ARIZONA STATE SENATE
RESEARCH STAFF
TO: JOINT LEGISLATIVE AUDIT COMMITTEE HEATHER OWENS
Senator Robert Blendu, Chairman LEGISLATIVE RESEARCH ANALYST
HEALTH COMMITTEE
Representative John Nelson, Cochair Telephone: ( 602) 926- 3171
Facsimile: ( 602) 926- 3833
DATE: December 3,2007
SUBJECT: Sunrise Application of the Arizona Alliance of Non- Physician Surgical Assistants
Attached is the final report of the sunrise review of the application s~. ibmittedb y the Arizona
Alliance of Non- Physician Surgical Assistants, which was conducted by the Senate Health and House of
Representatives Health Committee of Reference.
This report has been distributed to the following individuals and agencies:
Governor of the State of Arizona
The Honorable Janet Napolitano
President of the Senate Speaker of the House of Representatives
Senator Tim Bee Representative James Weiers
Senate Members
Senator Tom O'Halleran, Cochairman
Senator Barbara Leff
Senator Paula Aboud
Senator Thayer Verschoor
Senator Amanda Aguirre
Arizona Alliance of Non- Physician Surgical Assistants
Arizona State Library, Archives & Public Records
Office of the Auditor General
Senate Majority Staff
Senate Research Staff
Senate Minority Staff
Senate Resource Center
House Members
Representative Bob Stump, Cochairman
Representative Nancy Barto
Representative Rick Murphy
Representative David Bradley
Representative Linda Lopez
House Majority Staff
House Research Staff
House Minority Staff
Chief Clerk
HO/ j as
Attachment
Senate Health and House o fRepresentatives Health
Committee of Reference Report
SUNRISE REQUEST OF THE ARIZONA ALLIANCE
OF NON- PHYSICIAN SURGICAL ASSISTANTS
Background
Pursuant to Arizona Revised Statutes ( A. R. S.) 5 32- 3 104, the Joint Legislative Audit Committee
( JLAC) assigned the sunrise review to the Senate Health and House of Representatives Health
Committee of Reference. Attached is a copy of the application submitted by the Arizona Alliance of
Non- Physician Surgical Assistants ( Alliance).
Committee of Reference Sunset Review Procedures
The Committee of Reference held one public meeting on November 6, 2007, to review the
Alliance's sunrise application pursuant to A. R. S. 5 32- 3 104 and to hear public testimony.
Committee of Reference Recommendations
The Committee of Reference recommends that the Legislature approve the sunrise application
submitted by the Alliance. However, the Committee of Reference did not approve a specific regulatory
board or procedures for regulating non- physician surgical assistants.
Attachments:
1. Staff memo.
2. Sunrise request of the Arizona Alliance of Non- Physician Surgical Assistants.
3. Meeting notice.
4. An excerpt of the minutes of the Committee of Reference meeting relating to the sunrise
application.
ARIZONA STATE SENATE
RESEARCH STAFF
TO: MEMBERS OF THE HOUSE AND SENATE HEATHER OWENS
HEALTH COMMITTEE OF REFERENCE ASSISTANT ANALYST
HEALTH COMMITTEE
DATE: October 10,2007
Telephone: ( 602) 926- 3 17 1
Facsimile: ( 602) 926- 3833
SUBJECT: Sunrise Request of the Arizona Alliance of Non- Physician Surgical Assistants
The following memo is background information regarding the request for regulation of
nonphysician surgical assistants. Also attached is a copy of the sunrise application submitted by the
Arizona Alliance of Non- Physician Surgical Assistants ( Alliance). A public meeting is scheduled for
November 6,2007, to allow you to ask questions of the Alliance, take public testimony and make a final
recommendation as to the Alliance's request. Ifyou have any questions or need additional information,
please feel free to contact me.
BACKGROUND
Nonphysician surgical assistants are individuals who perform tasks and assist in surgery under
the direction of a surgeon. Hospitals and surgeons use surgical assistants depending upon the
complexity of the operation and medical condition of the patient. Nonphysician surgical assistants
include individuals from various licensed health professions, including nurses and physician assistants,
but also may include individuals who do not currently fall under the jurisdiction of an Arizona
regulatory board. Nonphysician surgical assistants may be employed by hospitals, surgeons or HMO's,
or they may be employed as independent contractors who are called in by a surgeon as needed.
The U. S. General Accounting Office reports that, because surgical assistants include a variety of
health professionals, there is no widely accepted set of uniform requirements for experience and
education. However, hospitals and other medical facilities may credential the surgical assistants that are
used in those settings. The National Surgical Assistant Association ( NSAA) was created in 1983 to
establish standards for nonphysician surgical assistants. The NSAA has a process to certify individuals
who wish to receive the Certified Surgical Assistant ( CSA) credential.
Three other states currently regulate nonphysician surgical assistants in some manner. In Texas,
persons who wish to practice as surgical assistants must be licensed by the Texas Medical Board.
Kentucky requires surgical assistants to hold and maintain certification by either the NSAA or the
Liaison Council on Certification for the Surgical Technologist. Illinois requires registration of surgical
assistants through the Illinois Department of Public Registration.
The Alliance submitted sunrise applications for regulation of surgical assistants in 1994, 1998,
2000 and 2006. In 2006, the Health Committee of Reference recommended regulation of surgical
assistants through certification. However, the resulting legislation ( Senate Bill 1294) was held in
committees, and the Alliance determined to submit a new sunrise application for licensure of surgical
assistants.
