- Email: [email protected]
Developing collaborative practice agreements
PH C
DEPARTMENT
SECTION EDITOR M a u re e n Va n D i n t e r, M S , C P N P, F N P - C D e p a r t m e n t o f Fa m i ly M e d i c i n e U n ive r s i t y o f Wi s c o n s i n M a d i s o n , Wi s c o n s i n
PROFESSIONAL INSIGHTS
Developing Collaborative Practice Agreements
R u t h M . H e i t z , J D, & M a u r e e n Va n D i n t e r, C P N P, F N P - C
I
n the past few years, health care practitioners have struggled to keep pace with the changes in the health care industry. Many medical facilities and practice groups have been inundated with options for improving the care they provide. Given the dynamic nature of the health care system, nurse practitioners (NPs) are now accepting a greater variety of roles. Many of these changes are controlled by licensing laws. Others are determined by legislative action affecting other professions, such as the decrease in house staff hours necessitating the use of NPs in intensive care units and emergency departments (Beal et al., 1999). Evaluation of practice arrangements has in some cases resulted in mergers of practice groups, physician relocation to areas where there is a perceived shortage of health care practitioners, and the hiring of nonphysician clinicians to provide a well-rounded array of services and increase patient satisfaction (Cohen & Juszczak, 1997). Specifically, many practice groups and solo practitioners are increasingly turning their attention to NPs to serve as a vital part of a dynamic, competitive medical team. Furthermore, although NPs have long been used in a variety of primary care sites, they now have new expanded roles and responsibilities. The NP in today’s health care system is expected to practice independently and interdependently to provide a broad range of health care services, including health promotion, assessment, diagnosis, and management of potential or actual health problems (American Association of Col-
200
leges of Nursing, 1996). Safriet (1992), in her seminal study “Health Care Dollars and Regulatory Sense,” reports that although NPs improve the quality and continuity of care, decrease health care costs, and increase team efficiency, they are not physician substitutes. Whereas physicians treat and cure illness, NPs place more focus on illness prevention and health promotion.
CURRENT TRENDS IN PRACTICE According to the American Medical Association (AMA), there were 22,000 NPs in 1990, 30,000 in 1994, and 71,000 in 1996, and the AMA estimates that there will be 106,500 NPs in 2005 (AMA, 1999). The AMA also stated that NPs function at a high degree of autonomy as measured by the tasks they perform and that their education should reflect that appropriate autonomy (Buerhaus & Steiger, 1996). In many situations, NPs may provide care in distant community clinics supported by a larger medical center or organization. To facilitate improved access to health care and expand the scope of practice for NPs, as well as to receive direct reimbursement, ongoing lobbying efforts for regulatory change have been made by the profes-
sional NP organizations and the boards of nursing. This diligence has been fruitful; Medicare rules now allow NPs to obtain Medicare billing numbers and to receive direct reimbursement (Towers, 1999). Many other health insurers also allow direct billing by NPs. NPs have become active players in developing their role responsibilities and in controlling their work environments. NPs continue to actively define their working relationships with others and establish their practices. Even within the managed care systems now developing throughout the United States, space exists for the creation of realistic practice agreements. These arrangements will form the basis of a true partnership with both parties having equal value. A practice agreement will offer professional satisfaction for the NP and may avoid unnecessary limitations on professional activities or an institutional focus of task-oriented goals. The Health Care Financing Association (HCFA) is increasing access to care for young children through easier reimbursement practices. One component of these changes is the requirement that NPs meet the standards for collaborative practice as established by the state in
Ruth M. Heitz is Associate General Counsel, State Medical Society–Wisconsin. Maureen Van Dinter is a pediatric and family nurse practitioner at the Department of Family Medicine, University of Wisconsin, Madison. Reprint requests: Maureen Van Dinter, CPNP, FNP-C, 3209 Dryden Dr, Madison, WI 53704-3099. J Pediatr Health Care. (2000). 14, 200-203. Copyright © 2000 by the National Association of Pediatric Nurse Associates & Practitioners. 0891-5245/2000/$12.00 + 0 25/8/108127 doi:10.1067/mph.2000.108127
July/August 2000
PH PROFESSIONAL INSIGHTS C which they are practicing. Because collaborative relationships may have differing bases, it is important to actually document the extent of this process and how it affects the work performed. In this article the intent is to describe the development of that agreement and to offer measures the NP can use to protect his or her practice environment. The collaborative practice agreement is a mechanism to define practice standards. It establishes the level of care that the NP agrees to provide, the means to evaluate the quality of that care, and how conflicts over care issues are resolved. It is important that NPs have a written agreement to define and preserve their roles and provide possible legal protection.
