Policy and Political Action

Policy & Political Action

Proposed Amendments to Regulation 965 made under the Public Hospitals Act - Proposals 11-HLTC027

Resource Type: 
Submission / Letter

Hon. Deb Matthews
Minister

Ministry of Health and Long-Term care
Health Human Resources Strategy Division
56 Wellesley Street West, 12th floor.
Toronto, ON M5S 2S3

Via email: dmatthews.mpp@liberal.ola.org
ccu.moh@ontario.ca

Re: Proposed Amendments to Regulation 965 made under the Public Hospitals Act – Proposal 11-HLTC027

Dear Minister Matthews,

As the professional association for registered nurses who practice in all roles and sectors across Ontario and a strong voice for healthy public policy, the Registered Nurses’ Association of Ontario (RNAO) welcomes the additional enhancements to the practice of nurse practitioners (NPs) to enable them to practice to full scope and optimize their contributions to Ontarians. The proposed amendments to Regulation 965 under the Public Hospitals Act will enable NPs to admit and discharge hospital in-patients, an important step that the RNAO unequivocally is convinced will improve patient centred care and outcomes, as well as health system efficiency and effectiveness.

Overall, RNAO is very pleased with the direction of the proposed regulation and applauds efforts by the Ministry to eliminate legislative and regulatory barriers faced daily by NPs, which limit their ability to practice to full scope. Evidence strongly supports the benefits of NP integration to enrich patient satisfaction, prevent unnecessary hospital admissions, decrease length of stay and promote early hospital discharge. Authorizing NPs to admit and discharge hospital in-patients will improve patients’ experiences and outcomes, advance health system effectiveness and efficiency, and lead to robust inter-professional collaboration.

Admission to Hospital by Hospital-Based Nurse Practitioners

RNAO supports, in the strongest possible terms, the regulation extending authority to NPs to admit in-patients to hospitals – to be in effect as soon as possible -- and no later than July 1, 2012. Enabling NPs to admit in-patients to hospitals will increase client access to health services, enhance continuity of care and caregiver, and reduce fragmentation of the client experience while improving patient flow through the system -- thus reducing overall wait times. It is therefore in the best interest of Ontarians to enable NPs to admit in-patients to hospitals. Effective admission and discharge processes work best hand-in-glove as more admissions by NPs will contribute to hospital care effectiveness. Improvements in timely discharge and reductions in lengths of stay will serve to advance hospitals’ efficiency. RNAO looks forward to implementation of admission of in-patients by NPs as soon as possible and no later than July 1, 2012.

Streamlining care for the most effective and efficient use of health care resources requires us to conceive of admission as a process of providing care, and not a single act. Continuity of care provider is facilitated by the most appropriate care provider who admits patients from the ED. Frequently this may be the NP, who takes brief histories and assessments in the ED and can then follow up with the same patients on the unit to which they are being transferred. Authorizing NPs to admit in this manner reduces duplication of assessments, decreases the potential for miscommunication and enables a more therapeutic and satisfying nurse-patient relationship. Furthermore, the need for time-consuming and inefficient medical directives is eliminated.

Currently 30 per cent of NPs work in various acute care environments including emergency departments (ED). Extending NPs’ authority to admit in-patients provides continuity of caregiver along with quality and safety improvements for patients in clinical areas such as:

1. General cardiology
2. Cardiac surgery
3. Neurology
4. Neurosurgery
5. Nephrology
6. Organ transplant
7. Adult Critical care (general and specialized)
8. General surgery
9. Pediatric critical care
10. Orthopedic surgery
11. Neonatal intensive care
12. Plastic surgery
13. Trauma
14. Vascular surgery
15. Rehabilitation medicine
16. Acute and chronic pain teams
17. General medicine
18. Wound management teams
19. Palliative care teams
20. Respirology
21. Gerontology/seniors’ health teams
22. Mental health
23. Oncology
24. Rheumatology
25. Gastroenterology

Change management will be required to implement these new regulations. This is best introduced when reinforced by institutional policies and by-laws. Currently there are inconsistencies between admission and discharge policies in hospitals across Ontario. Where such policies have been established, they are usually outlined in by-laws and policies. Providing NPs with the authority to admit and discharge requires revisions to individual hospital by-laws to allow NPs to fully exercise this authority within the inter-professional team and the practice setting. It would be helpful to have templates created by the OHA in collaboration with the RNAO, that would address key points for standardization among hospitals, rather than individual practices that may not completely enable the full scope of practice for the NP.

