Written Collaborative Agreements and Collaborative Relationships

(65/65-35. Written Collaborative Agreements)

 

In addition to being properly licensed, for the first time the 1998 Nursing Act required APNs who are CNMs, CNPs, or CNSs to practice only if they have a written collaborative agreement (WCA) with a "physician licensed to practice medicine in all of its branches.” A physician licensed to practice medicine in all of its branches refers to medical doctors (MDs) and doctors of osteopathy (DOs).  As the nature of CRNA practice tends to be different from that of other APNs, it was understood that a typical collaborative agreement was of no benefit in guiding the work of CRNAs in hospitals and ambulatory surgical treatment centers (ASTCs). Furthermore, there are practice settings where CRNAs were allowed to provide anesthesia services "pursuant to the order of” a licensed dentist or licensed podiatrist, which were collaborative relationships not afforded other APNs. However, a CRNA who wished to have prescriptive authority (meaning the authority to hand a patient a written prescription) had to meet the same WCA requirements expected of other APNs.

 

The 2007 Nursing Act expanded the types of "doctors” with whom an APN may have a WCA to include podiatrists. As had been accepted for the preceding decade, CRNAs were still allowed to work with podiatrists and dentists. Added in 2007 was the ability for other APNs (i.e., NPs and CNSs) to collaborate with podiatrists, as well as MDs and DOs. However, NPs and CNSs who collaborate with podiatrists must still adhere to the requirement that "The services of the advanced practice nurse shall be services that the collaborating physician or podiatrist is authorize to and generally provides to his or her patient in the normal course of his or her clinical medical practice…” (65/65-35, b).  In other words, an APN collaborating with a podiatrist is not allowed to provide primary care or other services not generally considered the purview of a podiatrist. The chief advantage to including podiatrists as a collaborating doctor is for those APNs whose practice includes wound care, which is common area of expertise for many CNSs and some NPs.

 

Throughout the decade following Illinois’ recognition of APNs, the employment opportunities for all specialties of APNs surged in hospitals and some ASTCs throughout the nation. As a result of these increased numbers of APNs of all specialties in institutions, the Joint Commission on Accreditation on Health Organizations (now called Joint Commission) issued a standard that APNs be credentialed and privileged by the institutions where they worked. Typical institutional credentialing and privileging process is very detailed; indeed, the application process was standardized in Illinois by the Health Care Professional Credentials Data Collection Act in 1999, the same year the Nursing Act was revised to recognize APNs.   It became obvious that the usual collaborative agreement was superfluous to the entire credentialing and privileging process; thus, in 2007, the requirement for a signed WCA was removed for all specialties of APNs who are employed and privileged by hospitals and ASTCs. The purpose of this exception was to facilitate the typical practice of APNs whose work in these institutions may involve "writing orders,” including those for medication, but does not involve handing patients prescriptions to be filled by pharmacies outside of the institution. If, however, an APN is so privileged, but his/her position includes the actual writing of prescriptions, s/he also is required to have a WCA.  This provision regarding being privileged in a hospital or ASCT is a real boon for APNs who work with several physicians (e.g., the entire staff of the OB/Gyne department), as well as those APNs  such as some CNSs, whose practice is primarily to support other nursing services, rather than providing care typically seen as the purview of medicine. However, the Nursing Act does state: "If an advanced practice nurse engages in clinical practice outside of a hospital or ambulatory surgical treatment center in which he or she is authorized to practice, the advanced practice nurse must have a written collaborative agreement” (65/65-35, a-5).

 

An APN may apply for an APN license before getting a written collaborative agreement signed or becoming privileged, but s/he may NOT practice as an APN nor should s/he identify himself or herself to patients as an APN without having an APN license and without having a WCA or privileging in place.  

 

Points that are to be included in the WCA are as follows (65/65-35):

 

"The agreement shall be defined to promote the exercise of professional judgment by the advanced practice nurse commensurate with his or her education and experience.”

 

"…describe the working relationship of the advanced practice nurse with the collaborating physician or podiatrist and shall authorize the categories of care, treatment, or procedures to be performed by the advanced practice nurse.” (There is also language about a collaborative agreement with a dentist that refers to subsection c-10 in this section.  Subsection c-10 refers to CRNAs exclusively.)

 

"Collaboration means the relationship under which an advanced practice nurse works with a collaborating physician or podiatrist in an active clinical practice to deliver health care services in accordance with (i) the advanced practice nurse’s training, education, and experience and (ii) collaboration and consultation as documented in a jointly developed written collaborative agreement.”

 

"The agreement need not describe the exact steps that an advanced practice nurse must take with respect to each specific condition, disease, or symptom but must specify which authorized procedures require the presence of the collaborating physician or podiatrist as the procedures are being performed.”  

