Recertification. The Start

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1 Recertification Susan Caulk, past Director of Continuing Education and Recertification. Developer of the recertification program and designer of the computer applications needed to implement the recertification program. Retirement as the Director of Continuing Education, Recertification, and Certification in October More information about the author and a list of her publications can be found at the end of this article. The Start In the 1960 s, the American Association of Nurse Anesthetists (AANA), along with other nursing and medical professional organizations realized the increasing consumer awareness of the health care industry. More importantly, the public was beginning to recognize the critical nature of the services provided by nurse anesthetists. This prompted the AANA to begin a study of the relationships of continuing education, recertification, and professional competence recognizing that the scientific and technological base of nurse anesthesia practice required a high level of knowledge, judgment and ability. The AANA Education Committee was directed to study the possibility of setting up a recertification plan for members. They developed a plan called the Certification of Professional Excellence (CPE). This was the start of the AANA s first voluntary continuing education program. This plan made it possible for members to earn periodic certificates of professional excellence at five year intervals based on a point system, allowing a member to accumulate 100 points in three categories over a period of five years. Category I allowed points for actual clinical experience. Category II allowed points for attendance at state or national meetings, hospital inservice conferences, and publication of scientific papers. Category III allowed points for serving as an officer of a state or national organization. This program was utilized by a large number of members and was discontinued in 1978 with the implementation of the recertification process. At this time, the individuals who had proposed this plan believed the main objective would be to have evidence that each member continued to advance in knowledge since the points allowed for actual participation in various educational activities. At this time also, the Education Committee felt that the term recertification was misunderstood by many members and decided that the word be eliminated from discussion of the CPE program or the point system. At that time also, the current AANA president had this to say about the upcoming proposal: Of all the goals before us that of continuing education is paramount. We plan to have this program for continuing education on a voluntary basis and hope that the members will accept the challenge for their own improvement. There was discussion about making this program mandatory but after study, it was concluded that it was not feasible at this time despite indications that the end result would be desirable. Other allied health groups were beginning to formulate similar programs and had asked the AANA for information about its program, and it was a sense of pride with the AANA that the members had taken the initiative in establishing the current CPE program. In the 1970 s, there were two developments that resulted in the AANA changing its organizational structure to form three Councils and adopting a mandatory recertification and continuing education process. First, there was legal challenge involving a professional organization that required membership in order for its members to be certified. The end result was that professional organizations could no longer require membership in their organization for members to be certified, recertified or awarded a professional credential. This affected many organizations and set the course for the formation of alternate certifying and recertifying bodies separate from their respective professional associations. The second development concerned the AANA accreditation status. The AANA had been the official accrediting agency tor nurse anesthesia programs for over 20 years. The Health Education and Welfare Department (HEW) of the US Government had adopted new criteria for accrediting agencies which stemmed from social trends which were currently being reflected in legislation, judicial rulings, and other governmental regulations. These new social trends included autonomy, public accountability, nondiscrimination, due process, consumer protection, fair and ethical practices, avoidance of possible conflicts of interest and self evaluation. The AANA received a letter from the US Office of Education (OE) 1

2 to clarify how it intended to meet the new criteria for accrediting agencies, more specifically, to explain a possible conflict of interest since the accrediting and certifying functions carried out by the association indicated that a single body handling both functions could control these functions for the economic benefit of their members rather than for the public welfare. The AANA formed a task force to prepare for organization structure changes and a mechanism which would separate the evaluation of professional competence from association activities and meet the new criteria for accrediting agencies. It took several years of planning but in the end, the members adopted the proposed restructuring of the AANA to accommodate the formation of three Councils: Council on Accreditation, Council on Certification, and Council on Practice, within the corporate structure of AANA. By 1975, the accreditation and certification functions had been separated from the AANA professional association, made less threatening due to the AANA s membership continued commitment to public accountability. Shortly thereafter, the membership voted into use a new mandatory continuing education and recertification program. There needed to be a body to administer the new mandatory program which resulted in the formation of