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					National-Interstate Council of
State Boards of Cosmetology
             (NIC)

        August 26, 2006
         Portland, Maine
                                 1
   Standing the Test of Time
           Mutual
          Recognition
            and the
             Nurse
           Licensure
           Compact

Myra A. Broadway, JD, MS, RN
                                             2
Executive Director, Maine Board of Nursing
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
                                          3
Much has changed . . .

              except regulation




                                  4
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

                                                  5
Early Efforts
to Regulate Nursing Practice

  Each state had its own requirements


  Hospitals trained their own


  States wrote their own examinations



                                         6
 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 arm…We are
 more alike than we are different             7
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                   8
Factors      (continued)

Technological Advances:
 Acceptance of World Wide Web/Internet
 Telephone
 Computers
 Videoconferencing, teleconferencing
 Advanced electronic diagnostic technologies

 Robotics
                                                9
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
                                               10
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                                       11
    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                                12
The National Council of State Boards of
Nursing (NCSBN): Definition of Telenursing
       The practice of nursing over
      distance, using electronic means




                                         13
Telenursing

   Delivery of patient care by means of
    telecommunication
   Telephone
   Facsimile
   Cellular phones
   Computers
   Teleconferencing
   Videoconferencing
                                           14
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 patient’s
                   home or by “telecommuni-
                   cative” means
                                                 15
Regulatory Issues
                                      ?
 State’s 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?
                                             16
Dilemma: What model of nurse licensure
is best for the 21st century?
    Licensure remains state based
    Practice is not bound by state lines




                                            17
Vision Statement:
  A state nursing license recognized
    nationally and enforced locally




                                       18
Policy Goal
 Simplify governmental processes


 Remove regulatory barriers to increase
  access to safe nursing care




                                           19
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                                            20
Models Considered:
  Reciprocity
  Fast Endorsement
  Corporate credentialing (institutional
   licensure)
  Ontario Model
  Mutual Recognition
  Limited License for Telehealth

                                            21
Solution: Mutual Recognition
A state-based license, nationally recognized &
locally enforced

   Multi State Regulation
    (MSR) Task Force
   Surveys, interviews,
    conferences
   Best model to protect
    public & decrease barriers
                                             22
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 state’s practice
  laws and discipline
 Practice allowed physically or electronically
 Each state must enter into interstate
  compact


                                                  23
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

                                                  24
Why is the individual in the NLC limited to
one license in the home state?
1) The policy decision was made specifically to
   enhance public protection while retaining
   state based authority & reducing
   administrative burdens




                                               25
2)   Determining the state of practice would
     be challenging in an era of multiple
     employers, at multiple sites across
     state lines & through telenursing




                                               26
3) Tracking a nurse in the event of a
   complaint is better accomplished through
   residence than the employment link




                                          27
Effects of Mutual Recognition

 Nurses
 Public
 Health Care
  Institutions
 Government
 Revenue

                                28
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


                                             29
Interstate Compact

   Formal agreement between 2 or more states
    to remedy a problem or multi-state concern
    (Black’s Law Dictionary)
   Each state enacts a compact via legislation
   Mutual recognition of those who enact the
    legislation


                                                30
 Affords states the opportunity to
    develop self regulatory adaptive
    structures to meet new challenges over
    time

   Example - Driver’s License Model


                                             31
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


                                              32
General Purposes of the Compact
   Facilitate the states’ responsibility to
    protect the public’s health and safety

   Ensure and encourage the cooperation of
    party states

   Facilitate the exchange of
    information between party
    states
                                               33
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



                                                 34
Nurse Licensure
Compact Addresses…
             1) Jurisdiction
             2) Discipline
             3) Information Sharing
             4) Compact
                Administration




                                      35
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
                                              36
2) Discipline

 Complaint is filed where
  violation occurs

 Board takes action on privilege to practice
  and issues an Order

 State of licensure notified

                                                37
 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

                                               38
   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                                   39
3) Information Sharing – NURSYS

   A comprehensive information system
    containing data on all nurses

   Coordinates existing and future nurse
    databases

   Used to verify nursing licenses

                                            40
4) Compact Administration

   Authorizes the formation of the Compact
    Administrators Group
   A separate body composed of participating
    state board administrators in charge of the
    state’s compact operations is called the
    “Nurse Licensure Compact Administrators,”
    or NLCA
   Authorizes the development of rules and
    regulations to administer the Compact
                                              41
   Current Model
       Vs
Mutual Recognition

How do they compare?




