Hello, and welcome to this presentation on the American Association of Nurse Anesthesiology, the past, present, and the future. I'm Jeff Darna. Let's go ahead and get started. First is our disclosures. I have no financial relationships with any commercial interest related to the content of this activity, and I will not discuss all that we'll use during this presentation. A little bit about myself. I am a program administrator for a university based in Southern California. I am a past president of the California Association of Nurse Anesthesiology. In addition, I'm a practitioner and educator, but also a researcher and policy advocate. And my interests rely in improving access to anesthesia services within the Veterans Administration, as well as in underserved communities across the United States. Here are our course objectives. So after the presentation, the attendee will be able to describe the American Association of Nurse Anesthesiology's organizational design, its mission, and vision. We'll be able to detail the ANA's history and major accomplishments and changes along the way, and discuss the value of continuous ANA membership. So what is the American Association of Nurse Anesthesiology? Well, the ANA is the professional trade organization that was founded in 1931, and it represents approximately 62,000 nurse anesthesiologists, or certified registered nurse anesthetists, nurse anesthesia residents, and associate members that would be registered nurses and other non-anesthesia advanced practice registered nurses here in the United States. The ANA is one of several important nurse anesthesiology organizations. Importantly, it is independent of other organizations that help support or advance our profession. For example, the National Board of Certification and Recertification for Nurse Anesthetists is charged with safeguarding the public and issuing the National Certification Exam, which is the gateway to becoming certified as a CRNA. That is an independent organization from the ANA. And while the two might collaborate on mutually shared interests and projects, they are independent of each other. So the NBCRNA does not answer to the ANA, and vice versa. Other important organizations that the ANA may collaborate with would be the Association of Veterans Affairs Nurse Anesthetists, the International Federation of Nurse Anesthetists, the Council on Accreditation of Nurse Anesthesia Education Programs, as well as all of our statewide trade organizations. At the center, you can see another independent organization, the American Association of Nurse Anesthesiology Foundation, that is our education and research arm. In order for us to understand why the ANA was organized and its purpose and how it has evolved over the decades, we need to go back in time. We need to look at some history as to the antecedents that led up to this incredible discovery of anesthesia. And so for the next couple slides, we'll talk a little bit about those historical milestones, what happened, and how they influenced the formation of this high-performance organization that we resource all the time. So let's start with Joseph Priestley. Joseph Priestley, in 1772, first identified the oxygen molecule. And that was really important. And while that wasn't anesthesia, he was able to describe the physiological benefits of having oxygen or an oxygen-saturated environment. Of course, that's something we use in clinical practice every day, and we have to thank Joseph Priestley for that scientific contribution. He's also credited with discovering nitrous oxide, that's NO. Nitrous oxide is something that we use in operating rooms to help augment our general anesthesia. And back then, while it wasn't discovered and immediately used for anesthesia, it did lay the foundation for other anesthetics to be discovered. How nitrous was used back then were for what they called nitrous oxide frolic parties. And so people would inhale this laughing gas at these social events and then frolic around until the effects of that gas wore off. It wasn't until much later, 1842, when a physician named Crawford Long first used ether in a Georgia operating room to demonstrate the effects of this new and very potent anesthetic. Unfortunately, Crawford Long didn't get all the accolades and recognition that he initially deserved. And that's because he didn't publish his work. The first credited published work went to a dentist by the name of William Morton at Mass General Hospital in an operating theater, was surrounded by physicians and dentists and other practitioners. Dr. Morton used ether to anesthetize a young man for the removal of a tube. It impressed all the practitioners. And it was at that moment that they had realized they had discovered one of modern medicine's greatest contributions, the ability to remove sensation, to induce an unconscious state, to help some shepherd somebody through what would ordinarily be a very painful procedure with ease and without pain. In fact, Oliver Wendell Holmes, Sr., he was a physician and poet and father of the soon be or would be Supreme Court Justice, coined the term anesthesia, or the term or the root had been around for a while. The application of that term wasn't used until Oliver Wendell Holmes could see the miracle of this drug called ether. John Snow was an English physician and epidemiologist who was really interested in public health, but also in anesthesia. He traveled to the United States to really explore this new drug called ether. He returned to England and started using a drug called chloroform and experimenting with that, trying to find the correct dosage during the administration. Chloroform can be a fairly toxic drug and when you administer it, you've got to be very careful. And during the initial administration of that particular anesthetic agent, there were a