MEMORANDUM
October 10,2007
Page 2
REQUEST FOR REGULATION
According to the Alliance, it is necessary to regulate surgical assistants because of the inherent
risks involved in surgery and the potential dangers of unregulated personnel putting patients at risk of
physical harm. Additionally, there is nothing at the state level to enforce codes of ethics for unlicensed
surgical assistants and no formal disciplinary process. The Alliance states that regulating surgical
assistants will protect the public by setting standards for the education, training and regulation of
surgical assistants and by allowing the public to contact a regulatory board to file complaints and make
other inquiries regarding surgical assistants. According to the Alliance, it is seeking licensure in order
to assure public confidence in the surgical assisting profession.
The Alliance proposes establishing the Arizona Board of Surgical Assistants ( Board), consisting
of seven members appointed by the Governor. The executive director of the Arizona Medical Board or
another existing body would serve as the Board's executive director. The Alliance envisions the Board
regulating surgical assistants by developing standards to govern the profession, adopting rules to
implement statutory requirements, establishing licensing fees and other fees, investigating complaints
and disciplining surgical assistants when necessary.
The Alliance proposes a funding scheme where the Legislature would appropriate funding as a
loan to the Board from the state General Fund, which would be repaid with interest as the Board begins
to collect fees and support its own operations. The Alliance does not specifl the amount of the loan it
would request from the state General Fund, nor does it indicate the current number of unlicensed
surgical assistants who would fall under the scope of the Board or an estimate of the licensing fees the
Board would implement. Thus, it is unclear at this time the exact amount of the loan required, the
expected revenue from the fees and the time frame for repayment of the loan.
HOIjas
Attachment
Tel602 248 2900
Fox6022482999
722 East Osborn Rood, Suite 100
Phoenix. Arizona 8501 4
August 3 1,2007
The Honorable Robert Blendu
Chairman, Joint Legislative Audit Committee
Arizona State Senate
1700 West Washington
Phoenix, Arizona 85007
Dear Senator Blendu:
I'ursuant to A. R. S. 8 32- 31 05, the Arizona Alliancc of Non- Physician Surgical Assistants
(" Applicant") hereby submit this Sunrise Application for Regulation: Request for Liccnsure of
Non- Physician Surgical Assistants to the Joint Legislative Audit Con~ mitteefo r consideration by
the Health Committee of Reference (" COJI").
In 2006, the COlI unanimously recommended that the Legislature require non- physician
surgical assistants who are not licensed by another regulatory board be cerlified by the Arizona
Medical Board. As discussion ensued during the legislative session, it appeared that licensurc
Imay be necessary to assure adequate public confidence in the surgical assisting profession.
' Therefore, Applicant is now seeking a general recommendation for licensure. This will ensure
that a range of options exist from which to draft a proper regulatory scheme for surgical
assistants.
Accordingly, Applicant rcquests that the COR generally reconimcnd that surgical
assistants be licensed by an appropriate regulatory board, subject to the Legislature's approval.
Applicant rcmains committed to working with legislators, their staff and the various interest
groups in the upcoming session.
Sincerely,
~ usynA . Cannata
SACIjf
Enclosure
cc: Office of the Auditor General ( wlcnc)
Representative John Nelson, Co- Chair,
Joint Legislative Audit Committee ( wtcnc)
Bill Boyd, Senate Rescarch Staff ( wtenc)
Carolyn Atwater, House Rcscarch Staff ( wlenc)
SUNRISE AI'I'LI CAT1 ON FOli REGULATION
IiEQUEST FOJi LICENSURE OF NON- J'HYSlCJAN SURGICAL ASSISTANTS^
I ( a). I~ efineth e problem and describe why regulation is necessiiry, including the nature of
the potential harm to the public if non- physician surgical assistants are not regulated and
the extent to which there is a threat to public health and safety.
Surgical assistants are intimately involved in providing care to the surgical patient in the
operating room. The American College of Surgeons deiines surgical assistants as those who
provide aid in exposure, hemostasis and other intraoperative technical functions and assist the
surgcon in accomplishing a safe operation with the best resu~ ts. A~ s members of a surgical team,
surgical assistants perform tasks under a surgeon's supervision, which may include, making
initial incisions (" opening"), cxposing the surgical site (" retracting"), stemming blood ilow
(" hemostasis"), reconnecting tissue (" suturing"), surgically ~ emoving veins and arteries to bc
used to bypass graAs (" harvesting") and completing the operation by reconnecting external tissue
(" closing"). Surgical assistants also may sterilize instruments and perform aseptic techniques,
draping procedures, drain placement, cathcterization and dressing techniques. They are also
knowledgeable about operating room equipment.
Surgcry is invasive by nature and has inherent risks. Not regulating surgical assistants creates
thc danger of allowing undertrained or inappropriately trained hcalth care professionals to bc
used in operating rooms, putting patients at risk of physical harm or death. Without proper
regulation, the likelihood of surgical assistants functioning outside of the direct visual scrutiny of
the surgcon also increases, likely resulting in mistakes being made. Potcntial errors of an
unskilled, unregulated surgical assistant may include: greater risk of infection, excessive blood
loss, allergic reactions, damage to major organs, disfiguring scars, loss of function of any limb or
organ, paralysis, brain damage and even death.
In addition to the physical dangers, not regulating surgical assistants may also create financial
risks for patients. Most surgical assistants are paid for their services through third- party
payment. I- Iowever, if a health insurance company refuses to pay for the ~ ervice, s~ u rgical
' This Sunrise Application seeks licensure for non- physician surgical assistants who are not licensed by another
regulatory board. References to " surgical assistants" in this Sunrise Application refer only to surgical assistants in
this limited group of non- physician, non- RN and non- PA surgical assistants.
