(While I am the named commenter, I am submitting this comment on behalf of the University of Virginia Health System.)

The University of Virginia Health System thanks you for the opportunity to comment on the promulgation of regulations to implement HB 793.  The University of Virginia Health System employs and teaches many people who hold divergent opinions concerning the implementation of HB 793.  Taking into account these different perspectives, we have identified the following issues of importance that we ask be considered when developing regulations for HB 793.

Equivalent of at least five years of full-time clinical experience:

• Consider implementing a system for the initial licensing of independent Nurse Practitioners (NPs) that is similar to the ACGME competencies review, including an evaluation of the NP’s skills each year.This will help ensure there is an accounting for all five years of clinical experience, and it will enable timely remediation of any weak areas.It is recognized that this could work for new NPs, but existing NPs with greater than five years’ experience should be allowed to provide other evidence of meeting the five year clinical experience requirement.

• On the other hand, consider whether such a system would create more barriers in the regulations than already exist in the statutory requirements and would thwart the intent of HB 793 to allow NPs to practice to their full scope and to meet the needs of patients.

Routine practice in a practice area included within the category for which the NP was certified and licensed:

• The approved legislation requires five years of collaborative practice in a specific practice area and patient population.Consider clarifying how practice area and patient population will be defined and clarify how a NP could move between populations and practice types, and what additional supervision/documentation would be required. For example, how would an NP transition from outpatient cardiology to inpatient CCU or floorcare? Or from outpatient cardiology to dermatology or vice versa?

• Consider adopting the APRN Consensus Model which is the regulatory model that guides these types of situations. This was developed in 2008 and endorsed by over 40 nursing organizations. This Model and later statements make it clear that an APRN's practice is not setting-specific but population-specific.For example, an Acute Care NP can manage heart failure patients with acute needs in any setting—from ICU to clinic to community.

• It will be important for hiring entities and credentials committees to know the specific patient population and practice area for which the NP qualified for independent practice.To this end, consider making this information readily available to hiring entities and credentials committees.The most straightforward way to accomplish this would be to specify the patient population and practice area on the BOM/BON issued license.As an alternative, the BOM/BON could develop a system to share this information with hiring entities and credentials committees by secure electronic means.

Requirements of an attestation of practice:

• The attestation could be a check-box type document that the collaborating physician could complete and sign.

• Indicate the FTE of the experience (1 FTE for fulltime, 0.8 FTE for 32 hours per week/part time, etc.)

• Consider including on the attestation form check-boxes specific to the patient populations and practice area that the NP has practiced in, and also check-boxes that cover the specific competencies the person has mastered in the practice area.

• Consider whether checking off a long list of NP competencies on the attestation form is too burdensome and creates unnecessary barriers for the NP.

Acceptance of “other evidence” demonstrating that the applicant met the requirements:

• There will be cases where the collaborating physician or physicians who worked with the NP during the required five years are unable or unwilling to sign off on approval of independent practice for that NP.In these cases, the NP may submit other evidence demonstrating that he or she has met the requirements.Consider developing a formal panel and procedures for evaluating such evidence that includes representatives from both the BON and BOM.The procedures should include actively seeking input from the NP’s collaborating physicians during the time period in question.

• Consider taking proactive action to prevent the above situation from occurring by adding a requirement to NP practice agreements requiring annual reviews as part of the five year clinical experience process. The collaborating physician should be required to discuss the review with the NP, and provide a copy. This could help with documentation and remediation issues, and could allow the NP to leave the practice if the collaborating physician failed to complete the review.On the other hand, consider whether such a requirement would set up the NP for failure if the collaborating physician failed to perform the annual evaluations; leaving the practice may not be a solution if the NP cannot locate a new collaborating physician.

Endorsement of experience in other states:

• We suggest that the BON/BOM follow a similar process as is required now for NPs, i.e., the NP provides primary validation from the school where the individual obtained the NP degree, evidence of NP licensure that is in good standing from another state, evidence of professional certification issued by an agency accepted by the BON/BOM, and fingerprinting.

• To meet Virginia’s five year clinical practice requirement, consider requiring the NP to meet the same attestation requirement that in-state applicants must provide, including allowing the out-of-state applicant the same opportunity to provide other evidence, if necessary, to demonstrate meeting the five year clinical practice requirement.

• Consider allowing the out-of-state applicant who has less than five years clinical experience to receive credit for their prior years of experience rather than requiring them to practice a full five years in Virginia before becoming eligible to practice independently.

• Consider the case of a NP that has practiced in a state that has a supervisory NP law rather than a collaborative NP law—how would that impact endorsement?

Fee associated with submission of attestation and issuance of autonomous designation:

• We suggest that the BON/BOM impose a reasonable fee, perhaps similar to the renewal fee and the frequency of renewal fees imposed on physicians by the BOM.

Unprofessional conduct – falsification of attestation:

• We suggest that the BON/BOM apply the same rules that already exist for physicians and nurses concerning unprofessional conduct.

Thank you for your consideration of these issues.