Sweeping changes in the healthcare environment reveal a greater need for the placement of qualified, cost-effective providers in all areas. Certified Registered Nurse Anesthetists (CRNAs) have a proven track record of safety. However, a gap exists in identifying, quantifying, and linking existing practice evidence to the performance of individual CRNAs. The purpose of this project was to develop a practice portfolio for each CRNA that would provide evidence of competent performance in a rural acute care setting. The project demonstrated that CRNA practice portfolios can be utilized to demonstrate competent practice through the compilation of objective and quantifiable evidence

Rizer, Carol

English

European Scientific Journal (European Scientific Institute)

European Scientific Journal May 2015 /SPECIAL/ edition Vol.2  ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431 26 DOCUMENTING COMPETENCE:  EVIDENCE OF EXCELLENCE IN NURSE ANESTHESIA PRACTICE    Carol Rizer, DNP, CRNA The University of Texas at Tyler, United States   Abstract   Sweeping changes in the healthcare environment reveal a greater need for the placement of qualified, cost-effective providers in all areas.  Certified Registered Nurse Anesthetists (CRNAs) have a proven track record of safety.  However, a gap exists in identifying, quantifying, and linking existing practice evidence to the performance of individual CRNAs.  The purpose of this project was to develop a practice portfolio for each CRNA that would provide evidence of competent performance in a rural acute care setting.  The project demonstrated that CRNA practice portfolios can be utilized to demonstrate competent practice through the compilation of objective and quantifiable evidence.  Keywords: Competence, practice portfolios, performance improvement, scholarly work  Introduction The value of CRNAs in the search for better, more efficient, cost effective, accessible, and high quality healthcare is significant (Plaus, Muckle, & Henderson, 2011).  Because the CRNA scope of practice allows nurse anesthetists to provide anesthesia-related care to diverse patient populations in multiple healthcare settings, CRNAs are strategically positioned to provide such care in a safe and cost-efficient manner (American Association of Nurse Anesthetists, 2013).  Dulisse & Cromwell (2010) found that there was no difference in the safety of anesthesia care in states where CRNAs function without physician supervision than in those states that require it, and that the CRNA model is more cost-effective).   The National Board of Certification and Recertification for Nurse Anesthetists ((NBCRNA) has modified the process of recertification so that it will provide further evidence of continued competence in the profession (NBCRNA, 2013a).  These requirements, however, will be implemented progressively through 2032, with mandatory testing for recertification European Scientific Journal May 2015 /SPECIAL/ edition Vol.2  ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431 27 beginning in full at that time (NBCRNA, 2013b).  Since mandatory testing will not begin for many more years, CRNAs may need an avenue for proving competence before then.  Even after that date, mandatory testing will only occur every other certification cycle which could overlook the need to demonstrate continuing competence in the interim (Plaus, Muckle, & Henderson, 2011).  The identification of measurable indicators that contribute to an accurate assessment of the competence of individual CRNAs would empower stakeholders to achieve a more definitive appraisal of the quality of patient care and safety actually being delivered.  I. The purpose of this project was to develop a portfolio defining and measuring pertinent indicators associated with nurse anesthetist performance in the acute care setting.  The reporting format in the portfolio included five sections.  Prior to study implementation, the author selected eleven indicators from a list of twenty-two currently used in the cohort hospital as being most reflective of actual provider performance and less influenced by patient comorbidities.  Beginning with the past quarter, any indicator event occurring for any provider during the data collection period was recorded.   Specific information included the total number of anesthetics performed by each CRNA, the number that did not pass the peer review process, and the outcome.   This information demonstrated evidence of specific and measurable negative outcomes in the course of anesthesia administration on a daily basis for every provider as well as over the long-term and comprised Section I of the portfolios.  Section II consisted of quarterly performance evaluations by a peer, the Medical Director, and a self-evaluation.  All of these sections utilized brief questionnaires in the form of a survey instrument.  Because self-efficacy and performance measurements have been shown to be consistently related, specific Likert items were selected to evaluate self-efficacy in hopes of extrapolating the results to measure performance.  Self-efficacy has less to do with the amount and type of skills a provider possesses, but rather about how confident he/she feels in the judgment calls utilizing those skills (Maurer & Pierce, 1998).  Section III was used to demonstrate evidence of the required licenses and continuing education credits in an easily accessible form, as well as evidence of advanced skills and certifications.  Section IV consisted of documentation identifying consistent and continuing compliance with accurate patient care documentation and billing records. Accuracy of patient care documentation is necessary for third-party payers such as Medicare to ensure appropriate reimbursement.  This data provided evidence of proper stewardship of goods and services through accurate and legible documentation and billing records.  European Scientific Journal May 2015 /SPECIAL/ edition Vol.2  ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431 28 In order to assess the accuracy of billing records, the administrative assistants employed by the business office documented incidences of inconsistent or illegible patient care documentation and/or absent documents necessary for billing purposes.  