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PERC: Nonpublic Remediation in Pennsylvania
PERC: Nonpublic Remediation in Pennsylvania Marguerite Witmer, DNP, MSN, RN-BC, MPA, and Colleen Rosborough, MSN, CRNP In 2008, the Pennsylvania State Board of Nursing (BON) started to explore alternatives to public discipline for nurses reported for certain violations of the laws and regulations governing nursing practice. In 2009, a pilot program, PERC (Practice, Education, Remediation, and Collaboration), was launched as an alternative program to public discipline. The program, which aims to improve practice while ensuring patient safety, uses education and monitored practice to remediate minor practice deficiencies. The results of the 2-year pilot program were presented to BON members in June 2012, and the BON determined that the program should continue as an option for licensees reported for minor practice-related violations.
T
he Pennsylvania State Board of Nursing (BON) meets its responsibility to protect the health, safety, and welfare of the public through professional licensing and, if a licensee violates the law or regulations governing nursing practice, through disciplinary action. The BON grants a license or certification to an applicant only when all licensing or certification requirements are met. A licensee whose license has lapsed or been placed on inactive status for more than 5 years must demonstrate competence before the license can be reactivated. When a licensee violates the law or regulations, the BON may impose discipline, which includes revoking or suspending a license, placing a licensee on probation, imposing a civil penalty, or imposing a public reprimand on the licensee. In 2008, the Pennsylvania BON started to explore alternatives to public discipline for nurses reported for certain minor violations of the laws and regulations governing nursing practice. They first reviewed all disciplinary cases for the last several years and found that 30 to 40 cases a year involved a practice deficiency. Some of these cases did not rise to the level of willful violation of the safe standards of nursing practice, gross negligence, or reckless behavior. Rather, they involved lapses in judgment, poor practice patterns, or failure to stay up to date with the current standards of nursing practice. In 2009, a 2-year pilot program, PERC (Practice, Education, Remediation, and Collaboration), was launched as an alternative program to public discipline. The program, which aims to improve practice while ensuring patient safety, uses education and monitored practice to remediate minor practice deficiencies. This article discusses the PERC program and the results of the pilot study.
Nursing Practice Deficiencies Nursing practice deficiencies (or errors) considered for PERC are those that have occurred due to human errors resulting from a lack of up-to-date practice skills or knowledge. The Just Culture Volume 4/Issue 1 April 2013
model identifies three categories of human behavior: human error, which is inadvertently doing something other than what should be done; at-risk behavior, which is making a choice that increases risk where the risk is considered justified or not recognized, and reckless behavior, which is consciously choosing to disregard a substantial risk. Human error and at-risk behavior offer opportunities to educate and coach the person to become aware of the potential risk and provide incentives to produce the desired behavior. Reckless behavior requires punishment and discipline (Griffith, 2010). Pepe and Cataldo (2011) contend that the delivery of safe health care should take into account human fallibility and system imperfection. Since reporting a practice deficiency is not required in Pennsylvania, there was a belief that employers would be more willing to report nurses who experienced a practice deficiency to the BON if there is a mechanism in place to help nurses improve their practice rather than suffer formal public discipline and have the employer lose an otherwise competent nurse (Shields et al., 2009).
