Hospitals serving Medicare or Medicaid patients will be required to update their rules in 2012 as a result of an executive order by President Obama to streamline and simplify federal regulations.1 Almost all hospitals in the United States serve these populations and receive reimbursement from the federal government for services rendered. This means that the anticipated improvements will change patient care and nursing practice for both RNs and advanced practice RNs (APRNs) in hospitals throughout the United States.
The Centers for Medicare and Medicaid Services (CMS) oversees these rules, called Conditions of Participation (CoPs), which are designed to protect Medicare and Medicaid beneficiaries' health and safety. Pursuant to the executive order, the CMS evaluated these rules governing hospitals that serve Medicare or Medicaid patients to remove or revise obsolete, unnecessary, or burdensome provisions.
The challenge in such an undertaking is to ensure that the quality of patient care isn't compromised by efforts to streamline administrative responsibilities or reduce costs. The American Nurses Association (ANA) reviewed the CMS's proposed changes from the perspective of both nurses and patients, and responded in December 2011 with a series of recommendations regarding those changes that most directly affect nurses and patient care. Key areas of concern for the ANA included safe staffing, changes to ease authentication and writing of orders, the role of APRNs on medical staffs, and several other issues affecting daily practice.
Staffing and delivery of care
Robust evidence demonstrates that optimal nurse staffing results in better patient outcomes and improved quality.2 Yet the lack of appropriate nurse staffing remains one of the more common problems in healthcare, resulting in gaps and errors in patient care and contributing to nurse burnout. This is particularly true in hospitals where there may be pressure to cut nurse staffing to balance budgets.
In its proposed rule changes, the CMS has the opportunity to promote appropriate nurse staffing. The ANA believes that the CMS should impose additional CoPs to ensure that each hospital implements its own staffing plan that would establish an appropriate number of RNs on each unit to meet the needs of the patients and expectations of those units.
This adjustable minimum number of RNs should be based on an assessment of the level and variability of intensity of care required by patients under existing conditions. In addition, the ANA recommends that hospitals be required to evaluate staffing plans at least once a year, using patient outcome data that are nursing sensitive, and to make staffing plans publicly available.3
Writing and authenticating orders
The CMS's proposal to remove undue administrative barriers to patient care focuses especially on inefficiencies related to who may write and authenticate orders, and the time window in which authentication must occur. The proposed changes acknowledge and accommodate the changing nature of patient care, in which qualified practitioners from a variety of disciplines share accountability for their hospital patients' quality of care.
One such proposed change would allow medications to be ordered by qualified practitioners, in addition to the admitting practitioner, as long as it complies with state law (including scope of practice) and the hospital's granted privileges. Nurses would have greater flexibility to address patients' immediate needs without the confusion and delay of sorting out and tracking down who has the primary responsibility for a patient's care. The CMS also recommended expanding the types of practitioners who can authenticate medication orders. However, the proposed authority for authenticating orders is more limited than the proposed authority for writing orders. The ANA argues that the same rationale for recognizing additional practitioners who write orders should apply equally in determining who may authenticate orders.
Another proposed rule change would affect hospitals' use of standing orders. The CMS proposes to streamline care by permitting preparation and administration of medications on orders contained within preprinted and electronic standing orders, order sets, and protocols for patient orders. Of concern, however, is that the proposal would concentrate authority for the development of standing orders in the hospital's medical staff, with only consultation with nursing and pharmacy leadership. The ANA reasons that full consideration and agreement among these groups, not simply “consultation,” is important because they're all partners in making the most effective use of standing orders and protocols.
In a move welcomed by nurses, the CMS proposes to end the controversial policy requiring verbal orders to be physically signed or otherwise authenticated within 48 hours. The 48-hour rule creates a significant burden for the ordering practitioner, the hospital, and particularly nurses who are often unofficially charged with making sure that ordering practitioners complete the authentication process. The proposed change would provide flexibility so that the signature or authentication would need to be procured “promptly,” thus crediting nurses, physicians, and others with having the professional judgment to follow up on verbal orders appropriately.
