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215.766.1280 [email protected] Utilization of Nurse Practitioners and Physician Assistants: Best Practices Please stand by. The webinar will begin shortly.
Utilization of Nurse Practitioners and Physician Assistants: Best Practices
Please stand by. The webinar will begin shortly.
Utilization of Nurse Practitioners and Physician Assistants: Best Practices
Edward L. Braud, MDSenior Contributing Specialist
Elaine Kloos, RN, NE-BC, MBASenior Consultant
Agenda
• Scope of practice• Goals of using NPPs• Benchmarks• Billing and Documentation• What works and what doesn’t work
3
NPPs defined• Non-Physician Practitioners (NPPs)
– Physician Assistant (PA)Licensed to practice medical care with physician supervision. Emphasis on the biological/ pathologic aspects of health, assessment, diagnosis and treatment. Practice model is a team approach relationship with physicians.
– Nurse Practitioner (NP)Registered nurses with advanced education/training who can perform delegated medical acts with physician supervision. Emphasis on disease adaptation, health promotion, wellness and prevention. Practice model is a collaborative relationship with physicians.
4
Scope of Practice
• Training and Licensure• State Regulations• Credentialing • Supervision of NPPs• Supervision by NPPs
5
Training and Licensure*Physician Assistant
• Training is affiliated with Medical Schools and previous heath care experience is required . First graduation class from Duke in 1967.
• Procedure and skill oriented including surgical skills.
• Requires completion from an accreditation program and national certification exam.
• Licensed by State Medical Board and Medical Practice Act provisions.
• Written guidelines required for prescribing.
* See Appendix
Nurse Practitioner• Originated in Mid 1960’s in response
to physician shortage. • Training is affiliated with Nursing
Schools, BSN required. • Training typically does not include
surgical settings. • Master’s required for exam, national
certification optional. • Collaborative agreement with
physician required to prescribe. • State Nursing license under the Nurse
Practice Act.
6
State Regulations*Physician Assistant
• State laws vary on how the scope of PA’s practice is determined.
• The majority of states allow the physician-PA team to establish the scope of the PA but some states require a regulatory board to set the scope of practice. Other states utilize a hybrid model.
• Resource for regulations: The American Academy of Physician Assistants www.aapa.org
* See appendix
Nurse Practitioner• Educational requirements, certification
and legal scopes of practice are decided at state level and vary considerably.
• Three levels of practice: Full Practice, Reduced Practice and Restricted Practice
• Resource for regulation: American Association of Nurse Practitioners www.aanp.org
* See appendix7
Credentialing
• Practices generally do not have specific credentialing policies.
• Hospital policies and/or by-laws may need to be updated to permit NPPs to practice.
8
Supervision of NPPs
• Regulations are different in each state *, although most do not require on-site supervision of NPPs by the supervising physician.
* See Appendix
9
Supervision by NPPsOffice Setting
• NPPs may serve as the supervising provider for therapeutic services within the scope of practice.
• Must be physically present in the office suite.
• Must be employed by the practice
Hospital Setting• NPPs may serve as the
supervising provider for therapeutic services within the scope of practice.
• Must be immediately available and able to step in and perform the procedure.
• Must be employed by the hospital if off-campus.
10
Goals in Hiring NPPs
• Determine Practice Model • Increase Physician Productivity
– # 1 Goal is to offload work from the physicians so more new patients can be seen in the practice
• Operational• Financial
11
Practice Models• Incident-to-Practice Model
– NPPs see patients independent of the physician; physician is present and available if needed.
– Alternate every other visit– Maximizes productivity and reimbursement
• Shared Visit Model– NPPs always see patients in conjunction with physician
• Independent Practice Model– NPPs see patients completely independent of physician
and the patient is not assigned to an oncologist. 12
Physician Productivity• Determine model, goals and tasks up front
– Work with entire group of physicians to perform tasks vs. work with one provider to perform multiple tasks
• Off load inpatient duties, i.e.consults (pre-work), rounds, discharges• Off load procedures, i.e.bone marrow bx, bladder instillations, etc.• See on treatment patients every other visit• Off load f/u appointments/Survivorship clinic• Assist with dictation • Prepare chemo orders for physician’s final review and approval
13
Operational Goals• The larger the practice, the more operational issues
will need to be considered• See same-day acute patients and add-ons• Supervise therapeutic services especially with
extended hours• Problem solve issues with nurses and pharmacists
regarding chemo orders• Maximize throughput for clinic operations
14
Financial Goals• Maximize productivity and revenue for physician providers• Determine productivity model for wRVUs – who gets credit
for patient interaction• Not all tasks that NPPs perform are billable, but that does
not mean they are not valuable• Maximize use of NPP’s training/licensure – advanced
practice– Do NOT use as scribe “only”• NPPs can perform new chemo teaching (billable event if
not on treatment day or consult day)15
Benchmarks• Unfortunately, benchmark data is not readily available to
determine when to hire a NPP. • JOP article(s) mention when a physician gets close to the
“Industry standard of 350 new patients per year or 7,000 wRVU per year” another physician or a NPP should be considered. 7,000 wRVU include chemo infusion visits for private practice settings. A 17% reduction in wRVU is appropriate for a physician that does not get credit for chemo.
• ASCO projects a shortfall of oncologists in the next decade with demand increasing 48% by 2020 and supply increasing by only 18%. NPPs will be in higher demand.*
*see appendix 16
Billing NPP Professional Services
Office Setting• Must be employed by
physician/practice.• Paid at 100% of physician
rates when physician is in the suite.
• Paid at 85% when physician is not in the suite.
Hospital Setting• If hospital-employed
– Paid at 85% of physician rates.
• If part of hospital-owned physician practice, same as Office Setting rules.
17
Documenting NPP Professional Services
Office Setting• Physician review of the chart
notes in order to monitor treatment progress and signature indicating physician is actively involved in course of treatment is required.
• Solo practitioners must directly supervise NPP. In group practices, any physician of the group may provide direct supervision.
Hospital Setting• Supervising/collaborating
physician review of the qualified NPP’s chart notes in order to monitor treatment progress is required.
• Supervising/collaborating physician signature indicating the physician is actively involved in the patient's course of treatment is required.
18
What Works and What Doesn’t
• Non-Physician Practice Models• Non-Physician Compensation Models• Physician Compensation Models• The Perfect Marriage
20
Non-Physician Compensation Models
• Salary only• Salary plus production• Production only
22
Physician Compensation Models
• Salary only• Salary plus production bonus• Salary plus production and other
incentives• Production only• The less than full time practice ???
23
The Perfect Marriage
• Must align the incentives and work paradigms for best outcome
• One-to-one vs One-to-many• Determine goals before setting rates
– New patients – RVUs– Value based
24
Questions
• Any questions not addressed here may be emailed to [email protected]
• OMC Group will compile questions and answers and distribute to webinar registrants
25
Thank You!• Sincere thanks to all of you for joining us
today. We hope that you will keep OMC Group in mind when consulting needs arise in the future.
26
• Financial and Market Analyses
• New Center Development
• Hospital/ PhysicianIntegration
• Strategic Planning
• Implementation and Interim Leadership
• Performance andFinancial
Benchmarking
• Operational Assessments
• Revenue Cycle Reviews
COMPARISON OF PHYSICIAN ASSISTANTS AND NURSE PRACTITIONERS CATEGORY PHYSICIAN ASSISTANT NURSE PRACTITIONER Definition
Health care professionals licensed to practice medical care with physician supervision.
Registered nurses with advanced education and training in a clinical specialty who can perform delegated medical acts with physician supervision.
Philosophy/Model
Medical/physician model, disease centered, with emphasis on the biological/pathologic aspects of health, assessment, diagnosis, treatment. Practice model is a team approach relationship with physicians.
Medical/Nursing model, Biopsychosocial centered, with emphasis on disease adaptation, health promotion, wellness, and prevention. Practice model is a collaborative relationship with physicians.
Education
Affiliated with Medical schools Previous health care experience required; most programs require B.S. and confer Masters degree. Program curriculum is advanced science based. Approx. 1000 didactic and over 2000 clinical hours. All PAs are trained as generalists in the primary care model and some receive post-graduate specialty training. Procedure and skill oriented with emphasis on diagnosis, treatment, surgical skills, and patient education.
Affiliated with Nursing schools BSN is prerequisite; curriculum is bio-psychosocial based, based upon behavioral, natural, and humanistic sciences. NPs choose a specialty-training track in adult, acute care, pediatric, women’s health or gerontology. Approx. 500 didactic hours and 500-700 clinical hours. Emphasis on patient education, diagnosis, treatment and prevention. Generally not trained for surgical settings. Master’s conferred.
Certification/Licensure Recertification
Separate but single accreditation and certification bodies require successful completion of an accredited program and NCCPA national certification exam. NCCPA certification is the gold standard and is required to obtain a PA license in Wisconsin. (Chapter Med 8) Recertification requires 100 hours of CME every 2 years and exam every 6 years. Recertification is comparable to family physicians. All PAs are licensed by their State Medical Board and the Medical Practice Act provisions.
Nursing accreditation and multiple nursing certification agencies. Master’s Degree required to sit for exam; national certification is voluntary. An optional certificate (APNP) and a written collaborative agreement with a physician are required for prescribing. (Chapter N 8) Recertification requires 1500 direct patient contact hours and 75 CEUs every 5-6 years. No exam is required. NP’s practice under their basic RN license under the Nurse Practice Act
CATEGORY PHYSICIAN ASSISTANT NURSE PRACTITIONER Scope of Practice
The supervising physician has relatively broad discretion in delegating medical tasks within his/her scope of practice to the PA in accordance with state regulations. Written guidelines are required for prescriptions. Does not require on-site supervision Chapter Med 8 in WI Administrative Code
Nursing care is provided as an independent function. However, protocols or written or verbal orders are required for delegated medical acts - such acts require general MD supervision. Sec. N6.03(2), WI Administrative Code
Third Party Coverage and Reimbursement
PAs are eligible for certification as Medicaid and Medicare providers, and generally receive favorable reimbursement from commercial payers.
NP’s are eligible for certification as Medicaid and Medicare providers, and generally receive favorable reimbursement from commercial payers.
References
http://academic.son.wisc.edu/wistrec www.wapa.org, www.aapa.org
http://www.nursingworld.org/ WI Regulatory Digest, www.nonpf.com www.wisconsinnurses.org
From the American Academy of Physician Assistants
Determining Physician Assistant Scope of Practice: A Summary of State Laws and Regulations
Physician assistants practice medicine with physician supervision. State laws, though, vary
somewhat on how the scope of a PA’s practice is determined. The majority of states allow the
physician-PA team to establish the scope for the PA, while some require that a regulatory board
set the scope of practice for PAs. Still others use some combination of these approaches. The
following chart provides at-a-glance information on how scope of practice is determined for PAs
in each state.