number of deaths that occurred. So it was quite controversial in England, particularly when Queen Victoria asked John Snow to administer chloroform to her for the birth of her child. It was successful and then subsequently, three years later, when she had her second child, he returned and provided those anesthesia services. And from there, chloroform started to proliferate along with ether and later on other anesthetics. In the 1860s and 70s, with this new incredible drug, that really accelerated our ability to provide surgical services, which had previously been off limits because they were too painful, they were too invasive, and we didn't have an adequate way of being able to control pain, much less stop patient movement. However, there was informal training back in the 1860s and not until the 1870s. And so how anesthesia was administered was pretty much in a very unregulated manner. Medical students and perhaps surgical trainees were pulled from the operating theater by the surgeon and selected to administer anesthesia to the patient, never having received any formal training in airway management, dosages, and so forth. And consequently, there were a number of mishaps, aspirations, deaths, and so forth. In fact, the famous neurosurgeon, Harvey Cushing, was called down to administer anesthesia during, when he was a medical student, and realizing he didn't know what he was doing, over-anesthetized the patient. The patient aspirated and subsequently died from that aspiration and anitis. And he said, you know what, this is really a dangerous and specialized field that really does need to be managed by experienced hands. Now let's turn to a little bit about some of the first nurse anesthesiologists or nurse anesthetists. The very first nurse anesthetist, or very first nurse that we are aware of that administered anesthesia, was during the Civil War in 1861, a person by the name of Catherine Lawrence. And she documented that in her autobiography. There are two other nurses during the Civil War who also was documented that they were administering anesthesia to Union soldiers on the battlefield to help perform surgical services such as amputations, ligation of bleeding vessels, and so forth. From there, we saw nurses really starting in the 1870s to specialize after basic nursing training in the field of anesthesia. And Sister Mary Bernard was one of the first individual, first nurses to be able to specialize in her training in the field of anesthesiology. Alice McGaw worked with the Mayo Brothers, the famous Mayo brothers, Alice McGaw worked with the Mayo Brothers, the famous Mayo Clinic, and became their nurse anesthetist and was very famous for publishing and documenting and publishing her work, along with a colleague of hers named Florence Henderson. In fact, in 1910, 1911, they published a record of 14,000 anesthetics that they personally administered without any mishaps, complications, or deaths. She was named the Mother of Anesthesia and today still holds that particular title. In California, the first nurse domesticist that we have documentation of is a person by the name of Ulta Bates. And she was in Oakland and had been administering anesthesia services to the hospitals in that particular area. Enter 1915, Agatha Hodgins, who will detail a little bit more in depth in the coming slides. She was a nurse anesthetist and a champion of nurse anesthesia education. And she opened the Lakeside Hospital of Nurse Anesthesia in 1915. Sensing some challenges to nurse anesthesia practice in the late teens after World War I and into the 1920s, Adeline Curtis, who was a California-based nurse anesthetist, began to collaborate with Sylvie Winton, another nurse anesthetist who owned a surgery center, a plastic surgery center for the stars in the late 20s and early 30s. And they started to form the state organization, the California Association of Nurse Anesthesiology. And they did this because they were getting headwinds from organized medicine who wanted to see nurse anesthetists essentially disappear and make the practice of anesthesia exclusively, or call it exclusively the practice of medicine. So it's important when we look at antecedents to the formation of the American Association of Nurse Anesthesiology, some geopolitical influencers that were occurring during a time. Let's go back to the Civil War. We had already discovered ether and chloroform was making its way to become another very popular anesthetic. Civil War was the bloodiest, the deadliest in United States war history. And we really saw a need for anesthesia services, particularly on the battlefield, for trauma stabilization and to be able to facilitate surgical intervention. This led to really an unregulated practice of anesthesia. And so state boards of medicine were formed. In fact, all states by 1898 had some type of state medical board to try to regulate the practice to ensure public safety. Back then too, medical schools were quite abundant. They had a lot of different admission criteria. Some had very little admission criteria, not even requiring a high school diploma. And so therefore a man who was not a physician named Flexner issued something called the Flexner Report in 1910. And what the Flexner Report in 1910 said was that of all these medical schools that are out there, we desperately need to standardize the way we educate our medical students and our physicians. First of all, as part of the admission criteria, we need to make sure that there is a curriculum in the basic sciences. In the first two years, the last two years should be focused on the clinical sciences. Admission criteria need to be improved. You need to have a four-year undergraduate degree, preferably in the sciences. And we need to make sure that all medical schools graduated individuals with a doctorate to reflect the rigor of the