The state of the state regulation of health professions

The Seal of Washington, Washington's state seal.
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Washington State is among the best states for nurse practitioner scope of practice. I knew this, of course, and it is one of the reasons I moved here 16 years ago. Therefore, I assumed that Washington State had to be that much better than Virginia when it came to the regulatory system for health professions. However, according to the results of the 2007 Performance Audit Report, Department of Health, Health Professions Quality Assurance Report by Brian Sonntag, Washington State Auditor, this is not the case. Governor Christine Gregoire requested this audit, largely as a result of media coverage of sexual abuse of patients by Washington state licensed health care providers. In 2005/2006 The Seattle Times published a investigative reporting series by Mike Berens called “License to Harm,” and in it he concluded that Washington State had a deficient health regulatory system that fostered abuse through weak and inefficient regulation.

One of the main problems as pointed out in the Performance Audit Report is the confusing government structure for Washington State health professions regulation. Whereas most all other states in the US have independent agencies regulating health professions, Washington State has an umbrella structure. Within the Department of Health there is Health Professions Quality Assurance (HPQA), which directly oversees 23 professions, but also provides support to 16 other boards and commissions. These boards and commissions are authorized by law to adopt their own rules and standards. Although HPQA is responsible for overseeing credentialing and discipline of health care professionals, it does not have responsibility or authority to direct boards and commissions in matters relating to case resolution and disciplinary actions. The report states that this divided governance structure does not provide for clear lines of performance management and accountability with regard to operations of the boards and commissions. In addition, it results in significant inconsistencies in disciplinary practices across professions.

Another interesting fact mentioned in the Audit Report is that since 2005, HPQA has taken steps to address public demand for more severe sanctions against health care providers. They do not specify how they have addressed this public demand for more severe sanctions, except by highlighting Governor Gregoire’s mandate to promptly investigate—without—exception—all allegations of sexual misconduct by all health professionals. They note that between 1995 and 2006, there was an 83% increase in the number of all complaints filed against health care providers in Washington State. The authors of the report recommended ways to increase public awareness about their right to file complaints against health care providers; however, the written response of HPQA to this recommendation was that they didn’t want to do this since they were inadequately staffed to handle the increased number of complaints.

So, in the past four years since this audit was done and recommended changes given to the Department of Health, the Governor and the State Legislature, what progress has been made? Since there was no follow-up report available on the HPQA website, I decided to call and e-mail them to find some answers to my questions. I’m happy to report that I got further with this line of inquiry than I did with comparable government personnel in Virginia. I spoke with Steve Hodgson in the Assistant Secretary’s Office of HPQA. He told me he had forwarded on my list of questions to Kristi Weeks, Director, Office of Legal Services, HSQA, and that they would get back with me with the answers by the end of the week this past week. In response to my ‘easy’ question, “What’s the difference between a board and a commission within HPQA?” he said that it boiled down to a difference of payment structure. That the board members of the four health professions’ boards (medicine, nursing, dentistry and chiropractic) receive $250/day in compensation for their board duties, whereas all commission members only get $50/day.

Here are some updates. There have been no changes in the umbrella/divided government structure of the health professions regulatory system in Washington State. In May 2006, the Secretary of Health adopted Uniform Sanctioning Guidelines as a tool for all of the boards and commissions to consistently impose similar sanctions for similar violations. The various health regulatory boards and commissions were not mandated to adopt these guidelines, and voluntarily adopted them at different times. As of this year, all boards and commissions have adopted them. However, as the results of the 2007 audit found, interpretation and implementation of such guidelines varies widely by professional group commission/board. All of the boards and commissions are now annually reporting performance measures to the HPQA. A planned follow-up audit of the health regulatory system in 2010 was canned due to lack of funds. However, Kristi Weeks writes, “The Legislature has mandated a report by December 15, 2013 that will evaluate, among other things, medical and nursing’s regulatory activities, including timelines, consistency of decision making, and performance levels in comparison to other disciplining authorities.” She did write that this is all subject to public disclosure and said I should feel free to share it.

A lingering question: Assuming the 2010 health regulatory system audit had been funded, what, if anything, would have been different in the cases of Kim Hiatt and the other Children’s hospital nurses recently charged by the Nursing Commission for misconduct?

Virginia Board of Nursing Wrap-up

In my previous blog post (Ir)regulation of the Health Professions, I briefly told the story of my run-in with the Virginia Health Regulatory Board, and how I was investigated by them for nine months. They (I think—I still have no written proof) then closed my case due to insufficient evidence. An independent state audit of the Virginia Health Regulatory Boards around the time of my encounter with them revealed that it took the Board of Medicine on average over two and a half years to conclude cases, and the Board of Nursing took over a year. In almost all cases, including ones involving serious violations, the Board of Medicine allowed physicians to continue practicing pending the outcome of the investigation. In contrast, the Board of Nursing usually ordered the nurse to not practice pending their final decision at the conclusion of the investigation. The Board of Nursing was the only health regulatory board to summarily suspend the license of nurses prior to the conclusion of the investigation. In the Virginia audit report, the authors pointed out that such long time delays in processing investigations posed a serious threat to public safety. They also stated that long delays in case processing placed an unfair burden on respondents (providers accused of wrong-doing).

 

Not having access to any written reports on my own case—including not knowing what I was accused of doing in the first place, I can only go by the notes I took during my meeting with the Attorney General at the time. From what I can gather, the Boards of Medicine and Nursing were disputing scope of practice standards for nurse practitioners and I was a likely test case. I remember testifying at a special hearing of the Virginia legislature about nurse practitioner scope of practice and why reforms in state laws were necessary for the provision of safety net services. Virginia remains one of the worst states in terms of nurse practitioner scope of practice. I don’t plan to practice there anytime soon, but I do hope they get their (nurse practice) act together. I know they are working on it.