PHYSICIAN AND NP PARTNERING RELATIONSHIPS ARE PRACTICAL The Nurse Practitioner Legislative Update (Pearson, 2000) reported that NPs have prescriptive authority under their own signature in every state except Georgia, Michigan, Ohio, and Pennsylvania. The laws of the various states differ greatly regarding the details of the prescriptive authority. In 10 states and the District of Columbia, NPs are not required to have a formal relationship with a physician to prescribe medications; the other states require some type of collaboration (Towers, 1999). Medicare rules for billing require that NPs meet the requirements for collaborative practice in the states in which they are practicing. The AMA and other medical groups have supported appropriate collaborative arrangements but have opposed independent practice by nonphysician clinicians. The lobbying efforts of the AMA and other medical groups for the imposition of a requirement of physician supervision of NPs have been largely unsuccessful. It seems that in some forums the battle regarding physician supervision and autonomous practice has been so divisive that physician groups and NPs have not created opportunities for the development of creative practice arrangements that utilize the skills of both groups to achieve the best possible care for patients. Research suggests, however, that collaborative roles for health care providers positively influence patient outcomes (Hammond, 1999). The education and training of NPs greatly evolved over the years from beginning continuing education programs
JOURNAL OF PEDIATRIC HEALTH CARE
Heitz & Van Dinter
to the now required masters preparation. Formal education efforts for NPs created common educational standards and core competencies. National standards now exist regarding educational and training requirements for NPs as well as for certification. Primary care physicians are increasingly recognizing the need to incorporate some of the techniques that have traditionally been characteristic of nursing practice, but they are often too constrained by time and patient volume to utilize them. Arecent study (Mundinger et al., 2000) reported comparable patient outcomes and satisfaction between NPs and physicians when providers were accorded similar opportunities for assessment and management. Collaborative practice arrangements give patients the best of both disciplines and may afford physicians the opportunity to devote more time to complex medical situations that are outside the scope of an NP’s expertise.
A
practice agreement
will offer professional satisfaction for the NP and may avoid unnecessary limitations on professional
as physicians because they can work within the scope of their expertise while referring situations outside of their expertise to physicians who are trained to handle them. A second barrier to utilization of NP services appears to be a combination of resentment and competition between physicians and NPs. Some physicians have expressed concern about NPs practicing independently; they believe NPs are attempting to be doctors without completing a formal education program. Collaborative practice agreements more clearly define the skills of the NP and place the best interest of patients above titles and egos.
COLLABORATION AGREEMENTS REMOVE BARRIERS Collaboration between professionals involves more than merely working together. It is frequently the case that professionals work in the same office or clinic setting for years without achieving a collaborative relationship. Black’s Law Dictionary (Black, 1979) defines “collaboration” as “the act of working together in a joint project.” Because collaboration can be such a powerful tool for resolving differences, governments, corporate entities, attorneys, social workers, and health care institutions have joined the ranks of professionals developing collaboration agreements (Booth, 2000). The importance of collaboration was explained in an article addressing collaborative relationships between lawyers and other professionals (Coming of age, 1999). The author stated:
activities or an institutional focus of task-oriented goals.