State Physician -
PA Team
Board Other /
Hybrid
Notes
AL
X
The PA is prohibited from performing any medical
service, procedure, function or activity which is not
specifically listed, in detail, in the job description
approved by the board.
AK X
“Examine, diagnose or treat” listed as general
description of scope
AZ
X List of duties in statute, but rules specify that physician
may delegate others
AR X
CA X
PA Committee Information Bulletin states: A
physician assistant may only provide those medical
services which: (1) he or she is competent to
perform, as determined by the supervising
physician, (2) are consistent with his/her education,
training, and experience, and (3) are delegated in
writing by the supervising physician responsible for
the patients cared for by the PA.
In accordance with these criteria and other
provisions set forth in the PA law and regulations,
and not withstanding any other provision of law, a
PA may work in any setting, and may provide any
medical service with the exception of certain
ophthalmological and dental procedures listed in
law.
CO X
CT X
Practice must be implemented in accordance with
written protocols established by supervising physician.
DE X
Physician assistants employed by health care facilities
must work under protocols approved by the board.
DC
X PAs may perform health care tasks that are delegated by
their SP(s), and that are within the PA’s skills and
within the physician’s scope of practice. Prior to the PA
beginning practice, the PA must file with the Board a
written delegation agreement using the form provided
by the Board.
State Physician -
PA Team
Board Other /
Hybrid
Notes
FL
X Physicians generally responsible for determining PA
scope, but several procedures listed in rule are
disallowed.
GA
X PA may perform tasks described in job description upon
notice of board’s approval. Tasks not in job description
may be performed under direct supervision and in
presence of supervising physician.
HI X
ID X
Scope of practice shall be defined in delegation of
services agreement and may include broad range of
diagnostic, therapeutic and health promotion and disease
prevention services.
IL X
Physician-PA team shall establish written guidelines that
are individual to PA in the practice setting.
IN X
It is the obligation of each physician-PA team to ensure
PA scope is identified, appropriate to the PA’s level of
competence and within the physician’s scope.
IA X
KS X
PA may perform acts which constitute the practice of
medicine and surgery when directly ordered, authorized
and coordinated by a responsible or designated physician
through
(a) immediate and physical presence; (b) when directly
ordered by supervising physician;(c) when authorized on
a form provided to the board by the responsible
physician; or (d) in an emergency situation.
KY
X Supervising physician must submit application describing
scope of medical services and procedures to be performed
by PA to board. PA’s scope may not exceed normal
scope of practice of supervising physician. Board may
impose restrictions.
LA
X Statutes and regulations allow for physician-PA team to
determine scope of practice. Board has issued numerous
advisory opinions in response to specific inquiries that
apply only to the individuals asking.
ME X
MD
X PA scope of practice limited to medical acts delegated by
the supervising physician, appropriate to the PA’s
education, training and experience, customarily in
supervising physician’s practice and consistent with
delegation agreement submitted to the board.
MA X
A physician may permit PAs to perform those services
which are within the competence of the PA as determined
by the physician’s assessment of the PA’s training or
experience and within the scope of services for which the
supervising physician can provide adequate supervision
to ensure accepted standards of medical practice are
followed.
MI X
PA may provide only those services that are within scope
of practice of supervising physician and are delegated by
supervising physician.
State Physician -
PA Team
Board Other /
Hybrid
Notes
MN X
Duties may include those delegated in the physician-PA
agreement.
MS
X PAs shall practice according to a Board-approved
protocol which has been mutually agreed upon by the
Physician Assistant and the supervising physician.
MO
X Statute lists permitted duties and includes such other
tasks not prohibited by law under the supervision of a
licensed physician as the PA has been trained and is
proficient to perform.
MT X
PA may diagnose, examine, and treat human conditions,
ailments, diseases, injuries, or infirmities, either physical
or mental, by any means, method, device or
instrumentality authorized by the supervising physician.
NE X
Supervising physician and PA must have written scope of
practice agreement delineating activities of PA and limits
of PA that is kept on file at practice and available for
review by department upon request. PA’s scope of
practice may include only those procedures in which
supervising physician is trained.
NV X
PA may perform such medical services as he is
authorized to perform by his supervising physician.
NH X
NJ
X Extensive list of duties in statute and rule, including other
procedures established by the employer provided
procedures are within training and experience of
supervising physician and PA; subject to board review.
NM X
NY X
NC X
ND X
PA may be involved with patients of the physician in any
medical setting for which the physician is responsible.
Under no circumstances shall the supervising physician
designate the PA to take over the physician’s duties or
cover the practice.
OH
X PA and supervising physician must have a supervision
agreement approved by the board prior to practice. When
practicing in a health care facility, the PA shall practice
in accordance with the policies of that facility. When
practicing outside a facility, the PA shall practice in
accordance with the board-approved agreement.
OK
X Statute and rules provide non-limiting list of duties as
well as illustrative guidelines. Also include the statement
that PA may provide health care services when services
are within PA’s skill, form component of physician’s
scope of practice, and are provided with supervision.
OR
X PA may perform at the direction of a supervising
physician and/or his agent only those medical services
that are included in the board-approved practice
description.
State Physician -
PA Team
Board Other /
Hybrid
Notes
PA
X PA may not provide medical service without a written
agreement with physician(s) which describes how PA
will assist, and which has been approved by the board.
PA may provide any medical service as directed by the
supervising physician, when the service is included in the
written agreement approved by the board.
RI X
SC X
PA must practice pursuant to written scope of practice
guidelines signed by supervising physician(s) and PA.
Guidelines to be on file at all practice sites. Must include
medical conditions for which therapies may be initiated,
continued, or modified, treatments that may be initiated,
continued, or modified, and situations that require direct
evaluation or immediate referral to physician.
SD X
Statute provides limiting list of PA duties but adds that
PA may be permitted to perform other tasks for which
adequate training and proficiency can be demonstrated.
TN X
Range of services provided by PA shall be set forth in a
written protocol jointly developed by the supervising
physician and the PA. The protocol shall contain
discussion of the problems and conditions likely to be
encountered by the PA and the appropriate treatment.
TX X
UT X
PA may provide any medical services not specifically
prohibited by law or regulations that are within his skills
and competence, within the supervising physician’s usual
scope of practice, and provided under physician
supervision in accordance with a delegation of services
agreement.
VT
X PAs may perform those duties and responsibilities,
including the prescribing and dispensing of drugs and
devices, that are delegated by supervising physician.
It is obligation of each PA/supervising physician team to
insure that written scope of practice submitted to board
for approval clearly delineates role of PA in medical
practice.
VA
X Each team of supervising physician and PA shall identify
PA’s scope of practice and delegated medical duties,
PA’s relationship with and access to physician, and
evaluation of PA’s performance.
Licensed physician or podiatrist may apply to the board
to supervise assistants and delegate certain acts which
constitute the practice of medicine to the extent and in the
manner authorized by the board.
WA
X
Physician assistant may perform those services as
outlined in standardized procedures reference and
guidelines established by commission. Requests for
approval of newly acquired skills shall be submitted to
commission and may be granted by a reviewing
commission member or at any commission meeting.
WV
X Board shall allow PA to perform those procedures and
examinations submitted in job description and approved
by the board.
WI
X PA may not exceed scope of patient services as set forth
in regulations, may not exceed scope of supervising
physician’s practice or own training and experience.
WY X
The PA may perform those duties and responsibilities
delegated to him by the supervising physician when the
duties and responsibilities are provided under the
supervision of board-approved physician, within the
scope of the physician’s practice and expertise and within
the skills of the PA.
The board does not recognize or bestow any level of
competency upon a physician assistant to carry out a
specific task. Such recognition of skill is the
responsibility of the supervising physician. However, a
physician assistant is expected to perform with similar
skill and competency and to be evaluated by the same
standards as the physician in the performance of assigned
duties.
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x30
Illi
nois
31
xx
xx
xx
xx
Ind
ian
a32
xx
xx
xx
xx
33
Iow
a34
xx
xx
x35
xx
Kan
sas3
6x
37
xx
xx
Ken
tuck
y38
x39
xx
xx
x40
xL
ou
isia
na4
1x
x42
x43
xx
xx
44
xM
ain
e45
x46
x47
xx
xx
xM
aryla
nd
48
xx
xx
xx
xx
Mas
sach
use
tts4
9x
xx
xx
xx
xx
Mic
hig
an50
x51
xx
52
xM
inn
esota
53
xx
xx
xx
xx
54
Mis
siss
ipp
i55
xx
xx
xx
xx
xM
isso
uri
56
xx
x57
xx
xM
onta
na5
8x
59
xx
xx
xx
Neb
rask
a60
x61
xx
xx
xx
xx
xN
evad
a62
xx
xx
xx
xN
ewH
amp
shir
e63
xx
xx
xx
xN
ewJe
rsey
64
xx
xx
xx
xx
65
New
Mex
ico
66
xx
xx
New
York
67
xx
x68
xx
xx
Nort
hC
aroli
na6
9x
xx
xx
xx
xx
xx
Nort
hD
akota
70
x71
xx
xx
xO
hio
72
xx
xx
xO
kla
hom
a73
x74
xx
xx
xx
75
Ore
gon
76
xx
xx
xx
UC
SF
Cen
ter
for
the
Hea
lth
Pro
fess
ions,
Fal
l2007
4
Over
sig
ht
Req
uir
emen
tsP
ract
ice
Au
thori
ties
2P
resc
rip
tive
Au
thori
ties
No
MD
Invo
lvem
ent
Req
’d
MD
Su
per
vis
ion
Req
’d
MD
Coll
abora
tion
Req
’d
Wri
tten
Pra
ctic
e
Pro
toco
l
Req
’d
Exp
lici
t
Au
thori
ty
to
Dia
gn
ose
Exp
lici
t
Au
thori
ty
toO
rder
Tes
ts
Exp
lici
t
Au
thori
ty
toR
efer
Au
thori
tyto
Pre
scri
be
w/o
MD
Invo
lvem
ent
Au
thori
tyto
Pre
scri
be
w/
MD
Coll
abora
tion
Wri
tten
Pro
toco
l
Req
’dto
Pre
scri
be5
Au
thori
tyto
Pre
scri
be
Con
troll
ed
Su
bst
ance
s
Nat
’l
Cer
tif.
