Report 2019-120

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Board of Registered Nursing

California State Auditor's Comments on the Response From the Board of Registered Nursing

Board of Registered Nursing

June 11, 2020

Elaine M. Howle, State Auditor
California State Auditor’s Office
621 Capitol Mall, Suite 1200
Sacramento, CA 95814

RE: Response from California Board of Registered Nursing to Audit 2019-120 - Oversight of Pre-Licensure Nursing School Programs

Dear Ms. Howle,

The California Board of Registered Nursing (Board) appreciates the time and effort you and your staff have dedicated to evaluating our oversight of pre-licensure nursing school programs and making recommendations to refine and improve the Board’s processes. The Board sets a high standard for itself and is always interested in identifying opportunities to better fulfill its mission of protecting California consumers. We are keenly aware of the critical role of registered nurses in maintaining the health and safety of Californians. Thus, we are committed to ensuring that our nurses receive a quality education that prepares them for the incredibly important jobs that they have in our communities. We thank you for your recommendations in the audit report, and respectfully submit the attached responses.

Should you have any questions or require anything else, please do not hesitate to contact the Board’s Assistant Executive Officer, Evon Lenerd Tapps at (916) 574-7610.

Sincerely,

Michael D. Jackson, MSN, RN, CEN                    Loretta Melby, RN, MSN
President                                                             Executive Officer
California Board of Registered Nursing                California Board of Registered Nursing

Attachment

The California Board of Registered Nursing (BRN) Responses
to the California Bureau of State Audits (BSA) Findings
June 11, 2020

Audit Name
Board of Registered Nursing – Oversight of Pre-Licensure Nursing School Programs

Audit Number
2019-120

BSA Recommendations to BRN and BRN Responses
Recommendation 1: To better ensure that California has an appropriate number of nurses in the future, BRN should do the following by January 1, 2021:

Revise the scope of work of its contract for workforce forecasting services to direct the contractor to incorporate regional analyses.
Ensure that the governing board’s enrollment decisions and other actions adequately take into consideration the regional analyses in BRN’s future workforce forecasts. Specifically, it should amend its policies to require that when its staff present information to the education committee and the governing board to inform it on pending enrollment decisions, they include relevant information related to BRN’s most recent forecast of the nursing workforce.

BRN Response 1:
BRN collects data which assists in determining if California has the appropriate number of nurses in the future. This includes, but is not limited to, information gained from the 2018 Regional Nursing Summits (Summit)¹, the raw data which the University of California, San Francisco (UCSF) collects on behalf of BRN, and information collected from pre-licensure nursing programs through their “written plan for evaluation of the total program” that includes, among other things, evaluation of the performance of the school’s graduates in meeting community needs. (16 CCR §1424(b)(1).) ²
On or about January 1, 2021, to better ensure California has an appropriate number of nurses in the future, BRN will:

BRN has a current contract for workforce forecasting services in place with an end date of
June 30, 2021, and work has already been performed for this contract period. BRN will request the contractor to include a regional analysis within the report ‘Forecasts of Registered Nurse Workforce in California’ that is published on the BRN website. BRN will ensure that the scope of work for future contracts for workforce forecasting services will incorporate regional data and analysis, in alignment with the data in the 2018 Summit report currently relied upon by the governing board.

¹ The goal of these Summits was to examine clinical capacity in more detail with the intent to address clinical capacity issues and associated factors in a collaborative and transparent manner. The data collected during the Summits included regional workforce differences and other regional data. Although this data is not typically presented by NECs, it is used by the governing board when making enrollment decisions. If future Summits occur, BRN will seek to participate in these Summits to address ongoing clinical capacity and collaborate with other stakeholders, as appropriate.

² This data is typically collected and evaluated during the five-year Continuing Approval Visit. BRN does not have regulatory authority to require a plan for evaluation of the total program on an annual basis, and to require that it include regional nursing workforce forecast data. Therefore, in order for BRN to require nursing programs to submit their written plan for evaluation on an annual basis, BRN would need to pursue a change to regulations, which would not feasibly be promulgated on or before January 1, 2021. However, BRN will consider revising its regulations to require nursing programs to submit their written plan for evaluation on an annual basis on or before October 1, 2021. On or before January 1, 2021, BRN will request nursing programs to submit their written plan for evaluation for their total program on an annual basis. BRN will also provide training to all impacted staff.