 

"The collaborative relationship under an agreement shall not be construed to require the personal presence or podiatrist at all times at the place where services are rendered. Methods of communication shall be available for consultations with the collaborating physician or podiatrist in person or by telecommunications in accordance with established written guidelines as set forth in the written agreement.”

 

The 2007 Nursing Act added language that "The agreement must contain provisions detailing notice for termination or change of status involving a written collaborative agreement, except when such notice is for just cause.” The purpose of this language was to provide some sort of protection against either the APN or collaborating physician suddenly terminating their relationship and adversely affecting the practice (and livelihood) of each, as well as the well-being of the patients under their care.

 

A sample (but not necessarily a model) WCA was provided at the very end of the Rules of the 1998 Nursing Act.  As noted before, the Rules have not yet been re-written to conform to the language of the 2007 Nursing Act. In any case, the sample WCA should be revised to reflect the nature of an APN’s practice of in a particular setting.  For example, language regarding CRNA practice is included in this sample, so if there are no CRNAs working at a particular setting, that language should be deleted. 

 

Many attorneys feel that a WCA should be just specific enough to describe an APN’s general scope of practice without being overly detailed.  The WCA is not an employment contract; therefore particulars about salary, benefits, work hours, etc. should not be included in the WCA. The language in the sample WCA under "scope of practice” has been written in general terms to cover what most APNs are prepared to do, but APNs (and their legal counsel) will likely wish to include a few more details in their own WCAs. For example, if an APN’s practice will be limited to only pediatric patients or female patients, it makes sense to note that fact.  Other descriptions of scope of practice might clarify if the APN will be working with a select group of patients (e.g., HIV-positive patients, rheumatology patients, etc.). 

 

The sample WCA also includes sample attachments: (a) "Practice sites” (if the APN will be working at more than one site), (b) Joint Orders or Guidelines”, and (c) Delegation of Prescriptive authority.  While the scope of practice is typically written in very general language, the joint orders or guidelines provide more detail of the parameters of the APN’s practice. This section is not as daunting to complete as it would appear.  A common approach is to list a few comprehensive references that cover most of the clinical situations that the APN would be expected to handle.  Citing some of the very detailed textbooks that APNs relied on in their educational programs is appropriate. Over time many "evidenced-based” guidelines are being generated by national panels of experts for certain conditions, such as diabetes, asthma, cardiovascular and lipid disease; thus, it makes sense to allude to the fact that national standards of care will also serve to direct the APN’s care of patients.  It is important, however, to keep this list of references current, as it would be imprudent to suggest that one is practicing according to outdated standards.

 

It is wise that the list of guidelines not be too lengthy, otherwise the APN is at risk for failing to abide by some set of guidelines on the list.  Furthermore, if an APN does not follow the practice that is recommended by the references on the list, there should be documentation (usually in the patient’s chart) why there was a deviation in the usual standard of care.  There are numerous, clinically-sound reasons why patients might need individualized treatment not recommended by commonly accepted standards of care.  To minimize liability, APNs, as well as other providers, simply need to substantiate their clinical reasoning for such deviation.  Furthermore, if an APN’s plan of care was developed as a result of a specific consultation with a physician or other health care provider (in person or by telecommunication), it make sense for the APN to document that communication.

 

A copy of the WCA is not routinely sent to IDFPR, as it has no storage space for the WCAs of the thousands of APNs licensed in Illinois.  However, a copy of the WCA, signed by both the APN and the collaborating physician, must be available should IDFPR request it. Both the advanced practice nurse and the collaborating physician should have copies of the WCA. The 2007 Nursing Act replaces the requirement that the WCA updated annually with the provision that it be updated "periodically.”

 

Role of the Collaborating Physician

The section on WCAs (65/65-35) further describes the relationship between an APN and a collaborating physician as follows:

Collaboration does not require an employment relationship between the collaborating physician and the advanced practice nurse. Collaboration means the relationship under which an advanced practice nurse works with a collaborating physician in an active clinical practice to deliver health care services in accordance with (i) the advanced practice nurse’s training, education, and experience, and (ii) collaboration and consultation as documented in a jointly developed written collaborative agreement.

Thus, the APN always needs to have a mechanism for consultation and referral with at least one physician, and that relationship is identified by the fact that both the physician’s and the APN’s signatures must appear on the WCA. If the APN's "ordained" collaborating physician is not available, there must be some physician(s) available to provide the consultation and referral in the collaborating physician's absence. This arrangement is noted in the sample WCA found at the end of the Rules: "The advanced practice nurse shall consult with the collaborating physician by telecommunication or in person as needed.  In the absence of the designated collaborating physician, another physician shall be available for consultation.”