                       42
Initial Licensure

Current Model
   Apply/pay fee to state(s) where expect to
    practice

    Comply with each state’s     requirements
    for licensure (not uniform)

    Practice only in state(s) where licensed
                                                43
Mutual Recognition
   Apply and pay fee to home state


   Comply with home state licensure
    requirements

   Practice in any party state

                                       44
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

                                      45
License Renewal
Current Model
   Accountable for each state’s renewal
    requirements
   Renew in every state where license is held

Mutual Recognition
   Accountable for home state’s
    renewal requirements
   Renew in home state only
                                                 46
Lapse -- Re-Entry -- Reinstate
Both
   Inactive status depends on laws of state
    licensure
Current Model
   Apply to each state, according to state’s
    laws
Mutual Recognition
   Apply to home state

                                           47
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
                                              48
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




                                             49
Advantages to Boards

 Public protection
 Jurisdiction over all nurses practicing in the
  state
 Unduplicated count of nurses in the country




                                               50
Major Concerns
 Sharing investigative information may violate
    the nurse’s 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
                                              51
Pros   &   Cons




                  52
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
                                                 53
Cons

 Will take time


 Requires legislation in each participating
  state

 State BON rules, regulations and
  procedures will need to change

                                               54
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.                            55
Implementation

                 Colorado,
                 Kentucky &
                 New Jersey are
                 members, but
                 not yet
                 implemented




                           56
Two Words Sum Up What Is Needed
to Make the NLC Work:
                    TRUST
 FLEXIBIILTY




                                  57
         Working Together to
        Enhance Public Safety
               FLEXIBILITY

We are all in this together and solving my
 licensure issue isn’t good enough if I don’t
 provide you the information you need to
 act.


                                                58
        TRUST

“Nobody does it better…”




                           59
   Keys to Success




Education & Collaboration


                            60
 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                                61
Rules Highlights

 Evidence of state of residence

 Work up to 30 days after move

 Limitations on probation

 Licensee may challenge
  information
                                   62
Findings of States in the Compact:
1) 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
                                            63
3)    The current system of duplicative licensure
     for nurse practicing in multiple states is
     cumber-some & redundant to both nurses
     AND states

4) Nurses do not always want to “give up” the
     first state of licensure & need advance
     education & notice regarding the change
                                               64
5) 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




                                            65
6) 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.


                                               66
7) 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                                       67
8) What determines primary state of
  residence?
  NLC defines primary or home state in the
  compact rules & regulations.
  Sources to verify primary residence may
  include: driver’s license, state where
  federal income tax is paid; voter
  registration
                                            68
9) 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 state’s Nurse Practice Act
   The NCLA carefully studied the various
   licensing requirements & agreed upon the
   core requirements all party states are to
   enact                                       69
10) Does the NLC affect the primary state’s
   authority to discipline?

   The NLC actually enhances the state’s
   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           70
11) 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.)
                                            71
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)
                                               72
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
                                          73
Communication
There are obstacles:
 Different Board
  Structures
  -- Umbrella vs independent
  -- Investigations & Legal in
  different departments or
  agencies
 Identification of key
  contacts
 Resources                      74
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)
                                                       75
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                                   76
Lobbying Efforts (continued)

  Identify key legislative sponsors

  Provide testimony (verbal & written)

  Organize letter writing campaigns

  Organize telephone trees


                                          77
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


                                                 78
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.
                                                    79
The End!


           80

				
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