Req
’d
Join
t
BoN
3/
BoM
4
Au
thori
ty
Pen
nsy
lvan
ia77
xx
xx
xx
78
xR
hod
eIs
lan
d79
xx
xS
ou
thC
aroli
na8
0x
xx
xx
xx
xx
Sou
thD
akota
81
xx
xx
x82
xx
Ten
nes
see8
3x
xx
xx
Tex
as84
xx
xx
xx
xx
Uta
h85
xx
xx
xx
Ver
mon
t86
xx
xx
xx
xx
Vir
gin
ia87
xx
xx
xx
xx
Was
hin
gto
n88
xx
xx
xx
xW
est
Vir
gin
ia89
xx
xx
xx
xW
isco
nsi
n90
xx
xx
xx
xx
Wyom
ing
91
xx
xx
xx
xT
OT
AL
S1
11
02
72
14
42
03
31
14
03
44
84
21
7
1R
efer
ence
s:1
)L
ind
aP
ears
on,
“The
Pea
rso
nR
epo
rt,”
The
Am
eric
an
Journ
alfo
rN
urs
eP
ract
itio
ner
s(F
ebru
ary
20
07
),htt
p:/
/ww
w.w
ebnp
.net
/im
ages/
ajn
p_
feb
07
.pd
f;2
)C
aro
lyn
Bup
per
t,N
urs
eP
ract
itio
ner
’sB
usi
nes
sP
ract
ice
and
Legal
Guid
e(T
hir
dE
dit
ion;
Jones
and
Bar
tlet
t2
008
);“J
oin
tR
egula
tio
no
fA
dvance
dN
urs
ing
Pra
ctic
e,”
U.S
.F
eder
alT
rad
e
Co
mm
issi
on
(20
07
),htt
p:/
/ww
w.f
tc.g
ov/o
s/co
mm
ents
/hea
lthca
reco
mm
ents
2/c
arso
nd
oc1
.pd
f.D
ata
up
dat
edb
yU
CS
FC
ente
rfo
rth
eH
ealt
hP
rofe
ssio
ns
inS
epte
mb
er2
00
7.
2Im
po
rta
nt:
The
Char
tis
des
igned
tob
ere
fere
nce
dfr
om
left
tori
ght.
Thus,
ifth
eC
har
tin
dic
ates
that
ph
ysi
cian
sup
erv
isio
no
rco
llab
ora
tio
nis
req
uir
ed,
then
NP
sm
ay
no
t
dia
gno
se,
ord
erte
sts
or
refe
rp
atie
nts
wit
ho
ut
ph
ysi
cia
nsu
perv
isio
no
rco
llab
ora
tio
n.
3B
oar
do
fN
urs
ing.
4B
oar
do
fM
edic
ine.
5A
bse
nt
exp
licit
stat
uto
ryo
rre
gula
tory
lan
guag
ere
quir
ing
ase
par
ate
wri
tten
agre
em
ent,
the
Char
td
oes
no
tin
dic
ate
that
aw
ritt
en
pre
scri
pti
ve
pro
toco
lis
req
uir
edin
stat
es
that
alre
ady
req
uir
eN
Ps
toes
tab
lish
wri
tten
pra
ctic
ep
roto
cols
wit
hp
hysi
cians.
See,
for
exam
ple
,M
aryla
nd
,M
assa
ch
use
tts
and
Ohio
.6
Ala
.C
od
e§
§3
4-2
1-8
0,
34
-21
-81
,3
4-2
1-8
6,
htt
p:/
/ww
w.a
bn
.sta
te.a
l.us/
main
/nurs
e-p
ract
ice-
act/
AR
TIC
LE
-5.p
df;
Ala
.A
dm
in.
Co
de
r.6
10
-X-2
-.0
5,
htt
p:/
/ww
w.a
bn.s
tate
.al.
us/
mai
n/d
ow
nlo
ads/
adm
in-c
od
e/C
hap
ter%
20
61
0-X
-2.p
df;
Ala
.A
dm
in.
Co
de
r.6
10
-X-5
,htt
p:/
/ww
w.a
bn.s
tate
.al.
us/
mai
n/d
ow
nlo
ads/
adm
in-c
od
e/C
hap
ter%
20
61
0-X
-5.p
df.
7A
lask
aS
tat.
§0
8.6
8.4
10
(1),
12
Ala
ska
Ad
min
.C
od
eti
t.1
2§
§4
4.4
30,
44.4
40
,44
.445
,htt
p:/
/ww
w.c
om
mer
ce.s
tate
.ak.u
s/o
cc/p
ub
/Nurs
ingS
tatu
tes.
pd
f.8
InA
lask
a,A
NP
s(a
dvan
ced
nurs
ep
ract
itio
ner
s)m
ust
have
five
yea
rso
fex
per
ience
inp
resc
rib
ing
bef
ore
they
may
app
lyfo
rau
tho
rity
top
resc
rib
eco
ntr
oll
edsu
bst
ance
s.1
2
Ala
ska
Ad
min
.C
od
eti
t.1
2§
44
.44
5.
9A
riz.
Rev.
Sta
t.§
32
-16
01
.15
,htt
p:/
/ww
w.a
zle
g.s
tate
.az.
us/
Fo
rmat
Do
cum
ent.
asp
?in
Do
c=/a
rs/3
2/0
16
01
.htm
&T
itle
=3
2&
Do
cTyp
e=A
RS
;
Ari
z.A
dm
in.
Co
de
§§
R4
-19
-40
2,
R4
-19
-50
8,
R4
-19
-51
1,
R4
-19
-51
2,
htt
p:/
/ww
w.a
zbn.g
ov/d
ocu
men
ts/n
pa/
LIN
KE
D-R
UL
ES
_JU
NE
%2
02
_2
00
7_
WE
B.p
df.
10
Ark
an
sas
law
dis
tin
guis
hes
bet
wee
nR
NP
san
dA
NP
s.T
he
Char
td
elin
eate
sth
eA
NP
’ssc
op
eo
fp
ract
ice.
Ark
.C
od
eA
nn.
§§
17
-87
-10
2,
17
-87
-302
,1
7-8
7-3
10
,
htt
p:/
/ww
w.a
rsb
n.o
rg/p
dfs
/pra
ctic
e_ac
t/N
UR
SE
PR
AC
TIC
EA
CT
_2
00
7__
5.p
df;
Po
siti
on
Sta
tem
ent:
Sco
pes
of
Pra
ctic
e,htt
p:/
/ww
w.a
rsb
n.o
rg/p
oss
itio
n_
st/9
5_
1.p
df;
Dif
fere
nce
bet
wee
nA
dvance
dN
urs
eP
ract
itio
ner
sand
Reg
iste
red
Nurs
eP
ract
itio
ner
s,htt
p:/
/ww
w.a
rsb
n.o
rg/p
dfs
/anp
&rn
bro
ch.p
df;
Ad
vance
dN
urs
eP
ract
itio
ner
,
htt
p:/
/ww
w.a
rsb
n.o
rg/p
dfs
/anp
bro
ch.p
df;
Fo
ur
Cat
ego
ries
of
Ad
van
ced
Pra
ctic
eL
icensu
re,
htt
p:/
/ww
w.a
rsb
n.o
rg/p
dfs
/4ca
tego
ries
.pd
f.11
InA
rkan
sas,
RN
Ps
must
pra
cti
ce“i
nco
llab
ora
tio
nw
ith
and
und
erth
ed
irec
tio
no
fa
lice
nse
dp
hysi
cian
or
und
erth
ed
irect
ion
of
pro
toco
lsd
evel
op
edw
ith
ap
hysi
cia
n.”
AN
Ps
wit
hp
resc
rip
tive
auth
ori
tym
ust
have
aco
llab
ora
tive
pra
ctic
eag
reem
ent
wit
ha
ph
ysi
cian.
Ark
.C
od
eA
nn.
§1
7-8
7-3
10
.12
InA
rkan
sas,
RN
Ps
may
no
tp
resc
rib
em
edic
atio
ns.
UC
SF
Cen
ter
for
the
Hea
lth
Pro
fess
ions,
Fal
l2007
5
13
Cal
.C
od
eo
fR
egs.
tit.
16
§§
14
80
(a),
148
5,
htt
p:/
/ww
w.r
n.c
a.go
v/r
egula
tio
ns/
titl
e16
.shtm
l;C
al.
Bus.
&P
rof.
Co
de
§§2
72
5,
27
25
.1,
28
36.1
,
htt
p:/
/ww
w.r
n.c
a.go
v/r
egula
tio
ns/
bp
c.sh
tml.
14
InC
alif
orn
ia,
the
stand
ard
ized
pro
ced
ure
(SP
)is
the
legal
mec
hanis
mfo
rA
PR
Ns
and
NP
sto
per
form
funct
ion
sth
atw
ould
oth
erw
ise
be
consi
der
edth
ep
ract
ice
of
med
icin
e.
SP
sm
ust
be
dev
elo
ped
coll
abo
rati
vel
yb
yth
enurs
ing,
med
icin
ean
dad
min
istr
ativ
ed
epar
tmen
tso
fth
ehea
lthca
resy
stem
wh
ere
they
wil
lb
euse
d.
Once
anS
Phas
bee
nsi
gned
by
the
nurs
e,p
hysi
cia
nand
faci
lity
,th
ep
ract
ice
isco
nsi
der
edin
dep
end
ent.
SP
sb
asic
ally
cov
erd
iagno
ses,
refe
rral
s,p
resc
rip
tio
ns
and
pro
ced
ure
sth
atin
vo
lve
pen
etra
tio
no
fti
ssue
funct
ions.
Pea
rso
n,
sup
ra,
no
te1
.15
InC
alif
orn
ia,
NP
sm
ay
“furn
ish”
or
“ord
er”
dru
gs.
Ho
wev
er,
they
may
no
t“p
resc
rib
e”d
rug
s.C
al.
Bus.
&P
rof.
Co
de
§2
83
6.1
.16
Co
l.R
ev.
Sta
t.§
§1
2-3
8-1
03
,1
2-3
8-1
11
.5,1
2-3
8-1
11.6
,htt
p:/
/ww
w.d
ora
.sta
te.c
o.u
s/N
UR
SIN
G/s
tatu
tes/
Nurs
ePra
ctic
eA
ct.p
df.
17
Co
nn.
Gen.