Amend its policies, as appropriate, to require that relevant information related to BRN’s most recent forecast of the nursing workforce, and other relevant regional data, be included in Agenda Item Summaries (AIS), presentations by Nursing Education Consultants (NEC; referred to as nursing education staff in the audit report), and supporting documentation, so that they may be taken into consideration when making enrollment decisions. These items may also include, but will not necessarily be limited to, the school’s report on how their graduates will be meeting community needs, which sometimes includes regional nursing workforce data.

Recommendation 2: To ensure that nursing education staff provide complete information to the governing board when it is considering enrollment decisions, by January 1, 2021, BRN should establish in policy the specific information that its staff should present to the education committee and governing board, including data about clinical facilities that nursing programs use for placements, the content areas for which the programs use those facilities, and the total number of available placement slots and the risk of clinical displacements at the facilities.

BRN Response 2:
Through discussions with BSA during the audit process, BRN initiated meetings and process improvement efforts to ensure consistency and uniformity with AIS and supporting documentation requirements when presenting to the ELC and governing board. BRN will continue to work with the ELC, the governing board, and the NECs to establish and implement a uniform format and reporting structure which informs the ELC and the governing board of appropriate information for enrollment decisions for pre-licensure nursing programs. On or before January 1, 2021, the information will include data about clinical facilities that nursing programs use for placements and the content areas for which the programs use those facilities. However, BRN can only include data relating to the total number of available placement slots and the risk of clinical displacements at the facilities once that information can be collected and analyzed, which will be after January 1, 2021.

BRN agrees that the available data on clinical placements can be enhanced; therefore, BRN has researched and discussed regional consortiums as a way to identify every student placement in all clinical settings, provide a transparent system for resolving clinical placement conflicts, and document problem areas. There are currently limited consortiums available in California and they are not uniform nor are they located in every region, and participation in the consortiums is voluntary. Without legislative and regulatory authority, BRN cannot implement a statewide consortium with a regional focus and require all clinical settings and academic institutions to participate. Such a system could ensure that data relating to the total number of available placement slots and the risk of clinical displacements at the facilities will be collected and analyzed. A statewide consortium with regional focus would provide a complete and accurate representation of available clinical placement slots.

Recommendation 3: To ensure that BRN is using up-to-date, accurate, and objective information to inform the governing board’s enrollment decisions and to assess clinical capacity for student placements,
by April 1, 2021, BRN should:

Update its clinical facility approval form to capture annual capacity estimates from clinical facilities, as well as annual clinical placement needs of programs.
Require nursing programs to report any changes they make to their use of clinical facilities within 90 days of making a change and report annually if the program has made no changes.
Compile and aggregate the information from the facility approval forms into a database and take reasonable steps to ensure that the information is accurate and current.
Annually publish clinical capacity information on its website for public use.
Immediately discontinue its practice of having nursing programs seek statements of support or opposition from neighboring nursing programs when considering requests for new programs or increased enrollment at existing programs.

BRN Response 3:
As mentioned in the responses for recommendations one and two, effective March 2020, BRN initiated meetings and process improvement efforts to amend its policies related to the AIS, the NEC presentation, and supporting documentation, which will ensure that the information presented to the ELC and the governing board is up-to-date, accurate, and objective, and provides sufficient information for the ELC and the governing board to assess clinical capacity for student placements in connection with enrollment decisions; additionally, BRN will take the following actions:

On or before April 1, 2021, BRN will update the clinical facility approval form to capture annual capacity estimates from clinical facilities as well as annual clinical placement needs of programs.

In order for BRN to require nursing programs to report any changes they make to their use of clinical facilities within 90 days of making the change and report annually if the program has made no changes, regulation sections including, but not limited to, CCR sections 1427 and 1432 will need to be revised. It is not feasible that a regulatory change could be promulgated on or before April 1, 2021. However, BRN will consider revising its regulations to require nursing programs to report any changes they make to their use of clinical facilities within 90 days of making the change and report annually if the program has made no changes.

In order for BRN to require nursing programs to submit the facility approval form, a regulatory change will need to be promulgated. It is not feasible that a regulation package could be promulgated on or before April 1, 2021. However, BRN will consider revising its regulations to require nursing programs to submit a facility approval form on or before October 1, 2021. On or before April 1, 2021, BRN will develop a policy to compile and aggregate the information from the facility approval forms into a database and take steps to ensure it is accurate and current.³ This information will be used to assess the risk of clinical displacement when gathering information related to enrollment decisions and will be reported to the ELC and the governing board in its newly developed uniform reporting format and structure. BRN will also provide training to all impacted staff.
On or before April 1, 2021, BRN will commence the process to analyze clinical capacity information that is available to BRN for the purpose of publishing it on the BRN website for public use on an annual basis.
As of March 11, 2020, BRN discontinued its practice of requiring nursing programs to seek statements of support or opposition from neighboring nursing programs when considering requests for new programs or increased enrollment at existing programs. BRN will update the 2020 Director’s Handbook with this information.

