Summary of Major Initiatives and Related Progress
The agency is undertaking two efforts to improve and streamline its licensing functions. One is for applicants, the other for in-house processing.
The agency’s licensing system has an on-line license application component that will enable applicants to enter basic licensure application data on-line and subsequently track the agency’s receipt of additional documentation and testing results through the Internet. This will significantly cut down on the volume of telephone and written correspondence related to the application process, thus enabling agency licensure staff to more productively devote their time to application evaluation and processing activities.
As a companion to that effort, the agency is centralizing the receipt and processing of checks received from applicants for fees associated with initial licensure. This effort is designed to reduce administrative requirements on board staff, improve the agency’s internal controls, and reduce the length of time required to make and process bank deposits.
Reform of the Disciplinary System
The agency has reformed its disciplinary system in order to achieve its goal of addressing 90% of allegations of practitioner misconduct relating to patient care within 250 business days by the end of FY 2009. The agency has undertaken a number of actions to help shape its reform plan including: formally operationally defining "patient care," rigorous analysis of historic case processing performance, and examination of open caseloads at the various levels to determine where "bottlenecks" occur.
Key reforms of the disciplinary process are:
• Creation of a tiered system for investigations. More work is done upfront in the central office before a case is assigned to a field investigator. Cases assigned to investigators have due dates as of January 1, 2008. For “Tier One” cases, an Investigative Assistant has been hired to collect basic documents and conduct preliminary telephone interviews. Early expert intervention is actively sought during the investigative phase and subject matter expert review may take place as early as the Intake, or initial, phase of an investigation. “Tier Two” cases undergo an initial probable cause review based on the results of preliminary investigation and include continued expert intervention/involvement. The initial probable cause reviewer may recommend closure without additional investigation or the reviewer may focus the subsequent investigation by providing specific guidance on what documents should be collected and which persons should be interviewed. If the reviewer determines that only documents are needed, the investigation may remain in the central office without the involvement of a field investigator. A “Tier Three” case entails a detailed investigation, either field or administrative.
• Increased use of administrative investigations for collecting documents. A new subpoena process implemented in November 2007 whereby the Enforcement Division issues subpoenas for records for cases under investigation instead of sending a request for such a subpoena to the Administrative Proceedings Division. A new process was implemented October 2007 for Medical Malpractice Payment Reports involving a focused investigation and early review by the Board of Medicine. A new process was implemented as of January 1, 2008 for cases involving dismissals from the Health Practitioners’ Monitoring Program. Reports of HPIP dismissals are sent directly from the HPMP Program Liaison to the relevant Board Section for potential disciplinary action. Additional Investigation is conducted only if necessary to support initiation of disciplinary action.
• Develop checklists for routine investigations. A new Investigative Report format was implemented in 2008. Checklists for recurring complaints where predictable information is to be obtained have been developed. For example, the Board of Pharmacy now routinely uses a checklist for unlicensed pharmacy technician cases.
• Legislation. In the 2008 session of the General Assembly, legislation was passed to amend Va. Code § 54.1-2406 to clarify that agency has the authority to request and receive patient records and other documents. There is now a succinct statement of the agency authority in the Code to demonstrate to persons who may challenge the agency’s authority in this regard, which in many cases has allowed investigation to proceed without the delay of intervention by the Office of the Attorney General to confirm the agency’s authority.
Further study is underway to insure institutionalize of reforms implemented as well as develop additional efficiencies in the investigative and adjudicative process.
Sanctions Reference Progress
One of the most difficult questions that members of the public often ask is, "Are licensing boards making the right decisions when they discipline a practitioner for misconduct?" To establish a framework for this important issue, the Department has developed a systematic approach using a point system, referred to as "Sanctions Reference," that enables each individual board to establish a consistent set of factors against which to judge similarly-situated cases and respondents. The research methods resulting in Sanctions Reference Point (SRP) systems for each board was modeled after that used to develop criminal sentencing guidelines in Virginia.
The aim of the SRP research is to enable everyone to understand the factors that each board considers important and the degree of importance of each of those factors in rendering fair and reasonable sanctioning decisions. By allowing boards to judge similarly-situated cases against the same, agreed-upon set of empirically derived factors and weights, SRP makes possible not only consistency but transparency into sanctioning decision-making. Further, because only those factors deemed appropriate are scored, when SRP-recommended sanctions are selected, SRP provides a reliable tool to effectively exclude the influence of defined inappropriate factors in the sanctioning decision process.
To date, the Boards of Medicine, Dentistry, Nursing, Veterinary Medicine, Funeral Directors and Embalmers, Pharmacy, Optometry, Counseling, Psychology, and Social Work have fully developed and begun using their respective SRP systems, The Board of Medicine began use of its system in August of 2004, and the Boards of Counseling, Psychology and Social Work in June of 2009. The program has been honored by the Council on State Governments and Southern Legislative Conference by being selected as one of the top ten finalists for the 2007 Council on State Governments Innovations Award.. The agency's remaining boards, Physical Therapy, Long-Term Care, and Audiology and Speech-Language Pathology are anticipated to have their systems in place before the end of calendar 2009.