Members of several health professionals, in addition 10 other statutorily permitted duties, also perform surgical
assisting functions of surgical assistants. The scope of practice for surgical assistants, however, is more restricted
than these other health care professionals.
' Based on past discussions with public and private Arizona insurance companies, third- party payments to surgical
assistants are generally denied because they are unlicensed by the State. Applicant is further researching the issue to
verify the reasons for non- reimbursement.
assistants dircctly bill the patient to collect the fee for the services provided. It is not uncommon
for patients to be uninformed that there would be an additional charge beyond hospital and
physician fees for services rendered during a surgery. The public is therefore at financial risk for
services that it believes will be covered by insurance.
I( b). 1) iscuss the extent to which consumers nced and will benefit from a method of
regulation identifying competent practitioners and indicate typical employers, if any, of
practitioners in the health profession.
Regulating surgical assistanls will benefit consumers because formal standards would be set for
educating, training, regulating, tracking and providing disciplinary oversight of the profession.
Thc public will also be aided by having thc 12egislature establish and approve the appropriate
scope of practice with input from all stakeholders, providing uniform guidelines to health care
professionals to properly regulate surgical assistants. More importantly, consumers will gain the
added protection of being able to access a regulatory body to inquire about surgical assistants,
file complaints, and seek corrective action.
The Commission on Accreditation of Allied I- lealth Education Programs ( CAAHEP)~ has
adopted standards for programs designed to train surgical assistants. ' I'hese standards have been
approved by the American College of Surgeons, the National Surgical Assistant Association, and
the Association of Surgical Technologists. While there are various CAAHEP accredited training
programs available, non- CAAHEP accredited distance learning programs are being used to train
surgical assistants, creating a potential risk for under- educating and under- training surgical
assistants at a cost to public safety. Additionally, because of the shortage of health care
professionals trained as surgical assistants, hospitals are train their operating room staff to meet
this shortage or use operating room personnel who are not formally trained as surgical assistants.
Without uniform regulation at the State or hospital level that requires surgical assistants to satisfy
approved and accredited standards for training and clinical experience, consumers will not have
confidence or reassurance that the surgical assistant helping with their surgery are properly
educated and experienced to perform
surgical tasks. Although hospitals credential their surgical assistants, the competency standards,
training and scopc of practice vary from institution to institution. Moreover, there is no specific
regulatory oversight of hospitals regarding surgical assistants.
By requiring surgical assistants to be licensed, the Legislature would create a uniform system of
accountability for surgical assistants that will allow consumers to identify competent surgical
assistants. Establishing a regulatory structure would assure that standards of practice are met and
that individuals engaged in the practice of- surgical assisting are competent.
CAAtlEP is " the largest programmatic accreditor in the health sciences field." http:// www. caahep. ord. In the
accreditation process, CAAHEP works with Sub- cornminee on Accreditation for Surgical Assisting, which is
cornp~ ised of rcprescntatives from the American College of Surgeons, the Association of Surgical Technologists,
and the National Surgical Assistant Association.
2
Finally, the typical employers of surgical assistants are hospitals, surgical assistant companies,
surgeons, and HMO's. Surgical assistants may also be requested by a surgeon on an as- needed
basis as an independent contractor.
l( c)( i). 1) escribe the extent of autonomy a surgical assistant has as indicated by the extent
lo which the health profession calls for independcnt judgment and the extent of skill or
experience required in making the independent judgment.
Undcr the proposed regulatory scheme, surgical assistants would not be pcrmiticd to make
decisions based on independent judgment. All functions and tasks performed by surgical
assistants would occur under the direction and direct supervision of a surgeon.
1 ( c)( ii). 1) escribe the extent to which surgical assistants are supervised.
Surgical assistanis would not be permitted to practice without the direction or direct supervision
of a surgeon.
2( a)( i). Descrihe the efforts made to address the problem, including voluntary efforts, if
any, by members of the health profession to establish a code of ethics.
The National Surgical Assistants Association ( httv:// www. nsaa. net) and the Association of
Surgical Technologists ( http:// www. ast. org) have both voluntarily established codes of ethics.
Idospital bylaws and policy and procedures also include codes of conduct governing cthics.
However, there is nothing at the state level that prescribes minimum requirements, enforce these
codes, or provide a complaint process if an ethical breach occurs. Thus, voluntary codes of
ethics, without regulation and an enforcement mechanism, do not provide the safeguards to
protect the public.
2( a)( ii). 1) escribe the efforts made to address the problem, including voluntary efforts, if
any, by members of the health profession to hclp resolve disputes between health
practitioners and consumers.
Without regulation and enforcement of discipline, there is no procedure in place to ensure that
disputes are resolved and the activities of surgical assistants are monitored.
2( b). Dcscribc thc efforts made to address the problcm, including rccoursc lo and the
cxtcnt of use of applicablc law and whcthcr it could bc amcndcd to control the problem.
No state law currently exists to regulate the non- physician, non- RN, and non- PA surgical
assistants as addressed in this application. Unfortunately, voluntary efforts are inadequate and
inconsistent to afford consumers the security that the surgical assistants participating in their
surgeries meet state- approved competency standards and intraopcrative care guidelines. This
Applicant is receptive to any solutions that would adequately address the concerns relating to
surgical assistants.
3( a). 1) cscribc thc altcrnativcs considcrcd, including rcgulating the business cmploycrs or
practitioncrs rathcr than cnlploycc practitioncrs.