³BRN agrees that collecting and analyzing clinical information is necessary; therefore, BRN has researched and discussed regional consortiums as a way to identify every student placement in all clinical settings, provide a transparent system for resolving clinical placement conflicts, and document problem areas. There are currently limited consortiums available in California and they are not uniform nor are they located in every region, and participation in the consortiums is voluntary. Without legislative and regulatory authority, BRN cannot implement a statewide consortium with a regional focus and require all clinical settings and academic institutions to participate. Such a system could provide a complete and accurate representation of available clinical placement slots and ensure that information presented to the ELC and the governing board to assess clinical capacity for student placements is up-to-date, accurate, and objective.

Recommendation 4: To identify additional facilities that might offer clinical placement slots, by
October 1, 2021, and annually thereafter, BRN should compare its nursing program database with OSHPD’s list of health care facilities. BRN should share the results of its comparison with nursing programs by publishing this information on its website.

BRN Response 4:
To identify additional facilities that might offer clinical placement slots, on or before October 1, 2021, and annually thereafter, BRN will compare its aggregated data in its nursing program database with OSHPD’s list of health care facilities and will share the results of the comparison by publishing to the BRN website. As stated by BSA in the audit report, OSHPD data will not show the clinical settings that do not have the capacity or the desire to offer placement slots; therefore, such a comparison might produce information that could be used to locate unused clinical sites, however it would not be an accurate representation of available clinical placement slots for nursing students. As previously stated, a statewide consortium with a regional focus would provide a complete and accurate representation of available clinical placement slots for nursing students. BRN needs legislative and regulatory authority to develop and implement a statewide consortium with a regional focus and require health care facilities and academic institutions to participate in the statewide consortium, which will ensure that BRN has accurate and current data on clinical placement slots.

BSA Recommendations to the Legislature and BRN Responses
Legislative Recommendation 1: To better inform the governing board’s decision making and stakeholders, the Legislature should amend state law to do the following:

Require BRN to incorporate regional forecasts into its biennial analyses of the nursing workforce.
Require BRN to develop a plan to address regional areas of shortage identified by its nursing workforce forecast. BRN’s plan should include identifying additional facilities that might offer clinical placement slots.

BRN Response to Legislative Recommendation 1:
Business and Professions Code section 2717 requires BRN to collect and analyze workforce data from its licensees for future workforce planning. BRN collects and analyzes this data via its contractor, the University of California, San Francisco (UCSF). However, BRN has not requested the regional information from UCSF for purposes of publishing to its website. BRN does not oppose the development of a plan to identify regional areas that are underserved and collaborating to identify options to address those underserved areas, including but not limited to finding additional facilities that may offer clinical placements to students.

Legislative Recommendation 2: As a part of BRN’s sunset review in 2021, the Legislature should consider whether the State would be better served by having BRN revise its regulations to leverage portions of the accreditor’s review to reduce duplication and more efficiently use state resources. For example, it could consider restructuring continuing approval requirements for nursing programs that are accredited and maintain certain high performance standards for consecutive years (for example, licensure exam pass rates, program completion rates, and job placement rates). Additionally, the Legislature should consider whether and how BRN could coordinate its review with accreditors to increase efficiency.

BRN Response to Legislative Recommendation 2:
BRN is not opposed to identifying and addressing any duplicative efforts involving third party accreditation entities and BRN’s statutory and regulatory oversight of pre-licensure nursing programs. However, this recommendation being addressed to the Legislature does not consider BRN’s ability and willingness to address any concerns regarding duplicative efforts. BRN is in the unique position to take the lead and 1) assess the roles of the accreditation entities and its current processes; 2) identify areas of overlap and areas of improvement; 3) incorporate feedback of the Deans and Directors of currently accredited ADN and/or BSN pre-licensure nursing programs; 4) implement enhancements to its processes; and 5) conduct continuous quality improvement assessments and implement revisions based on the data. BRN could report the progress and accomplishments of reducing these duplicative efforts during its sunset review for evaluation and additional input. BRN affirms its interest in ensuring that its processes are evidence based and that we continue to offer the highest level of protection to consumers, patients, nursing students, and licensees.