BARRIERS TO THE UTILIZATION OF NP SERVICES Misunderstandings regarding the training and experience of NPs have in some instances resulted in unreasonable demands for NPs to perform duties that are clearly outside the scope of their training and experience to maintain their employment. Acollaborative practice agreement can resolve any confusion regarding the qualifications of an NP by describing a clear scope of practice. A reference to core competencies in the collaborative practice agreement benefits NPs as well
“Unfortunately…simply bringing together a group of professionals does not necessarily ensure that they will function effectively as a team or make appropriate decisions. Effective teamwork does not occur automatically. Collaborative work involves more, including communication skills; knowledge about other disciplines, including their range of coverage and limitations; understanding of group process and team-building; self- and other-awareness, including the effects of one’s behaviors on others; and leadership skills. The difference between what frequently occurs now under the name of collaboration and collaboration as viewed by experts on group process is the teamwork spirit—it is the understanding that no one discipline
July/August 2000
201
PH PROFESSIONAL INSIGHTS C has the knowledge or skills to provide single-handedly the most effective assistance to the client” (italics added). Collaboration has proven to be effective because it focuses on problem solving through sharing relevant information and devising creative solutions. Power is mutually shared, as is the purpose and philosophy of the relationship. It also stimulates joint participation in the decision-making process by interested parties, which fosters a sense of ownership. Respect, recognition, and acceptance are mutual (Corser, 1998). Communication, which often has been instructive emanating from the physician to the NP, or advice seeking when directed from the NP to the physician, is now interactive to benefit the patient. Generally, the parties in a collaborative process view the development of a collaborative agreement as a work in progress that is reviewed periodically and revised, as needs change. The collaborative process eliminates traditional ideas about dependence and dominance and replaces them with a model of interdependence achieved through accountability, self-monitoring, and voluntary disclosure. Collaborating professionals usually achieve a greater degree of flexibility in their relationship because of broader participation, information sharing, and willingness to provide technical resources and a view that success is contingent on the contributions of all participants (Freeman, 1997). Although a collaborative practice agreement should contain the features previously identified, there is not a universal agreement that will fit every practice. Despite the fact that the substance of collaborative agreements will vary, it is recommended that practicing professionals develop a written agreement (Henry, 1995). The development of written agreements forces the parties to think more critically. The details of the agreement are not left to memories, which are fallible, and a written document often serves to create a greater sense of ownership in the final product. The collaborative practice agreement should identify the collaborating professionals by name and title (NPs and physicians) and outline the following: their professional training and experience, certifications (including specialty certifications), specialized areas of practice (eg, family medicine, obstetrics and
202
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Heitz & Van Dinter
gynecology), and standards of practice. The standards of practice for each of the various collaborating professionals might include a brief outline of the process of care, quality assurance measures, documentation of medical records, and research requirements. Some of this information seems rather basic but can add great value to the collaborative process. Identifying the parties’ names, titles, and areas of specialty helps the parties to determine whether it is necessary to use outside resources to better serve patients. A small practice group might consist of one physician specializing in internal medicine, one physician specializing in
T
he collaborative
process eliminates traditional ideas about dependence and dominance and replaces them with a model of interdependence achieved through accountability, self-monitoring, and voluntary disclosure.
obstetrics and gynecology, and an NP specializing in pediatrics. The parties of the small practice group might decide to create a partnering relationship with a physician in another practice group who specializes in pediatrics to handle complex cases that are outside of the NP’s scope of practice. Thus the process of developing a collaboration agreement can create a well-rounded practice and resolve any concerns regarding competency, education, and training because those issues are directly addressed. If the collaboration process reveals any practice limitations, then the parties can develop a process for
