2013 Legislative, Regulatory and Policy Update

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By Kelly M. Pyrek

Advocacy

Essential to the viability of infection prevention and control efforts is advocacy work undertaken by healthcare professionals. Whether grassroots or association-driven, forming and maintaining solid relationships with representatives in local and state government is critical to advancing the healthcare-associated infection HAI prevention agenda. We look at the efforts of three associations to further the causes that uphold patient safety.

IAHCSMM Advocates for Certification of Sterile Processing and Central Service Technicians

One of the legislative priorities of the International Association of Healthcare Central Service Materiel Management (IAHCSMM) is maintaining that every patient deserves to have a certified central service technician reprocessing his/her instruments, as well as actively promoting laws and regulations to ensure certification of central sterile supply personnel at the state level.

In its model legislation, IAHCSMM is asking that individuals who work as a central service technician in a healthcare facility should not be employed unless the person either 1) holds and maintains the Certified Registered Central Service Technician (CRCST) credential; or 2) provides evidence that the person was employed or otherwise contracted for the services as a central service technician in a healthcare facility on or in the two years immediately prior to the designated effective date; or 3) is a student or intern performing the functions of a central service technician if the student or intern is under the direct supervision of an appropriately licensed or certified healthcare professional and is functioning within the scope of the student or intern’s training. IAHCSMM says that a central service technician who does not meet these requirements has 12 months from the date of hire to obtain the Certified Registered Central Service Technician credential or the Certified Sterile Processing and Distribution Technician credential. In addition, the technician must annually complete 10 hours of continuing education to remain qualified to function as a central service technician.

While it was pushing hard for this model legislation in a number of states in 2012, IAHCSMM was focusing a tremendous amount of resources and attention on New York; however, the New York governor vetoed IAHCSMM's CS certification bill on Oct. 3, 2012, as well as vetoed the surgical technologists’ certification bill, according to Josephine Colacci, IAHCSMM's government affairs director. 

In June 2012, IAHCSMM's bill passed unanimously out of the Assembly and Senate. "We had no opposition from other organizations," said Colacci in a recent statement to IAHCSMM members. "Moreover, we received letters of support from CBSPD, AST, AORN, NY State Nurses Association, NY Chapter of the American College of Surgeons, APIC, and SEIU/1199. We even obtained a neutral letter from the New York Hospital Association. Our members, APIC members, and SEIU/1199 members sent an overwhelming number of letters and phone calls to the governor’s office to support our bill. After all of this, the governor vetoed it."

The governor issued a combined veto memo to IAHCSMM's bill, the surgical technologist bill, and a bill that would have certified the nurse anesthetists; the language from the veto memo: "All of the above bills seek, in one way or another, to govern the practice of certain 'professions' in the healthcare field. However, the bills fail to clearly address critical issues, such as scope of practice, supervision, and the oversight of role and regulatory jurisdiction of the affected agencies, namely the State Education Department and Department of Health. These omissions create a risk of inconsistent standards and confusion to consumers. The administration will work with the sponsors to address these issues of public concern, but for the above-mentioned reasons I cannot approve these bills."

As Colacci said in the statement to the IAHCSMM membership, "I cannot thank our members in New York enough for their time and dedication to this issue. We will prevail! Sometimes, it just doesn’t happen on the time frame that we want."

AORN Champions RN Circulator Legislation

Based on recommendations from the National Legislative Committee and the president-elect, each year the Association of periOperative Registered Nurses (AORN) board of directors establishes legislative priorities for its government affairs department to pursue in legislative and regulatory arenas nationwide. Going into 2013, ensuring that there is a perioperative registered nurse in the role of circulator in every operating room is AORN's top legislative priority, says Amy Hader, JD, AORN's director of government affairs.

"Making sure that there is an RN circulator in every room for every patient for the duration of the surgery has been our national priority and will stay the same going into the new year," Hader emphasizes. "We saw a few bills pass in the last few years but we still have 27 states with either no protection or weak protection for surgery patients that don't mandate an RN circulator be with each patient for the duration of the procedure. The OR is a very busy place and these are the people responsible for everything in the OR. We're not giving up on this and we are making encouraging progress. We tend to focus on two to three states per year with grassroots engagement of legislators."

