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NationalInterstate Council of

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Delegate Assembly Actions. 1994 - Task Force to Study Regulation ... Colorado, Kentucky & New Jersey are members, but not yet implemented. 57 ... – PowerPoint PPT presentation

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Title: NationalInterstate Council of


1
  • National-Interstate Council of
  • State Boards of Cosmetology (NIC)
  • August 26, 2006
  • Portland, Maine

2

Standing the Test of Time
  • Mutual Recognitionand theNurse Licensure Compact

Myra A. Broadway, JD, MS, RN Executive Director,
Maine Board of Nursing
3
The year was 1903
  • World Series had begun
  • Wright Brothers took flight
  • Ford Motor Co. was founded
  • Telephone had been in existence 27yrs
  • Computer would not be invented for
  • another 43yrs (1946)
  • NY, NJ, VA, NC passed the
    first Nurse Practice Acts in US

4
Much has changed . . . except regulation
5
Progression of Regulation
  • Based on the 10th Amendment to
    the U.S. Constitution
  • Legal authority to practice
    confined to the boundaries of the state which
    issued the license
  • Evolved state-by-state to meet the needs of the
    citizens of that state

6
Early Efforts to Regulate Nursing Practice
  • Each state had its own requirements
  • Hospitals trained their own
  • States wrote their own examinations

7
Times Change
  • More mobility
  • Nursing programs more uniform
  • Nursing programs accredited by same
    organization(s)
  • Eventually one test is written to be used
    nationally
  • An arm is an arm is an armWe are more
    alike than we are different

8
Factors Influencing a Re-Look at Licensure (Mid
1990s)
  • Healthcare Delivery System Restructuring
  • Managed care/capitation
  • Movement away from acute care
  • Mergers and acquisitions resulting in large,
    integrated health care delivery systems
  • Emergence of Demand Management Call Centers and
    Telephone Triage

9
Factors (continued)
  • Technological Advances
  • Acceptance of World Wide Web/Internet
  • Telephone
  • Computers
  • Videoconferencing, teleconferencing
  • Advanced electronic diagnostic technologies
  • Robotics

10
Factors (continued)
  • Consumerism
  • Growing expectation for health care information
  • Expectations for information about treatment
    options and inclusions in decisions about their
    own treatment plan
  • PEW Taskforce on Health Care Workforce
    Regulation, 1995 1998

11
Factors (continued)
  • Telecommunications Act of 1996
  • Barrier Report to Congress 1997
  • Changing health care environment
  • New practice setting and technology
  • Necessity of expedient access to qualified nurses

12
Factors (continued)
  • Increased number of nurses practicing across
    state lines
  • Expectation of rapid authorization to practice
  • Qualification for licensure in multiple states
    (cumbersome, costly inefficient)
  • Telenursing
  • Boards of Nursing need authority to regulate
    in-state practice

13
The National Council of State Boards of Nursing
(NCSBN) Definition of Telenursing
  • The practice of nursing over distance, using
    electronic means

14
Telenursing
  • Delivery of patient care by means of
    telecommunication
  • Telephone
  • Facsimile
  • Cellular phones
  • Computers
  • Teleconferencing
  • Videoconferencing

15
Telenursing Differs from Other Telepractice
  • Physician consultation generally involves a
    licensed practitioner in each state
  • Telenursing generally involves the nurse being in
    direct contact with the patient, frequently in
    the patients home or by telecommuni-cative
    means

16
Regulatory Issues
?
  • States right or Interstate Commerce 200 years
    of case law ruled that states have the right to
    protect consumers.
  • Where does practice occur location of provider
    or patient?
  • Does practice by electronic means constitute the
    practice of nursing?