the Council on Recertification of Nurse Anesthetists. This was set up in the same structure as the three previous councils, autonomous in financial and decision making processes. By 1978, the membership had adopted the proposed AANA bylaw amendments that provided for an organizational restructuring of the Association and established the Council on Recertification of Nurse Anesthetists (COR). This change officially separated AANA membership from the nurse anesthesia recertification processes. Recertification was available to all nurse anesthetists regardless of their membership in the AANA. Recertification would cover a two-year period, being offered biennially. The application of antitrust laws and equal opportunity regulations was responsible for the newly formed council in insuring that the new criteria was fair to all nurse anesthetists regardless of their professional association affiliation. All nurse anesthetists had to meet the criteria in the same manner; there could be no differentiation in fees or in any other criteria for AANA or non-aana members. In addition, with all the criteria, it was essential that the competence of the nurse anesthetist was demonstrated to ensure that the public interest was well served. The initial criteria only required a recertification fee, evidence of full or continual clinical practice and documentation of 40 CE credits. It took several years to standardize the criteria due to the changes in nurse anesthesia practice, evolving state and federal statutes and laws, and continuing pressure from the public for accountability and competent practitioners. Following is the current Criteria for Recertification and a brief discussion of various additions, modifications, clarifications, and changes made to reflect the constantly changing practice of nurse anesthetists, state and federal regulatory processes, and the public s demand for competent and accountable practitioners. Categories of Recertification. In order to take into account the different situations of applicants for recertification, there are two categories of recertification: Full and Interim. Full is granted to applicants who fulfill all recertification criteria. Interim has two categories, Provisional and Conditional and is granted to those who for a specific reason and for a limited period of time may not be in full compliance with all recertification criteria. Conditional Recertification. This category allowed the Council on Recertification to impose the same conditions on recertification as may be imposed by a State Board of Nursing. In this way the Council would not be forced to make an independent evaluation of competence to determine whether full recertification or non-recertification was warranted where a conditional RN license had been granted by the state. The Council had neither the resources not the time to make independent competency evaluations. In addition, individual competency evaluations would subject the Council to increased liability exposure any time that the recertification status differed from registered nurse licensure status. To impose greater restrictions by the Council than were imposed by the local State Board of Nursing would 2

3 suggest that the Council was making competency evaluations which would be difficult to justify in terms of resources, investigative powers, and first-hand knowledge of the circumstances involving a particular nurse anesthetist under review. Provisional Recertification. Over the years, there evolved 5 types of provisional recertification once again showing the need to adapt to changing practices in nurse anesthesia practice. Usually, provisional recertification was limited to one year, and depending on circumstances eligible for another year extension. Provisional Recertification Pending Review of Application. This was added to allow the Council to grant provisional recertification while it resolved questions related to whether an applicant should be recertified. Provisional Recertification Pending Fulfillment of Practice Requirement. This was added to provide the opportunity for individuals who did not meet the practice requirements to be provisionally recertified provided they complied with all recertification criteria other than the practice requirement. The fact that at the time of application an individual was not employed, and they were otherwise employed during the preceding year, should not preclude recertification. It was later modified to clarify the fact that Provisional Recertification could be granted to applicants who have not been substantially engaged in the practice of anesthesia during the prior two-year period only if such applicants were, in fact, currently able to practice anesthesia. That is, an applicant who was not substantially engaged in practice due to an ongoing physical or mental condition, which might interfere with the practice of anesthesia, was not eligible for Provisional Recertification. Provisional Recertification-Pending Completion of Treatment or Rehabilitation Program. This was added for nurse anesthetists who had an unrestricted registered nurse license and who had satisfied all other criteria for recertification but who were currently participating in a drug or alcohol-related treatment or rehabilitation program. It was later modified to accommodate applicants who were participating in other types of treatment or rehabilitation programs such as physical therapy or mental health treatment. Provisional Recertification Pending Completion of Probation. This created an additional category of eligibility for provisional if the applicant's recertification was on probation. Provisional Recertification - Pending Outcome of Investigation or Disciplinary or Legal Action. This addressed if the applicant's license was the subject of a pending investigation, or if the applicant was awaiting the outcome of a pending disciplinary or legal action, hearing, trial or appeal. Applicants whose circumstances fell within this