, if they are seeking to participate in programs as
specified or seeking to engage in postgraduate training in this
state.
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FISCAL EFFECT: According to the Assembly Appropriations Committee
analysis, dated August 20, 2012:
1)One-time information technology costs of $10,000 to the BRN to begin
collecting nursing program approval and renewal fee revenue.
Increased workload related to approval and regulation of nursing
schools of $100,000 annually, offset by increased revenue in the
same amount to the BRN special fund.
2)Potential increased staff costs to the Department of Justice of
$80,000 (charged to the BRN special fund) for approximately 0.5
Deputy Attorneys General to enforce or defend the BRN's ability to
issue cease and desist letters. These costs can vary depending upon
the number and complexity of cases.
COMMENTS:
1.Purpose. This measure is sponsored by the Author. According to the
Author, the changes to the BRN's nursing school approval process are
a result of the Oversight Hearing conducted by the Senate Business
Professions and Economic Development Committee (BP&ED) in March of
2011. The Author and the BRN believe that the following changes
will provide improvements to the BRN's nursing school approval
process by: 1) Granting complete authority over the approval of
nursing schools to the BRN rather than requiring a duplicative
process under the Bureau of Private Postsecondary Education (BPPE),
and to offset costs of the BRN in both approving and regulating
nursing schools; and 2) Providing the BRN with the ability to issue
a cease and desist order to a school of nursing which has not been
approved (or has been disapproved) by the BRN and requiring the BRN
to inform the Attorney General of a school which continues to
operate illegally. The measure will also make some other clarifying
and technical changes regarding the nursing school approval process
and to meetings of the BRN.
As to the changes to the physician licensing provisions for the MBC,
the Author indicates that it recently came to his attention that
physicians who have been practicing in other states in good standing
for many years are being refused a license to practice in California
because the foreign medical school they attended has not been
recognized by the MBC, even though it may have been recognized in
another state. The Author believes that the MBC should at least be
able to have the discretion to review the practice and other
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qualifications of the physician and surgeon who has been practicing
in another state, and make a determination whether they are
competent to practice within California even though they may have
attended a foreign medical school that is currently not on the
approved list of medical schools of the MBC. Current law does not
permit the MBC to make such a determination. There are other health
related boards which have the discretion to make a determination
about licensing of out-of-state practitioners about whether they
should practice in California, regardless of whether or not the
school they attended has been approved or accredited. This includes
the Board of Behavioral Sciences, the Psychology Board, the
Speech-Language Pathology and Audiology Board and the Veterinary
Medicine Board. With the potential shortage of physicians and
surgeons in this state and the advent of National Health Care
Reform, this will provide greater reciprocity for physicians to
practice in California. Out-of-state physicians will be reviewed
for licensure based on their 10-year or more history as a medical
practitioner as well as their education and training and in meeting
the other requirements to practice in this state. Their application
for a physician and surgeon's license will not be rejected solely
because the foreign medical school does not appear on the Board's
approved list of schools.
2.Background.
a) Approval of Nursing School Programs. Approval of
pre-licensure nursing programs is an integral component of the
BRN's operation. The purpose of approval is to ensure the
program's compliance with statutory and regulatory requirements.
Approval of advanced practice nursing (i.e., nurse practitioner
and nurse-midwifery) programs is voluntary and at the request of
the program. BRN approval of advanced practice programs is
advantageous to program graduates because it facilitates their
obtaining BRN certification as a nurse practitioner or
nurse-midwife. Currently, there are 148 approved pre-licensure
nursing programs and 26 approved advanced practice nursing
programs, as follows:
Pre-licensure Programs
90 associate degree (ADN)
39 baccalaureate degree programs (BSN)
19 entry-level master's degree programs (ELM)
110 Public Programs
38 Private Programs
Advanced Practice Nursing Programs
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22 nurse practitioner programs
4 nurse-midwifery programs
The approval process begins with a Letter of Intent from the
school or institution of higher education which is trying to
establish and offer a nursing program and must be submitted at
least one year in advance of the anticipated date for admission
of students. After a Letter of Intent is submitted, the
applicant must then submit a Feasibility Study to the BRN
documenting the need for the program and the program applicant's
ability to develop, implement, and sustain a viable pre-licensure
RN program. The feasibility study is rather extensive and
usually requires the applicant to seek the assistance of a
consultant familiar with providing the information needed by the
BRN in determining the feasibility of the program. Once the
feasibility study is accepted by the BRN, the program applicant
must then appoint a Program Director. The Program Director will
have responsibility for preparing a Self-Study for the proposed
program and coordinate any site visits by the BRN. The
Self-Study describes how the proposed program plans to comply
with all BRN nursing program related rules and regulations. The
BRN will assign a Nursing Education Consultant (NEC) who verifies
that the Self-Study satisfactorily addresses the rules and
regulations regarding a nursing program, and will also make
on-site visits where the program will be maintained and the
selected clinical sites. Once the Self-Study is completed, the
NEC will then complete a report to be submitted to the BRN and
recommend that the BRN either grant or deny approval, or defer
action to grant the program additional time to resolve areas of
non-compliance. Once the program is approved by the BRN, it
receives a certificate of approval.