training and the prestige of the degree. Those were some pretty good things that the Flexner Report did, but there were also some pretty bad things as well. They closed schools, medical schools that were there to help support persons of color and made recommendations to limit the number of women, if any, being allowed into schools of medicine. So with that said, organized medicine really started to come together and to dominate the healthcare field. We soon were thrust into World War I, again, demonstrating the value of anesthesia in the battlefield for surgical intervention. But this time was a little bit different because what we saw was nurses really traveling overseas to be the principal anesthetist and to work and teach physicians, English physicians, about the art and science of anesthesiology, how to effectively drop ether, how to adequately anesthetize somebody, how to time the breathing with the administration of that drop technique. At the same time, what we started seeing was that healthcare, because surgery was starting to save lives and we saw people living longer and we saw these incredible advancements in medical science, we saw the formation, albeit crude, of the business aspect within healthcare. And that's when physicians started really taking notice. And that became an incredibly tense moment between physician anesthetist, because that's how it was referred to back then, not anesthesiologist, and nurse anesthetist. In fact, many of the physician anesthetists did what they could to try to limit or restrict as much as possible the practice of nurse anesthetist because they saw them as competition and a disruptor to the potential business model. Here we have Dagmar Nelson. Dagmar Nelson was arguably probably the most important nurse anesthetist involved in a legal dispute that the outcome was favorable to nurse anesthetist and really redefined what the operational definition of anesthesia when best services are provided by a licensed healthcare provider. The background is this, is Dagmar Nelson had moved to California. She was practicing in Los Angeles when a group of physicians claimed that she was practicing, engaging in the unlawful practice of medicine when she was administering anesthesia. The claim was brought to the Board of Medicine. It worked its way through the court system. Eventually, the California Supreme Court reviewed the case and cited in favor of Dagmar Nelson saying that when a professional registered nurse administers anesthesia, that is considered the practice of nursing. When a licensed physician does it, it's considered the practice of medicine. When a licensed dentist administers anesthesia, it is considered the practice of dentistry. This is also the first time that the newly founded trade organization, the AANA, submitted its very first amicus brief, and that is a paper that helps support one position that's submitted to the court ahead of a decision for them to be able to review and consider. So huge case, arguably probably one of the biggest cases in the entire United States involving nurse anesthetists, one that sided with us and really redefined or gave us a solid definition of what anesthesia and who is allowed to be able to practice that. Here we have Agatha Hodgins. So Agatha Hodgins, as I said a few slides back, was an educator and a pioneer. She formed the Lakeside School of Anesthesia in 1915, and she was an anesthetist who had traveled overseas to provide services and teaching to English physicians during World War I. She sensed a need to be able to standardize education for nurse anesthetists, but she knew she couldn't do that by herself, that she needed to have a trade organization who had the power and the ability to set standards of practice and education. And she knew through education that if she could do that, that she could make policy, help policy changes. So she first tried to organize in 1926, when she saw a lot of headwinds and opposition from organized medicine. And she reached out to the American Nurses Association, and she was summarily rejected. Rejected because at the time, the American Nurses Association did not support nurse anesthetists. In fact, they held the position that what Agatha Hodgins and others were doing was the unlawful practice of medicine. Frustrated and slightly discouraged and disappointed, Agatha turned to others for more support. It turns out the American Hospital Association, the AHA, was that champion to support nurse anesthesia initiatives and causes. And so it was through their support and connections and collaboration that Agatha Hodgins, along with some other pioneering nurse anesthetists, was able to form the National Association of Nurse Anesthetists on June 17th, 1931. They elected Agatha Hodgins as the first president for which she sat for two years. She remained close to the profession, but had to take a medical leave because she had suffered a number of myocardial infarctions and then ultimately succumbed one in 1945. Here we see a picture from the very first official ANA meeting that was held in Milwaukee, Wisconsin. There were other get togethers prior to this official meeting, but they were small and they only had about 40 or so different nurse anesthetists and they were held within the Lakeside School. So this was the first time that they actually held a banquet and a full convention and it attracted more than 100 nurse anesthetists from across the country. This is 1933 when they also changed the name from the National Association of Nurse Anesthetists to the American Association of Nurse Anesthetists. Now on this slide here, I want to point out some highlights and accomplishments that the American Association of Nurse Anesthesiology has achieved over its nearly 100 year history. This list is by no means complete and nor does it highlight all the wonderful