minimizing limitations through periodic education, mentoring, etc. The written collaboration agreement should include language regarding utilization of clinical practice guidelines, such as those developed by the Agency for Health Care Policy and Research (National Guideline Clearinghouse, 2000). A copy of clinical practice guidelines for the various specialty practice areas should be maintained in a central location and updated as needed. The actual guidelines should not be included in the collaboration agreement. If appropriate, the collaborating team can augment any clinical practice guidelines by jointly developing additional guidelines to cover particular circumstances or procedures. The use and development of clinical practice guidelines serve to reduce the risk of malpractice for all of the practicing professionals by ensuring that the standard of care is consistent with the standard commonly held in the professional community. The written collaboration agreement might include guidelines regarding the anticipated volume of patients for each health care professional as well as any billing expectations. An up-front discussion about patient volume allows the parties to appropriately utilize resources. If the parties determine that it is beneficial to patients for the NP to allocate more time to patient visits to increase patient education, then the parties will develop a schedule where the NP will see fewer patients on some days, but have more lengthy visits. A discussion of scheduling, billing, and patient volume issues is likely to resolve potential problems with scheduling, referral of patients between members of the collaborating team and to outside practitioners, and determining when it is appropriate to close a practice to new patients, and it is likely to establish reasonable expectations regarding generation of revenue for the practice. It is important that the written collaboration agreement include a discussion regarding delegated medical acts. If the parties determine that the NP will perform delegated medical acts outside of the scope of his or her practice, such as colposcopic evaluation of cervical pathology or colonoscopy for evaluation of colon pathology, then the agreement should address the type of acts to be performed, the provision of training
JOURNAL OF PEDIATRIC HEALTH CARE
PH PROFESSIONAL INSIGHTS C (if necessary), and the degree of support that the delegating physicians will provide. It is helpful for collaborating parties to include information regarding professional responsibility in the agreement. This would include expectations regarding retention of licensure and certifications and timely recredentialing with professional boards and various insurers. It would also include obtaining and maintaining appropriate hospital privileges, Drug Enforcement Administration registration, and Medicare enrollment. The collaboration agreement should address the responsibility of each participating professional to strictly adhere to the corporate compliance plan of the practice group. The Health Care Financing Administration has recommended that all health care providers develop a corporate compliance plan to reduce the potential for fraud and abuse of government resources (Medicare and Medicaid) and promote adherence to federal and state laws (Nurse Practitioner Services, 1999). The corporate compliance plan will likely contain information regarding compliance standards, auditing of medical records, and education expectations to promote compliance with relevant laws. Because a corporate compliance plan can have a great impact on a practice, it is appropriate to incorporate essential elements of the compliance plan into the collaboration agreement. The parties should periodically evaluate the collaboration agreement. Consequently, the written agreement should contain information regarding the frequency of review, for example, review on an annual basis. All of the parties should sign the collaboration agreement. The collaboration agreement should not be used as an employment agreement. It should be a separate document that examines and defines relationships (how the parties work together). An employment agreement or employment contract, on the other hand, would address issues such as duration of the employment term, compensation, benefits, licensure requirements, and methods and notice requirements for terminating
JOURNAL OF PEDIATRIC HEALTH CARE
Heitz & Van Dinter
employment. In some practice groups, the parties might have both an employment contract and a collaborative practice agreement. The parties should understand the differences between the two types of agreements to avoid confusion.
T
he collaboration
agreement should not be used as an employment agreement. It should be a separate document that examines and defines relationships (how the parties work together). CONCLUSION The development of a collaboration agreement is often time consuming and requires diligence, patience, and open communication. Once the agreement is developed, the parties are usually rewarded with a strong, healthy working relationship characterized by mutual respect among the participants and a high degree of satisfaction among the clients (patients) of the venture. A recent study by Aquilino, Damiano, Willard, Momany, and Levy (1999) suggests that primary care physicians who have worked with NPs have a more positive attitude toward NPs, believe that they provide high-quality patient care, and believe that NPs are likely to attract new patients to a practice. Health care practitioners striving to meet increased patient care expectations, incorporate new technology, and maintain the success of a medical group must redefine business relationships. One of the best methods of positively redefining relationships is through the creation of a collaborative practice