17
Dilemma What model of nurse licensure is best
for the 21st century?
  • Licensure remains state based
  • Practice is not bound by state lines

18
Vision Statement
  • A state nursing license recognized nationally
    and enforced locally

19
Policy Goal
  • Simplify governmental processes
  • Remove regulatory barriers to increase access to
    safe nursing care

20
Delegate Assembly Actions
  • 1994 - Task Force to Study Regulation
  • 1995 - Regulation Task Force charged to consider
    models Telecommunications Task Force authorized
  • 1996 - Study Issue (magnitude of need, impact on
    state regulatory processes)
  • August 1997 - Endorsed Mutual Recognition Model
  • December 1997 (special) - approved Interstate
    Compact

21
Models Considered
  • Reciprocity
  • Fast Endorsement
  • Corporate credentialing (institutional licensure)
  • Ontario Model
  • Mutual Recognition
  • Limited License for Telehealth

22
Solution Mutual RecognitionA state-based
license, nationally recognized locally enforced
  • Multi State Regulation (MSR) Task Force
  • Surveys, interviews, conferences
  • Best model to protect public decrease barriers

23
Basic Concepts of Mutual Recognition
  • Allows nurse to have one license in the state of
    residence and practice in party states
  • Nurse is subject to each states practice laws
    and discipline
  • Practice allowed physically or electronically
  • Each state must enter into interstate compact

24
Panel of Legal Experts
  • Mutual recognition is workable
  • Reflects full faith and credit among U.S.
    jurisdictions
  • Can be implemented incrementally
  • Implementation could begin without uniform
    requirements

25
Why is the individual in the NLC limited to one
license in the home state?
  • The policy decision was made specifically to
    enhance public protection while retaining state
    based authority reducing administrative burdens

26
  • Determining the state of practice would be
    challenging in an era of multiple employers, at
    multiple sites across state lines through
    telenursing

27
  • Tracking a nurse in the event of a complaint is
    better accomplished through residence than the
    employment link

28
Effects of Mutual Recognition
  • Nurses
  • Public
  • Health Care Institutions
  • Government
  • Revenue

29
First Compact Adopted 1783
  • Nurse License Compact (NLC) is one of 200
    compacts
  • Average compacts per state 27
  • NLC Allows for One License in Home State

30
Interstate Compact
  • Formal agreement between 2 or more states to
    remedy a problem or multi-state concern (Blacks
    Law Dictionary)
  • Each state enacts a compact via legislation
  • Mutual recognition of those who enact the
    legislation

31
  • Affords states the opportunity to develop self
    regulatory adaptive structures to meet new
    challenges over time
  • Example - Drivers License Model

32
Examples of Interstate Compacts (IC)
  • Interstate Compact for the Placement of Children
    (1960s)
  • IC for Supervision of Parolees and Probationers
    (1937)
  • IC for Juveniles (developed between 2000 and
    2002) in 35 states
  • Dairy Compacts

33
General Purposes of the Compact
  • Facilitate the states responsibility to protect
    the publics health and safety
  • Ensure and encourage the cooperation of party
    states
  • Facilitate the exchange of information
    between party states

34
Purposes (continued)
  • Promote compliance with the laws governing the
    practice of nursing in each jurisdiction
  • Invest all party states with the authority to
    hold a nurse accountable

35
Nurse Licensure Compact Addresses
  • Jurisdiction
  • Discipline
  • Information Sharing
  • Compact Administration

36
1) Jurisdiction
  • Nurse is licensed in state of residence (home
    state)
  • Nurse may only have one license
  • Nurse is granted the privilege (via the Compact)
    to practice nursing in other party states, i.e.,
    remote states

37
2) Discipline
  • Complaint is filed where violation
    occurs
  • Board takes action on privilege to practice and
    issues an Order
  • State of licensure notified

38
  • Complaints in a party state are processed
    reported to the home state
  • The party state may revoke the privilege issue
    a cease desist order the home state may take
    action against the license
  • The party home state agree on who will
    investigate so the information is taken only once

39
  • The home or remote state(s) may take disciplinary
    action
  • Only the home state can take action on the
    license
  • The remote state (where the violation occurred)
    may take action allowed by the state
  • Any party state can deny authority to practice

40
3) Information Sharing NURSYS
  • A comprehensive information system containing
    data on all nurses
  • Coordinates existing and future nurse databases
  • Used to verify nursing licenses

41
4) Compact Administration
  • Authorizes the formation of the Compact
    Administrators Group
  • A separate body composed of participating state
    board administrators in charge of the states
    compact operations is called the Nurse Licensure
    Compact Administrators, or NLCA
  • Authorizes the development of rules and
    regulations to administer the Compact

