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

Maryland Regulatoryand

Legislative Update: Past and Present

Michelle Hayes Duell, CRNA, DNPMANA spring meeting

March 2015

1

ObjectivesObjectives

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

OverviewOverview

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

RegulationsRegulations

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

RegulationsRegulations

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

CRNA RegulationsCRNA Regulations

HistoryEstablished December 1, 1979COMAR (Title 10 Chapter 06) of the

Maryland Nurse Practice ActRegulations Available Online

Regulate our practiceCollaboration Agreement Required

Now referred to as an “Attestation”

6


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

Maryland CRNA RegulationsMaryland 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

Maryland CRNA RegulationsMaryland 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


Collaboration Agreement issue .02 Certification.

A. An 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

Old Agreement Old Agreement

11

NEW NotificationNEW Notification

12

Attestation 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 [email protected]

13

mailto:[email protected]





Written Requirements by StateWritten Requirements by State

The states in red have some form of written requirement in their agreement.

14


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


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

The Instituteof

MedicineReport

2010

17

18

The 2010 IOM ReportThe 2010 IOM Report

1. Remove scope of practice barriers2. Expand opportunities for nurses to lead in

collaborative efforts3. Implement nurse residency pro4. Increase the proportion of nurses with a

baccalaureate degree to 80% by 20205. Double the number of nurses with a

doctorate by 20206. Ensure that nurses engage in lifelong

learning7. Prepare and enable nurses to lead change

to advance health8. Build an infrastructure for the collection

and analysis of inter-professional health care workforce data

The 2010 IOM ReportThe 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

Legislative History

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



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



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



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



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



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



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

Physician Assistant LegislationPhysician Assistant Legislation

PA legislation surfaced in the 2010 legislative session

This is an example of a bill that inadvertently has consequences not planned.

28

Physician AssistantPhysician Assistant

Overall, I feel this legislation was a “lose” situation for CRNAs

However, the best case scenario was obtained

29

Physician AssistantPhysician 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

Certified Nurse MidwivesCertified Nurse Midwives

Collaborative plan was eliminated September 2014

31

NP LegislationNP 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

Questions?

Documents

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