agreement to achieve interdependence and respect and to provide better patient care as a team than either practitioner could provide alone.
REFERENCES American Association of Colleges of Nursing. (1996). Essentials of master’s education for advanced practice nursing (p. 15). Washington, DC: Author. American Medical Association. (January 1999). Report of the Council on Medical Education (CME Report No. 6–H-160.950). Chicago: Author. Aquilino, M. L. Damiano, P. C., Willard, J. C., Momany, E. T., & Levy, B. T. Primary care physician perceptions of the nurse practitioner in the 1990s. Archives of Family Medicine, 8, 224-227. Beal, J. A., Richardson, D. K., Dembinski, S., Hipp, K. O., McCourt, M. S. D., & Vaccaro, D. M. (1999). Responsibilities, roles and staffing patterns of nurse practitioners in the neonatal intensive care unit. American Journal of MaternalChild Nursing, 24, 169-175. Black, H. C. (1979). Black’s law dictionary (5th ed., p. 158). Eagan, MN: West Publishing Co. Booth, B. (February 7, 2000). Collaboration seen as a key to the Future. American Medical News, 43, 4. Buerhaus, P. I., & Staiger, D. O. Managed care and the nurse workforce. JAMA, 276, 1487-1493. Cohen, S. S., & Juszczak, L. (1997). Promoting the nurse practitioner role in managed care. Journal of Pediatric Health Care, 11, 3-11. Coming of age: Recognizing the importance of interdisciplinary education in law practice. (1999). 74 Washington Law Review, 319, 328-329. Corser, W. D. (1998). A conceptual model of collaborative nurse-physician interactions: The management of traditional influences and personal tendencies, Scholarly Inquiry for Nursing Practice, 12, 325-341. Freeman, J. (1997). Collaborative governance in the administrative state. 45 UCLA Law Review, 1, 23. Hammond, K., Bandak, A., & Williams, M. (1999). Nurse, physician, and consumer role responsibility perceived by health care providers. Holistic Nurse Practitioner, 13, 28-37. Henry, P. F. (1995). The nurse practitioner’s guide to practice agreements. Nurse Practitioner Forum, 6, 4-5. Mundinger, M. O., Kane, R. L., Lenz, E. R., Totten, A. M., Tsai, W. Y., Cleary, P. D., Friedewald, W. T., Siu, A. L., & Shelamski, M. (2000). Primary care outcomes in patients treated by nurse practitioners or physicians. JAMA, 283, 59-68. National Guideline Clearinghouse (April 2000). Agency for Health Care Policy and Research: Clinical practice guidelines [On-line]. Available: http://www.guideline.gov Pearson, L. J. (2000). Annual legislative update. Nurse Practitioner, 25, 16–68. Safriet, B. (1992). Health care dollars and regulatory sense. Yale Journal on Regulation, 9, 417-487. Nurse practitioner services, 42 C.F.R. § 441.22 (1999). Towers, J. (1993). Standards of Practice, American Academy of Nurse Practitioners. Washington, DC: American Academy of Nurse Practitioners.
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DEPARTMENT
SECTION EDITOR M a u re e n Va n D i n t e r, M S , C P N P, F N P - C D e p a r t m e n t o f Fa m i ly M e d i c i n e U n ive r s i t y o f Wi s c o n s i n M a d i s o n , Wi s c o n s i n
PROFESSIONAL INSIGHTS
Developing Collaborative Practice Agreements
R u t h M . H e i t z , J D, & M a u r e e n Va n D i n t e r, C P N P, F N P - C
I
n the past few years, health care practitioners have struggled to keep pace with the changes in the health care industry. Many medical facilities and practice groups have been inundated with options for improving the care they provide. Given the dynamic nature of the health care system, nurse practitioners (NPs) are now accepting a greater variety of roles. Many of these changes are controlled by licensing laws. Others are determined by legislative action affecting other professions, such as the decrease in house staff hours necessitating the use of NPs in intensive care units and emergency departments (Beal et al., 1999). Evaluation of practice arrangements has in some cases resulted in mergers of practice groups, physician relocation to areas where there is a perceived shortage of health care practitioners, and the hiring of nonphysician clinicians to provide a well-rounded array of services and increase patient satisfaction (Cohen & Juszczak, 1997). Specifically, many practice groups and solo practitioners are increasingly turning their attention to NPs to serve as a vital part of a dynamic, competitive medical team. Furthermore, although NPs have long been used in a variety of primary care sites, they now have new expanded roles and responsibilities. The NP in today’s health care system is expected to practice independently and interdependently to provide a broad range of health care services, including health promotion, assessment, diagnosis, and management of potential or actual health problems (American Association of Col-
200
leges of Nursing, 1996). Safriet (1992), in her seminal study “Health Care Dollars and Regulatory Sense,” reports that although NPs improve the quality and continuity of care, decrease health care costs, and increase team efficiency, they are not physician substitutes. Whereas physicians treat and cure illness, NPs place more focus on illness prevention and health promotion.
