NR 506NP Week 8 NP Advocacy Case Paper Example

Advocacy Case: California Should Stop Medical Staff Bylaws From Requiring Standardized Procedures for Certified 103 Nurse Practitioners After Six Months, Following Maryland's 2015 Shift From Physician Attestation to an 18-Month Mentor

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College of Nursing, Chamberlain University

NR 506NP: Healthcare Policy and Leadership

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Advocacy Case: California Should Stop Medical Staff Bylaws From Requiring Standardized Procedures for Certified 103 Nurse Practitioners After Six Months, Following Maryland's 2015 Shift From Physician Attestation to an 18-Month Mentor

One State, One Change

California's AB 890 gave nurse practitioners who complete 4,600 hours of transition to practice freedom from standardized procedures in any group setting shared with a physician (California Business and Professions Code, 2025). It left the organizations themselves free to write those procedures back in through their medical staff bylaws. This paper argues for one change: a statute providing that any organization privileging a certified 103 NP could insist on half a year of focused review at the start, and could not afterward require standardized procedures as a condition of privileges. The change is aimed at one state, California, and at one kind of document, bylaws, because that is where the law's promise is being lost.

A State That Already Did It

The closest precedent is Maryland. In 2015, the Maryland General Assembly passed HB 999, enacted as Chapter 468 and effective October 1, 2015. It repealed the rule that a certified nurse practitioner could not practice without an approved attestation of an agreement for collaboration and consultation with a physician. In its place, it required applicants for initial certification to name a certified NP or licensed physician to act as a mentor for 18 months (Maryland General Assembly, 2015). A companion Senate bill, SB 723, was later vetoed, and the Senate sustained the veto 46 to 0 in January 2016; the House bill was already law, so the veto of the duplicate did not change the outcome.

Maryland's trade is the model for this proposal. It removed a permanent physician relationship as a condition of practice and replaced it with a time-limited mentoring period for new NPs. The six-month focused evaluation in this proposal follows the same logic: a defined period of oversight at the start, then no standing condition. What Maryland does not show is what happens inside hospitals, because its law addressed the state's permission to practice rather than organizations' privileging decisions. The precedent supports the structure of the proposal, not every part of its effect, and this paper did not find a Maryland study of patient outcomes after 2015 or any attempt to restore the attestation requirement in the sources reviewed.

Evidence Carrying Its Own Limits

The evidence for the safety of NP primary care is real but bounded. In the Veterans Health Administration, veterans moved to an NP's panel when their physician departed were admitted to hospital less often, including for conditions good outpatient care should prevent, than veterans moved to a new physician, at comparable cost and with similar control of diabetes, cholesterol and blood pressure (Liu et al., 2020). In Medicare patients with diabetes, NP primary care was associated with fewer potentially preventable hospitalizations after propensity adjustment, though the study's own instrumental variable analyses could not fully balance the groups (Kuo et al., 2015). Neither study examined NPs in private organizations governed by the kind of bylaws this proposal addresses, and both concern NPs working in systems with physicians nearby, which is what a 103 NP does by definition. That last point strengthens the fit: the proposal concerns NPs in exactly the kind of setting these studies describe.

The Other Side, Before the Recommendation

Two groups will oppose this bill for different reasons, and both should be heard before any recommendation. Physicians, speaking through their state association, took an oppose-unless-amended stance on AB 890 and argued that physician-based care ensures the greatest patient safety and that easing supervision elsewhere had not improved access in underserved communities (Reynolds, 2020). They will see this bill as a second attempt to achieve what AB 890 left to local decision.

Hospitals will object for a different reason. The California Hospital Association supported AB 890 (Medical Board of California, 2020), but a bill that tells a hospital what its medical staff bylaws may contain intrudes on how hospitals and their medical staffs govern the quality of care in their own buildings. Their strongest argument is not about NPs at all: it is that the organization, not the legislature, bears responsibility for the care delivered within it, and needs the tools to evaluate every clinician it privileges.

The six-month focused evaluation answers that second argument directly, by leaving the organization a real tool. It does not answer the physicians' argument, and it is not meant to. The legislature settled that question in 2020, when it decided that certified 103 NPs could practice without standardized procedures.

The Paragraph That Keeps It Real

This bill may not pass, and it may not need to. A statute is the heaviest way to change a bylaws provision, and many organizations may change their own bylaws once 103 NPs are common and the evidence from their own practice accumulates. The honest case for a bill is that waiting has a cost: every year that bylaws require standardized procedures for certified NPs, the 4,600 transition hours that the law demanded buy nothing in the settings where those NPs work. If the bill fails, the same evidence, collected for the bill, becomes the basis for proposals to individual credentials committees, starting with my own health center's.

There is also a risk that the bill hurts the relationship it depends on. A 103 NP works, by definition, in a setting where physicians practice alongside them, and many of those physicians sit on the credentials committees in question. A statute forced on them could make daily collaboration harder, not easier. That is a reason to lead with evidence gathered from the clinics themselves and to invite physicians who already work well with NPs to speak for the bill, rather than framing it as nurses against doctors.

A Place, Not a Category

The recommendation is addressed to a place: the federally qualified health centers of California's Central Valley, where I work, where primary care shortages are severe, and where NPs already provide a large share of visits. The proposal should be introduced in the 2027 session, with community clinics and health centers as its first sponsors, because they bear the cost of the current bylaws without the institutional interest that makes hospitals cautious. If the hospital association's opposition cannot be moved to neutral, the bill should be narrowed to clinics and health centers rather than abandoned. Either way, the first evidence the committee sees should come from those clinics: the bylaws text, the number of certified 103 NPs they employ, and the number still required to practice under standardized procedures.

References

California Business and Professions Code, §§ 2837.103, 2837.104 (2025). https://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=BPC&division=2.&chapter=6.&article=8.5.

Kuo, Y.-F., Chen, N.-W., Baillargeon, J., Raji, M. A., & Goodwin, J. S. (2015). Potentially preventable hospitalizations in Medicare patients with diabetes: A comparison of primary care provided by nurse practitioners versus physicians. Medical Care, 53(9), 776-783. https://doi.org/10.1097/MLR.0000000000000406

Liu, C.-F., Hebert, P. L., Douglas, J. H., Neely, E. L., Sulc, C. A., Reddy, A., Sales, A. E., & Wong, E. S. (2020). Outcomes of primary care delivery by nurse practitioners: Utilization, cost, and quality of care. Health Services Research, 55(2), 178-189. https://doi.org/10.1111/1475-6773.13246

Maryland General Assembly. (2015). HB 999: Health occupations: Nurse practitioners: Authority to practice (Chapter 468). https://mgaleg.maryland.gov/mgawebsite/Legislation/Details/hb0999?ys=2015RS

Medical Board of California. (2020). Legislative analysis: AB 890 (Wood), nurse practitioners: scope of practice: practice without standardized procedures (Board meeting materials, Agenda Item 11A, November 12, 2020). https://www.mbc.ca.gov/About/Meetings/Material/30815/brd-AgendaItem11A-20201112.pdf

Reynolds, K. A. (2020, December 17). California law releases nurse practitioners from physician oversight. Oncology Nursing News. https://www.oncnursingnews.com/view/california-law-releases-nurse-practitioners-from-physician-oversight