An applicant of a private postsecondary school or program must
then go through a secondary process that requires approval from
the Bureau of Private Postsecondary Education (BPPE) if they are
not accredited by the Western Association of Schools and Colleges
(WASC) or by a regional accreditor. This approval process can
also take some time to complete and it is not clear what
advantage it provides in performing similar requirements for
feasibility and self-study which are already required by the BRN.
(It should be noted that currently both the Medical Board of
California and the Dental Board are the only agencies that
respectively approve either medical schools or dental schools in
California, as well as other states and in foreign countries).
The BRN indicated that the average length of time from beginning
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to completing the initial BRN approval process is about 18
months, but there have been instances in which this approval
process has taken almost four to five years for particular
programs, especially if they are private postsecondary schools.
Data has shown that these schools are a growing sector in the
training of health care workers. From 2001 to 2009, the
percentage of nursing degrees awarded by private postsecondary
schools throughout the U.S. grew from 4 % to 11 % of the national
total, while nursing awards from public colleges shrank from 78
to 70%. In California, the share of public nursing programs has
decreased from its high of 85.6% to its current share of 76.1%.
Private programs in California grew from just 14 programs in
2001, to now over 38 in 2010. Also, student enrollment grew from
951 students in 2001, to 4,607 in 2010. It is anticipated that
this growth of private nursing programs will continue,
particularly in California.
a) Approval of Medical Schools. The MBC's long-standing statutes
and regulations govern the approval of medical schools, including
international medical schools, by the MBC. The MBC's medical
school approval process is a thorough and rigorous assessment of
an institution's competency in meeting California's statutory and
regulatory requirements for the education and training of medical
doctors. These requirements were designed to ensure the
integrity of the profession and protect the consumers of health
care services.
Specific statutory requirements apply to international Ýforeign]
medical schools. A school that applies to the MBC for approval
must complete and submit a self-assessment report including
information about the institution's mission and objectives,
organizational structure, curriculum, governance, faculty,
admissions and promotion standards, financial resources,
facilities, medical students, records, branch campuses, and
affiliation agreements. The MBC may request follow-up
information and may require a site visit before approving or
disapproving a medical school, which is a lengthy and
labor-intensive process. A school that has been neither approved
nor disapproved is considered unrecognized.
Even with the MBC's robust review process, hundreds of approved
medical schools are listed on the MBC's website in dozens of
countries. Only 10 disapproved schools are listed, the last of
which was disapproved in 2007. There are 19 states which
recognize the same medical schools as the MBC, but 31 states
which may recognize medical schools which are not recognized by
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the MBC. Approximately 75 medical schools are undergoing the
MBC's medical school approval process, and the MBC has approved
about 10 or 12 schools in the past nine months. However, there
are approximately 1400-1600 foreign medical schools that are
currently unrecognized by the MBC for various reasons. The MBC
indicates that because of workload and staffing issues there is
currently a backlog of foreign medical schools to be reviewed by
the MBC.
1.This Committee's Recommendations Regarding the BRN's Nursing School
Approval Process and Oversight of Approved Schools. It was
indicated in this Committee's Report in 2011, that the involvement
of the BPPE in the approval of nursing school programs seems
unnecessary and therefore the BRN should assume all responsibility
regarding approval of these programs. In doing so, the BRN should
be given authority to charge an appropriate fee to cover their costs
for reviewing documents, consulting with the program and conducting
site visits. This fee should be similar to fees currently assessed
by the BPPE for approval of school programs. Current student
protections provided under the Act will continue to apply to those
nursing programs which are currently approved by BPPE and the BRN
would now assume the responsibility of responding to student
complaints regarding a nursing program.