To further reinforce these important changes, it is important to move away from terminology that suggests singular access to hospital services and use team-based terminology that better represents the evolving decision-making authority around the provision of care. “Most Responsible Physician” needs to be replaced by “Most Responsible Provider” as this best reflects multiple points of access to appropriate service providers. Further, standardized templates that assist NPs and their organizations in clarifying professional responsibilities, accountabilities and expectations will reduce the potential for inter-professional tensions.

Recommendations:
· Enable NPs to admit in-patients as soon as possible and no later than July 1, 2012
· Require amendments to hospital by-laws and policies that would reflect NP authority, including:
o Replacing all Most Responsible Physician policies with Most Responsible Provider policies
o Transforming the Medical Advisory Committees (MACs) to be Health Professionals Advisory Committees (HPACs), to attain congruency with the Local Health Integration Structures.
o Ensuring that all professions have a seat on the HPACs and that nursing is represented by the Chief Nurse Executive (CNE) and,
o Assigning the CNE to oversee NP Admit and D/C authority
· Develop standardized templates for NPs to use in guiding changes to the Most Responsible Provider admission processes and accountability (OHA in collaboration with RNAO).

Discharge of Patients from Hospital by Hospital-Based Nurse Practitioners

RNAO is in full support of the regulation extending authority of NPs to discharge hospital in-patients -- to be in effect by July 1, 2011. Evidence suggests patients realize many benefits when NPs discharge patients. In a recent study of specialty NPs,[iv] team members, including physicians, nurses, pharmacists and others -- all suggested that it would be an advantage to have NPs able to discharge patients. Four specific advantages noted by the teams were:

· Increased role clarity, when the NPs scope of practice was not fragmented,
· Safer and faster patient assessments prior to discharge, with timely access to NPs,
· Greater consultation among team members with NPs, compared to physicians, along with increased accuracy and safer readiness for discharge assessments, and
· Earlier discharges, enabled by ongoing NP assessments in collaboration with the team.

Similar to the admission process, discharge is best conceived as a continuous process of care and not a single act. NPs will already be integral to the discharge process in being able to diagnose, prescribe for and treat in-patients and are therefore appropriate providers for completing the final steps of ordering the discharge, signing off on prescriptions and coordinating follow up care when required. Using NPs to discharge, particularly when they have functioned as the Most Responsible Providers and know the needs of their patient best, advances client-centred care and system effectiveness and efficiency. As with admission, RNAO firmly supports a requirement that all hospitals implement NPs in their capacity to discharge patients by completing the necessary by-law and policy changes in a timely manner; thereby making this change in process smooth, timely and efficient.

Recommendations:
· Enable NPs to discharge in-patients by July 1, 2011
· Require amendments to hospital by-laws and policies that would reflect NP authority, including:
o Replacing all Most Responsible Physician policies with Most Responsible Provider policies
o Transforming the Medical Advisory Committees (MACs) to be Health Professionals Advisory Committees (HPACs), to attain congruency with the Local Health Integration Structures.
o Ensuring that all professions have a seat on the HPACs and that nursing is represented by the Chief Nurse Executive (CNE) and,
o Assigning the CNE to oversee NP Admit and D/C authority
· Develop standardized templates for NPs to use in guiding changes to the Most Responsible Provider admission processes and accountability (OHA in collaboration with RNAO).

Summary

RNAO wishes to express our deep appreciation to the Ministry of Health and Long-Term Care for facilitating broad and comprehensive consultation on enabling Nurse Practitioners to admit and discharge in-patients in Ontario hospitals. NPs have a vital and necessary role to play in the admission and discharge processes of all Ontario hospitals. Utilizing NPs’ education, competencies and skills to full scope will improve patient access to hospital care and the hospitalization experience. It will undoubtedly result in improved patient, organizational and system outcomes, as well as advance robust inter-professional collaboration. We urge government to approve and implement the proposed regulation without delays.

With warmest regards,

Doris Grinspun, RN, MSN, PhD, O.ONT.
Executive Director, RNAO

David McNeil, RN, BScN, MHA, CHE
President, RNAO

feedback