Practice, Education, Remediation, and Collaboration Program Through the PERC program, a nurse reported to the BON for a violation perceived as a minor deficiency may be offered an avenue to remediate the deficiency. Before the PERC program, all disciplinary cases, whether for a serious or minor violation of the law or regulations, were treated the same way—with public discipline. The imposition of public discipline results in a permanent notation on a nurse’s license. However, nurses who are eligible for and complete the PERC program have no notation of disciplinary action on their licensees. Eligibility
Complaints against nurses are filed with the Department of State’s Professional Compliance Office. The Department of State’s Bureau www.journalofnursingregulation.com
49
Table 1
PERC Inclusion and Exclusion Criteria To ensure public safety and protect the citizens of Pennsylvania from the unsafe practice of nurses, the BON carefully considered the criteria for inclusion and exclusion in the PERC (Practice, Education, Remediation, and Collaboration) program. Inclusion criteria ⦁⦁ Nursing practice deficiency resulting from unintentional error or knowledge deficit ⦁⦁ Nursing practice deficiency that can be remediated through education or monitored practice ⦁⦁ Eligibility for employment even if licensee was terminated by previous employer Exclusionary criteria ⦁⦁ Intentional misconduct ⦁⦁ Reckless conduct ⦁⦁ Sexual misconduct ⦁⦁ Fraud or deceitful behavior ⦁⦁ Drug diversion ⦁⦁ Drug/substance abuse–related issue ⦁⦁ Patient abuse ⦁⦁ Serious patient harm or death ⦁⦁ Pending criminal investigation, especially criminal charges for violent crimes
of Enforcement and Investigation then investigates the complaints and forwards the results of the investigation to a prosecuting attorney. If the attorney believes the information indicates a minor violation, the attorney discusses the case with the nursing practice advisors to determine if the licensee meets the eligibility criteria for PERC. Violations deemed eligible for the PERC program include poor documentation, unprofessional behavior, poor nursing assessment skills, poor medication administration techniques, violation of workplace policy such as giving another staff member a password to the medication dispensing system, and poor wound care technique. Violations deemed inappropriate include abuse and neglect, drug diversion, and inappropriate nursing care that caused patient harm. (See Table 1.) When determining if a nurse is appropriate for the PERC program, the prosecuting attorney and the nursing practice advisors also consider the following: ⦁⦁ Length of time the licensee has been in practice ⦁⦁ History of discipline ⦁⦁ Frequency of practice deficiencies ⦁⦁ Cooperation with the investigation ⦁⦁ Circumstances of the complaint, including when and where the event occurred and whether others were involved ⦁⦁ Assurance that the public will be protected in the future ⦁⦁ Reasonable likelihood that remediation will correct the practice deficiency ⦁⦁ Recognition of the error by nurse 50
Journal of Nursing Regulation
Remediation Plan
The specific remediation plan for an eligible nurse is determined on a case-by-case basis, and the attorney develops a consent agreement that incorporates the plan and explains that the licensee is responsible for all costs incurred by participating in it. After the licensee agrees to and signs the consent agreement, it is presented to the BON for approval. Before this presentation, all identifying information is redacted. If the plan is approved, the licensee receives written notification that he or she must contact a nursing practice advisor to start the remediation plan. If the licensee does not agree with the plan, the case may be presented to the BON as a public discipline case. (See Figure 1.) Each eligible licensee must complete 20 to 30 continuing education hours and, if appropriate, a 6-month period of monitored practice with his or her current employer. Monitored practice requires a monthly report to the nursing practice advisor from the licensee’s manager. If the practice deficiency involved medication administration, the monitored practice could include another nurse monitoring the licensee administering medications for a period of time. The continuing education topics may include documentation, medication administration, geriatric assessment, scope of practice, stress management, ethics, professional boundaries, anger management, communication skills, and professionalism. The remediation plan requires that the licensee select specific courses that address the practice deficiency. Once a course is approved by the BON, the licensee can begin and complete the course within the required time period. The remediation plan specifies that continuing education hours completed as part of the PERC program may not be counted towards the hours needed for biennial license renewal. At times, specific education courses are difficult to find, very expensive, or seldom offered. In these cases, consideration is given to having the licensee complete a course that may not pertain directly to the violation, but may provide education that can be applied to practice in most areas of nursing care. The biggest challenge in the monitoring practice part of a remediation plan has been finding a practice location for a licensee who has been terminated because of the practice deficiency and is unable to obtain a new position. In these instances, the remediation plan is presented to the BON for approval, but the nurse cannot enter (or begin) the PERC program until he or she finds an employer who is willing to perform the monitoring outlined in the remediation plan. A violation of the PERC agreement, including a failure to complete the program in the prescribed time period, is referred back to the prosecuting attorney as a violation. The prosecuting attorney makes the final decision whether to proceed with formal prosecution for the alleged violation. If formal prosecution proceeds, the nurse has the right to a hearing before the Board on the alleged violations. The Board will ultimately decide whether or not a sanction should be imposed through the issuing of Adjudication and Order.
Figure 1
PERC Program Flowchart Complaint received and reviewed by the Professional Compliance Office (PCO). If necessary, sent to Bureau of Enforcement and Investigation for investigation.
Investigation determines if complaint is a practice deficiency and meets eligibility criteria for PERC. YES NO Attorney reviews case for remediation.
Attorney reviews case for discipline or closure.
Not Appropriate BON advisors and attorney review case and determine appropriateness for remediation.
The PERC pilot program results were presented to the BON at its June 2012 meeting, and the BON decided unanimously to continue the program as an alternative to public discipline.