CURRENT TRENDS IN PRACTICE According to the American Medical Association (AMA), there were 22,000 NPs in 1990, 30,000 in 1994, and 71,000 in 1996, and the AMA estimates that there will be 106,500 NPs in 2005 (AMA, 1999). The AMA also stated that NPs function at a high degree of autonomy as measured by the tasks they perform and that their education should reflect that appropriate autonomy (Buerhaus & Steiger, 1996). In many situations, NPs may provide care in distant community clinics supported by a larger medical center or organization. To facilitate improved access to health care and expand the scope of practice for NPs, as well as to receive direct reimbursement, ongoing lobbying efforts for regulatory change have been made by the profes-
sional NP organizations and the boards of nursing. This diligence has been fruitful; Medicare rules now allow NPs to obtain Medicare billing numbers and to receive direct reimbursement (Towers, 1999). Many other health insurers also allow direct billing by NPs. NPs have become active players in developing their role responsibilities and in controlling their work environments. NPs continue to actively define their working relationships with others and establish their practices. Even within the managed care systems now developing throughout the United States, space exists for the creation of realistic practice agreements. These arrangements will form the basis of a true partnership with both parties having equal value. A practice agreement will offer professional satisfaction for the NP and may avoid unnecessary limitations on professional activities or an institutional focus of task-oriented goals. The Health Care Financing Association (HCFA) is increasing access to care for young children through easier reimbursement practices. One component of these changes is the requirement that NPs meet the standards for collaborative practice as established by the state in
Ruth M. Heitz is Associate General Counsel, State Medical Society–Wisconsin. Maureen Van Dinter is a pediatric and family nurse practitioner at the Department of Family Medicine, University of Wisconsin, Madison. Reprint requests: Maureen Van Dinter, CPNP, FNP-C, 3209 Dryden Dr, Madison, WI 53704-3099. J Pediatr Health Care. (2000). 14, 200-203. Copyright © 2000 by the National Association of Pediatric Nurse Associates & Practitioners. 0891-5245/2000/$12.00 + 0 25/8/108127 doi:10.1067/mph.2000.108127
July/August 2000
PH PROFESSIONAL INSIGHTS C which they are practicing. Because collaborative relationships may have differing bases, it is important to actually document the extent of this process and how it affects the work performed. In this article the intent is to describe the development of that agreement and to offer measures the NP can use to protect his or her practice environment. The collaborative practice agreement is a mechanism to define practice standards. It establishes the level of care that the NP agrees to provide, the means to evaluate the quality of that care, and how conflicts over care issues are resolved. It is important that NPs have a written agreement to define and preserve their roles and provide possible legal protection.
PHYSICIAN AND NP PARTNERING RELATIONSHIPS ARE PRACTICAL The Nurse Practitioner Legislative Update (Pearson, 2000) reported that NPs have prescriptive authority under their own signature in every state except Georgia, Michigan, Ohio, and Pennsylvania. The laws of the various states differ greatly regarding the details of the prescriptive authority. In 10 states and the District of Columbia, NPs are not required to have a formal relationship with a physician to prescribe medications; the other states require some type of collaboration (Towers, 1999). Medicare rules for billing require that NPs meet the requirements for collaborative practice in the states in which they are practicing. The AMA and other medical groups have supported appropriate collaborative arrangements but have opposed independent practice by nonphysician clinicians. The lobbying efforts of the AMA and other medical groups for the imposition of a requirement of physician supervision of NPs have been largely unsuccessful. It seems that in some forums the battle regarding physician supervision and autonomous practice has been so divisive that physician groups and NPs have not created opportunities for the development of creative practice arrangements that utilize the skills of both groups to achieve the best possible care for patients. Research suggests, however, that collaborative roles for health care providers positively influence patient outcomes (Hammond, 1999). The education and training of NPs greatly evolved over the years from beginning continuing education programs
JOURNAL OF PEDIATRIC HEALTH CARE
Heitz & Van Dinter
to the now required masters preparation. Formal education efforts for NPs created common educational standards and core competencies. National standards now exist regarding educational and training requirements for NPs as well as for certification. Primary care physicians are increasingly recognizing the need to incorporate some of the techniques that have traditionally been characteristic of nursing practice, but they are often too constrained by time and patient volume to utilize them. Arecent study (Mundinger et al., 2000) reported comparable patient outcomes and satisfaction between NPs and physicians when providers were accorded similar opportunities for assessment and management. Collaborative practice arrangements give patients the best of both disciplines and may afford physicians the opportunity to devote more time to complex medical situations that are outside the scope of an NP’s expertise.
A
practice agreement
will offer professional satisfaction for the NP and may avoid unnecessary limitations on professional
as physicians because they can work within the scope of their expertise while referring situations outside of their expertise to physicians who are trained to handle them. A second barrier to utilization of NP services appears to be a combination of resentment and competition between physicians and NPs. Some physicians have expressed concern about NPs practicing independently; they believe NPs are attempting to be doctors without completing a formal education program. Collaborative practice agreements more clearly define the skills of the NP and place the best interest of patients above titles and egos.