Current regulations govern business employers and practitioners. Unfortunately, these
regulations do not provide specific guidance to employers and practitioners regarding their
relationships or use of surgical assistants. Without first defining how surgical assistants will be
regulated, it would be impracticable and diflicult to govern them through employers and
practitioners. Additionally, many surgical assistants are also cmployed as independent
contractors.
3( b). 1) escribc the ;~ ltcrnativcs considcrcd, including regulating the program or scrvicc
rathcr than the individual practioncrs.
Regulating the program or service would negatively affect other health care providers, like RN's
and PA7s, whose scope of practice includes the duties that surgical assistants perform in addition
to the other responsibilities authorized by law. One of the important goals of this application is
not to create undue regulations on other health care professions whose laws have been carefully
amended to meet the needs of their members and the public. Because a statewide program or
scope of practice does not exist for surgical assistants, the program or service cannot be
regulated.
3( c) & ( d). 1) cscribc the alternatives considcred, including regulating and certifying all
practitioners.
In determining the appropriate level of regulation, certification and licensure have been
considcred and will continue to be considered. Applicant is open to whatever level of regulation,
licensure or certification, that best accomplishes the public safety goals set forth in this
application. While last year's application specified " certification," Applicant has received
information suggesting licensure may be necessary to assure adequate public confidence in the
surgical assisting profession. Applicant is seeking approval for licensure to have available the
full range of alternatives and is committed to working with stakeholders to craft the most
4
appropriate regulatory scheme.
3( e). Describe the alternatives considered, including other alternatives.
At this time, Applicant sees no viable alternative to regulating surgical assistants at the state
level. Applicant submitted a Sunrise Application in 1994, 1998, and in 2000. In 2005, the
application was withdrawn. Applicant has been attempting to seek a resolution of this issue for
many years and has engaged in ongoing dialog with members of the Legislature, health
insurance providers, AHCCCS, the Governor's Office, the Arizona Department of Insurance, the
Osteopathic Medical Board, the Arizona Medical Association, and the Arizona l- lealth Care and
I- lospital Association regarding regulating surgical assistants.
In 2006, the Joint Committee of Reference unanimously accepted Applicant's Sunrise
Application to regulate this profession through certification. During the legislative session, it
appeared that certification was insufficient, and Applicant was advised that if licensure was
sought, a new Sunrise Application should be submitled.
Applicant will explore alternative solutions with ANCCCS and other groups and also seeks
guidance from the Legislature and its staff.
3( f). 1) escribe why the use of the alternatives specified in the preceding paragraphs would
not be adequate to protect the public interest.
The other proposed alternatives would be inadequate to protect the public interest particularly
because of the mobility of surgical assistants that has resulted from the nationwide shortage of
health care professionals. Without a regulatory scheme that requires surgical assistants to bc
licensed and subject to mandatory oversight, particularly in a profession with varying
competency and educational standards, the public would not be provided the higher degree of
protection that a licensing scheme affords, especially when encountering an under- qualified or
untrained professional could result in great physical harm.
3( g). Describe why licensing would serve to protect the public interest.
Requiring state licensure as a prerequisite to practicing as a surgical assistant ensures that these
health care professionals have satisfied the State's standards for education, training, and
oversight. Of particular need and value are the enforcement capabilities of a regulatory board to
monitor surgical assistants on the public's behalf. Finally, because licensure is mandatory and
certification is voluntary, licensure would be beneficial because the fimds needed to initiate the
regulatory program would be met without financially draining the State General Fund.
5
4( a). Describe the benefit to the public if regulation is granted, including the extent to
which the incidence of specific problems present in the unregulated health profession can
reasonably be expected to be reduced by regulation.
As this Sunrise factor recognizes, no guarantee can be provided that practitioners will not violate
codes of conduct, scope of practice limitations, or state laws. The Legislature, however, has the
authority and the ability to foresee the dangers to the public, establish standards for training
practitioners, define a narrow scope of practice, provide complaint procedures, and impose
disciplinary procedures that include revoking a license and requiring a practitioner to cease
practicing in the regulated field.
Statewide standards in the form of licensure also provide confidence to the public and other
industries regarding surgical assistants. Not regulating the profession in this manner will
continue to expose the unwary public to unforeseen health care expenses when services rendered
by surgical assistants are not paid through third- party agreements.
4( b). Describe the benefit to the public, including whether the public can identify qualified
practitioners.
The public will be able to identify the practitioner by a title such as Arizona Licensed Surgical
Assistant and through verifying the qualifications of a surgical assistant with a regulatory body.
4( c)( i). Describe whether the proposed regulatory entity would be a board composed of
members of the profession and public members or a state agency, or both, and, if
appropriate, their respective responsibilities in administering the system of registration,
certification, or licensure, including the composition of the board and the number of public
members, if any, the powers and duties of the board or state agency regarding
examinations and for cituse revocation, suspension, and non- renewal of registrations,
certificates or licenses, the adoption of rules and cannons of ethics, the conduct of
inspections, the receipt of complaints and disciplinary action taken against practitioners
and how fees would be levied and collected to pay for the expenses of administering and
operating the regulatory system.
As currently proposed, surgical assistants would be regulated in a manner similar to physicians,
registered nurses, and physician assistants, with both a state agency and a board overseeing the
surgical assistants.