Without correct and complete information from all these components (and legible handwriting from the anesthetist), the administrative assistant who bills for anesthesia services may be forced to call the hospital medical records department in order to have the needed information retrieved from the patient chart and faxed to her, decreasing the efficiency of the billing process.  Section V consisted of scholarly work by the CRNA, including accomplished or ongoing research, papers, projects, utilization of evidence-based practice materials, and publications.  The portfolios were assembled by the administrative assistants with direct input from individual CRNAs.  Project Evaluation  The project was evaluated through the use of Likert scale questionnaires completed by each CRNA, the Medical Director, and each Administrative Assistant.  The majority of study respondents agreed that the components included in the portfolio provided adequate, reasonable, and truthful evidence of CRNA professional competence and the portfolio did appear to be an improvement over the previous method (recording only credentialing and licensing information).  Most CRNAs felt that the addition of peer review and the feedback on documentation/billing packet completeness and legibility would inspire practice change and the Medical Director felt that the portfolio would make it much easier to do annual performance reviews. All respondents viewed the portfolio as an easier way to organize and access the data; most believed the portfolio would be very functional in regard to the information they would need or use, as well as making the hospital credentialing process more efficient.  The CRNAs felt that having the performance improvement data in their own portfolio would keep them informed of the data that the hospital is tracking and aware of quarterly reporting results on a regular basis. This information trail would enable them to analyze their own progress and performance.    The majority of CRNAs responded that if they received information about incomplete documentation or illegible billing packets, they would take measures to improve it.  The billing and documentation data collected over the last month showed that all CRNAs were deficient in at least one billing packet.  One CRNA was deficient in eleven billing packets.   There is no conclusive data establishing a complete list of performance indicators for CRNAs, or any other medical specialty.   However, the majority of respondents in this study felt that performance European Scientific Journal May 2015 /SPECIAL/ edition Vol.2  ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431 29 improvement data was an important component in evaluating CRNA performance and that the eleven performance improvement indicators chosen from the hospital-utilized indicators were very reflective of CRNA performance and competence.  The Medical Director specifically spoke to the advantage of having a peer review done among the CRNAs, stating that persons practicing in the same profession can provide the most appropriate feedback about competence in practice.  Several comments were made regarding the renewed incentive, both personally and professionally, when new information is disseminated, as well as the effectiveness of collaboration and discussion about practice issues and areas for improvement.    Implications for Practice Instead of defining the standards of care based on what any prudent provider would do in the same situation, today’s definition has broadened to include several other considerations.  For example, whether or not the clinician did the right thing at the right time, whether it was effective, or was provided safely and in a timely manner, and whether or not the outcome was the best that could be expected based on the patient’s condition, comorbidities, and the current best evidence must now be addressed as well (Buppert, 2012).    Conclusion  Outcomes of this project suggest that a CRNA practice portfolio could help bridge the evidence gap in defining practice competence of individual CRNAs, utilizable by the CRNA provider, as well as stakeholders such as employers, hospitals, third-party payers, and perhaps even patients.  By providing retrospective and prospective data, CRNAs are able to view their own achievements, evaluate their professional progress, identify gaps in learning, and plan personal and professional goals and objectives (Hawks, 2012).  Through the demonstration of best practice, CRNAs may be more readily identified as providers of quality anesthesia care.    References: American Association of Nurse Anesthetists (2013).  Scope of Nurse Anesthesia Practice.  Retrieved from http://www.aana.com/resources2/professionalpractice/Documents/PPM%20Scope%20of%20Nurse%20Anesthesia%20Practice.pdf Buppert, C. (2012). Nurse Practitioner’s business practice and legal guide (4th Ed.). Sudbury, MA: Jones & Bartlett Learning. Dulisse, B., & Cromwell, J. (2010). No harm found when nurse anesthetists work without supervision by physicians. Health Affairs, 29(8), 1469-1475. European Scientific Journal May 2015 /SPECIAL/ edition Vol.2  ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431 30 Hawks, S. J. (2012). The use of electronic portfolios in nurse anesthesia education and practice. AANA Journal, 80(2), 89-93. Maurer, T. J., & Pierce, H. R. (1998). A comparison of Likert scale and traditional measures of self-efficacy. Journal of Applied Psychology, 83(2), 324-329. National Board of Certification and Recertification of Nurse Anesthetists, NBCRNA (2013a).  Changing needs:  Limitations of the current system.  Retrieved from http://www.nbcrna.com/cpc/Pages/Changing-Needs.aspx National Board of Certification and Recertification of Nurse Anesthetists, NBCRNA (2013b).  Time frame.  Retrieved from http://www.nbcrna.com/cpc/Pages/Timeframe.aspx Plaus, K., Muckle, T. J., & Henderson, J. A. (2011). Advancing recertification for nurse anesthetists in an environment of increased accountability. AANA Journal, 79, 413-418.      

DOCUMENTING COMPETENCE: EVIDENCE OF EXCELLENCE IN NURSE ANESTHESIA PRACTICE

European Scientific Journal, ESJ

https://eujournal.org/index.php/esj/article/download/5579/5374

DOCUMENTING COMPETENCE: EVIDENCE OF EXCELLENCE IN NURSE ANESTHESIA PRACTICE

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European Scientific Journal (European Scientific Institute)

European Scientific Journal, ESJ