successes that the organization has accomplished. Rather, it is a random selection of accomplishments over the years. So in 1940s, with the onset of World War II, it was the American Association of Nurse Anesthesiology that promoted and asked the US military for a special recognition of the profession and the role of the nurse anesthetist. Now that ultimately wasn't granted until after World War II ended, but it was the ANA who initiated that conversation and worked with the Army Corps of Nurses to be able to achieve that particular accolade and rank. In 1945, shortly after the death of Agatha Hodgins, the very first certification exam was administered. It was pretty special for Agatha Hodgins, unfortunately, who was not allowed to see that because she had passed, but this had always been a vision of hers to be able to create a national certification exam and then turn back to others to use that as evidence, seriousness, and the rigor of the training that nurse anesthetists underwent in this country. In 1956, the credential CRNA, or Certified Registered Nurse Anesthetist, was officially adopted, and that still holds true today, although we've modified the descriptor anesthetist and we've put in the optional anesthesiologist to represent our value and contributions to healthcare. In 1981, the ANA, sensing a need for research and education, formed the ANA Foundation, and it was this that produced a tremendous amount of research still today, scholarships, and other educational initiatives that really are used for policy development and other advocacy initiatives, not just for nurse anesthetists, but also for advanced practice nurses, as well as cost-effectiveness within healthcare when we're talking about comprehensive anesthesia delivery services. In 1992, the ANA purchased their headquarters in Park Ridge, Illinois. We subsequently have sold that building and it relocated to a facility just outside Chicago O'Hare Airport, and we did that just a few years ago. In 2016, we reached a milestone with 50,000 members, and we continue to grow to those numbers year over year, and currently just on the precipice of 62,000 members as of the recording of this lecture. In addition to those wonderful accomplishments, we've also been very, very fortunate to be surrounded by some wonderful and very incredible forward-thinking leaders. And again, this is just a very partial list of the incredible men and women and individuals who are our colleagues and who were pioneers in this area and who are our colleagues and who were pioneers in advancing our profession and our particular interest. We start with Goldie Bragman, who was one of the nurse anesthetists who was instrumental in saving Dr. King's life in New York after he was shot. She served as our first African-American president of the organization in 1973. John Gard was the first male president as well as the youngest president of the American Association of Nurse Anesthetists. He later went on to serve in the executive director role. We have Ira Gunn, who was a military CRNA and absolutely instrumental in forming policy and history and other educational initiatives within the ANA. Helen Lamb was one of our first educators as well as a president of the American Association of Nurse Anesthetists. And Florence McKillen was our very first CEO and executive director. And then we have other individuals as well, particularly Sandy Ouellette, who has served as president of this organization. She was the program director at Wake Forest for a number of years, and she is an incredible historian and a champion of policy initiatives and somebody we're all very, very thankful for. So again, just a handful of some wonderful individuals and leaders who have made the organization what it is today. So a little bit about the name Evolution. As I told you at the beginning of this presentation, when we first formed, we were called the National Association of Nurse Anesthetists. That name was later changed in 1933 to the American Association of Nurse Anesthetists. In 1939, we reincorporated with the state of Illinois. We'll be able to share those papers, those reincorporation papers and articles of reincorporation with you on the next slide. And then sensing a lot of geopolitical changes, a need for better driven initiatives to better recognize the role, the value, the rigor, the training of nurse CRNAs in present day healthcare, we modified our name to doing business as the American Association of Nurse Anesthesiology. And that change became effective in 2021. And that's how we are referred to as of current day. So a lot of changes, a lot of evolution going on and all done with keeping in mind the incredible value that we bring to healthcare every single day. Here are the 1939 articles of incorporation. This is a great document. So if you wanna just pause the video here for just a few minutes and really read through this and look at all the individuals who had signed on to endorse as trustees this organization. One of the things I wanna point out to you is number one, is if you look in the center panel about Midway Down, what the objectives of the organization are. And the objectives are to advance the science and art of anesthesiology, not of nurse anesthetist or anesthetist or something that resembles more of a technical or technician's contribution, but rather the science, the art of what we do day in and day out. And that's something to remember because that is an objective of ours still today because these articles of incorporation are still valid. All high performance organizations you should have a mission, vision and values. And this is the beacon. This is what brings people, members together and keeps us focused, particularly in times when there may be divergent ideas or geopolitical headwinds. But our mission at the ANA is very, very