category currently could be granted provisional recertification under pending review of application. However, for administrative reasons, the Council believed it would be helpful to make this a separate section since it The Council retained the discretion to determine whether the circumstances underlying the investigation or legal or disciplinary action would have an impact on the applicant's current ability to practice nurse anesthesia so as to preclude even provisional recertification. A nurse anesthetist may, under certain circumstances, be eligible for both provisional and conditional recertification. Both forms of recertification would be appropriate when an anesthetist has not met the practice requirement for recertification, and also has a restricted license. Initial Certification. Initial certification is granted by the Council on Certification of Nurse Anesthetist and required by all applicants who apply for recertification by the Council on Recertification of Nurse Anesthetists. A new graduate who applies for recertification for the first time must meet all of the requirements set forth in the Criteria. Based upon the date of initial certification, determined the date that the first application for recertification was due and the period during which eligible CE credits could be earned. Registered nurses seeking to practice in the United States cannot apply for recertification unless 3

4 they were initially by the Council on Certification. Licensure. An applicant must document practice as a registered nurse, and authority to practice nurse anesthesia, if such authority is granted, in all states in which the applicant practices. For those individuals employed by the United States Government, such as the military, the license may be issued by any state or territory of the United States. For a time, the Council did not accept copies of the RN licenses from Web Sites. The applicant had to submit the paper copy of a valid RN license that could be presented on demand to their employers and other entities. However, this policy changed when some state boards of nursing discontinued issuing paper licenses and relied on websites for verification of licensure. Also, when recertification became possible electronically, accepting website verification of licensure was necessary. Both the RN license and the advanced practice registered nurse license (APRN) had to be current and display a current expiration date. If applicants had practiced in more than one state during the two-year recertification period, they had to submit documentation that they were appropriately licensed during the relevant time of practice in each state in which they practiced. Continuing Education. The 40 CE credits had to be earned within the applicant s two year recertification cycle. If the applicant's recertification period was shorter than two years, for any reason such as a late application filing or late satisfaction of the recertification criteria, the applicant has to document completion of the required 40 hours with the shortened period. Both the Continuing Education (CE) Committee and the COR were aware of establishing the relationship between the courses and evidence of continued ability in nurse anesthesia, such that attendance at and completion of such courses would lead one to grant recertification of the individual. The criteria for the CE course must establish that the courses would have content validity for the decision making process on one s recertification. Through the years, the acceptance of certain CE courses for credit was frequently debated. Some nurse anesthetists wanted certain courses mandated for credit (such as attendance at state meetings) while others found that certain personal enrichment courses (tai chi, yoga, computer use) should be considered for credit. The Council frequently reviewed requests and made decisions based on their original purpose that CE courses for recertification purposes should be applicable to improving the nurse anesthetist s knowledge, skills, and ability in nurse anesthesia practice. Practice. Initially, the COR adopted the criteria that documentation of clinical practice of nurse anesthesia should be by signature on the application of applicant's employer of such engagement. The definition of employer included anyone who had hired the nurse anesthetist or could represent himself on behalf of the employer. In the case of free lance anesthetists, this included hospitals, clinics, and other entities where the nurse anesthetist provided services. Self-employed applicants could have the signature of an administrator or surgeon from their place of employment on the recertification application. In addition, the COR needed to establish some guidelines to provide for temporary unemployment due to job transfers, disability, or resumption of education. The inclusion of a requirement to demonstrate continual clinical practice employment was intended because the COR thought that a long and extended absence from practice could substantially affect an individual's clinical competence to administer anesthesia. The fact that a nurse anesthetist was employed was an additional indication that some independent third party had evaluated the individual's experience, training, and demonstrated ability and concluded that these were adequate to permit administering of anesthesia. Continual" was initially included to attempt to disqualify individuals who may work one or two weekends a year since that was not considered to be sufficient clinical experience to maintain professional competence. Eventually, the word employment was replaced with practice to recognize the fact that some nurse anesthetists are engaged in independent practice rather than in an 4