42
Current Model
  • Vs
  • Mutual Recognition
  • How do they compare?

43
Initial Licensure
  • Current Model
  • Apply/pay fee to state(s) where expect to
    practice
  • Comply with each states requirements for
    licensure (not uniform)
  • Practice only in state(s) where licensed

44
  • Mutual Recognition
  • Apply and pay fee to home state
  • Comply with home state licensure requirements
  • Practice in any party state

45
Moving to a Party State
  • Both
  • Apply and pay fee to new state
  • Meet requirements for new state
  • Current Model
  • May hold multiple licenses
  • Mutual Recognition
  • Only one license

46
License Renewal
  • Current Model
  • Accountable for each states renewal requirements
  • Renew in every state where license is held
  • Mutual Recognition
  • Accountable for home states renewal
    requirements
  • Renew in home state only

47
Lapse -- Re-Entry -- Reinstate
  • Both
  • Inactive status depends on laws of state
    licensure
  • Current Model
  • Apply to each state, according to states laws
  • Mutual Recognition
  • Apply to home state

48
Discipline
  • Both
  • Action by state where patient was (or where
    incident occurred, if no patient)
  • Standards used are those of disciplinary state
  • Mutual Recognition
  • Licensure action taken only by state of
    licensure
  • Remote state may apply non-licensure penalties,
    such as fines or cease-and-desist orders

49
Advantages of Mutual Recognition to Nurses
  • Pay for one license
  • Practice in any party state without obtaining
    additional license
  • NURSYS facilitates endorsement
  • Eliminates barriers to practice

50
Advantages to Boards
  • Public protection
  • Jurisdiction over all nurses practicing in the
    state
  • Unduplicated count of nurses in the country

51
Major Concerns
  • Sharing investigative information may violate the
    nurses right to privacy
  • Licensure based on state of residence instead of
    state of practice
  • Compact only applies to RNs
    LPNs
  • Strike breakers in collective
  • bargaining states
  • Revenue loss subsequent
  • increase in licensing fees

52
Pros Cons
53
Pros
  • Drives uniform standards
  • Facilitates mobility and lawful practice
  • Facilitates continuity of care for consumers
  • Reduces duplicative regulatory processes
  • Allows state regulatory agencies to reallocate
    resources
  • Discipline
  • Global decision-making

54
Cons
  • Will take time
  • Requires legislation in each participating state
  • State BON rules, regulations and procedures will
    need to change

55
How is the NLC Implemented?
  • When enacted, a compact constitutes not only the
    law, but a contract which may not be amended,
    modified or otherwise altered without the consent
    of all parties. The legislative sponsor may
    need to be reminded that legislation must have
    substantive sameness, be identical or mirror
    the legislation in other states or the compact
    may not be binding or recognized by other states.

56
Implementation
Colorado, Kentucky New Jersey are members, but
not yet implemented
57
Two Words Sum Up What Is Needed to Make the NLC
Work
  • FLEXIBIILTY
  • TRUST

58
Working Together to Enhance Public Safety
  • FLEXIBILITY
  • We are all in this together and solving my
    licensure issue isnt good enough if I dont
    provide you the information you need to act.

59
  • TRUST
  • Nobody does it better

60
Keys to Success
Education Collaboration
61
  • Communication and Collaboration are the keys to
    Compact Implementation success
  • Our successes and challenges are not unique
  • - A new initiative from the Council of State
    Governments
  • - How can we learn from the experience of others?
  • Our policies address communication
  • Strategies for improving communication and
    collaboration

62
Rules Highlights
  • Evidence of state of residence
  • Work up to 30 days after move
  • Limitations on probation
  • Licensee may challenge information

63
Findings of States in the Compact
  • The expanded mobility of nurses the use of
    advanced communication technologies require
    greater coordination cooperation among states
    in the areas of nurse licensure regulation
  • 2) New practice modalities
    technology make compliance with
    individual state nurse licensure laws
    difficult complex

64
  • The current system of duplicative licensure for
    nurse practicing in multiple states is
    cumber-some redundant to both nurses AND states
  • Nurses do not always want to give up the first
    state of licensure need advance education
    notice regarding the change

65
  • The message needs to be framed in many different
    ways for nurses, employers, recruiters ONE
    license for each type and no more is permitted by
    the state of residency

66
  • The legislation to enact the NLC must mirror
    language in all party states. Legislation
    materially different has resulted in states not
    being able to join the NLC In order to join the
    NLC, state legislators must enact the compact
    into state law or regulation.