Nursing participation on the medical staff
The CMS proposed to change the composition of the medical staff to give hospitals the option to include practitioners other than physicians, as long as it's consistent with state law. The ANA urges the CMS to go further and make such inclusion obligatory, rather than optional. This change is necessary to ensure that a hospital's governing body fully adopts the ethos of interprofessional, team-based care. Hospitals must adapt to the evolving nature of patient care. This is particularly true in light of the growing prevalence and importance of qualified healthcare professionals other than physicians, and the opportunity to utilize these professionals to address the looming shortage of physicians in several specialty and geographic areas.
The hospital medical staff is a key decision-making body for hospital policy and procedure and serves as a gateway for privileging, credentialing, and hospital committee eligibility, among other functions. Its members possess both rights and responsibilities, including voting rights and full due process, which should be afforded to all qualified practitioners. The ANA's request to the CMS is consistent with the landmark 2011 Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, which recommends that the CMS, “amend or clarify the requirements for hospital participation in the Medicare program to ensure that advanced practice registered nurses are eligible for clinical privileges, admitting privileges, and membership on medical staff.”4
The ANA also urges the CMS to expand eligibility for medical staff governance so that leadership roles are available to any members who are best qualified and appropriate to perform the necessary oversight activities. At a minimum, APRNs should be included in this pool of candidates. APRNs receive educational preparation in organizational leadership and ethics in their undergraduate nursing and graduate APRN programs.5–7 Nurses have amply demonstrated their excellence in key leadership roles within healthcare systems, organizations, and the U.S. government. Nurses are CEOs of hospitals and hospital systems, and many nurses are at the helm of quality improvement programs throughout the country. Hospital medical staffs shouldn't be barred from taking advantage of the leadership skills offered by their own nursing community.
Other proposed rule changes
- Administering blood transfusions and I.V. medications. The CMS proposes to eliminate the current requirement that nonphysicians have “special training” in administering blood transfusions and I.V. medications. Given the immediate and significant risk to a patient if these procedures are done incorrectly, the ANA recommends that the practitioner authorized to provide these services should be an RN, APRN, physician assistant, or physician.
- Self-administration of medications. The CMS proposes to permit patients, under well-defined policies and procedures, to self-administer certain medications, whether hospital-issued and/or brought from home. The ANA supports this change because it will help nurses who are the principal practitioner responsible for teaching a patient (and his or her family) self-care, particularly in the transition back home or to less-intensive care settings.
- Infection control. The CMS proposes that a hospital's infection control officers be authorized to develop their own system for identifying, reporting, investigating, and controlling infections and communicable diseases among patients and personnel. Most of these officers are RNs, and the ANA supports the institutionally appropriate flexibility that the proposed rule change would permit.
- Patients' rights: Reporting deaths associated with use of restraints. The ANA urges the CMS to reconsider a proposed change that, although retaining most existing requirements to report deaths associated with restraints or seclusion, would require only a log entry in the case of soft wrist restraints. The ANA believes that all restraint and seclusion-related deaths should be reported in the same manner, regardless of the form of restraint or seclusion, in the interest of hospital accountability and administrative consistency. The CMS has updated the rules so that reporting can occur by electronic means, as well as by telephone or facsimile.
More nursing input needed in the future
The CMS notes that many of the proposed revisions to the Medicare and Medicaid CoPs are the result of ideas provided by hospitals and organizations representing healthcare professionals and other stakeholders. This input augmented and informed the CMS's own research and evaluation of current practices. The CMS acknowledges that a dearth of data creates significant uncertainty regarding the financial impact of reforms and solicits suggestions on better ways to make such assessments.
Although this set of changes to the hospital CoPs will be finalized and implemented in 2012, the CMS specifically says that it also welcomes future suggestions that would further reduce unnecessary burdens on hospitals, while preserving federal standards of safe, high-quality patient care. As the largest single group of healthcare professionals in the United States, RNs have more direct, ongoing interaction with hospital patients and their families than any other single category of healthcare professionals. Sixty percent of all RNs are employed by hospitals as direct care nurses, administrators, and case managers, among other roles.8 RNs are encouraged to work with their own hospitals to evaluate practices and protocols that may have outlived their usefulness and take time away from RNs' ability to provide direct patient care. Submitting these suggestions to the CMS may just result in their inclusion in the next round of regulatory streamlining.