Legislative Recommendation 3: To ensure that BRN and stakeholders have an understanding of clinical placement capacity in California, the Legislature should amend state law to require BRN to annually collect, analyze, and report information related to the number of clinical placement slots available and the location of those clinical placement slots within the State.

BRN Response to Legislative Recommendation 3:
BRN supports advancing the understanding of clinical placement capacity and supports working in collaboration with other stakeholders, including but not limited to, hospitals and other health care facilities eligible to offer clinical placements to nursing students, for the purpose of collecting, analyzing and reporting information related to the number and location of clinical placement slots available in California. BRN believes that a statewide consortium with a regional focus could accomplish this. In order to implement such a statewide consortium and require health care facilities and academic institutions to participate, BRN needs legislative and regulatory authority. Such a system could ensure that data relating to the total number of available placement slots and the risk of clinical displacements at the facilities can be collected and analyzed. This would allow for identification of every student placement in all clinical settings, provide a transparent system for resolving clinical placement conflicts, and allow for documentation of problem areas. In the absence of legislative authority for a statewide consortium, BRN believes that OSHPD and/or the California Department of Public Health (CDPH) are in a better position to annually collect information on clinical placement slots, as they have statutory authority over health care facilities. BRN will analyze and report clinical placement slots for nursing students based on the data that OSHPD and/or CDPH collect.

Comments

CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM THE BOARD OF REGISTERED NURSING

To provide clarity and perspective, we are commenting on BRN’s response to our audit. The numbers below correspond to the numbers we have placed in the margin of BRN’s response.

Notwithstanding the other information that BRN asserts its governing board members consider, the nursing education staff do not typically present regional workforce data to the governing board. Further, as we note in the Audit Results, nursing programs have cited nursing shortages as a reason for requesting an enrollment increase and referenced other forecasts to support their requests. However, BRN’s forecasts do not include relevant regional information that would allow its nursing education staff to verify those assertions. Thus, BRN should ensure that the forecasts it is paying its contractor to develop every two years include regional variations in the projected supply and demand of nurses, to better inform the governing board’s enrollment decisions.

We recommended that BRN revise the scope of its contract for workforce forecasting services to incorporate regional analyses and ensure that the governing board’s enrollment decisions and other actions adequately take into consideration those regional analyses in future forecasts. We did not recommend that BRN require nursing programs to provide a plan for evaluation of the total program on an annual basis.

BRN misunderstands the time frames of our recommendations. We recommended that by January 1, 2021 BRN establish in policy the specific information its staff should present. As for the time frame for collecting the information, we recommended that BRN compile and aggregate the information by April 1, 2021. Although BRN expressed some concern in its response about promulgating regulations by April 1, 2021, we expect BRN to take actions to implement our recommendations and provide us documentation of its progress as part of its 60‑day, 6‑month, and 1‑year responses.

BRN does not describe how the consortium—a group of nursing programs and health care facilities that work together to address clinical placement issues—it mentions in its response would function to address our recommendations. Moreover, we believe BRN can implement our recommendation without using a consortium to identify clinical placements as BRN suggests. Specifically, BRN is well‑positioned to gather and analyze data regarding clinical placements. As we state in the Audit Results of our report, nursing programs must get BRN approval before using a clinical facility and BRN documents that approval on a facility approval form. Therefore, BRN should already have a record of all facilities that nursing programs are using for clinical placement slots. We believe that BRN can and should collect on the facility approval form the total number of clinical placement slots a clinical facility can accommodate annually and how many slots the programs that use the facilities will need each year.

We believe that it is imperative that BRN implement our recommendations to ensure its governing board has complete information about clinical placements when it is considering enrollment decisions. We look forward to BRN’s 60-day, six month, and one‑year response to our audit report, which should include documentation demonstrating the actions it is taking to implement our recommendations.

To clarify, we note in the Audit Results of our report that just because a nursing program is not using a facility does not necessarily mean the facility is available for use or willing to provide clinical placement slots for nursing students. However, we believe such a comparison and the necessary follow-up could identify additional clinical placement slots, thereby alleviating potential constraints on enrollment for nursing programs in areas with nursing shortages.

Nothing in our recommendation to the Legislature precludes BRN from taking the actions it identifies in its response. In fact, we believe these actions, if taken, would facilitate the Legislature’s implementation of our recommendation.