The Arizona Board of Surgical Assistants (" the Board") would be established, consisting of
seven members appointed by the Governor: three surgical assistants, two public members, one
licensed osteopathic and one allopathic physician, both who must have at least five years'
6
experience as a practicing surgeon. The Board's duties would include: ( a) protecting the public
from unlawful, incompetent, unqualified, impaired, or unprofessional surgical assistants; ( b)
licensing and regulating surgical assistants; ( c) initialing investigations and determining if a
licensee has engaged in unprofessional conduct or is or may be incompetent or mentally or
physically unable to safely perform health care tasks; ( d) establishing licensing and other fees
and penalties; ( e) developing and recommending standards governing the profession; ( e)
disciplining and rehabilitating surgical assistants; and ( 0 making and adopting rules to
administer statutory requirements.
The executive director of the Arizona Medical Board or another existing state body would serve
as the Board's executive director and would possess similar duties, responsibilities, and authority
as prescribed in the Arizona Medical Board statutes. These include: ( a) at the Board's direction,
preparing and submitting recommendations for amcndrnents to the surgical assistant statutes for
the Legislature's consideration; ( b) appointing and employing mcdical consultants and agents
necessary to conduct investigations, gather information, and perhrm those duties that the
Executive Director determines are necessary and appropriate; ( c) issuing licenses to applic'mts
who meet the statutory requiremcnts; ( d) initiating investigations of surgical assistants; ( e)
reviewing all complaints; and ( f) performing all other administrative, licensing, or regulatory
duties as required by the Board.
To initially fund the Board, a loan would be appropriated from the State Gcneral Fund to be
repaid with interest as the Board collects fees to gcncrate its own revenue. The Board would
establish fees for thc initial application not to cxcccd amounts sufficient to repay the loan and
support the workings of the Board.
4( c)( ii). Describe the benefit to the public if regulation is granted, including if there is a
grandfather clause, whether grandfathered practitioners will be recluired to meet the
prcrcquisite qualifications established by the regulatory entity at a later date.
Without a grandfathering provision, surgical assistants who have thousands of hours of clinical
experience would be at risk of losing their livelihoods, which would also exacerbate the current
shortage of health care professionals. Grandfathering, however, would be restricted to those who
satisfy the statutorily imposed requirements. To provide additional public safety, only those
surgical assistants who mcet all of the following requirements would be exempted from the
education requirements: ( 1) be certified as a surgical assistant by a national professional
certification organization; ( 2) have been practicing as a surgical assistant for at least two years
with a minimum of a specified number of operations or hours of clinical experience before the
effective date of the legislation; and ( 3) satisfy all of the other licensing requirements imposed by
the new licensing scheme. Additional requirements are being considered to further ensure that
grandf'athered surgical assistants mcet appropriate competency requirements.
4( c)( ii). Describe the benefit to the public if regulation is granted, including the nature of
the st; rndards proposed for registration, certification, or licensure as compared with the
standards of other jurisdictions.
The proposed standards are similar to those that have been adopted in have been adopted in
Texas ( licensure), Kentucky ( certification), Illinois ( registration), and Washington D. C.
( licensure). Applicant is commitled to establishing standards that are, at a minimum, as rigorous
as the highest standards currently in effect.
4( c)( iv). l> escribe the benefit to the public if regulation is granted, including whether the
regulatory entity would be authorized to enter into reciprocity agreements with other
jurisdictions.
At this time, the regulatory agency would not be authorized to enter into reciprocity agreements
with other jurisdictions for licensure. However, the agency would be authorized to engage in the
full exchange of information with the licensing and disciplinary boards and professional
associations of other states and jurisdictions and foreign countries and statewide associations for
surgical assistants.
4( c)( v). Ilescribe the benefit to the public if regulation is granted, including the nature and
duration of any training including whether the training includes substantial amount of
supervised field ( clinical) experience, whether training programs exist in the state, if there
will be ; rn experience requirement, whether the experience must be acquired under a
registered, certified or licensed practitioner, whether there are alternative routes of entry
or methods of meeting the prerequisite qualifications, whether a11 applicants will be
rcquired to pass an examination, and if an examination is required, by whom it will be
developed and how the cost of development will be met.
Applicants for licensure as surgical assistants will be required to have completed a program in
surgical assisting education that has been accredited by CAAHEP' or other programs that satisfy
standards of education and clinical experience that are approved by the Board. Applicants will
also be rcquired to pass a national certifying exam for surgical assistants, as CAAI- IEP
recognizes on its website: http:// www. caahep. or~ Content. aspx? lD= 52. To be eligible to take
the credentialing exams from a national organization, candidates must satisfy educational and
clinical The clinical experience must be acquired under the direct supervision and
' The CAAHEP Standards and Guidelines for the Profession of Surgical Assisting is available at
h~ p:// www. caahep. org/ documents/ ForPro~ mDirectors/ SStAa ndards. pdf.
National Board for Surgical Technology and Surgical Assisting eligibility requirements available at:
~:// www. nbstsa. org/ certif~ in~ exam/ eli~ ibilitva. nhdt mtlh e National Surgical Assistant Association requirements
may be found at: http:// www. nsaa. net/ membership. shtml.
8
instruction of licensed and usually board certified surgeon. The competency exam would be
given by Schroeder Measurement Technologies for the National Surgical Assistant Association
and the National Board of Surgical Technology and Surgical Assisting for the Association of
Surgical Technologists.
While formal training programs are not yet available in Arizona, training programs are available
in other states. Two CAAHEP- accredited distance learning programs are also available to
Arizona applicants.
Finally, there are no alternative routes of entry into this medical professional category. The only
route available would be the competency certification requircmcnts that have been established by
the National Surgical Assistant Association and the National Board of Surgical Technology and
Surgical Assisting for the Association of Surgical Technologists.