Sta
t.§
§2
0-8
7a,
20
-94
a,htt
p:/
/ww
w.c
ga.
ct.g
ov
/20
07
/pub
/Chap
37
8.h
tm;
Ad
van
ced
Pra
ctic
eR
egis
tere
dN
urs
eL
icen
sure
,htt
p:/
/ww
w.c
t.go
v/d
ph/c
wp
/vie
w.a
sp?a=
31
21
&q
=3
894
00.
18
Del
.C
od
eA
nn.
tit.
24
§1
902
,htt
p:/
/del
cod
e.d
elaw
are.
go
v/t
itle
24
/c0
19
/ind
ex.s
htm
l;
Del
.R
egis
ter
of
Reg
s.ti
t.2
4§§
8.0
-8.1
8,
htt
p:/
/reg
ula
tio
ns.
del
aw
are.
go
v/A
dm
inC
od
e/ti
tle2
4/1
900
%2
0B
oar
d%
20
of%
20
Nurs
ing.s
htm
l#T
op
OfP
age.
19
Del
aw
are
law
dis
tin
guis
hes
bet
wee
n“m
edic
ald
iag
no
ses”
and
“nurs
ing
dia
gno
ses.
”D
el.
Co
de
Ann.
tit.
24
§1
90
2.
20
InD
elaw
are,
anN
Pm
ay
only
refe
rp
atie
nts
too
ther
pro
vid
ers
ifau
tho
rize
du
nd
era
wri
tten
coll
abo
rati
ve
agre
em
ent
wit
ha
ph
ysi
cian.
Del
.R
egis
ter
of
Regs.
tit.
24
§8
.6.2
.14
.21
D.C
.M
un.
Reg
s.ti
t.1
7,
Ch.
59
,htt
p:/
/hp
la.d
oh.d
c.go
v/h
pla
/fra
mes.
asp
?d
oc=
/hp
la/l
ib/h
pla
/pro
f_li
cense
/ser
vic
es/
pd
ffil
e/nurs
ing/n
urs
e_p
ract
itio
ner
__
chap
_5
9_
regs_
8-1
0-0
5.p
df;
D.C
.C
od
eA
nn.
§§
3-1
20
1.0
2,3
-12
06
.01
,3
-12
06
.03
,3
-12
06.0
4,
3-1
20
6.0
8.
22
Fla
.S
tat.
§§
46
4.0
03,
464
.01
2,
Fla
.A
dm
in.
Co
de
Ann.
64
B9
,htt
p:/
/ww
w.d
oh.s
tate
.fl.
us/
mq
a/n
urs
ing/i
nfo
_P
ract
iceA
ct.p
df;
Fre
quen
tly
Ask
edQ
uest
ions,
htt
p:/
/ww
w.d
oh.s
tate
.fl.
us/
mq
a/nurs
ing/n
ur_
faq
.htm
l#A
RN
P;
200
6L
egis
lati
ve
Chan
ges
for
Nurs
ing,
htt
p:/
/ww
w.d
oh.s
tate
.fl.
us/
mq
a/n
urs
ing/i
nfo
_le
gis
um
mer
ies.
pd
f.23
Ga.
Co
mp
.R
.&
Reg
s.§
41
0-1
2-.
03
,htt
p:/
/so
s.geo
rgia
.go
v/a
cro
bat
/PL
B/R
ule
s/chap
t41
0.p
df;
Ga.
Co
de
Ann.
§§
43
-26
-3,
43
-34
-26
.1,4
3-3
4-2
6.3
,htt
p:/
/ww
w.l
exis
-
nex
is.c
om
/ho
tto
pic
s/gac
od
e/d
efau
lt.a
sp.
24
InG
eorg
ia,
ap
hysi
cian
may
del
egat
eth
eauth
ori
tyto
per
form
cert
ain
med
ical
acts
und
era
nurs
ep
roto
col
agre
em
ent.
Ga.
Co
de
An
n.
§4
3-3
4-2
6.3
.25
InG
eorg
ia,
the
Bo
ard
of
Med
ical
Exam
iner
sp
rom
ulg
ates
the
rule
san
dre
gula
tio
ns
for
the
nurs
ep
roto
col
agre
ement.
Ga.
Co
de
An
n.
§4
3-3
4-2
6.1
(c).
26
Haw
.R
ev.
Sta
t.§
§4
57
-8.5
,45
7-8
.6,
htt
p:/
/ww
w.h
aw
aii.
go
v/d
cca/
area
s/p
vl/
main
/hrs
/;H
aw
.A
dm
in.
R.
§§
16
-89
,1
6-8
9C
,htt
p:/
/ww
w.h
aw
aii.
go
v/d
cca/
area
s/p
vl/
mai
n/h
ar/.
27
The
rule
sto
imp
lem
ent
NP
auth
ori
tyto
pre
scri
be
contr
oll
edsu
bst
ance
sar
ecu
rrentl
yb
ein
gd
raft
ed.
See,
ww
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State of Oncology PracticeResults of the ASCO Study of CollaborativePractice Arrangements
By Elaine L. Towle, CMPE, Thomas R. Barr, MBA, Amy Hanley, Michael Kosty, MD,Stephanie Williams, MD, and Michael A. Goldstein, MD
Oncology Metrics, a division of Altos Solutions, Los Altos, CA; American Society of Clinical Oncology, Alexandria, VA; Scripps Clinic,La Jolla, CA; Hematology Oncology Associates of Illinois, Chicago, IL; Beth Israel Deaconess Medical Center, Boston, MA
See article in Journal of Clinical Oncology 29:3599-3600, 2011
AbstractPurpose: ASCO projects a shortfall of oncologists in the nextdecade. The study was designed to address the workforceshortage by exploring collaborative oncology practice modelsthat include nonphysician practitioners (NPPs).
Methods: ASCO contracted with Oncology Metrics, a division ofAltos Solutions, to conduct a national survey of NPP integration andidentify collaborative practice models and services provided byNPPs, as the first phase of the ASCO Study of Collaborative Prac-tice Arrangements. Results of the national survey were used toidentify practices for the next phase, in which selected practicesparticipated in a more detailed data survey and satisfaction surveys.Focus groups or interviews were conducted with NPPs to collectadditional subjective information to inform the project.
Results: The incident-to practice model was the predominantmodel. Satisfaction was universally high for patients and gener-ally high for physicians and NPPs. In virtually all cases (98%),patients recognized they were seeing an NPP rather than a phy-sician. Practices in which the NPP worked with all practice phy-sicians showed significantly higher productivity than thosepractices in which the NPP worked exclusively with a specificphysician or group of physicians.
Conclusion: The use of NPPs in oncology practices increasesproductivity for the practice and provides high physician and NPPsatisfaction. Patients were aware when care was provided by anNPP and were very satisfied with all aspects of the collaborative carethat they received. The integration of nonphysician practitioners intooncology practice offers a reliable means to address increased de-mand for oncology services without adding physicians.
IntroductionASCO projects a shortfall of oncologists in the next decade,with the demand for oncologists outpacing the supply ofnew oncologists going into clinical practice. Demand forvisits to oncologists is expected to increase 48% by 2020,whereas supply will rise by only 14%. The doubling of thenumber of Americans 65 years and older and an 81% in-crease in people living with, or surviving, cancer will drivethis demand.1
ASCO’s Workforce Advisory Group has suggested that ex-panded use of nonphysician practitioners (NPP)—generallynurse practitioners and physician assistants in the oncologypractice setting—has the potential to extend the supply of on-cologist services, particularly in the context of ongoing care andcare for the growing number of cancer survivors. Better integra-tion of NPPs also could improve practice quality and efficiencyand, by better balancing workload and skills, may increase pro-fessional satisfaction for providers.
The ASCO Study of Collaborative Practice Arrange-ments (SCPA) was designed to address the workforce short-age by exploring collaborative practice models betweenoncologists and NPPs. The goals of the SCPA were to inven-tory and describe model practices for collaboration betweenoncologists and NPPs; document the impact of collaborativepractice models on practice productivity and efficiency; and
document the impact of collaborative practice models onpatient, oncologist, and NPP satisfaction. ASCO contractedwith Oncology Metrics, a division of Altos Solutions (LosAltos, CA), to conduct this study.
MethodsThe SCPA was launched in March 2009 with a national survey ofoncology practices. This brief survey identified practices that haveintegrated NPPs across a range of practice types (eg, physician-owned private practice, hospital-owned practice, academic) andidentified the collaborative practice model and services provided bythe NPPs in each of the responding practices. A total of 226 prac-tices participated in the survey (“survey group”).
Results of the national survey were used to identify practicesfor the next phase of the SCPA, a more in-depth study ofpractices. The primary goal of practice selection was diversity.In an attempt to increase the number of hospital-owned prac-tices in the study, we reached out to the Association of CancerExecutives, a national organization whose members are primar-ily cancer program administrators in institution-based pro-grams, and with their assistance added several practices to thesurvey group. Practice size, geographic location, and collabora-tive practice model were evaluated, and selected practices werethen invited to participate in the study. Thirty-three practiceswere initially chosen for participation (“study group”). Study
Special Series
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requirements included submission of practice data such as staff-ing information, visit volumes, and practice expense data; com-pletion of physician and NPP satisfaction surveys; anddistribution of patient satisfaction surveys. The SCPA wasgranted an exemption from review by the New England Insti-tutional Review Board in Cambridge, MA.
A second survey was administered to the study group to furtherrefine the practice information and begin analysis of practice efficiencymeasures.Datawerecollectedforadiscrete6-monthperiod.Objectivedata elements collected in this survey included units of service pro-vided, total practice expense, and total drug expense.
Satisfaction with the collaborative practice model in eachpractice was measured through surveys of physicians, NPPs,and patients. Physicians and NPPs were invited to participate ina brief online satisfaction survey. Several follow-up contactswere made to the practitioners to increase participation. Patientsatisfaction was measured by using an anonymous paper-basedsurvey instrument that was provided to each practice in thestudy group for distribution. Practices were instructed to haveNPPs distribute the surveys to all patients being seen by theNPP on a given day. This ensured that the patients participating inthe study were indeed receiving care in a collaborative practicemodel. Patients were instructed to complete the survey at homeand return it in a stamped, self-addressed envelope. Patient surveyswere mailed to an independent third-party survey organization fordata aggregation. At the completion of the data collection phase ofthe study, focus groups and individual interviews were completedwith NPPs from the study group practices to collect qualitativeinformation to further inform the project.
Results and Discussion
DemographicsThe survey group included respondents from 226 practices in43 states. The majority (73%) of the respondents were fromphysician-owned private practices; academic practices (8%),hospital-owned practices (12%) and other types (7%) were alsorepresented. As a first step in identifying practices appropriate
for the study group, respondents were asked whether they em-ploy NPPs in their medical oncology practice; 58% of the sur-vey group respondents said yes.