5 employee capacity. Once again, due to changes in nurse anesthesia practice and confusion from practitioners as to what exactly constituted continual employment, this requirement was modified. The criteria now required the nurse anesthetist to be "substantially" engaged in anesthesia practice. Inclusion of the term substantially was meant to give credibility to the practice requirement and avoid the situation in which an anesthetist may claim that one day of practice every two years is enough to satisfy the practice requirement for recertification. This change also reflected the Council's view that practice was necessary to maintain an anesthetist's skills and that the amount of practice should be more than the minimum. The Council felt that the "substantially engaged" requirement was preferable to requiring a fixed number of hours of practice because it allowed consideration of the anesthetist's individual practice schedule. The word employment was replaced with practice to recognize the fact that some nurse anesthetists are engaged in independent practice rather than in an employee capacity. Another change to the practice documentation was the requirement of a record of practice to help determine whether an applicant has met the practice requirements and to give the Council information necessary to spot check the information received. With this change, the employer's signature requirement was eliminated since the council has all the information it needed. The final change to this practice requirement resulted in the addition of this recommendation: the that minimum practice should be 850 hours and there was clarification that "anesthesia-related" activities must be directly related to the delivery of anesthesia care to patients and/or the improvement of delivery of anesthesia care to patients. Prior to this recommendation, the criteria required that applicants certify that they had been substantially engaged in the practice of anesthesia during the two-year period prior to their upcoming recertification date. It did not define or quantify the term "substantial engagement." Without a numerical requirement to refer to, the decision as to whether an applicant had satisfied the practice requirement had a subjective element to it. During the last few years, the Council had received numerous requests from applicants, and from at least one state regulatory agency, for information regarding the minimum number of hours of practice that would constitute "substantial engagement." In selecting this criteria, the Council concluded that: (1) the practice requirement should attempt to provide an objective and realistic criterion by which the Council could determine whether an applicant "has engaged in the practice required to maintain an adequate level of skill;" (2) applicants for recertification had a right to be informed regarding the general guidelines by which the Council administered the practice requirement; and (3) the practice requirement should remain sufficiently flexible to allow consideration of each individual applicant's practice schedule. Recognizing that individual practice experiences vary, the proposed changes provided a recommendation, not a requirement, for the minimum of 850 hours. Currently the record of practice on the Application for Recertification must include the name and address of the facility, dates during which the applicant practiced at each facility, full or part time status, facility contact person, nurse anesthetist position, facility phone number, and an area of specialization if applicable (8 or more hours per week) such as pain management, OB, pediatrics, cardiac, or neurosurgery. Certification by the Applicant. Currently, the applicant must certify the following: I do not currently suffer from a mental or physical condition which might interfere with the practice of nurse anesthesia; I do not currently suffer from drug of alcohol addition or abuse; I have not been convicted of and am not currently under indictment for any felony; My RN and/or APRN license has never been revoked, restricted, surrendered, suspended or limited by any state, and is not the subject of a pending action or investigation except those actions or pending actions that previously were disclosed to the Council; My record of practice is accurate and I have been or will have been substantially engaged in the practice of nurse anesthesia during the two-year period prior to my upcoming August 1 recertification date; and my statement on this application are true accurate and complete to the best of my knowledge. 5

6 During the initial process of establishing the criteria for recertification, the COR considered a number of methodologies to attempt to fulfill its responsibility to the profession and the patients to provide some minimal screening of nurse anesthetists who suffer from mental or physical conditions which may adversely affect the patient during the administration of anesthesia, including the use of drugs or alcohol in such a manner that the nurse anesthetist's ability to practice would be impaired. Recognizing the difficulty in effective policing, the Council concluded that the only realistic approach at the present time would be to require applicants for recertification to certify their absence from such a condition. The term "abuse" as used in the statement was intended to relate to habits or practices of nurse anesthetists with respect to the use of these substances in such a way so that their ability to administer anesthesia care to the patient is impaired. Social use of alcohol or other substances on off duty hours would not be considered by the Council to be abuse. The Council was aware that the requiring of a certification by the applicant was not the most effective screening method to ascertain physical or mental condition. However, in light of resources available to it, and the health care delivery system in general, the Council thought that such certification was the only practical solution. Certifying as to the accuracy of this statement was a condition for recertification. Refusal to sign such a statement resulted in non recertification. In response to questions regarding reformed alcoholics and drug abusers, legal