5( a)( i). Describe the extent to which regulation might harm the public, including the extent
to which regulation will restrict entry into the health profession including whether the
proposed standards arc more restrictive than necessary to ensure safe and effective
performance.
Regulation of non- physician surgical assistants will only benefit the public. It will establish state
approved standards of excellence for intraoperative patient care that currently do not exist. With
the aid of other health care associations and organizations, legislators, and legislative staff;
Applicant is confident that the proper balance between ensuring public safety and maintaining
access to the surgical assisting profession will be achieved.
S( a)( ii). 1) escribe the cxtent to which regulation might harm the public, including the
cxtent to which regulation will restrict entry into the health profession including whether
the proposed legislation requires registered, certified or licensed practitioners in other
jurisdictions who migrate to this state to qualify in the same manner as state applicants for
registration, certification and licensure if the other jurisdictions has substantially
equivalent requirements for registration, ccrtific: ition or licensure as those in this state.
Surgical assistants migrating from other states will be required to satisfy the same licensing
requirements proposed in this regulatory scheme, particularly because most of the other states do
not currently regulate surgical assistants. Because the requirements proposed in Arizona arc
similar to those of the jurisdictions that have enacted regulatory schemes, surgical assistants
coming from those locations will be able to comply with the Arizona requirements.
S( b). Describe the extent to which regulation might harm the public, including whether
there are professions similar to that of the applicant group which should be included in, or
9
portions of the applicant group which should be excluded from, the proposed legislation.
First, there are no similar professional groups in existence. However, to the extent that the scope
of practice of other health care professionals includes surgical assisting f~ lnctionsa mong their
other duties, those groups will be exempted from also obtaining a surgical assisting license.
6( a). Describe the maintenance of standards, including whether effective quality assurance
standards exist in the health profession, such as legal requirement associated with specific
programs that define or enforce standards or codes of ethics.
No legal requirements exist in Arizona associated with specific programs that enforce standards
or a code of ethics for surgical assistants. The National Surgical Assistant Association and the
Association of Surgical Technologists have self- imposed standards and codes of ethical conduct.
Hospitals also maintain bylaws, competency requirements, and approved scope of practice,
which may vary from institution to institution. Because of the inconsistent standards that apply
to surgical assistants, a statewide system of regulation is necessary to protect the public and
provide a neutral source of regulation and information. The inability to track surgical assistants
has also been a major complaint of hospitals and medical insurance providers for years.
6( b)( i). 1) escribe the maintenance of standards, including how the proposed legislation will
assure quality including the extent to which a code of ethics, if any, will be adopted.
As previously stated, the Board, which will be comprised of professionals from several health
care disciplines, will be authorized to develop and recommend standards governing the
profession of surgical assisting. The Board's authority will also include imposing appropriate
disciplinary measures, including suspending and revoking state licenses.
6( b)( ii). Describe the maintenance of standards, including the extent to which regulation
might harm the public, including grounds for suspension or revocation of registration,
certification, or licensure.
The grounds for suspension or revocation of the license to practice would follow those already
accepted for other medical professionals such as RNs and PAS.
7. Describe the group proposed for regulation, including a list of associations,
organizations and other groups representing the practitioners in this state, an estimate of
the number of practitioners in each group and whether the groups represent different
10
levels of practice.
The practitioners in this state are represented by the National Surgical Assistant Association and
the Association of Surgical Technologists. There are approximately 100 practitioners in Arizona
that havc a national professional certification and are not currently regulated by the State. The
number of surgical assistants who are not certified by a national organization but are providing
intraoperative patient care is undetermined. Regulating surgical assistants would require these
uncertified practitioners to become licensed to be able to continue providing surgical care to
patients in the operating room.
8( a) & ( b). Ilescribe the expected cost of regulation, including the impact that licensure
will have on the costs of service to the public and the cost to the State and to the general
public of implementing the proposed legislation.
Regulation will benefit the public financially because medical insurance providers would be
more willing to pay for surgical assisting services. The State will provide an initial appropriation
to the Board to begin operations because the Board will not immediately begin collecting fees to
support its own operations. The " loan" will be repaid to the State with interest by a date certain.
A SUJiGEONS I'ERSI'ECTIVE
13Y
EDWARD B. ( TED) 1) IETl- IIUCI- I, MI)
1998
" Dramatic changes are occurring in our health care delivery system. We have already witnessed
a call for reduction of costs associated with surgical procedures. The goal is to reduce
expenditures but not sacrifice patient care.
Our cardiac and vascular experience at the Arizona Heart Hospital recognizes the importance of
the operative surgeon and the non physician surgical first assistant. Acting under the supervision
of the operating surgeon, the non physician surgical first assistant has a specific delineation of
duties for which he or she has been explicitly trained. Once integrated into the stugical team, this
person becomes an integral part of the care of the patient from the time of entry into the
operating room until the operative procedure is completed and the paticnt transferred to a post
anesthesia recovcry unit. It has been our experience that this position once functional becomes
essential to the satisfactory performance of surgical procedures in this environment of high
quality/ low cost.
I- laving practiced cardiovascular surgery for over a quarter of a century in Phoenix, Arizona, I
have come to appreciate that the initiation of these new types of programs are a part of our
changing environment and structure in health care of a surgical patient. Fortunately, these
changes have been positive, promoting excellent outcomes for our patients."
AMERICAN COLLEGE OF SURGEONS
STATEMENT ON QUALlFlCATlONS OF
NON- PHYSJCIAN SURGICAL ASSISTANTS
" The first assistant to the surgeon during a surgical operation should be a trained individual who
is capable of participating in the operation and actively assisting the surgeon as part of a good
working team."