Although not a primary goal of the project, respondents whodid not use NPPs were asked to indicate their primary reasonfor not doing so. The most prevalent responses included “phy-sicians are not interested in working with NPPs,” “we do nothave the patient volume to support an NPP,” and “we haveworked with NPPs in the past and it didn’t work out.”
Practices in the study group were selected from the surveygroup. The primary goal of practice selection was to achieve varietyin practice size, structure, and geographic distribution. Thirty-three practice sites in 24 states agreed to participate. Approximately40% of the study group practices were from the midwest, 30%from the east coast, 20% from the west, and 10% from the south.Two sites withdrew very early in the study, one small practicebecause their only NPP left the practice, the second because ofreluctance to share data required for the study. Of the 31 remainingpractice sites, 27 provided complete data for the study.
Similar to the survey group, the majority (84%) of the studygroup practices were physician-owned private practices; 16% werehospital-owned practices. Academic practices were excluded fromthe study group at the direction of the Workforce Advisory Group.
Practices were instructed to indicate the services routinelyprovided by NPPs from a list of 15 options. Figure 1 shows thepercentage of respondents providing services in each of the listedcategories for both the survey group and the study group. As can beobserved here, results for the two groups are remarkably consistent,particularly for the services most frequently provided. Figure 2shows the training model used by both the survey and studygroups, and once again the results are remarkably consistent be-tween the two. Other data in the study showed these same similar-ities. Although the study group data set is small, we believe thestudy group is representative of the larger survey group.
Practice ModelsBuswell et al2 reported results from a single-institution aca-demic practice study of provider practice models in July 2009.
Assist patients during treatment visits
Pain and symptom management
Follow-up care for patients in remission
Patient education and counseling
Address emergent care
End-of-life/hospice care
Order routine chemotherapy
Provide non–cancer-related primary care for…
Assist with consultations
Inpatient hospital rounds
Research-related activities
Procedures (eg, bone marrow bx)
Night or weekend call
Survivorship clinics
Other
Survey groupStudy group
%001%0 90%80%70%60%50%40%30%20%10%
Figure 1. Services provided by nonphysician practitioners. bx, biopsy.
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In that article, the authors defined three practice models: theindependent visit model, the shared visit model, and the mixedvisit model. We revised these models to apply more closely topractice style in the physician office and hospital settings. Sur-vey respondents were asked to identify their practice modelfrom three descriptive options; responses were then categorizedinto one of three collaborative practice models.
• In the incident-to practice model (ITPM), NPPs routinelysee patients independent of the physician. The physician isgenerally present in the office suite but does not routinelysee patients with the NPP.
• In the shared practice model, NPPs always see patients inconjunction with the physician.
• In the independent practice model, NPPs see patients com-pletely independent of the physician. Patients are assignedto the NPP and not assigned to an oncologist.
The ITPM is the prevalent model in both the survey group andthe study group (Appendix Table A1, online only). This isclearly a response to the increasingly challenging economic en-vironment for oncology practices today. In the ITPM, NPPs seepatients independent of the physician but with a physician pres-ent and available in the office if needed. The NPPs follow a careplan developed by the physician and consult with the physicianas necessary. In many practices that use this model, patientsalternate visits between the NPP and the physician on a prede-termined schedule. This allows both the NPP and physician tomaximize their patient schedules. Importantly, in the privatepractice setting, the ITPM allows practices to bill Medicare forNPP services as though they were rendered by the physician andto receive reimbursement at the full physician fee schedule rate,rather than at 85% of the physician fee schedule as would be re-quired if the services were billed under the NPP’s own providernumber. The ITPM not only provides access to both the NPP andphysician at alternating visits, but also maximizes reimbursement,an important consideration for today’s oncology practice.
In addition to the collaborative practice model, respondentswere also asked to report on their collaborative style. Collabor-
ative styles were characterized as “all” when the NPPs work withall practice physicians and see a wide variety of patients (approx-imately 60% of the study group practices), or “exclusive” whenthe NPPs work exclusively with a specific physician (or physi-cians) and see only their patients (35% of study group prac-tices). The remaining 5% indicated that their NPPs generallywork with specific physicians but there is not exclusivity.
SatisfactionAs previously stated, one goal of the SCPA was to document theimpact of collaborative practice models on patient, oncologist,and NPP satisfaction. Patient satisfaction was measuredthrough the use of an anonymous paper-based survey instru-ment that was distributed to patients by NPPs in the studygroup practices during patient visits. Surveys were completedand returned by 1,538 patients in the original 33 practice sites;data are presented for 1,237 patients in the 27 sites that pro-vided complete data for the study.
Patients were first surveyed to assess the level of their aware-ness that an NPP was providing clinical service to them. Theaverage of patient awareness for the study group was 98%. Thedata reveal that in every study site the overwhelming majority ofthe patients who responded to this question were aware thatthey received treatment from an NPP.
Eight dimensions of patient satisfaction with their care ina collaborative practice model were measured in the survey.Each response was assigned a numerical value ranging from�2 for “highly satisfied, ” “excellent,” or “highly likely torecommend” to �2 for “highly dissatisfied, ” “poor,” or“highly unlikely to recommend.” For each of these ques-tions, adding the ratings of each respondent from the prac-tice to each question and then dividing the sum by the totalnumber of respondents generated a weighted satisfactionscore. Because �2 would indicate that every respondentrated at the highest possible level of satisfaction, a score of 16represents perfect satisfaction on every dimension. The av-erage overall satisfaction score for patients in all study sites
Practice uses an informal/on-the-job-trainingprogram for all new NPPs.
Practice hires only NPPs with previous onc/heme experience; they require little training.
Other
Practice has designed a formal training programfor use with all new NPPs.
Practice uses resources developed by others fortraining all new NPPs.
Survey groupStudy group
%07%0 60%50%40%30%20%10%
Figure 2. Training for new nonphysician practitioners (NPPs).
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was 14.8 or 92.5%; patients were extremely satisfied with theservice that they received at every study site.
Six dimensions of physician satisfaction with their collabor-ative practice model were measured by using an online satisfac-tion survey tool. As with the patient satisfaction survey, eachresponse was assigned a numerical value for analysis. Responsesfor four questions ranged from �2 to �2, with the same ratingdescriptors used for patient satisfaction; two questions had athree-point range, with �1 as the highest possible score and �1the lowest. The physician score for each question was added tocalculate a total for all physicians at each study site. That sumwas then divided by the number of physicians to get the averagefor the responding physicians at the site. A score of 10 repre-sents perfect satisfaction. Although patient satisfaction was uni-versally high in every dimension at every study site, physiciansatisfaction varied from site to site. The average overall physi-cian satisfaction score for the study group was 7.98, or 79.8%.
Five dimensions of NPP satisfaction with the collaborativepractice model were measured. As with the patient and physi-cian satisfaction scores, the NPP score for each question wasadded to calculate a total for all NPPs at each study site. Thatsum was then divided by the number of NPPs to get the averagefor the responding NPPs at the site. For each of the five ques-tions, 10 represents perfect satisfaction on every dimensionmeasured. As was observed with the measurement of physiciansatisfaction, there is some variation in NPP satisfaction; theaverage overall NPP satisfaction score was 7.82, or 78.2%.There is no correlation (coefficient of correlation � 0.16) be-tween the physician and NPP satisfaction scores.
Perception of WorkloadIn addition to measuring satisfaction, we also asked physiciansand NPPs in the study group to indicate their perception oftheir own workload (Figure 3). The majority (58%) of physi-cians responded that their workload was too busy. Conversely,slightly more than 50% of NPPs said that their workload wasabout right, and another 33% felt they were not busy enoughand could see more patients.
ProductivityAnother goal of the SCPA was to document the impact ofcollaborative practice models on practice productivity and effi-ciency. Study group practices reported the number of patientencounters for selected evaluation and management codes for a6-month reporting period. The total number of patient encounterswas divided by the total number of full-time equivalent (FTE)providers, defined as physicians and NPPs. Productivity was re-ported at the provider level for each practice. We then looked at thecorrelation between perception of workload and productivity asmeasured by the number of patient encounters per FTE provider(Figure 4).
As shown in Figure 4, there is no correlation between thesubjective perception and objective measurement of workload.Larger gold circles, indicating higher productivity per FTE pro-vider, appear in the upper right quadrant (could be busier);smaller red circles, indicating lower productivity, appear in the
lower left quadrant (too busy). It appears that being busy rein-forces the idea that more patients could be seen; five of the ninepractices that produced higher than average patient encountersper FTE provider felt they could be even busier. Conversely,being less busy is associated with the subjective perception ofbeing able to see fewer patients, as demonstrated by three of theeight practices with lower than average productivity.
Collaborative Style and ProductivityWe also analyzed the correlation between collaborative styleand productivity. The average number of patient encountersper FTE provider for the group in which the collaborative stylewas “exclusive” (NPPs work exclusively with specific physi-cian(s) and see only their patients) was 897 � 146 in the6-month observation period, with 95% confidence. The aver-
NPPsPhysicians
Not busy enough; could see
more patients
About right Too busy; workload should
be reduced
Pere
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60
40
30
20
10
0
Figure 3. Perception of workload among physicians and nonphysicianpractitioners (NPPs).
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--->
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Figure 4. Perception of workload and patient encounters per full-timeequivalent (FTE) provider. Each circle represents a practice; their sizeand color indicate practice productivity based on the number of patientencounters per FTE provider in the reporting period. The smaller redcircles indicate below average productivity; blue is average; and thelarger gold circles indicate greater than average productivity. The hori-zontal axis reflects the nonphysician provider (NPP) perception of work-load and the vertical axis the physician perception. Circles in the upperright quadrant represent sites where both physicians and NPPs thinkthey could see more patients. Circles in the lower left quadrant repre-sent sites where both the physicians and the NPPs think they are seeingtoo many patients.
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age number of patient encounters per FTE provider for thegroup in which the collaborative style was “all” (NPPs workwith all practice physicians and see a wide variety of patients) was1,066 � 146 in the observation period, with 95% confidence. Thedifference represents a productivity increase of 19% in favor of thesites where NPPs work with all physicians (Figure 5).
ConclusionAlthough there are many interesting observations to be madefrom the data collected in this study, there are five importantconclusions. First, oncology patients are aware when care isprovided by an NPP and are very satisfied with the care theyreceive in a collaborative practice model. This is evidence thatsuch collaborative practice arrangements are well accepted bypatients, and we believe there should be no lingering concernsthat patients will react negatively to oncology care provided bynonphysician practitioners in a collaborative practice model.