clear. The ANA advances, supports and protects nurse anesthesiology and its vision, which is a reach statement. In other words, what do we aspire to be? And that is that the ANA will become the transformational leader that drives innovation and excellence in healthcare. And that is two of those statements is what make amongst many other things, the ANA a high performance organization. And that's recognized by many of our physician colleagues and other advanced practice nursing specialty organizations. Our governance is dictated by bylaws of the ANA. In here, you can see that we have several different articles article one through article 17. And this basically in 28 pages, 17 articles talks about how the organization is going to come together, how it is going to function and how it is going to exist going forward. Article number one talks about our name. So when we made a name change a few years ago, this article had to be modified and voted and approved upon by the membership. That means the active CRNAs who are active members of the organization. Speaking of membership, that's an article two that defines who can become a member. It's not just certified registered nurse anesthesiologist, but also our nurse anesthesia residents because we know that we need to cultivate that next generation of anesthesia professional. We also have new categories as well and opportunities for professional registered nurses who are interested in the practice of nurse anesthesiology and other non anesthesia advanced practice nurses who might wanna make that transition over to the field such as nurse practitioners. Article three talks about the dues. And so this organization is unique in which our dues are housed within our bylaws and other organizations it's outside of that. When we wanna have a dues increase as we recently did, we have to make a change to our bylaws and that has to be approved by the membership. Articles four and article five talk about our board of directors and the officers of the organization, what are the qualifications and as well as their duties, but also their term and how they get elected and then subsequently reelected. And speaking of elections, article six details the election process. Article seven focuses on committees and like all wonderful organizations, we have several committees that do work on the ANA and those committees are staffed by CRNAs who volunteer their time and that are selected for committee work. Article eight talks about the geographic organizations and the relationship that we have to the different districts across the United States. We'll get a little bit more into that in just the next few slides. Article nine talks about our state association. So when you become a member of the American Association of Nurse Anesthesiology, you also become a member of your state organization. In fact, a percentage of the dues, approximately one third of your annual dues is directed to the state that you were domiciled in. You only get to select one state. So if you live in California and Hawaii, you gotta choose which one you're domiciled in and that particular state organization then receives a portion of the dues that you pay to the ANA and that's how those state organizations are funded and that is how they operate in terms of state advocacy efforts. Article 10 talks about membership meetings. We have about three meetings per year. We'll cover that in just a few minutes. Resolutions in article 11, how we're accredited and certified in article 12, professional conduct in article 13, article 14 is more on administrative operations, indemnification insurance by article 15 and then parliamentary authority. You know, we use Robert's rules to run all of our meetings and this is to ensure that parliamentary law is upheld and that we are conducting business in a productive and an effective way that upholds respect and for order and control. And then article, the last article focuses on amendments and amendment process. Here we see just the relationship of the ANA board of directors which are elected by the membership and we have officers on top and then we have regional directors at large below. So you have a president, you have a president-elect. The president-elect is elected and then the following year, he, she, they will then become a president of the organization. We have a vice president as well as a treasurer. Each of these individuals has a specific role. The directors are all at large and they all oversee a particular region within the United States. Seven directors, seven different regions. And those directors work with the state presidents to keep the ANA board of directors abreast of things that are going on at the state and within the region. Typically things that happen in Massachusetts might also affect new legislation in Connecticut. And so we need a vehicle to be able to communicate what's going on. And those directors are that vital communication. The ANA also has executive leadership. And in this particular case, we can see that we have a chief executive officer and then we have a chief under each particular service line. So we have a chief scientific officer, chief innovation officer, financial officer and so forth and so forth. And these individuals all have managers and directors and other staff that help carry out the operations of the ANA. There is well over 100, over 125 individuals who work for the American Association of Neurosanesthesiology, which is headquartered in Chicago. Here is a map of the different regions of the ANA. We can see regions one through seven, one being New England and then all the way to region five, which is a really large area covering Montana to California, Alaska, and Hawaii. And it may be in the future that we see as the size of the organization increases and some of the legislative challenges become more