The American College of Surgeons in their Statement on Principles, American College of
Surgeons ( Illinois 1974, revised 1997), part 11, Section B, p. 8 " Tl~ esien dividuals are not
arrtllorized to operate in~ lrpendentlvP. ractice privileges of individuals acting as first assistants
should be based upon verified credentials, should be reviewed and approved by the hospital
credentials committee, and sl~ ouldh e within the rlefined limits ofs tate law."
Interim agendas can be obtained via the Internet at http: llwww. azleg. state. az. usllnterimCommittees. asp
ARIZONA STATE SENATE
INTERIM MEETING NOTICE
OPEN TO THE PUBLIC
SENATE HEALTH AND HOUSE HEALTH COMMITTEE OF REFERENCE
Date: Tuesday, November 6,2007
Time: 9: 30 A. M.
Place: SHR 1
AGENDA
1. Call to Order
2. Opening Remarks
3. Sunset Review of the Board of Homeopathic Medical Examiners
Presentation by Auditor General
Response by Board of Homeopathic Medical Examiners
Public Testimony
Discussion
Recommendations by the Committee of Reference
4. Sunset Review of the Regulatory Board of Physician Assistants
Presentation by Regulatory Board of Physician Assistants
Public Testimony
Discussion
Recommendations by the Committee of Reference
5. Sunset Review of the Board of Behavioral Health Examiners
Presentation by Board of Behavioral Health Examiners
Public Testimony
Discussion
Recommendations by the Committee of Reference
6. Sunset Review of the Acupuncture Board of Examiners
Presentation by Acupuncture Board of Examiners
Public Testimony
Discussion
Recommendations by the Committee of Reference
7. Sunset Review of the Board of Occupational Therapy Examiners
Presentation by Board of Occupational Therapy Examiners
Public Testimony
Discussion
Recommendations by the Committee of Reference
Page 1 of 2
8. Sunrise application of the Arizona Alliance of Non- Physician Surgical Assistants
Presentation by Arizona Alliance of Non- Physician Surgical Assistants
Public Testimony
Discussion
Recommendations by the Committee of Reference
9. Sunrise application of the Southern Arizona Behavioral Health Coalition
Presentation by Southern Arizona Behavioral Health Coalition
Public Testimony
Discussion
Recommendations by the Committee of Reference
10. Sunrise application of the Arizona Dental Association
Presentation by Arizona Dental Association
Public Testimony
Discussion
Recommendations by the Committee of Reference
1 1. Sunrise application of Radiology Practitioner Assistants
Presentation by Radiology Practitioner Assistants
Public Testimony
Discussion
Recommendations by the Committee of Reference
12. Adjourn
Members:
Senator Tom O'Halleran, Co- Chair
Senator Paula Aboud
Senator Amanda Aguirre
Senator Barbara Leff
Senator Thayer Verschoor
Representative Bob Stump, Co- Chair
Representative Nancy Barto
Representative David Bradley
Representative Linda Lopez
Representative Rick Murphy
Persons with a disability may request a reasonable accommodation such as a sign language interpreter, by contacting the
Senate Secretary's Office: ( 602) 926- 4231 ( voice). Requests should be made as early as possible to allow time to arrange the accommodation.
Page 2 of 2
ARIZONA STATE LEGISLATURE
Forty- eighth Legislature - First Regular Session
SENATE HEALTH AND HOUSE HEALTH
COMMITTEE OF REFERENCE
Minutes of Interim Meeting
Tuesday, November 6,2007
Senate Hearing Room 1 - 9: 30 a. m.
Chairman O'Halleran called the meeting to order at 9: 32 a. m. and attendance was noted by the
secretary.
Members Present
Senator Tom O'Halleran, Co- Chair Representative Bob Stump, Co- Chair
Senator Amanda Aguirre Representative Nancy Barto
Senator Barbara Leff Representative David Bradley
Senator Thayer Verschoor Representative Linda Lopez
Representative Rick Murphy
Members Absent
Senator Paula Aboud
Speakers Present
Kiln Hildebrand, Performance Audit Manager, Office of the Auditor General
Todd Rowe, Board of Homeopathic Medical Examiners
Christine Springer, Board of Homeopathic Medical Examiners
Jerry Weinsheink, representing himself
Marianne Cherney, representing herself
Neil Garfield, Association for Public Access to Medicine
Barney Nugent, representing himself
Linda Heming, CHOICE
Iris Bell, Doctor, Arizona Homeopathic and Integrative Medical Association
Cliff Heinrich, Doctor, representing himself
Kathleen Fry, Doctor, representing herself
Denise Nugent, representing herself
Lee Bakunin, Attorney, representing herself
Bruce Shelton, Doctor, Arizona Homeopathic and Integrative Medical Association
Amanya Jacobs, Director of Evolution of Self School of Homeopathy
Cindy Zukerman, representing herself
Shelly Malone, representing herself
Stan Klusky, representing himself
Gladys Conroy, representing herself
SENATE HEALTH AND HOUSE HEALTH
COMMITTEE OF REFERENCE
November 6,2007
Joan Reynolds, Regulatory Board of Physician Assistants
Debra Rinaudo, Board of Behavioral Health Examiners
Stuart Goodman, Board of Behavioral Health Examiners
Bev Hermon, BH Consulting
Richard Poppy, Therapeutic Practitioners Alliance of Arizona ( The Alliance)
Rachael Hopkins, representing herself
Ronald Anton, representing himself
Josephine Sbrocca, representing herself
Cedric Davis, Board of Behavioral Health Examiners
Della Estrada, Arizona Acupuncture Board of Examiners
Kathryn Babits, Arizona State Board of Occupational Therapy Examiners
Eugene Smith, Arizona Alliance of Non- Physician Surgical Assistants
Susie Cannata, Arizona Alliance of Non- Physician Surgical Assistants
Rory Hays, Arizona Nurses' Association