Logistically, it is far easier if there is only one physician who has the designation of collaborating physician because the collaborating physician has certain "duties" to perform, such as the meeting monthly with the APN. The 1998 Nursing Act described the monthly meeting as "monthly site visits,” which strongly suggested that the visit had to be at the site where the APN actually rendered service. That implication posed a particular problem for those APNs who had only one collaborating physician, but worked at more than one geographic location. When the Rules were being written between 1999 and 2001, the APN board wanted to clarify that the point of the 1998 law was that the APN and the collaborating physician needed to meet at least once a month, but not necessarily at the location(s) of the APN’s practice.  Thus, the Rules included language that the site of the monthly visit was to be stipulated in the collaborative agreement. Despite this attempt at clarification, many APNs (and physicians and legal counsels) remained confused about monthly site visits, largely because many who study the Nursing Act fail to also read its Rules.

Therefore, the 2007 Nursing Act language says that the collaborating physician or podiatrist must meet "in person with the advanced practice nurse to provide collaboration and consultation.” This 2007 language also replaced the expectation that that the collaborating physician had to also provide "medical direction,” which many APNs found objectionable.

In any case, it is clear that it is the signature of the official collaborating physician is required on the WCA, but the Nursing Act does not stipulate that the collaborating physician and the whole host of consulting physicians have to sign the WCA. In any case, it seems logical that the reference to consulting physicians should be as general as possible. Take, for example, if an APN were working in a large group practice (XYZ Medical Practice) that employs several physicians. The APN would specifically name the one physician who is her/his actual collaborating physician, but note in the agreement that there are occasions where s/he will consult with any or all physicians employed by XYZ Medical Practice (or all the physicians in a particular department of XYZ Medical Practice). The point is that the WCA should not have to be changed every time one of the consulting physicians leaves or joins the practice. If an APN works with only one physician who has physician colleagues from other practices take call or cover for his/her patients when s/he's out of town, an APN might describe this situation in a generic fashion such as "in Dr. Jones' absence, will consult with the physicians associated with ABD Medical Practice."

It is important that consulting physicians clearly understand their role. If an APN is consulting with physicians within their own (large) practice, this is easily accomplished because there are probably other internal documents that apprise those physicians that they may be called upon to work with the APN from time to time. However, if the APN is going to consult outside of the practice, then it would probably be a good idea to have some signed document that indicates that this is acceptable to those outside physicians. The main reason for such a document is to prevent some physician from coming back at a later date claiming that s/he did not agree to be the APN's consultant in the absence of the collaboration physician. Again, this document should indicate that these other physicians are NOT the official collaborating physician, to make it clear that these other physicians will not be responsible for monthly site visits or ongoing oversight of the APN's practice.

As noted previously, the services that an APN provides to patients have to be similar to those that the collaborating physician "generally provides to his or her patients in the normal course of his or her clinical medical practice" (65/65-35). For example, if an APN sees patients of all ages, and there isn’t a family practitioner available to be the APN’s collaborating physician, then the APN would need to collaborate with at least two collaborating physicians (e.g., a pediatrician and an internist).  If the APN works for multiple employers, the APN must have separate WCAs for each practice setting which are signed by physicians affiliated with each practice setting.  Furthermore, the APN must provide copies of each WCA to each physician with whom s/he has a collaborative relationship.

The 2007 Nursing Act reinforces certain 1998 notions about what constitutes "adequate” collaboration and consultation if a collaborating physician or podiatrist does the following: "Participates in the joint formulation and joint approval of orders or guidelines with the advanced practice nurse and he or she periodically reviews such orders and the services provided with patients under such orders in accordance with accepted standards of medical practice and advanced nursing practice” (65/65-35, c). However, what has changed in this language is that the collaborating physician needs to only "periodically” review the WCA versus doing so on an annual basis, as stipulated in 1998.

It is common for hospital or health systems to develop unnecessary policies that are steeped in long-held traditions that are based on hearsay, versus actual statutory requirements. For example, the Nursing Act does not require that a physician co-sign an APN’s charting or perform chart audits.  Nor, for that matter, do Joint Commission or most reimbursers have such a requirement.   

Furthermore, as noted in the citation above, the Nursing Act promotes the concept of joint formulation and joint approval of orders or guidelines, thus implying that the collaborative process is a two-way street, not a passive process for the APN.  Advanced practice nurses and their collaborating physicians should rejoice that the Nursing Act allows variation and individuality in how they define their collaborative relationships and seize the opportunity to develop creative and productive activities that promote excellent, evidence-based care that is enriching to all parties.