complicated, we might even see some new regions being developed, particularly in these larger areas where one director might be challenged to oversee 13 or 14 different states at one time. So, but at present day, seven regions, one director at large for each of them which is appointed by the ANA to the region in which they will serve. And we get to meet with our region directors at least three times a year and more often if you're serving as a president of your state organization. And that is an opportunity at the meetings to find out what other states are doing and to really hear as a direct communication vehicle from the board directors of the ANA directly with the membership. Here is I mentioned earlier during the bylaws discussion that the American Association of Nurse Anesthesiology has a state association that's affiliated with this. When you become a member of the ANA you will then select the state that you're domiciled in and a portion of your dues will be directed to support state functions and operations. This is just of course just a partial listing to show you all the incredible states that come together to make our profession strong but to always make sure that they're championing your rights as an anesthesia professional. Not just at the federal level which is what the ANA does but also at the state level and local level as well. The standing committees, committee work is really it is feeding the farm. It is making sure that the work of the organization is done to advance nurse anesthesiology the art and science of it. And that comes in the form of committee work. Now as a certified registered nurse anesthetist or nurse anesthesiologist I can apply for a particular committee and if selected I serve on either a one or two year appointment. There are committees in which the membership will elect the individual to. Those are the bylaws and resolutions committee as well as the leadership identification committee. The bylaws and resolutions committee is either a one or two year elected position and the same with the the LIC or the leadership identification committee. Other very special committees which are very important and have done some incredible work is diversity, equity, inclusion. Making sure that we recruit and we retain a diverse healthcare workforce because we need to make sure that the people that we graduate from nurse anesthesiology residencies represent the changing demographics in the United States and that's really really important. Also important is to make sure that people feel welcomed and that they're supported. We also have a big initiative on health and wellness. You know anesthesiology whether you are a nurse or a physician or a dentist or somewhere else in between is a profession where you have unfettered access to some very very potent very very dangerous drugs and substance use disorder can certainly be a challenge or somebody's at risk for that in our particular industry and we need to make sure that we help support persons who have substance use disorders and that we support them towards a road towards lifelong recovery. Also wellness making sure that we address the stress and the burdens of life because unfortunately there are individuals who die by suicide and we never want to lose anybody in this profession or anywhere to suicide. So we have a lot of concerted outreach efforts to make sure that we can help people who fall into times or periods of crisis. So really really important committees here doing some incredible work. So in addition to all the committee work and we really take at the ANA a very strong stance on promoting advocacy and advocacy to make sure that we're promoting health policy initiatives that help improve access to care, high quality care, patient safety, but also care that is very cost effective that is in the form of efficiency driven anesthesia modeling. And so 67 percent of state pro seority legislation involves in one form or another full practice authority. This means having nurse anesthesiologists practice the top of their education and training and when we do that we can optimize our health care workforce and increase the number of health care providers which subsequently will increase access to care and hopefully reduce cost and make cost more effective. We also have initiatives on proper recognition of our credentials, our tiling, and our contributions to health care. A big component of what we do is in direct reimbursement. You know in the 1980s CRNAs were the first advanced practice nurses to get secured direct reimbursement from Medicare for providing care to Medicare recipients and that was a really monumental moment for us because at that point we started leveling the field with our physician counterparts. We could imagine, might not have been overly excited that we had entered a realm in which they had dominated for a number of decades, but it was the ANA that championed those particular policy changes and really opened up the floodgates for other advanced practice clinicians to follow suit including nurse practitioners. Still today we have challenges with direct reimbursement. Some payer sources, commercial insurance, will only pay CRNAs 85 cents on the dollar where a physician is being paid a full dollar and despite legislation of provider non-discrimination, some of those rules have not, there are no enforcement rules surrounding that legislation and so therefore insurance companies will still continue those unlawful practices, but we are there to try to stop that and to promote proper rule making to ensure that you as an anesthesia professional are reimbursed equally to what physician care is because at the end of the day there is no difference between the care provided by a CRNA and the anesthesia care provided by a physician anesthesiologist. Seven percent involves, legislation