Scott Leckie, Radiology Practitioner Assistants
Jane Van Valkenburg, Certification Board for Radiology Practitioner Assistants ( CBRPA)
Mary Connell, M. D., representing herself
Christine Lung, American Society of Radiologic Technologists ( ASRT)
John Gray, Grand Canyon University
Joyce Geyser, Arizona Radiological Society
James Abraham, National Society of Radiology Practitioner Assistants
Heather Owens, Senate Health Analyst
Aubrey Godwin, Medical Radiologic Technology Board of Examiners ( MRTBE)
Teresa Rodgers, Behavioral Health Coalition of Southern Arizona
David Giles, Behavioral Health Coalition of Southern Arizona
Holly Baumann, Southwest Autism Research and Resource Center
John MacDonald, Arizona Dental Association ( ADA)
Rick Murray, Arizona Dental Association
Anita Elliott, Arizona Dental Association
Nicole Laslavic, Arizona State Dental Hygienists' Association
Janet Midkiff, Arizona State Dental Hygienists' Association
Nicole Albo, Arizona Dental Assistants' Association
Alisa Feugate, Arizona Dental Hygienists' Association
OPENING REMARKS
Chairman OYHalleran welcomed everyone and requested that the speakers keep their comments
as brief as possible, as the committee members are well- versed in the issues to be discussed
today.
SUNSET REVIEW OF THE BOARD OF HOMEOPATHIC MED
Presentation by Auditor General
Kim Hildebrand. p e r m u d i t Manager. Office of the Auditor General, gave a
ndings issued in August, 2007 ( Attachment 1). She described the history
SENATE HEALTH AND HOUSE HEALTH
COMMITTEE OF REFERENCE
2 November 6,2007
Recommendations bv the Committee of Reference
- pational Therapy Examiners for ten years. The motion carried by a voice vote.
SUNRISE APPLICATION OF THE ARIZONA ALLIANCE OF NON- PHYSICIAN
SURGICAL ASSISTANTS
Presentation bv Arizona Alliance of Non- Phvsician Surgical Assistants
Eugene Smith, Arizona Alliance of Non- Physician Surgical Assistants, addressed the committee
to explain that the application now requires licensure rather than certification, which is
voluntary.
Senator Leff explained that non- physician surgical assistants are currently in limbo because,
although they work in the operating room under a surgeon, they do not have a separate license.
She stated they were not getting paid because insurance companies did not recognize their
service as they recognize a surgical nurse or a physician's assistant. Hence, she stated, this
profession must be licensed by the state. Further, she said, the Arizona Medical Board is now
saying that these individuals are practicing medicine without a license, which can jeopardize the
supervising surgeon's medical license.
Public Testimonv
Susie Cannata, Arizona Alliance of Non- Physician Surgical Assistants, addressed the committee
to state that this is an attempt to legitimize what is currently going on.
Rorv Hays, Arizona Nurses' Association, stated that she is neutral on this but does have concerns
regarding educational training, testing, scope of services, and regulation. She also spoke about
grandfathering, which is an important step to be taken, but with assurances regarding testing and
educational programs.
Recommendations by the Committee of Reference
Senator Leff moved that the Senate and House Health Committee of Reference
recommend the Legislature approve the sunrise application submitted by the
Arizona Alliance of Non- Physician Surgical Assistants. The motion carried by a
voice vote.
Presentation by Radiolow Practitioner As
SENATE HEALTH AND HOUSE HEALTH
COMMITTEE OF REFERENCE
11 November 6,2007
Janet Midkiff, Arizona State Dental Hygienists' Association, stated that they support the concept
of training community people to be dental health representatives, and that the definition of the
COHR does make sense to them. She stated concerns about the education, licensing, or
certification of the people who fill the COHR positions. She said that her organization would
like to work with the ADA and to be a part of the access to care issue.
Nicole Albo, Arizona Dental Assistants' Association, stated her support for the COHR program
provided that the positions will be filled by certified dental assistants with additional training
components. She stated that she has been working with the ADA to develop a curriculum for
expanded COHR training.
Representative Murphy asked if the committee could approve the concept but not specify the
details, letting the Legislative process do that. Mr. Murray stated that the supervision issue is the
biggest concern.
Alisa Feugate. Arizona Dental Hygienists' Association, stated that she supports the concept of
the COHR but is neutral on the application at this time due to concerns about supervision and
scope of practice.
Recommendations by the Committee of Reference
Cochairman Stump moved that the Senate and House Health Committee of
Reference recommend that the Legislature amend the statutes of the Arizona Board
of Dental Examiners to create a new certified professional, the Community Oral
Health Representative, to coordinate community- based oral health promotion and
provide specified dental care under the general supervision of a licensed dentist.
The motion carried by a voice vote.
Without objection, the meeting adjourned at 4: 15 p. m.
Jane Dooley, Committee Secretary
November 6,2007
( Original minutes, attachments and audio on file in the Office of the Chief Clerk; video archives
available at http:// www. azleg.~ ov/)
SENATE HEALTH AND HOUSE HEALTH
COMMITTEE OF REFERENCE
November 6,2007