Conclusion The PERC program reflects a new way of thinking about reports of practice violations. While maintaining public safety, the program allows the BON to distinguish reckless and willful violations from minor violations that can be corrected with remediation. The program has been successful in that the BON has received no reports of patient harm or recidivism, participants have improved their practice through education and monitored practice, and participants have been able to remain in the workforce providing safe, quality patient care. Statistics will be maintained as the PERC program continues as a permanent part of the BON’s work. Successes and failures will be monitored, and the numbers of cases reviewed for eligibility and licensees enrolled in the program will be maintained. A review of the statistics is ongoing and, if necessary, the eligibility criteria and program implementation will be revised to meet the goals of improving licensee education and maintaining public safety.
Appropriate Nonpublic consent agreement developed and sent to board of nursing (BON) for consideration. Licensee is monitored by nursing practice advisors.
Licensee successfully completes program. No formal discipline recorded.
Licensee does not complete program; referred to PCO for violation of BON order. Formal discipline action taken.
Note. PERC = Practice, Education, Remediation, Collaboration.
Results of Pilot Study Fifty-one candidates (30 RNs, 21 LPNs) were reviewed, and 32 (20 RNs, 12 LPNs) were deemed eligible for the PERC pilot program. Of the 32 participants, 26 have completed the program, and 6 are in the process of completing it. All the candidates enrolled in the PERC program were compliant with the remediation plan as outlined in the consent agreement, and no cases of practice errors have been reported while a licensee was completing the program. To date, the 26 licensees who completed the program have had no incidents of recidivism. The other 19 candidates were deemed ineligible for the remediation program because their violations were too serious for remediation or were the result of a system failure. Volume 4/Issue 1 April 2013
References Griffith, K. S. (2010). Column: Error prevention in a just culture: System design or human behavior? The Joint Commission Perspectives on Patient Safety, 10(6), 10–11. Retrieved from http://legacy.justculture.org/media/JustCultureColumn3.pdf Pepe, J., & Cataldo, P. J. (2011). Manage risk, build a just culture. Health Progress, 92(4), 56–60. North Carolina Board of Nursing. PREP: Practitioner Remediation and Enhancement Partnership Program. Retrieved from www.ncbon. com Ohio Board of Nursing. PIIP: Practice Intervention and Improvement Program. Retrieved from www.nursing.ohio.gov Shields, J. (2009). An alternative to public discipline program for nurses with practice problems. Pennsylvania State Board of Nursing Newsletter. August 2009.
Marguerite Witmer, DNP, MSN, RN-BC, MPA, is a former nursing practice advisor for the Pennsylvania State Board of Nursing, and Colleen Rosborough, MSN, CRNP, is a nursing practice advisor for the Pennsylvania State Board of Nursing.
www.journalofnursingregulation.com
51
T
he Pennsylvania State Board of Nursing (BON) meets its responsibility to protect the health, safety, and welfare of the public through professional licensing and, if a licensee violates the law or regulations governing nursing practice, through disciplinary action. The BON grants a license or certification to an applicant only when all licensing or certification requirements are met. A licensee whose license has lapsed or been placed on inactive status for more than 5 years must demonstrate competence before the license can be reactivated. When a licensee violates the law or regulations, the BON may impose discipline, which includes revoking or suspending a license, placing a licensee on probation, imposing a civil penalty, or imposing a public reprimand on the licensee. In 2008, the Pennsylvania BON started to explore alternatives to public discipline for nurses reported for certain minor violations of the laws and regulations governing nursing practice. They first reviewed all disciplinary cases for the last several years and found that 30 to 40 cases a year involved a practice deficiency. Some of these cases did not rise to the level of willful violation of the safe standards of nursing practice, gross negligence, or reckless behavior. Rather, they involved lapses in judgment, poor practice patterns, or failure to stay up to date with the current standards of nursing practice. In 2009, a 2-year pilot program, PERC (Practice, Education, Remediation, and Collaboration), was launched as an alternative program to public discipline. The program, which aims to improve practice while ensuring patient safety, uses education and monitored practice to remediate minor practice deficiencies. This article discusses the PERC program and the results of the pilot study.