COLLABORATION AGREEMENTS REMOVE BARRIERS Collaboration between professionals involves more than merely working together. It is frequently the case that professionals work in the same office or clinic setting for years without achieving a collaborative relationship. Black’s Law Dictionary (Black, 1979) defines “collaboration” as “the act of working together in a joint project.” Because collaboration can be such a powerful tool for resolving differences, governments, corporate entities, attorneys, social workers, and health care institutions have joined the ranks of professionals developing collaboration agreements (Booth, 2000). The importance of collaboration was explained in an article addressing collaborative relationships between lawyers and other professionals (Coming of age, 1999). The author stated:
activities or an institutional focus of task-oriented goals.
BARRIERS TO THE UTILIZATION OF NP SERVICES Misunderstandings regarding the training and experience of NPs have in some instances resulted in unreasonable demands for NPs to perform duties that are clearly outside the scope of their training and experience to maintain their employment. Acollaborative practice agreement can resolve any confusion regarding the qualifications of an NP by describing a clear scope of practice. A reference to core competencies in the collaborative practice agreement benefits NPs as well
“Unfortunately…simply bringing together a group of professionals does not necessarily ensure that they will function effectively as a team or make appropriate decisions. Effective teamwork does not occur automatically. Collaborative work involves more, including communication skills; knowledge about other disciplines, including their range of coverage and limitations; understanding of group process and team-building; self- and other-awareness, including the effects of one’s behaviors on others; and leadership skills. The difference between what frequently occurs now under the name of collaboration and collaboration as viewed by experts on group process is the teamwork spirit—it is the understanding that no one discipline
July/August 2000
201
PH PROFESSIONAL INSIGHTS C has the knowledge or skills to provide single-handedly the most effective assistance to the client” (italics added). Collaboration has proven to be effective because it focuses on problem solving through sharing relevant information and devising creative solutions. Power is mutually shared, as is the purpose and philosophy of the relationship. It also stimulates joint participation in the decision-making process by interested parties, which fosters a sense of ownership. Respect, recognition, and acceptance are mutual (Corser, 1998). Communication, which often has been instructive emanating from the physician to the NP, or advice seeking when directed from the NP to the physician, is now interactive to benefit the patient. Generally, the parties in a collaborative process view the development of a collaborative agreement as a work in progress that is reviewed periodically and revised, as needs change. The collaborative process eliminates traditional ideas about dependence and dominance and replaces them with a model of interdependence achieved through accountability, self-monitoring, and voluntary disclosure. Collaborating professionals usually achieve a greater degree of flexibility in their relationship because of broader participation, information sharing, and willingness to provide technical resources and a view that success is contingent on the contributions of all participants (Freeman, 1997). Although a collaborative practice agreement should contain the features previously identified, there is not a universal agreement that will fit every practice. Despite the fact that the substance of collaborative agreements will vary, it is recommended that practicing professionals develop a written agreement (Henry, 1995). The development of written agreements forces the parties to think more critically. The details of the agreement are not left to memories, which are fallible, and a written document often serves to create a greater sense of ownership in the final product. The collaborative practice agreement should identify the collaborating professionals by name and title (NPs and physicians) and outline the following: their professional training and experience, certifications (including specialty certifications), specialized areas of practice (eg, family medicine, obstetrics and
202
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Heitz & Van Dinter
gynecology), and standards of practice. The standards of practice for each of the various collaborating professionals might include a brief outline of the process of care, quality assurance measures, documentation of medical records, and research requirements. Some of this information seems rather basic but can add great value to the collaborative process. Identifying the parties’ names, titles, and areas of specialty helps the parties to determine whether it is necessary to use outside resources to better serve patients. A small practice group might consist of one physician specializing in internal medicine, one physician specializing in
T
he collaborative
process eliminates traditional ideas about dependence and dominance and replaces them with a model of interdependence achieved through accountability, self-monitoring, and voluntary disclosure.