counsel concluded that although reformed alcoholics or drug addicts may technically still be categorized medically as "abusers," the statement for which certification is requested relates only to such conditions to the extent to which it interferes with the practice of nurse anesthesia. Therefore, reformed addicts or abusers could sign the statement without any risk or misrepresentation or revocation of recertification." Additionally, the criteria was modified so that once the applicant reported the actions in writing to the COR, the nurse anesthetist did not need to report the same past action again. The requirement than an applicant to provide information regarding any mental or physical condition, drug or alcohol-related problem, or legal status which might interfere with their ability to practice anesthesia was to enable the Council to have information which will help it evaluate an applicant's current ability to practice. Administrative Procedures Revocation of Recertification. At the onset, the COR felt that the basis for revocation of recertification status should represent the essential elements of the practice of anesthesia so that the public was not mislead because of a conflict between the actions of the individual and the public perception of the meaning of recertification. The criteria adopted for revocation was: (a) a failure to maintain RN licensure; (2) suffering from permanent physical impairment which precludes practicing nurse anesthesia; (3) being adjudicated as mentally incompetent; (4) suffering from drug or alcohol addiction; and (5) being convicted of a felony. Automatic revocation occurred for failure of the individual to maintain any licensure to practice as a registered nurse. Additional changes to this criterion allowed the Council discretion that in some situations, the necessity for revocation should be a matter of judgment and should not be automatic. There were provisions in the criteria for revocation to distinguish between conviction of or pleading no contest to a felony related to the practice of nursing or nurse anesthesia, which would result in automatic revocation, and other felonies, which could result in discretionary revocation by the Council. The last changes made to this section provided for a section entitled Discretionary Revocation, Suspension, Modification, or Probation. This change provided that the Council could, at its discretion, determine that suspension or probation was more appropriate than revocation and that the Council could grant provisional recertification to an individual whose recertification has been placed on probation. It also provided more detail as to specific circumstances that may lead to discretionary revocation by the Council, including the use of fraudulent recertification cards. The addition of modification as a possible 6

7 action gave the Council more flexibility and allowed it, for example, to grant provisional recertification after reconsideration of an initial decision to deny an application for recertification. Operations. Several years after the formation of the Councils, the auditors suggested that the AANA and Councils consider a more formal written agreement concerning administrative personnel and services, office space, equipment, and supplies since these were currently all shared in part as a way to reduce operating costs and eliminate duplicate services. As a result of the auditor s recommendations, the Councils developed Service Contracts which are still reviewed and updated annually. Due Process Procedures. The criteria should assure the individuals and programs of substantive due process, i.e., the utilization of criteria which are objectively valid and uniformly applied. The Council adopted the Hearings and Appeals procedures which criteria gave nurse anesthetists the right to have the Council reconsider any adverse action. It reflected the Council's intention to afford every anesthetist the opportunity to present additional facts or arguments that might cause the Council to change a decision and to insure that all Council decisions were made in accordance with fair procedures. The nurse anesthetist had the right to seek reconsideration of the Council's decision by submitting a written request for reconsideration, together with an explanation of the basis for the request and any supporting documentation within thirty days of a notice of an adverse action. In addition, the nurse anesthetist could reapply or request an alteration in recertification status when the situation underlying the Council's decision had been remedied. Under certain circumstances, the nurse anesthetist had the opportunity to request a hearing. An important feature of the Rules for Appellate Review of Decisions of the Council on Recertification of Nurse Anesthetists that was revised by their appellate body, the Council on Public Interest, stated that, in matters of hearing appeals, the Council on Public Interest would either uphold the decision of the Council on Recertification or refer the decision back to the Council on Recertification for reconsideration. They could not grant or deny recertification. The COR was the only entity authorized to grant recertification. Any decisions of the Council for Public Interest could only be advisory. The COR adopted the following documents, "Internal Guidelines for Responding to Complaints" and "Guidelines in Determining the Procedure to Use when Considering Revocation of Recertification" when the issue was competence, rather than an adverse action on an RN license by a state board of nursing. For example, if an issue of competence or inappropriate action of a nurse anesthetist was reported by an employer or other external source. This enabled the Council to investigate the complaint in a consistent manner. Public Disclosure and Investigation. The Council adopted policies that both the recertification status of an anesthetist and the dates of recertification were matters of public record and would