Nursing Practice Deficiencies Nursing practice deficiencies (or errors) considered for PERC are those that have occurred due to human errors resulting from a lack of up-to-date practice skills or knowledge. The Just Culture Volume 4/Issue 1 April 2013
model identifies three categories of human behavior: human error, which is inadvertently doing something other than what should be done; at-risk behavior, which is making a choice that increases risk where the risk is considered justified or not recognized, and reckless behavior, which is consciously choosing to disregard a substantial risk. Human error and at-risk behavior offer opportunities to educate and coach the person to become aware of the potential risk and provide incentives to produce the desired behavior. Reckless behavior requires punishment and discipline (Griffith, 2010). Pepe and Cataldo (2011) contend that the delivery of safe health care should take into account human fallibility and system imperfection. Since reporting a practice deficiency is not required in Pennsylvania, there was a belief that employers would be more willing to report nurses who experienced a practice deficiency to the BON if there is a mechanism in place to help nurses improve their practice rather than suffer formal public discipline and have the employer lose an otherwise competent nurse (Shields et al., 2009).
Practice, Education, Remediation, and Collaboration Program Through the PERC program, a nurse reported to the BON for a violation perceived as a minor deficiency may be offered an avenue to remediate the deficiency. Before the PERC program, all disciplinary cases, whether for a serious or minor violation of the law or regulations, were treated the same way—with public discipline. The imposition of public discipline results in a permanent notation on a nurse’s license. However, nurses who are eligible for and complete the PERC program have no notation of disciplinary action on their licensees. Eligibility
Complaints against nurses are filed with the Department of State’s Professional Compliance Office. The Department of State’s Bureau www.journalofnursingregulation.com
49
Table 1
PERC Inclusion and Exclusion Criteria To ensure public safety and protect the citizens of Pennsylvania from the unsafe practice of nurses, the BON carefully considered the criteria for inclusion and exclusion in the PERC (Practice, Education, Remediation, and Collaboration) program. Inclusion criteria ⦁⦁ Nursing practice deficiency resulting from unintentional error or knowledge deficit ⦁⦁ Nursing practice deficiency that can be remediated through education or monitored practice ⦁⦁ Eligibility for employment even if licensee was terminated by previous employer Exclusionary criteria ⦁⦁ Intentional misconduct ⦁⦁ Reckless conduct ⦁⦁ Sexual misconduct ⦁⦁ Fraud or deceitful behavior ⦁⦁ Drug diversion ⦁⦁ Drug/substance abuse–related issue ⦁⦁ Patient abuse ⦁⦁ Serious patient harm or death ⦁⦁ Pending criminal investigation, especially criminal charges for violent crimes
of Enforcement and Investigation then investigates the complaints and forwards the results of the investigation to a prosecuting attorney. If the attorney believes the information indicates a minor violation, the attorney discusses the case with the nursing practice advisors to determine if the licensee meets the eligibility criteria for PERC. Violations deemed eligible for the PERC program include poor documentation, unprofessional behavior, poor nursing assessment skills, poor medication administration techniques, violation of workplace policy such as giving another staff member a password to the medication dispensing system, and poor wound care technique. Violations deemed inappropriate include abuse and neglect, drug diversion, and inappropriate nursing care that caused patient harm. (See Table 1.) When determining if a nurse is appropriate for the PERC program, the prosecuting attorney and the nursing practice advisors also consider the following: ⦁⦁ Length of time the licensee has been in practice ⦁⦁ History of discipline ⦁⦁ Frequency of practice deficiencies ⦁⦁ Cooperation with the investigation ⦁⦁ Circumstances of the complaint, including when and where the event occurred and whether others were involved ⦁⦁ Assurance that the public will be protected in the future ⦁⦁ Reasonable likelihood that remediation will correct the practice deficiency ⦁⦁ Recognition of the error by nurse 50
Journal of Nursing Regulation
Remediation Plan
The specific remediation plan for an eligible nurse is determined on a case-by-case basis, and the attorney develops a consent agreement that incorporates the plan and explains that the licensee is responsible for all costs incurred by participating in it. After the licensee agrees to and signs the consent agreement, it is presented to the BON for approval. Before this presentation, all identifying information is redacted. If the plan is approved, the licensee receives written notification that he or she must contact a nursing practice advisor to start the remediation plan. If the licensee does not agree with the plan, the case may be presented to the BON as a public discipline case. (See Figure 1.) Each eligible licensee must complete 20 to 30 continuing education hours and, if appropriate, a 6-month period of monitored practice with his or her current employer. Monitored practice requires a monthly report to the nursing practice advisor from the licensee’s manager. If the practice deficiency involved medication administration, the monitored practice could include another nurse monitoring the licensee administering medications for a period of time. The continuing education topics may include documentation, medication administration, geriatric assessment, scope of practice, stress management, ethics, professional boundaries, anger management, communication skills, and professionalism. The remediation plan requires that the licensee select specific courses that address the practice deficiency. Once a course is approved by the BON, the licensee can begin and complete the course within the required time period. The remediation plan specifies that continuing education hours completed as part of the PERC program may not be counted towards the hours needed for biennial license renewal. At times, specific education courses are difficult to find, very expensive, or seldom offered. In these cases, consideration is given to having the licensee complete a course that may not pertain directly to the violation, but may provide education that can be applied to practice in most areas of nursing care. The biggest challenge in the monitoring practice part of a remediation plan has been finding a practice location for a licensee who has been terminated because of the practice deficiency and is unable to obtain a new position. In these instances, the remediation plan is presented to the BON for approval, but the nurse cannot enter (or begin) the PERC program until he or she finds an employer who is willing to perform the monitoring outlined in the remediation plan. A violation of the PERC agreement, including a failure to complete the program in the prescribed time period, is referred back to the prosecuting attorney as a violation. The prosecuting attorney makes the final decision whether to proceed with formal prosecution for the alleged violation. If formal prosecution proceeds, the nurse has the right to a hearing before the Board on the alleged violations. The Board will ultimately decide whether or not a sanction should be imposed through the issuing of Adjudication and Order.