obstetrics and gynecology, and an NP specializing in pediatrics. The parties of the small practice group might decide to create a partnering relationship with a physician in another practice group who specializes in pediatrics to handle complex cases that are outside of the NP’s scope of practice. Thus the process of developing a collaboration agreement can create a well-rounded practice and resolve any concerns regarding competency, education, and training because those issues are directly addressed. If the collaboration process reveals any practice limitations, then the parties can develop a process for
minimizing limitations through periodic education, mentoring, etc. The written collaboration agreement should include language regarding utilization of clinical practice guidelines, such as those developed by the Agency for Health Care Policy and Research (National Guideline Clearinghouse, 2000). A copy of clinical practice guidelines for the various specialty practice areas should be maintained in a central location and updated as needed. The actual guidelines should not be included in the collaboration agreement. If appropriate, the collaborating team can augment any clinical practice guidelines by jointly developing additional guidelines to cover particular circumstances or procedures. The use and development of clinical practice guidelines serve to reduce the risk of malpractice for all of the practicing professionals by ensuring that the standard of care is consistent with the standard commonly held in the professional community. The written collaboration agreement might include guidelines regarding the anticipated volume of patients for each health care professional as well as any billing expectations. An up-front discussion about patient volume allows the parties to appropriately utilize resources. If the parties determine that it is beneficial to patients for the NP to allocate more time to patient visits to increase patient education, then the parties will develop a schedule where the NP will see fewer patients on some days, but have more lengthy visits. A discussion of scheduling, billing, and patient volume issues is likely to resolve potential problems with scheduling, referral of patients between members of the collaborating team and to outside practitioners, and determining when it is appropriate to close a practice to new patients, and it is likely to establish reasonable expectations regarding generation of revenue for the practice. It is important that the written collaboration agreement include a discussion regarding delegated medical acts. If the parties determine that the NP will perform delegated medical acts outside of the scope of his or her practice, such as colposcopic evaluation of cervical pathology or colonoscopy for evaluation of colon pathology, then the agreement should address the type of acts to be performed, the provision of training
JOURNAL OF PEDIATRIC HEALTH CARE
PH PROFESSIONAL INSIGHTS C (if necessary), and the degree of support that the delegating physicians will provide. It is helpful for collaborating parties to include information regarding professional responsibility in the agreement. This would include expectations regarding retention of licensure and certifications and timely recredentialing with professional boards and various insurers. It would also include obtaining and maintaining appropriate hospital privileges, Drug Enforcement Administration registration, and Medicare enrollment. The collaboration agreement should address the responsibility of each participating professional to strictly adhere to the corporate compliance plan of the practice group. The Health Care Financing Administration has recommended that all health care providers develop a corporate compliance plan to reduce the potential for fraud and abuse of government resources (Medicare and Medicaid) and promote adherence to federal and state laws (Nurse Practitioner Services, 1999). The corporate compliance plan will likely contain information regarding compliance standards, auditing of medical records, and education expectations to promote compliance with relevant laws. Because a corporate compliance plan can have a great impact on a practice, it is appropriate to incorporate essential elements of the compliance plan into the collaboration agreement. The parties should periodically evaluate the collaboration agreement. Consequently, the written agreement should contain information regarding the frequency of review, for example, review on an annual basis. All of the parties should sign the collaboration agreement. The collaboration agreement should not be used as an employment agreement. It should be a separate document that examines and defines relationships (how the parties work together). An employment agreement or employment contract, on the other hand, would address issues such as duration of the employment term, compensation, benefits, licensure requirements, and methods and notice requirements for terminating
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employment. In some practice groups, the parties might have both an employment contract and a collaborative practice agreement. The parties should understand the differences between the two types of agreements to avoid confusion.
T
he collaboration
agreement should not be used as an employment agreement. It should be a separate document that examines and defines relationships (how the parties work together). CONCLUSION The development of a collaboration agreement is often time consuming and requires diligence, patience, and open communication. Once the agreement is developed, the parties are usually rewarded with a strong, healthy working relationship characterized by mutual respect among the participants and a high degree of satisfaction among the clients (patients) of the venture. A recent study by Aquilino, Damiano, Willard, Momany, and Levy (1999) suggests that primary care physicians who have worked with NPs have a more positive attitude toward NPs, believe that they provide high-quality patient care, and believe that NPs are likely to attract new patients to a practice. Health care practitioners striving to meet increased patient care expectations, incorporate new technology, and maintain the success of a medical group must redefine business relationships. One of the best methods of positively redefining relationships is through the creation of a collaborative practice
agreement to achieve interdependence and respect and to provide better patient care as a team than either practitioner could provide alone.
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