According to the Committee's Report, it was also found that the
efforts of the BRN to only inform students of "unaccredited"
programs may not be sufficient. In 2010, there was a nursing
program that continued to operate for over two years, even though
the BRN did not grant approval and in 2007 had ordered the school to
close. As many as 300 students paid $20,000 each to enroll and
attend classes at this school, some attending for over two years.
If potential students had checked the BRN Website they would not
have found this school listed as an approved program, but sadly many
potential students do not know that the BRN provides this
information and warning. The AG was able to assure that the
institution was finally shut down and reached a settlement agreement
with the owner and operators of the school for $500,000 as
restitution to the former students. According to the then AG,
Edmund G. Brown, Jr., this sham nursing school created "the illusion
it was training future nurses by pretending to offer an accredited
nursing program and tricking graduates into believing they had
qualified to become nurses."
The Committee Report indicated that something must be done to assure
that once the BRN has decided that a program should not operate in
California, that school does not then find a way to open its doors
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to students who ultimately spend two to three years of their lives
in a school they think will qualify them to be a nurse, which sadly
will not. Better communication between the BRN and the AG's Office
and the BRN revisiting the school site may be an option. It was
recommended that the BRN must work more closely with the AG's Office
and perform site visits to assure that a nursing program which is
not approved does not continue to operate in California. There must
be a requirement for it to cease and desist operation and there must
be an IMMEDIATE shut down of this program if it continues to operate
so that students are not ultimately deceived and waste precious
years of their lives attending a phony program.
2.Measure Reflects the MBC's Recommended Language for Licensure of
Out-of-State Physicians Who Attended Unrecognized Foreign Medical
Schools. The MBC currently has authority to review certain
applicants for a physician and surgeon license that have not met all
of the specified requirements for licensure if they have been
licensed in another state for a period of time and are board
certified in a specialty. However, all of these applicants have
graduated from a school that is recognized by the MBC. The MBC
recommended some additional consumer protection elements due to the
fact that the applicants who could seek licensure under this new
pathway attended or graduated from an unrecognized or disapproved
school. The language proposed by the MBC included in this measure
takes into consideration that other states do use the recognized
list of medical schools of the MBC and that the MBC will only be
considering individuals who have been licensed for a considerable
length of time. The language requires that the education be
obtained from a resident course of instruction. It allows the
applicant who has attended an unrecognized school or graduated from
an unrecognized school, to apply after 10 years of licensed practice
in another state as long as conditions of specialty board
certification, exams, and no/discipline/adverse actions have been
achieved. The MBC selected 10 years as the acceptable time for this
type of applicant, as the MBC has not reviewed the medical school,
but has some reason to believe, by virtue of the applicant being
licensed by another state for 10 years and having met the additional
requirements, that public protection can be served. On the other
hand, the MBC proposed an increased number of years of practice and
performance (20 years) if the applicant has attended or graduated
from a disapproved school.
3.Related Legislation. SB 538 (Price) of 2011extended the sunset date
of the BRN and made a number of changes to the BRN's authority and
operations and to the Nursing Practice Act, including provisions
substantially similar to the provisions of this bill. This bill was
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vetoed by the Governor for reasons unrelated to these provisions.
4.Arguments in Support. The BRN is in support of this measure and
feels that the provisions in this bill are very important for the
implementation and approval of educational programs. The BRN states
that it is imperative to provide for cease and desist orders in
order to protect the public from fraudulent nursing programs
operating in California.
The MBC is in support of this measure and feels that the requirements
in this bill that apply to individuals that graduated or attended
unrecognized or disapproved schools, are substantial enough to
ensure consumer protection. "Allowing individuals that meet the
requirements in this bill to be eligible for physician and surgeon
licensure in California will provide another licensure pathway to
allow competent physicians to obtain a California license and serve
patients in California."
SUPPORT AND OPPOSITION:
Support:
American Nurses Association/California
Board of Registered Nursing
Medical Board of California
Opposition:
None on File as of August 28, 2012.
Consultant:Bill Gage