In its RN Circulator Legislative Policy Statement, AORN asserts that "it is the right of the patient to receive the highest quality nursing care. No other person is more knowledgeable or qualified to handle the multiple critical issues surrounding patient safety in the operating room than the registered nurse (RN) who is specifically trained in perioperative nursing. The perioperative RN, through professional and patient-centered expertise, is the primary patient advocate in the operating room and is responsible for monitoring all aspects of the patient’s condition. The presence of the RN in the circulating role throughout each surgical procedure is essential for timely delivery of quality surgical care and optimal patient outcomes." The statement adds further, "One perioperative RN is dedicated to the patient during that patient’s entire intraoperative experience. During surgery, most patients are anesthetized or sedated and are powerless to make decisions on their own behalf. By employing critical thinking, assessment, diagnosing, outcome identification, planning, and evaluation skills, RN circulators direct the nursing care and coordinate activities of the surgical team for the benefit of the patient, whose protective reflexes or self-care abilities are compromised by the procedure. These critical nursing functions of the RN circulator are not delegable in the operating room."

According to AORN, at least 23 states have laws or regulations in place that are specific to having a registered nurse serve as the circulator in hospitals, and there are 16 states with similar language for ambulatory surgery centers. Many state boards of nursing and the Center for Medicare & Medicaid Services affirm through public directives, advisory opinions, practice guidelines, or regulations that the circulating role belongs to the perioperative RN.

As the RN Circulator Legislative Policy Statement notes, "The role of the RN in the perioperative setting is vital to the provision of optimal and safe patient care. The perioperative RN is the healthcare practitioner with the knowledge, training, and skills to successfully perform circulating duties in the surgical setting. Using sound nursing judgment, critical thinking skills, and interpersonal communication skills, the RN circulator is able to assess and evaluate individual patient needs and to ensure positive patient outcomes. To ensure that patients receive the highest quality and standard of nursing care, it is essential that there is a perioperative registered professional nurse in the role of the circulator throughout every operative or invasive procedure."

"Everyone agrees that having an RN as circulator is a best practice, but the disagreement seems to come in on whether there is a necessity for legislation or regulation on the topic, and the opposition varies by state," Hader says. "What we are hearing is a disagreement on need for legislation protecting a practice that everyone agrees is best. Our answer to that is, we think it's a best practice and to our knowledge everyone is staffing with an RN circulator  but as cost pressures keep hitting hospitals, we don't want any departure from that high standard happening in hospitals today. So we view legislation as a safeguard going into the future."  

Hader says that infection preventionists can partner with perioperative nurses to not only champion patient safety and infection control, but to help advocate for RN circulator legislation.

"The circulating nurses are responsible for a lot before, during and after the procedures -- one of those jobs is maintaining infection control throughout the surgery, so I see room for infection preventionists to work with perioperative nurses and with AORN to promote safety and optimal outcomes for all surgery patients," she says. We all want the same thing. We work hard to empower nurses to feel confident to be advocates not just for their profession, but for their patients. Nurses are the voices of the surgery patients. The surgical team, in collaboration with all healthcare providers, is important for safeguarding patient safety. In a state without an RN circulator law, nursing and infection prevention staff can work together to create a hospital policy that requires an RN circulator to be with every patient in every room for the duration of the surgical procedure."

APIC Unveils State Advocacy Toolkit

In October 2012, the Association for Professionals in Infection Control and Epidemiology (APIC) unveiled its Voice for Infection Prevention (VIP) Advocacy Toolkit as a guide for infection preventionists' visits with  their state legislators.