Second, practices in which the NPPs work with all practicephysicians and see a wide variety of patients demonstrate a 19%increase in productivity as measured by patient encounters perFTE provider compared with practices in which NPPs workexclusively with one or more physicians in the practice.
Next, in both the survey group and the study group, reim-bursement economics appear to drive the selection and devel-opment of the collaborative practice. This is evidenced by theprevalence of the incident-to practice model in this study.
Another important conclusion is that there is little observedcorrelation between the subjective perception of workload andthe objective measure of work production. Five of the ninepractices that produced higher than average patient encountersper FTE provider indicated that they could be even busier.Conversely, three of the eight practices with lower than averageproductivity reported that they were too busy.
Finally, physician and NPP satisfaction with their collabor-ative practice model is high, indicating a positive professional
experience. Taken together, these findings provide strong sup-port for the inclusion of NPPs in oncology practices.
Accepted for publication on July 15, 2011.
AcknowledgmentThis study was funded by Susan G. Komen for the Cure and conductedfor ASCO. Analysis was conducted by Oncology Metrics, a division ofAltos Solutions, under the guidance of the ASCO Workforce AdvisoryGroup. We thank members of the ASCO Workforce Advisory Group fortheir participation in this project, including Michael A. Goldstein, MD,Co-Chair, Beth Israel Deaconess Medical Center, Boston, MA; DeanBajorin, MD, Co-Chair, Memorial Sloan-Kettering Cancer Center, NewYork, NY; Michael P. Kosty, MD, Scipps Clinic, La Jolla, CA; R. StevenPaulson, MD, Baylor Charles A. Sammons Cancer Center, Dallas, TX;Kathleen W. Beekman, MD, Ypsilanti, MI; Patrick A. Grusenmeyer, ScD,Helen F. Graham Cancer Center, Newark, DE; Gladys I. Rodriguez, MD,South Texas Oncology Hematology, San Antonio, TX; Stephanie F.Williams, MD, Hematology-Oncology Associates of Illinois, Chicago, IL.We also thank Suanna Bruinooge and M. Kelsey Mace for their contri-butions to the study.
Authors’ Disclosures of Potential Conflicts of InterestAlthough all authors completed the disclosure declaration, the followingauthors indicated a financial or other interest that is relevant to thesubject matter under consideration in this article. Certain relationshipsmarked with a “U” are those for which no compensation was received;those relationships marked with a “C” were compensated. For a de-tailed description of the disclosure categories, or for more informationabout ASCO’s conflict of interest policy, please refer to the AuthorDisclosure Declaration and the Disclosures of Potential Conflicts ofInterest section in Information for Contributors.
Employment or Leadership Position: Elaine L. Towle, OncologyMetrics, a division of Altos Solutions (C); Thomas R. Barr, OncologyMetrics, a division of Altos Solutions (C) Consultant or Advisory Role:None Stock Ownership: None Honoraria: None Research Funding:None Expert Testimony: None Other Remuneration: None
Author ContributionsConception and design: Elaine L. Towle, Thomas R. Barr, AmyHanley, Michael Kosty, Stephanie Williams, Michael A. GoldsteinAdministrative support: Elaine L. Towle, Thomas R. Barr, AmyHanleyProvision of study materials or patients: Elaine L. Towle, ThomasR. BarrCollection and assembly of data: Elaine L. Towle, Thomas R. BarrData analysis and interpretation: Elaine L. Towle, Thomas R. Barr,Michael Kosty, Michael A. GoldsteinManuscript writing: Elaine L. Towle, Thomas R. Barr, Amy Hanley,Michael Kosty, Stephanie Williams, Michael A. GoldsteinFinal approval of manuscript: Elaine L. Towle, Thomas R. Barr, AmyHanley, Michael Kosty, Stephanie Williams, Michael A. Goldstein
Corresponding author: Elaine L. Towle, CMPE, Oncology Metrics, LLC,351 Fremont Rd, Chester, NH 03036; e-mail: [email protected].
DOI: 10.1200/JOP.2011.000385
References1. Erikson C, Salsberg E, Forte G, et al: Future supply and demand for oncolo-gists: Challenges to assuring access to oncology services. J Oncol Pract 3:79-86,2007
2. Buswell LA, Ponte PR, Shulman LN: Provider practice models in ambulatoryoncology practice: Analysis of productivity, revenue, and provider and patientsatisfaction. J Oncol Pract 5:188-192, 2009
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Filling the Gap: Development of the Oncology NursePractitioner Workforce
By Brenda Nevidjon, MSN, RN, FAAN, Paula Rieger, RN, MSN, AOCN, FAAN,Cynthia Miller Murphy, MSN, RN, CAE, Margaret Quinn Rosenzweig, PhD, FNP-BC, AOCNP,Michele R. McCorkle, RN, MSN, and Kristen Baileys, RN, MSN, CRNP, AOCNP
Duke University School of Nursing, Durham, NC; Oncology Nursing Society; and University of Pittsburgh School of Nursing,Pittsburgh, PA
One goal of the ongoing health care reform debateis to increase access to care through insurance re-form. In contradistinction to these efforts, thefuture shortage of health care professionals will
clearly limit such access. In cancer care, shortages of health careprofessionals will occur in conjunction with a growing olderpopulation, expanded treatment options, and increased cancersurvivorship.1,2 Cancer care is distinguished by its inter-professional and multispecialty model. The ASCO Fall 2008Workforce Statement urged development of the workforce toensure continuous delivery of high-quality cancer care.3 Devel-oping new strategies for oncology care delivery by increasingthe numbers and expanding the roles of nonphysician practi-tioners, such as nurse practitioners (NPs) and physician assis-tants (PAs), is critically important to meet the current andpotential cancer care needs of the US population. There aredifferences that each discipline brings, and this article willpresent an overview of advanced practice registered nurses(APRNs) in oncology and demonstrate potential collaborativeopportunities for the Oncology Nursing Society (ONS) andASCO in closing the gap between demand and supply.
Advanced Practice NursesThere are four distinct advanced practice nursing roles: NP,clinical nurse specialist (CNS), nurse midwife, and nurse anes-thetist. The two APRN roles in oncology are CNS and NP. TheCNS functions as a clinical expert, consultant, educator, men-tor, researcher, and institutional change agent. The NP mayshare some of these roles, but his or her primary role is individ-ual patient care management.
NPs, in general, have grown in number and capabilities overthe past several years. They are licensed independent practitio-ners who have been educated at the graduate level, with a min-imum of a master’s degree. Traditionally, NP education hascovered a broad spectrum of patient populations but lackedconcentrated attention to specific diseases. A majority of NPsworking in the oncology setting have completed graduate pro-grams that did not focus on the specialty (Oncology NursingCertification Corporation [ONCC] 2008 survey, data not pub-lished). Cancer care reaches across all patient populations, mak-ing no NP educational preparation (eg, family, adult, acutecare, and women’s health) entirely adequate for the care ofpatients with cancer and their families. Although all APRNshave been educated in at least one age-specific population, some
are additionally prepared to work in a subspecialty, such asoncology. However, only a minority of accredited NP programsin the United States offer a specialty in oncology.4
Currently, a master’s degree is the entry-level educationalrequirement for NPs. An emerging NP educational path is thedoctor of nursing practice degree. In its Statement on the Prac-tice Doctorate in Nursing, the National Organization of NursePractitioner Faculties recognized the practice doctorate as “animportant evolutionary step for the preparation of NPs,” whichit expects “will become the future standard for entry into NPpractice.”5 Some of the factors building momentum for thischange in nursing education at the graduate level include therapid expansion of knowledge underlying practice; the in-creased complexity of patient care; national concerns about thequality of care and patient safety; and shortages of nursingpersonnel, which demand a higher level of preparation.6 Nurs-ing education is moving in a direction similar to those of otherhealth professions, such as pharmacy (PharmD), psychology(PsyD), physical therapy (DPT), and audiology (AudD), whichall offer practice doctorates.6
RegulationEach state board of nursing independently determines the re-quirements for entry into practice and the legal scope of practicefor NPs. This variability limits the mobility of NPs in practicingfrom state to state as well as patient access to the care providedby NPs. Of most concern is variability in the legal scope ofpractice for NPs from state to state, including prescriptive au-thority, admitting privileges, and other functions, which in turnalso affect reimbursement.7 In 2004, a national work groupcomprising representatives from nursing education, certifica-tion, accreditation, and regulation began a process to establish aconsensus model for advanced practice nursing regulation. In2008, a new model for the regulation of advanced practicenurses was launched, and 46 nursing organizations have en-dorsed it to date. The model is to be fully adopted by 2015.Under the new model, all advanced practice nurses, includingNPs, are licensed as independent practitioners who have com-pleted an accredited graduate education program with a focuson a specific patient population. They hold board certificationat the population level, and this certification is required by thestate board of nursing for regulatory purposes. The graduateeducation program may include an emphasis on a specialty(eg, oncology) beyond the population level (eg, adult). How-
Feature Article
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ever, these competencies must be taught in addition to thecompetencies at the population level and assessed in a separatecertification examination.8
Specialty certification for NPs became available in 2005 (seeBoard Certification for Oncology Nurse Practitioners). How-ever, in the future, specialty certification will not be required atthe regulatory level. This is similar to requirements for physi-cians, wherein licensure is based on the general medical boardexamination, and specialty board certification is required in theworkplace but not by state regulatory medical boards. Underthis model, the oncology NP of the future will attain graduateeducation imparting competencies focused on a broad popula-tion-based area, which will qualify the graduate to take theboard certification examination in that area (eg, adult or fam-ily). This certification will be the proxy for licensure as an adultor family NP. Ideally, the graduate program will also includedidactic and clinical courses in oncology, qualifying the NP totake the board certification examination in oncology, whichwill be a requirement in the oncology workplace. For those whodo not attain the oncology competencies in the graduate pro-gram, alternate educational strategies, such as those described inthis article, will be needed to attain the knowledge, skills, andabilities to competently practice in oncology.
