1. Maryland Regulatory and Legislative Update: Past and Present Michelle Hayes Duell, CRNA, DNP MANA spring meeting March 2015 1

2. Objectives  Awareness of Nurse Anesthesia regulations in Maryland  Appreciate the history and changes of the regulations  Acknowledge past & present legislation impacting Nurse Anesthesia regulations  Compare current Maryland regulations to those regulations in other states 2

3. Overview  CRNA Regulations  History  Changes  Collaboration Agreement  Advanced Practice Nursing Initiatives  “The Future of Nursing” 2010 IOM Report  Recent Legislative History  Anesthesiology Assistant Bill  Physician Assistant Bill  Nurse Practitioner Bill 3

4. Regulations  Advanced Practice Nurses in Maryland  CRNAs (730)  Advanced Practice Registered Nurse/Psychiatric Mental Health ( APRN/PMH)  Certified Nurse midwives (243)  Nurse Practitioners (5,200)  (New) CNS - October 2014 4

5. Regulations  In 2002, an Advanced Practice Nurse was placed on Maryland Board of Nursing  Specialty Changes  CRNAs were first (John Bing)  APRN/PMH (Susan Krause)  Midwife is up next… 5

6. CRNA Regulations  History  Established December 1, 1979  COMAR (Title 10 Chapter 06) of the Maryland Nurse Practice Act  Regulations Available Online  Regulate our practice  Collaboration Agreement Required  Now referred to as an “Attestation” 6

7. CRNA Regulations  Three changes documented  2000 terminology was changed which allowed for scope of practice to be listed separately  2006 agreement not necessary before obtaining license  2007 Master’s degree requirement and grandfathering of CRNAs prior to January 1, 2008 7

8. Maryland CRNA Regulations 8 Regulation “A CRNA may not practice in this state until the CRNA has notified the Board of the name and license number of the collaborating physician or dentist.” 27.06.02 (c) p. 1592

9. Maryland CRNA Regulations 9 Collaboration “The development and implementation of an agreement between a nurse anesthetist and an anesthesiologist, licensed physician, or dentist concerning the practice of nurse anesthesia.” 27.06.02 (c) p. 1592

10. CRNA Regulations  Collaboration Agreement issue .02 Certification. A. A n applicant for certification as a CRNA shall.. B. If the applicant's nurse anesthetist program was completed after January 1, 2008…program with a master's degree or higher. C. A CRNA may not practice in this State until the CRNA has notified the Board of the name and license number of the collaborating physician or dentist. D. The Board shall forward the name and license number of the collaborating physician or dentist to the appropriate regulatory board. 10

11. Old Agreement 11

12. NEW Notification 12

13. Attestation  UPDATED NOTIFICATION OF COLLABORATION  The Code of Maryland Regulations (COMAR) 10.27.06.02 C. requires that Certified Registered Nurse Anesthetists (CRNAs) provide the Maryland Board of Nursing (MBON) a notification of collaboration. The notification shall include the name of ONE collaborating physician or dentist. Additional notices for specific work sites are not required.  Collaborator most recently named will be the physician or dentist collaborator of record.  If you currently have more than one collaborator on file, please notify the board as soon as possible to indicate which ONE collaborator of record you wish to maintain. Please call (410) 585-1926 or email quandra.horton@maryland.gov quandra.horton@maryland.gov 13

14. Written Requirements by State The states in red have some form of written requirement in their agreement. 14

15. CRNA Regulations  Take C and D away under certification? .02 Certification… C. A CRNA may not practice in this State until the CRNA has notified the Board of the name and license number of the collaborating physician or dentist. D. The Board shall forward the name and license number of the collaborating physician or dentist to the appropriate regulatory board.  Clarify definition of collaboration?  Add Podiatrists 15

16. CRNA Regulations  Peer Advisory Committee  CRNA members 08 CRNA Peer Review/Advisory Committee. A. The Board shall appoint at least four CRNAs to act as the Board's advisory committee. B. The Committee shall: (1) Meet at least four times a year; (2) Report at least annually on its overall activities; and (3) Function at the Board's direction and provide the Board with expert advice related to the practice of nurse anesthesia. C. Members of the Committee shall be appointed for a 4- year term and may be reappointed for one additional 4- year term. 16