The rate of compliance with SRP recommendations was modeled based upon "typical" cases, so the predicted agreement rate was between 70-75%, As of July 1, 2009, 81% of applicable cases received sanctions recommended by SRP. Anecdotal reports from the participating boards have been uniformly positive. The reasons for departure have ranged from extreme remorse to significant patient vulnerability. A formal evaluation of the SRPs patterned after the methodologies used to assess the efficacy of the criminal sentencing guidelines will be conducted during calendar year 2010. Continuous review by the boards, the broader regulatory and research communities, as well as the public is required to determine if SRP will be as effective in the regulatory arena as Virginia's Sentencing Guidelines are for criminal justice. It is hoped that by bringing self-correcting empirical methods of science to what had been an inherently subjective process, SRP can continue to enhance boards' abilities to fulfill their mandate to protect the public while rendering fair and impartial sanctions.
Because Sanctions Reference informs on the relative importance of factors related to disciplinary issues, the agency has also used SRP research to develop an improved method of operationally defining "patient care" versus "non-patient care" cases. Three of the agency's Key Performance Measures pertaining to discipline: Clearance Rate, Age of Pending Caseload, and Time to Disposition reference patient care case resolution because of the preminence of patient health issues over non-clinical matters. In July 2009, the agency began using a revised case category assignment system which provides rules for determining whether a case is patient care or non-patient care and how to record the designation in the agency's disciplinary database for better tracking. This new system gives the agency a clearer picture of both the elements (i.e., category of issues involved) as well as the seriousness of the case (i.e., priority).
Prescription Monitoring Program Progress
The Prescription Monitoring Program made available to all licensees of the Department of Health Professions an online course on Chronic Nonmalignant Pain Management developed by the School of Medicine at Virginia Commonwealth University and mailed out over 19,000 books which were donated to the Department of Health Professions by the Federation of State Medical Boards (FSMB). The book, Responsible Opioid Prescribing, A Physician’s Guide was written by Dr. Scott Fishman, translates FSMB’s Model Policy for the Use of Controlled Substances for the Treatment of Pain into practical terms for clinical practice. It is widely recognized that the management of pain is challenging, the amount of training given in medical or pharmacy school is not great, and there is not a great amount of evidence based data for treatment guidelines available for certain pain syndromes. The course and book bridges the gap between what is taught and what is actually needed to manage the treatment of pain.
The program is planning an intense marketing campaign to educate health practitioners about the new capabilities of the program to include 24/7 access as well as the educational resources available to them over the next 2 years.
The Prescription Monitoring Program is also working on implementing software that will allow users to receive reports from other state programs without having to register with each state and make multiple requests. This “interoperability” feature is now being tested by some of Virginia’s neighboring states with production capable software expected by the end of this year. The program has legislation authorizing this new feature and will work toward procurement and implementation of software as soon as other software enhancements have been completed.
Establishment of the Health Care Workforce Data Center
The Governor's Health Reform Commission report from September of 2007 recommended the formation of a healthcare workforce data center for Virginia to be located within the Department of Health Professions. The Department currently houses an extensive licensure database for all professions regulated by its boards, a phyician profile database, and periodic workforce surveys conducted by the Board of Nursing, Board of Medicine, and Board of Pharmacy. The aim of the Center is to serve as the Commonwealth's source of validated health provider workforce information. By emloying appropriate research methodologies, the Cener will collect valid, policy-relevant information from health care providers through licensure application and renewals and surveys and will maintain a dedicated data repository. From this repository, the Center will produce standard, periodic, publicly available data, tables, as well as other status and trend reports designed to answer key questions about Virginia's current and future healthcare workforce. Additionally, data may be made available upon requests from parties outside of the Department of Health Professions upon the approval of the Department's Director and in keeping with Virginia statutes.
Among the goals achieved, to date, are the hiring of staff, establishment of the DHP Healthcare Workforce Data Center Advisory Council, comprised of key Virginia stakeholders in healthcare workforce issues. Additionally, subcommittees were developed to provide specific advice for physicians, nursing and nursing education workforce data. Nationally recognized consultants and DHP staff have aided the subcommittees and Council in the analysis of existing data and survey instruments, in the development of a physician demand model at the state level, and in determining appropriate formating of Center reports and other publications.
Presentations on the state of Virginia's nursing and physician workforce to policy makers, contstitutent groups, and other interested parties are planned. Information on physician assistants, nurse practitioners, certified nurse aides, dentists, and dental hygienists are expected to be added as the workforce studies are completed and verified. Other professionals, such as clinical psychologists, will be targeted for gathering, analyzing, and disseminating strategic workforce information as resources permit.