Role of the APRN in the InterdisciplinaryCancer Care TeamNursing represents the largest segment of the US health careworkforce and therefore has a significant role in patient care.The oncology NP (ONP) has been providing care in a variety ofprimary, acute, and tertiary settings, including physician prac-tices. ONPs are also beginning to practice at nontraditional
health care sites, such as survivorship and symptom manage-ment clinics as well as high-risk and early detection clinics,demonstrating the unique skills ONPs have to offer in thedelivery of quality cancer care. In multiple care settings, evi-dence has demonstrated the cost effectiveness, patient satisfac-tion, and quality care outcomes produced by NPs, promptingthis growth of ONPs in cancer care.9-13 Improved outcomeshave been documented in quality of life and cost outcomes inbreast cancer care,14 but these must be further clarified in im-portant subspecialties such as cancer survivorship.15
NPs are uniquely educated at the master’s or doctoral levelto provide quality care within a comprehensive health promotionframework.5 Equivocal or superior patient outcomes by advancedpractice nurses in primary,16 acute specialty,17 and home-basedcancer care18 have been well documented. Particular strengths ofNPs are patient education, communication, duration of visits,16
and adherence to evidence-based practice guidelines.
Gaps in Learning Needs:The ONP PerspectiveA descriptive analysis of NP learning needs was conducted by anational panel convened by ONS to address educational needsfor NPs on entry to cancer care.19 A survey of 104 self-describedONPs was conducted through ONS in June 2009 to determinethe educational gaps experienced by NPs on entry to practice incancer care. The respondents reported they were well preparedfor the foundational NP skills of obtaining a history, perform-ing a physical exam, and writing and presenting a patient case.The clinical practice components for which the ONPs feltpoorly prepared were specific to cancer care. The followingitems ranked as “not at all prepared” by the highest level ofrespondents included oncology-specific procedures such asbone marrow biopsies, thoracentesis, paracentesis, and lumbarpunctures; chemotherapy/biotherapy competency; billing andreimbursement; and recognition and management of oncologicemergencies. The manner in which the respondents learnedthese clinical skills was most often via collaborating/supervisingphysician (80.8%) and self study (61.5%) and less often viacollaborating/supervising NP (34.6%) and institutional training/orientation (26.9%).
These results have implications for hiring institutions andsupervising physicians.20 Although it is reasonable to assumethat invasive-procedure psychomotor skills will be obtained inmentored, supervised on-the-job training, other content areassuch as competency in chemotherapy and biotherapy and rec-ognition and management of oncologic emergencies are criti-cally important components of cancer care and cannot betaught on the job for NPs practicing with a high level of auton-omy and patient care responsibility.
Improving and standardizing the cancer care educationavailable to NPs entering oncology is essential to providingoptimal, safe cancer care. Innovative approaches must be em-ployed to assist NPs in gaining the knowledge and skills theyneed to competently practice in the oncology setting. This canbe accomplished through extensions of current graduate educa-tion programs and continuing education programs and work-
Board Certification for OncologyNurse Practitioners
• Administered by the Oncology Nursing CertificationCorporation, an independent certifying body affiliatedwith the Oncology Nursing Society
• To be eligible for the Advanced Oncology CertifiedNurse Practitioner (AOCNP) examination, a nursemust hold a valid, active, unrestricted registered nurselicense and must have attained a minimum of a mas-ter’s degree in nursing, completed an accredited nursepractitioner (NP) educational program, and com-pleted a minimum of 500 hours of supervised clinicalpractice as an oncology NP
• Administered at computer testing sites throughout theUnited States and available year round
• Currently, 652 NPs hold AOCNP certification• NPs renewing AOCNP certification have the option of
again passing the certification examination or document-ing 125 points of professional development every 4 years
• Visit http://www.oncc.org for details and moreinformation
Oncology NP Workforce DevelopmentOncology NP Workforce Development
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shops. ONS has developed entry-level competencies for ONPsthat can be used as outcome measures for these educationalprograms.20
Developing the ONP WorkforceProfessional membership societies play an important role ineducating their constituents in their respective professionalfields. ONS serves as a professional home for oncology nurses,including ONPs and other APRNs, and serves as a resource forthe profession of nursing and nurses caring for patients withcancer. ONS is uniquely positioned to understand what nursesneed to know and how to deliver the education. Ongoing com-prehensive continuing education is important for NPs to attainand maintain current knowledge and skills in the specialty.ONS offers intensive continuing education specifically for ad-vanced practice nurses (presented in Oncology Nursing SocietyResources for the Nurse Practitioner). Each fall, the ONS APNConference provides a full 3 days of didactic instruction on arange of oncology topics for NPs and CNSs. The conferenceis preceded by a skills workshop offering both didactic andhands-on training in skills such as bone marrow biopsy andlumbar puncture. ONS held its second annual workshop for thenovice ONP in November 2009, entitled “The Nuts and Boltsof Advanced Oncology Care—Oncology Nursing Society’sNovice Oncology NP Workshop.” The goals of this workshopare twofold: to establish a foundation for advanced practice inoncology for the NP with limited or no prior experience inoncology and to establish a network and resource set for the NPnew to oncology. The evaluation of the pilot program held inNovember 2008 indicated that because of the workshop, thecare of participants’ oncology patients improved as a result of a“better basic understanding of cancer and the treatment that itentails.” Respondents also said the workshop enhanced theircollaboration with physician colleagues by “validating theirknowledge base for delineation of privileges” and “gave me amore comprehensive understanding of the treatment processand the fundamental knowledge to enable me to help coordi-nate in that care” (ONS 2008 evaluation, data not published).ONS also offers educational tracks for APRNs at its annualconference in addition to many other CNE offerings gearedtoward the APRN.
An additional model for continuing education may be theexpansion of university programs offering oncology contentinto clinical practice areas. A traditional 15-week, three-creditoncology course for NP students at the University of PittsburghSchool of Nursing (Pittsburgh, PA) was redesigned for NPs andPAs new to cancer care as a weekly, day-long seminar for 6weeks of didactic and experiential learning. Content was devel-oped on the basis of the ONS Oncology Nurse PractitionerCompetencies20 and through consultation with leaders in nurs-ing and medicine at the University of Pittsburgh Cancer Insti-tute. Pre- and post-testing and anecdotal information fromparticipants and supervising physicians noted improvementin knowledge and clinical skills including history taking anddecision making.
Oncology Nursing Society Resources for theNurse Practitioner
National Conferences• 2009 Advanced Practice Nursing Conference Vir-
tual Meeting: http://www.softconference.com/ons/• Coming in 2010: Advanced Practice Nursing Con-
ference, November 11-13, 2010, Orlando, FL• Visit http://www.ons.org for details and more infor-
mation
Publications• Oncology Nurse Practitioner Competencies:
http://www.ons.org/media/ons/docs/publications/npcompentencies.pdf
• Oncology Nursing Society Position Statement: TheRole of Advanced Practice Nurses in OncologyCare: http://www.ons.org/Publications/Positions/APNrole
• Master’s Degree With a Specialty in Advanced Prac-tice Oncology Nursing
• Standards of Oncology Education: General andAdvanced Practice Levels
• Statement on the Scope and Standards of AdvancedPractice Nursing in Oncology
• Advanced Oncology Nursing Certification Reviewand Resource Manual
• Putting Evidence Into Practice: Improving Oncol-ogy Patient Outcomes
• Clinical Manual for the Oncology Advanced Prac-tice Nurse
• The Oncology Nurse Practitioner and You: Partner-ing to Provide Quality Cancer Care
• “So, You Want to Be an Oncology Nurse Practitio-ner?!”
• A Guide to Symptom Management• Advancing Nursing Science
Journals• Oncology Nursing Forum• Clinical Journal of Oncology Nursing
Continuing Nursing Education Courses• Access Devices: The Virtual Clinic• Advanced Oncology Certified Nurse Practitioner
Online Review Course• Cancer Basics• Cancer Biology• Chemotherapy and Biotherapy• Genetics• Reimbursement for Nurses and Managers• Safe Handling of Hazardous Drugs• Sessions from the 10th National Conference on
Cancer Nursing Research• Treatment Basics• Other site specific courses available• Visit http://www.ons.org for new releases in 2010
Networking• Nurse Practitioner Special Interest Group and vir-
tual communities: http://nursepractition.vc.ons.org
Nevidjon et alNevidjon et al
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Challenges to Developing theONP WorkforceAs the need for NPs who specialize in oncology increases, thebarriers to practice that NPs currently experience need to beresolved. Professional organizations, such as ONS and ASCO,can work together to help resolve these obstacles. Issues of con-cern include the lack of formalized academic education for NPsin the specialty of oncology and lack of uniformity in the reg-ulatory requirements for NPs among states. Compoundingthese issues is the movement among some medical organiza-tions to limit the practice of NPs.
A 2008 survey of advanced practice ONS members, con-ducted by the ONCC, revealed that only 16% of the NPs whoresponded had completed an NP program that focused on on-cology (data not published). The vast majority had completed aprogram that focused on a broader population-based area likefamily or adult in primary or acute care. Of those who havetaken the board certification examination for ONPs since itsinception in 2005, only 21% have completed graduate educa-tion focusing specifically on oncology care, with the majorityhaving completed a family or adult NP program. However, it isimportant to note that most ONPs have had a significantamount of experience working as RNs in the specialty of oncol-ogy before becoming NPs. The survey revealed that approxi-mately 63% of the NPs had more than 10 years of experience inoncology nursing, with only 25% working as ONPs for morethan 10 years. Even for NPs with oncology experience, there isadditional education specific to this unique role that is necessaryfor the provision of safe and appropriate care for patients withcancer and their families across the cancer care trajectory.21-23
The broad population-based programs do not offer this in-depth specialty education. Although in the minority, there arealso those with no RN oncology experience who complete anadult or family NP program and then choose to work in oncol-ogy. These NPs need even more intense postgraduate trainingto attain the specialty competencies.
Another issue of concern that may create barriers to prac-tice for NPs is the movement among some medical groups tolimit the scope of practice of NPs. Although the need for NPsis clear, and the safety, quality, and cost effectiveness of NP
care in a variety of specialties has been demonstrated, the Amer-ican Medical Association is continuing to move to restrict theindependent practice of health care professionals who are notphysicians.24,25 These efforts are divisive and impede ratherthan enhance patient access to quality care. Physicians and NPsin various specialties share common goals of providing high-quality care, improving patient outcomes, and enhancing thehealth of the US population. They also share concerns regard-ing the declining workforce and provision of appropriate reim-bursement for services. A high-quality and efficient health caresystem requires effective multidisciplinary teams that collabo-rate to provide patient-centered care.26-28 Collaborative effortsare needed to strengthen the dialogue between physicians andNPs to improve future health care delivery.29 There is strongneed to work together to eliminate barriers to practice throughpolitical advocacy.