17. The Institute of Medicine Report 2010 17

18. 18 The 2010 IOM Report 1.Remove scope of practice barriers 2.Expand opportunities for nurses to lead in collaborative efforts 3.Implement nurse residency pro 4.Increase the proportion of nurses with a baccalaureate degree to 80% by 2020 5.Double the number of nurses with a doctorate by 2020 6.Ensure that nurses engage in lifelong learning 7.Prepare and enable nurses to lead change to advance health 8.Build an infrastructure for the collection and analysis of inter-professional health care workforce data

19. The 2010 IOM Report  Remove Scope of Practice Barriers  Conform to National Council of State Boards of Nursing (NCSBN) Model Nursing Practice Act  Fee for Service and reimbursement Arrangements  Hospital participation requirements  Restrictive state regulations should be amended 19

20. 20 Legislative History

21. Anesthesiologist Assistant Legislation  We hear “through the grapevine”, Johns Hopkins Hospital may put forth legislation for AA’s to practice.  Early fall 2008 this “talk” starts  MANA begins preparing for legislation to be filed in the upcoming session.  Fall fundraisers are attended.  MANA holds a fundraiser for HGO Chair Pete Hammen 21

22. Anesthesiologist Assistant Legislation  Johns Hopkins Hospital chief anesthesiologist is spearheading the legislative effort.  MANA lobbyist requests a meeting with him in December to discuss this proposed idea one-on-one.  Meeting December 16, 2008 22

23. Anesthesiologist Assistant Legislation  JHH sited decreased manpower as the reason for initiating an AA program.  MANA supported a study to be done to evaluate the staffing shortages  University of Maryland SON NAP offers site specific students to alleviate “shortage”  Waited…and waited…and waited… 23

24. Anesthesiologist Assistant Legislation  A company that specializes in grassroots was hired to put together letters and packets to be mailed to CRNAS  A automated phone service was initiated prompting CRNAs to call their legislators  Groups of CRNAs were organized for multiple days each week to make visits to both house and senate  These CRNAs were educated on what needed to be said  Buy in from influential parties was attempted: MNA, MBON, BOM  Those CRNAs that would speak for all CRNAs in Maryland during the hearing were selected  Recruiting as many CRNAs as possible to be present during the hearing to show support 24

25. Anesthesiologist Assistant Legislation  Senate bill was introduced first by Senator Conway (SB 798)  Remind you that Senator Andy Harris sat on the Senate committee this bill was assigned to.  Lobbying and grassroots efforts began 25

26. Anesthesiologist Assistant Legislation  Senate Hearing-March 13, 2009  Large support presence from CRNAs  Met resistance from Senator Harris  AA’s testified about their practice  Maryland PA/AA stayed completely neutral  BOM testified they could not regulate another group of providers 26

27. Anesthesiologist Assistant Legislation  Senate Chair stated that discussion was required for the bill and that it would be sent to summer study.  Within a hour of Senate hearing finishing, Chair of the House committee called MANA lobbyist and informed him that the sponsor of the HGO bill had respectfully pulled his bill! 27

28. Physician Assistant Legislation  PA legislation surfaced in the 2010 legislative session  This is an example of a bill that inadvertently has consequences not planned. 28

29. Physician Assistant  Overall, I feel this legislation was a “lose” situation for CRNAs  However, the best case scenario was obtained 29

30. Physician Assistant 10.32.03.06.06 Delegation Agreements — Approval. B. Core Duties. (1) Upon receipt of a delegation agreement at the Board of Physicians, a physician may delegate and a physician assistant may perform delegated core medical acts. (2) The Board shall notify the primary supervising physician and the physician assistant of the Board’s receipt of the delegation agreement. C. General Anesthesia and Neuroaxial Anesthesia. (1) Regardless of setting or other factors, a supervising physician may not delegate and a physician assistant may not perform general anesthesia or neuroaxial anesthesia before the Board has approved the delegation. (2) The Board shall provide written notification of approval or disapproval of the delegation under §C(1) of this regulation. 30

31. Certified Nurse Midwives  Collaborative plan was eliminated September 2014 31

32. NP Legislation  2010 NP Bill  Practice authority under Board of Nursing only  Attestation verses multiple page agreement  Regulation, but also statute  2015 proposed legislation  Remove attestation requirement  HB999 and SB723 32

33. 33 Questions?