67
  • What is meant by the multi-state licensure
    privilege? Multi-state licensure privilege means
    the authority to practice in any compact party
    state.
  • Human Resource staff need non technical
    explanations of the compact requirements. HR
    staff also need assistance education on how to
    validate licenses from other states. Some
    mistakenly assumed they did not need to validate
    in the home state declared by the applicant

68
  • What determines primary state of residence?
  • NLC defines primary or home state in the compact
    rules regulations.
  • Sources to verify primary residence may include
    drivers license, state where federal income tax
    is paid voter registration

69
  • Does the NLC reduce states licensure
    disciplinary requirements?
  • Under the NLC, states continue to have complete
    authority in determining licensure requirements
    disciplinary actions based on the states Nurse
    Practice Act
  • The NCLA carefully studied the various licensing
    requirements agreed upon the core requirements
    all party states are to enact

70
  • Does the NLC affect the primary states authority
    to discipline?
  • The NLC actually enhances the states ability to
    discipline through the full disclosure exchange
    of disciplinary investigative information
  • Consider assigning specific investigative staff
    to the NLC complaint cases to gain experience in
    learning how to track, expedite share case
    information

71
  • Case law assists in better understanding how the
    compacts have been interpreted by the courts
    informs the NLCA how to better understand the
    context of the law/contract
  • Examples of Compact Case Law
  • Compacts are not uniform laws but contracts that
    may not be altered without the consent of all
    parties (Nebraska v Cent. Interstate Low Level
    Radioactive Wast Com.)

72
Examples (continued)
  • Compacts are not mere administrative agreements
    but solemn treaties between states (Rhode Island
    v Massachusetts)
  • Compacts are both binding in state law a
    contract between states that no one state can
    unilaterally act in conflict with the terms of
    the compact (McComb v Wambaugh)

73
Compact Development
  • Challenges
  • 1 Educating legislators others
  • 2 Drafting language to mirror other
    states
  • 3 Determining funding needs revenue
    resources
  • 4 Balancing compact jurisdictions with
    member state sovereignty

74
Communication
  • There are obstacles
  • Different Board Structures
  • -- Umbrella vs independent
  • -- Investigations Legal in different
    departments or agencies
  • Identification of key contacts
  • Resources

75
Grassroots Lobbying Efforts
  • Identify Key Stakeholders
  • - BONs
  • - Professionals
  • - Employers (multi-state HMOs, travel agencies)
  • - Nurse executives and recruiters
  • - Organizations and associations
  • -- State nurses associations specialty orgs
  • -- State hospital associations
  • -- Consumer groups (AARP)
  • - Legislators (nurse, healthcare providers)

76
Lobbying Efforts (continued)
  • Educate, educate, educate
  • Widespread informational campaign (include
    advantages and concerns)
  • Identify message(s)
  • --(i.e. efficiency, access, jurisdiction,
    technology)
  • May use different message for different audiences
  • Utilize media contacts

77
Lobbying Efforts (continued)
  • Identify key legislative sponsors
  • Provide testimony (verbal written)
  • Organize letter writing campaigns
  • Organize telephone trees

78
Emerging Issues Future Potential Compacts
  • Criminal Justice Information Sharing would
    allow multi-jurisdictional access to criminal
    justice information
  • Emergency Medical Assistance compact for
    interstate cooperation for medical assistance

79
A New Initiative from the Council of State
Governments
  • Formed the National Center for Interstate
    Compacts
  • - Combines policy research with best practices
  • - Designed to meet the unique needs of Compact
    Administrators
  • - Promotes interstate compacts as an ideal tool
    to meet the demand for cooperative state action
  • Conducted a 2004 Survey of interstate compacts in
    50 states.

80
  • The End!
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