In a foreword to the toolkit, Nancy Hailpern, APIC's director of regulatory affairs, and Lisa Tomlinson, APIC's senior director of government affairs, explain, "As the amount of legislation and regulation governing the practice of infection prevention increases, it becomes more important for policymakers to hear from experts to help guide them through the intricacies of the profession and provide advice on evidence-based practices that lead to increased patient safety without overburdening providers. Infection preventionists are ideally suited to provide this information to state policymakers. However, the idea of visiting legislators can be intimidating. The Voice for Infection Prevention (VIP) Advocacy Toolkit: a Guide for Visits to State Legislators is a multi-component toolkit designed to facilitate planning for visits to state legislators by APIC chapters. We hope that your chapter will consider planning visits with your state legislators. Since many legislators may not be familiar with your profession, a good place to start would be a 'meet and greet' visit to provide basic information about APIC and infection prevention, so that if the issue does arise in the legislature, legislators will have the names of experts to contact for additional information."

The toolkit was borne out of the experiences of two members of APIC Chapter 73 (Greater St. Louis) during the planning and execution of a legislative day -- Cassandra Landholt, epidemiology technician at Barnes-Jewish Hospital, and Jeanne Yegge, RN, BSN, MPH, CIC, infection prevention consultant at BJC Learning Institute.

"The advocacy day was the idea of our chapter's legislative representative Jeanne Yegge," explains Landholt. "I was excited to get involved because I hadn't met our state legislators yet. We wanted to get our names and faces out there, and determine the level of infection prevention knowledge that our state legislators had, as well as to see if they were aware of APIC, what we needed to educate them about, and lay the groundwork for interactions to come." Landholt adds, "We met face to face with the chairs and vice chairs of the healthcare committee, and  with so many of them being clinicians, they were very aware of APIC and of healthcare-associated infections. In fact, one of them we met with helped write the HAI Action Plan, so it was good to know they had that framework. We kept our conversation basic, focusing on what APIC is, who infections preventionists are and what we do -- the essential groundwork to ensure we are all on the same page."

The toolkit provides checklists designed to take the guesswork out of a legislative visit, covering purpose, planning and logistics, as well as helpful hints for effective follow-up with legislators and their staff. The toolkit also suggests a number of talking points for legislative visits, such as the scope of HAIs, the work in which infection preventionists engage daily, and ways to partner for the future.  Additionally, the toolkit contains sample brochures as well as templates for appointment request letters, follow-up letters, and "sorry we missed you" letters for legislators.

First-time jitters can be calmed with a little preparation, Landholt says. "I had never done any kind of advocacy day work previous to my visit to the state capitol, but Jeanne Yegge was with me and her level of prior legislative-visit experience was comforting. Planning is critical to the success of a legislative visit. If you are not prepared, with certain conversations in mind, you could easily become overwhelmed in a place like a state capitol. I had to learn where to start and what to think about, and planning is essential."

Infection preventionists may be concerned about the time required for advocacy work, but Landholt says it's a matter of "divide and conquer." She adds, "If you can gain the support of your chapter and get everyone to pitch in an hour or two, that would make the planning easier and quicker for everyone involved. In terms of balancing workload, we have a lot of support from our managers and use small bits of our work time. mostly an hour after work here and there -- probably 18 to 20 hours for planning and we each took the day off from work for the actual advocacy day. We are very fortunate that in St. Louis, most of the hospitals have the support from upper management to promote infection prevention and have face time with legislators and other venues for advocacy."

"We're very excited about how the Voice for Infection Prevention (VIP) Advocacy Toolkit can help our members," says Hailpern. "We're hoping it will encourage our chapters to conduct state-level advocacy similar to what the St. Louis chapter is doing, without having to be afraid of what to do or how to get started. We also hope APIC members will use it as a starting point and they will call us for more information so we can help them with their advocacy efforts. And as more chapters start conducting advocacy work, we anticipate they will report back on what they have experienced so that others will see that it's not such a daunting thing to do. Maybe chapters can even meet with legislators as a get-to-know-you endeavor instead of lobbying on a particular issue of piece of legislation. The more they do advocacy work and see that other chapters are doing it too, it might seem less intimidating."

Hailpern says she recently made a presentation to a quarterly meeting of the California APIC Coordinating Council, an intrastate group comprised of 12 APIC chapters in that state, explaining the toolkit and advising how it can be used in the council's advocacy efforts. 

"It's good to know our experiences, through the creation of the toolkit, are  benefitting others," says Landholt. "We are looking forward to hearing about other infection preventionists' experiences with their advocacy work and their interaction with their legislators."

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