Changes to the Health Practitioners’ Monitoring Program
The Health Practitioners’ Monitoring Program (HPMP), Va. Code § 54.1-2515 et seq., was created in 1997 as an alternative to disciplinary action for impaired health care practitioners. Provided certain conditions are met, a practitioner may get a stay of disciplinary action and be allowed to practice under terms and conditions dictated by a recovery monitoring contract.
Pursuant to legislation passed by the 2009 session of the General Assembly, effective July 1, 2009, the name of the Health Practitioners’ Intervention Program changed to the Health Practitioners’ Monitoring Program (HPMP). The legislation clarifies that the purpose of the Program is to monitor impaired health professionals, rather than to intervene on or treat them. Additionally, the membership of the Health Practitioner's Monitoring Program Committee was expanded to include a registered nurse engaged in active practice and the agency is authorized to assess participants a fee for participation.
In an effort to contain costs of the Program, the following changes have been implemented as of July 1, 2009. Maintenance of a current, active license is required to participate in the HPMP. Applicants will be eligible to participate in the HPMP for up to one year after making application to be licensed. Continued participation of HPMP participants who do not meet new eligibility requirements will be handled on a case-by-case basis and the terms of participation/recovery monitoring contracts remain effective. “Secondary Monitoring” has been eliminated for persons who are not practicing in Virginia. Over the next year, the agency will explore the feasibility of charging participants a reasonable fee related to the costs of participation in the Program, although no participant shall be denied entry into the Program due to the inability to pay a portion of the costs related to participation.
Review of Emerging Health Professions
By virtue of its statutory authority in §54.1-2510 of the Code of Virginia to advise the Governor, the General Assembly, and the Department Director on matters related to the regulation and level of regulation of health care occupations and professions, in April of 2008, the Board of Health Profession began an ongoing review of emerging health professions. The Board has been evaluating the need to regulate orthotists, prosthetists, pedorthists, central service/sterile technicians, orthopaedic technicians, orthopedic physicians assistants, polysomnographers, medical interpreters, surgical assistants, and surgical technologists. Soon genetic counselors and potentially kinesiologists will be added. Each group has relatively few practitioners in Virginia and, as such, could not reasonably be expected to financially support its own separate board. The alternative that is typically recommended is for new profession to be assigned to an existing board, such as the Board of Medicine or the Board of Nursing. This practice has stretched the resources of both of these boards and has led the Board of Health Professions to consider a study into the need for an allied health board in Virginia.
The Department of Health Professions management strongly supports the Commonwealth's telework initiative which has been well received by staff. Its current telework policy allows Central Office staff whose position is suited for telework to submit a proposal to work one day a week from home. This policy continues to be reviewed and is expected to expand as business needs evolve and technology support advance. Current telework demographics indicate that 17% of the agency's employee population telework one day a week from home and 28% telework 40 hours a week from home. The later group is comprised largely of investigative staff stationed thoughout the state.
Electronic Content Management
In conjunction with a broad, statewide effort, DHP is moving into electronic content management (ECM). Viewed as a multi-year endeavor, the agency began it’s ECM efforts in earnest early in the 2008-10 biennium with the procurement of Documentum, a proprietary ECM product linked to the agency’s licensing system. The concept is to fully integrate all of the agency’s records, from entry into or creation by the agency to long-term archival, including records retention and destruction schedules.
It is expected that ECM will have far-reaching productivity improvements, particularly with respect to the investigation and adjudication of complaints against licensed health care providers. Investigation files contain multiple types of documents, from copies of patient records to X-rays to investigator notes and reports. Each case is initiated in the central office, assigned to an investigator in the field, returned to the central office, reviewed by multiple parties in the central office, prepared for use during informal conferences and formal hearings, and ultimately archived through microfilm. Depending on the nature of the complaint, case files can be voluminous. The amount of paper passing through the agency is daunting.
Reducing the amount of paper required to deal with the investigatory and disciplinary process is only one objective. A second important objective is to enable future staff to easily retrieve and use previous case histories.
Many of DHP’s licensees practice for decades. It is not uncommon for a licensee to have a case opened early in his career, be quiescent for many years, and then have a second complaint several decades later. Presently, case histories are archived on microfilm. This requires a manual search using a medium that hasn’t changed much in 40 years, printing off needed sections, and then the rekeying of portions of the old case into the new report. Moreover, any physical evidence referenced in the old case, such as a dental appliance, is not available for review. Through Documentum, all case records, including copies of X-rays and pictures of physical evidence, will be available for use by an investigator of the future as if the previous case was closed the day before. We view this as a quantum leap in how we manage and use our documents and records.
The use of ECM will support operational and strategic performance improvements; increase the efficiency and thoroughness of case completion; provide a prepared response to emergencies and disasters; provide accessible and accurate information; meet compliance and regulatory mandates; provide outstanding customer service; and increase evidentiary reliability and document security.