Figure 1
PERC Program Flowchart Complaint received and reviewed by the Professional Compliance Office (PCO). If necessary, sent to Bureau of Enforcement and Investigation for investigation.
Investigation determines if complaint is a practice deficiency and meets eligibility criteria for PERC. YES NO Attorney reviews case for remediation.
Attorney reviews case for discipline or closure.
Not Appropriate BON advisors and attorney review case and determine appropriateness for remediation.
The PERC pilot program results were presented to the BON at its June 2012 meeting, and the BON decided unanimously to continue the program as an alternative to public discipline.
Conclusion The PERC program reflects a new way of thinking about reports of practice violations. While maintaining public safety, the program allows the BON to distinguish reckless and willful violations from minor violations that can be corrected with remediation. The program has been successful in that the BON has received no reports of patient harm or recidivism, participants have improved their practice through education and monitored practice, and participants have been able to remain in the workforce providing safe, quality patient care. Statistics will be maintained as the PERC program continues as a permanent part of the BON’s work. Successes and failures will be monitored, and the numbers of cases reviewed for eligibility and licensees enrolled in the program will be maintained. A review of the statistics is ongoing and, if necessary, the eligibility criteria and program implementation will be revised to meet the goals of improving licensee education and maintaining public safety.
Appropriate Nonpublic consent agreement developed and sent to board of nursing (BON) for consideration. Licensee is monitored by nursing practice advisors.
Licensee successfully completes program. No formal discipline recorded.
Licensee does not complete program; referred to PCO for violation of BON order. Formal discipline action taken.
Note. PERC = Practice, Education, Remediation, Collaboration.
Results of Pilot Study Fifty-one candidates (30 RNs, 21 LPNs) were reviewed, and 32 (20 RNs, 12 LPNs) were deemed eligible for the PERC pilot program. Of the 32 participants, 26 have completed the program, and 6 are in the process of completing it. All the candidates enrolled in the PERC program were compliant with the remediation plan as outlined in the consent agreement, and no cases of practice errors have been reported while a licensee was completing the program. To date, the 26 licensees who completed the program have had no incidents of recidivism. The other 19 candidates were deemed ineligible for the remediation program because their violations were too serious for remediation or were the result of a system failure. Volume 4/Issue 1 April 2013
References Griffith, K. S. (2010). Column: Error prevention in a just culture: System design or human behavior? The Joint Commission Perspectives on Patient Safety, 10(6), 10–11. Retrieved from http://legacy.justculture.org/media/JustCultureColumn3.pdf Pepe, J., & Cataldo, P. J. (2011). Manage risk, build a just culture. Health Progress, 92(4), 56–60. North Carolina Board of Nursing. PREP: Practitioner Remediation and Enhancement Partnership Program. Retrieved from www.ncbon. com Ohio Board of Nursing. PIIP: Practice Intervention and Improvement Program. Retrieved from www.nursing.ohio.gov Shields, J. (2009). An alternative to public discipline program for nurses with practice problems. Pennsylvania State Board of Nursing Newsletter. August 2009.
Marguerite Witmer, DNP, MSN, RN-BC, MPA, is a former nursing practice advisor for the Pennsylvania State Board of Nursing, and Colleen Rosborough, MSN, CRNP, is a nursing practice advisor for the Pennsylvania State Board of Nursing.
www.journalofnursingregulation.com
51