be disclosed by the Council. However, the Council would continue to attempt to keep confidential any information received during the recertification process. The Council also developed policies which authorized the Council to investigate, consider and evaluate any facts which raised an issue about recertification and to verify application information. Procedures for Revising Recertification Criteria. This section was added which authorized expedited revision of the criteria to the extent required by developments in federal, state or local law. Otherwise, all changes or revisions to the recertification criteria had to be published and available for comment by the applicants before they were adopted. Work for Hire Agreement and Confidentiality Statements. These documents were adopted by the Council for use by current and all and future Council members. In 1997, the new legal trend suggested that associations were asserting that the product of work done by volunteers on behalf of the association was considered to belong to, or be owned by, the association. Thus any work, done by Council members, on behalf of the Council was the property of the Council. Revisions in the Criteria. Though the criteria continued to be updated and changed, nothing prepared the council for the planned changed in The COR proposed a change in the criteria which would establish a classification between clinicians and educators/administrators and establish a minimum 7

8 number of practice hours for recertification. There were more negative comments received from nurse anesthetists than at any other time of proposed changes to the criteria. There were simply too many problems with determining the number of hours needed for practice, e.g., how one number can fit everyone and what kinds of activities do you count for the differences practice settings. The separation of clinical and educational was simply not feasible, since many of the nurse anesthetists could shift from one category to another multiple times in a recertification period. So after a thorough review of all the comments, the Council withdrew these proposed changes to the criteria. Did It Raise Professional Standard and to what Extent The continued competence of nurse anesthetists has always been important to the council. Their underlying philosophy behind the adoption of the recertification process has been responsive to the public expectation that a nurse anesthetist, once certified, will maintain and expand their knowledge, skills, and abilities over time. The recertification process, with its strong continuing education component, has raised the professional standard for nurse anesthetists. The CE program has been recognized by state boards of nursing for use by registered nurses meeting the requirements for continuing education for practice. The CE Program is also recognized by the American Nurses Association through their credentialing body, the American Nurses Credentialing Center (ANCC). Further evidence of success is that recertification is required for nurse anesthetists to receive payment through the government s Medicare Program since nurse anesthetists can bill directly insurance carriers for their services. Recertification requirements based on the Council s criteria have been recognized by the majority of state laws in licensure statues or rules for registered nurses and advanced practice nurse practitioners. Most employers require documentation of certification and recertification for employment. New graduates from a nurse anesthesia program cannot practice until their employer is presented with documentation of their initial certification from the Council on Certification of Nurse Anesthetists. The hospital accreditation process from the Joint Commission on Accreditation of Health Care Organizations (JACHO) requires documentation of certification and recertification of nurse anesthetists to be available in the department records. Nurse anesthesia practice would not have survived more than a century despite tremendous challenges if their competence had not been unequaled. Recognizing that not just clinical skills would be enough for the future, the council made sure that knowledge about the direction of health care, political action at state and federal levels, and involvement at local community and institutional levels were part of the recertification process understanding that these factors were essential strategically for nurse anesthetists to survive and thrive. To date, the most significant sign that this has been successful is that there has not been any evidence brought forth to demonstrate that the current process of recertification does not continue to meet the needs of nurse anesthetists, regulatory bodies, third party payers, and the public. 8

9 Publications: Caulk, Susan. A Developmental Historical Perspective of the Qualifying Examination First Administered in American Association of Nurse Anesthetists, Caulk, Susan; Zaglaniczny, Karen; Chapter 6. Nongovernmental Regulation of Nurse Anesthesia Practice. A Professional Study and Resource Guide for the CRNA. Editors Scot Foster, PhD, CRNA; Faut-Callahan, Margaret, DNSc, CRNA Caulk, Susan; History of Continuing Education. American Association of Nurse Anesthetists, Caulk, Susan; History of Council on Recertification of Nurse Anesthetists. American Association of Nurse Anesthetists, Caulk, Susan; History of Council on Certification of Nurse Anesthetists. American Association of Nurse Anesthetists, Caulk, Susan; Plaus, Karen; Essay. The Development of the Certifying Examination for Nurse Anesthetists. Book to be Published: The Complete History of Anesthesia. Editors are Edmond I. Eger, II, MD; Lawrence J. Saidman, MD; and Rodney N. Westhorpe, MD, MS. FRCA, FANZCA Awards: August 9, Recipient of the 2006 Agatha Hodgins Award. American Association of Nurse Anesthetists 73 rd Annual Meeting. Cleveland, Ohio. This is the highest honor given by the American Association of Nurse Anesthetists. 9