ConclusionONS is the professional home of more than 37,000 RNs andother health care providers dedicated to excellence in patientcare, education, research, and administration in oncology nurs-ing. ONS recognizes the value ONPs bring to the interdiscipli-nary oncology team and has assumed a leadership role inproviding education to generalist NPs and in advocating for theNP role in oncology. By working collaboratively, organizationssuch as ONS, the ONCC, and ASCO can provide the resourcesrequired to develop the workforce necessary to meet the needsof patients with cancer through appropriate education and theelimination of barriers to practice.
Accepted for publication on November 17, 2009.
Authors’ Disclosures of Potential Conflicts of InterestThe authors indicated no potential conflicts of interest.
Corresponding author: Michele R. McCorkle, RN, MSN, OncologyNursing Society, 125 Enterprise Dr, Pittsburgh, PA 15275; e-mail:[email protected].
DOI: 10.1200/JOP.091072
References1. Erikson C, Salsberg E, Gaetano F, et al: Future supply and demand for on-cologists: Challenges to assuring access to oncology services. J Oncol Pract3:79-86, 2007
2. Institute of Medicine: Ensuring quality cancer care through the oncology work-force: Sustaining research and care in the 21st century. http://www.iom.edu/CMS/26765/57463.aspx
3. American Society of Clinical Oncology: 2008-2013 Workforce strategic plan:To ensure continuing access to quality cancer care. http://www.asco.org/ASCO/Downloads/Research%20Policy/Workforce%20Page/ASCO%20Workforce%20Strategic%20Plan.pdf
4. Oncology Nursing Society: Statement on the Scope and Standards of Ad-vanced Practice Nursing in Oncology, Pittsburgh, PA, Oncology Nursing Society,2003
5. National Organization of Nurse Practitioner Faculties: Position statement onnurse practitioner specialization, 2006. http://www.nonpf.org/associations/10789/files/NONPFSpecialtyPosition%20Statement0406.pdf
6. American Association of Colleges of Nursing: Fact sheet: The doctor of nursingpractice (DNP), 2009. http://www.aacn.nche.edu/Media/FactSheets/dnp.htm
7. Phillips SJ: Legislative update: Despite legal issues, APNs are still standingstrong. Nurse Pract 34:19-41, 2009
8. APRN Consensus Work Group, APRN Joint Dialogue Group: ConsensusModel for APRN Regulation: Licensure, Accreditation, Certification and Educa-tion. http://www.apna.org/files/public/Consensus_Model_Full_Report.pdf
9. Bush N, Watters T: The emerging role of the oncology nurse practitioner: Acollaborative model within the private practice setting. Oncol Nurs Forum 28:1425-1431, 2001
10. Magdic K, Rosenzweig M: Integrating the acute care nurse practitioner intoclinical practice: Strategies for success. Dimens Crit Care Nurs 16:208-214, 1997
11. Kinney A, Hawkins R, Hudman K: A descriptive study of the role of theoncology nurse practitioner. Oncol Nurs Forum 24:811-820, 1997
12. Oftus L, Weston V: The development of nurse-led clinics in cancer care. J ClinNurs 10:215-220, 2001
13. Mandelblatt J, Traxler M, Lakin P, et al: A nurse practitioner intervention toincrease breast and cervical cancer screening for poor, elderly black women.J Gen Intern Med 8:173-178, 1993
Oncology NP Workforce DevelopmentOncology NP Workforce Development
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14. Ritz L, Nissen M, Swenson K, et al: Effects of advanced practice nursing careon quality of life and cost outcomes of women diagnosed with breast cancer.Oncol Nurs Forum 27:923-932, 2000
15. Rosenzweig MQ: The oncology nurse practitioner: A unique provider for thefollow-up for early-stage breast cancer. J Clin Oncol 24: 3710-3711, 2006
16. Mudinger MO, Kane RL, Lenz ER, et al: Primary care outcomes in patientstreated by nurse practitioners or physicians: A randomized trial. JAMA 283:59-68,2000
17. Hoffman L, Tasota F, Zullo T, et al: Outcomes of care managed by an acutecare nurse practitioner/attending physician team in a subacute medical intensivecare unit. Am J Crit Care 14:121-130, 2005
18. McCorkle R, Strumpf NE, Nuamah I, et al: A specialized home care interven-tion improves survival among older post surgical cancer patients. J Am GeriatrSoc 48:1707-1713, 2000
19. Rosenweig M, Giblin J, Mickle M, et al: Exploring the gap between oncologynurse practitioner education and entry to practice. Onc Nurs Forum 36:E346,2009
20. Oncology Nursing Society: Oncology Nurse Practitioner Competencies,Pittsburgh, PA, Oncology Nursing Society, 2007
21. Rudy EB, Davidson LJ, Daly BJ, et al: Care activities and outcomes of pa-
tients cared for by acute care nurse practitioners, physician assistants: A com-parison. Am J Crit Care 7:267-281, 1998
22. Kleinpell R, Hravnak M: Strategies for success in the acute care nurse prac-titioner role. Crit Care Nurs Clin North Am 17:177-181, 2005
23. Melander S, Kleinpell R, Hravnak M, et al: Post-masters certification pro-grams for nurse practitioners: Population specialty role preparation. J Am AcadNurse Pract 20:63-68, 2008
24. Croasdale M: Physician task force confronts scope-of-practice legislation.http://www.ama-assn.org/amednews/2006/02/13/prl10213.htm
25. Coalition for Patients Rights: Joint statement: Health care professionals urgecooperative patient care; oppose SOPP and AMA Resolution 814. http://www.patientsrightscoalition.org/Joint-Statement.aspx
26. Institute of Medicine: Crossing the Quality Chasm, Washington, DC, NationalAcademies Press, 2001
27. Institute of Medicine: Health Professions Education: A Bridge to Quality,Washington, DC, National Academies Press, 2003
28. American Nurses Association: Teaching IOM: Implications of the Institute ofMedicine Reports for Nursing Education (ed 2), Silver Spring, MD, AmericanNurses Association, 2009
29. American College of Physicians: Nurse Practitioner in Primary Care PolicyMonograph, Washington, DC, American College of Physicians, 2009
The Editors and Staff wish to sincerely thank the following authors (A–K)who wrote articles for Journal of Oncology Practice in 2009.
Amy P. AbernethyJame AbrahamLori AlexanderAlpesh N. AminJoseph S. BailesEdward P. BalabanJeff BarnettThomas R. BarrJackie BenderRoy BeveridgeDouglas W. BlayneyKatherine BonelliRobert L. Bretzel, Jr.Suanna BruinoogeRoberta BuellLola BurkeHoward A. Burris IIIAndrew BushmakinLori A. BuswellJoanna Mary CainRalph CameronMarci CampbellJoseph C. CappelleriEduardo CazapDavid CellaPatricia Chaney
Claudie CharbonneauIsan ChenSteven B. ClauserDiane D. ColaizziRobert L. ComisJohn V. CoxK. Michael CummingsMildred DawsonDavid J. DebonoLisa DillerChristopher M. DodgionLindsay DudbridgeJoan EakinCraig EarleEric P. ElkinCathy EngClese EriksonAnne FavretMichael FeuersteinWilliam D. FiggLaurie FisherCatherine FitzgeraldMarie FlanneryJulie FleshmanMichael FordisLyssa Friedman
Patricia A. GanzMaria A. GarciaDean GesmeSharlene GillJohn GlaspyElizabeth GossRichard J. GrallaEsther GreenCaprice GreenbergSheldon GreenfieldCandice GriffinRyan J. GrollHans W. GrunwaldMarc GustasKaren HagertyDaniel G. HallerElizabeth H. HammondAmy HanleyJames A. HaymanPaul R. HelftJames E. Herndon IIPaul J. HeskethHeather K. HoffmanJanice HopkinsMarc E. HorowitzDianna S. Howard
Richard HyerKaren JacksonLinda A. JacobsGeraldine M. JacobsonJoseph O. JacobsonIsmail JatoiMichael A.S. JewettMary JohnstonBarbara JonesMarjorie Kagawa-SingerCarol Kando-PinedaHagen KenneckeSindy T. KimLinda G. KimmelKristen KingMichael KolodziejJenna KohnkeScott KopetzMichael KostySusan Krause
Nevidjon et alNevidjon et al
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ncology. All rights reserved.
general in nature. It is not intended to be, and should not be construedas, legal advice relating to any particular situation.
Authors’ Disclosures of Potential Conflicts of InterestThe authors indicated no potential conflicts of interest.
Author ContributionsConception and design: Allison R. BaerAdministrative support: Allison R. BaerCollection and assembly of data: Allison R. Baer
Manuscript writing: Allison R. Baer, Claire F. Verschraegen
Final approval of manuscript: Allison R. Baer, John A. Hohneker,Teresa L. Stewart, Claire F. Verschraegen
Corresponding author: Allison R. Baer, RN, BSN, Department of Re-search Policy, American Society of Clinical Oncology, 2318 Mill Rd, Ste800, Alexandria, VA 22314; e-mail: [email protected].
DOI: 10.1200/JOP.091082
References1. Zon R, Meropol NJ, Catalano RB, et al: American Society of Clinical OncologyStatement on minimum standards and exemplary attributes of clinical trial sites.J Clin Oncol 26:2562-2567, 2008
2. Good clinical practice research guidelines reviewed, emphasis given to re-sponsibilities of investigators: Second article in a series. J Oncol Pract 4:233-235,2008
3. National Cancer Institute: Restructuring the NCI Clinical Trials Enterprise:START Clauses. http://restructuringtrials.cancer.gov/initiatives/standardization/highlights/start
4. National Cancer Institute, CEO Roundtable on Cancer: Proposed Standard-ized/Harmonized Clauses for Clinical Trial Agreements. http://restructuringtrials.cancer.gov/files/StClauses.pdf
5. US Department of Health and Human Services: US Food and Drug Adminis-tration: FDA Forms. http://www.fda.gov/aboutfda/reportsmanualsforms/forms/default.htm
ERRATUM ERRATUM ERRATUM ERRATUM ERRATUMThe January article by Nevidjon et al, entitled “Filling the Gap: Development of the Oncology Nurse PractitionerWorkforce” (J Oncol Pract 6:2-6, 2010), contained an error in the corresponding author’s e-mail address. It wasoriginally published as [email protected], whereas it should have been [email protected]. The online version hasbeen corrected in departure from the print. Journal of Oncology Practice apologizes to the authors and readers for themistake.
DOI: 10.1200/JOP.091091
110 JOURNAL OF ONCOLOGY PRACTICE • VOL. 6, ISSUE 2 Copyright © 2010 by American Society of Clinical Oncology