involves pain, keeping in mind that CRNAs engage in pain practice and that we are champions of avoiding the opioid prescriptions and using other pain ameliorating therapies, whether that's through injections or other types of therapies to avoid exposure to harmful effects of opioids. And these are just a few of the things that the ANA is helping support at the state but also at the federal level too. When we look at the federal level, a big one of course is better access to anesthesia services for veterans. Here we have a map and we call this an opt-out state and so in addition to securing reimbursement back in the 80s, in the 90s after nearly a decade's long advocacy campaign, we were able to, this is the ANA, able to secure what we call an opt-out from Medicare Part A conditions of participation. There are four parts to Medicare, Medicare Part A, B, C, and D. Part A is how hospitals get reimbursed, B is how providers such as myself get reimbursed, and then C is advantage and then D is the drug coverage. So for Medicare Part A, for those hospitals to get reimbursed for providing services to patients through Medicare, they had to have some type of supervision of physician supervision of nurse anesthetists. Well, after a decade's long of advocacy, we said this is no way, this is not an effective way of delivering anesthesia services. So we worked very closely with the Clinton administration to remove that particular requirement. Unfortunately, after Clinton left office, Bush took over the Oval Office and put a temporary moratorium on this particular rule change. In exchange for having a 100% opt-out, he left it to each individual state to make a determination, this is the state governor, would write a letter to CMS after consulting both the boards of medicine and boards of nursing, an opt-out option for their particular state saying that they would opt out from that condition of participation of Medicare Part A, meaning hospitals within that state would then have the option to pursue an anesthesia delivery model that best fit their needs. And keeping in mind that CRNAs are the principal anesthesia professionals in underserved rural communities, that really benefited a lot of hospitals across the country. And to date, 24 states have opted out of physician supervision. Those are the states in green. The states in blue have a partial opt-out for critical access hospitals, which use certain definitions, certain number of beds, 25 beds or less. The red states represent, have not opted out yet, but we expect more states to continue to opt out in the coming years. And we are pushing forward with legislation and their advocacy efforts that would guarantee a national opt-out because we've demonstrated the benefits of doing so and the safety of the care that you provide day in and day out. So when we look at value proposition, why do you become a member of the American Association of Nurse Anesthesiology? And better yet, why do you stay a member of the ANA? Well, there are so many different benefits and like similar slides, I can't go through every component, but here is a select few of them that provide some value back to you. First, we get annual reports talking about market forces and our salary. We're well compensated and the highest advanced practice nursing specialty compensation here in the United States. And we need to understand what that looks like in the changing dimensionality of compensation here, particularly post-pandemic. We have other initiatives such as emotion, being able to explore different career options as a nurse anesthesiologist. We pinpoint accuracy right down to a zip code of what is available in a particular area. We've got clinical resources, practice guidelines, and other valuable initiatives for you to be able to use in your everyday practice, whether you're practicing as a clinician or as an organizational leader, perhaps in a surgery center or a hospital, you're a chief CRNA and how governance models work. In addition, we've got something called Room 8. Room 8 is the ANA's innovation lab and it was named after the eight founding ANA trustees. And it was created to allow members, many of my colleagues are really individuals and wonderful ideas, innovative ideas to come to this lab to be able to help develop those ideas and bring them to fruition. We meet at least three times a year. We've got the ADCE or the Assembly of Didactic and Clinical Educators as we're educators for all the nurse anesthesiology training programs come together and we share exchange ideas and emerging trends. We have the Mid-Year Assembly. This is where we come together in Washington, D.C. and learn about policy and advocacy efforts. And we meet with our legislators to talk about the impact and the value that nurse anesthesiology has on the healthcare system and importantly their constituents. Then we have our Annual Congress. And this is where we come together in a select city every single year, typically in late summer. And we have our exchange of ideas. We do our education. We meet on our business meeting as held here. And this is where we make decisions about bylaw changes and so forth. It's an incredible event. All of these events are incredibly welcoming to nurse anesthesia residents, but also opportunities for those who want to learn more about our field of nurse anesthesiology, such as our professional registered nurse colleagues and other advanced practice nursing specialties. And finally, we have our Educators Edge. And this is a new platform in which we can provide the best in learning science and other learning initiatives to help ensure that we're educating the next generation of anesthesia professional with the best available evidence and scientific knowledge. So what does the future look like for nurse anesthesiology and the ANA? Well, this is just a small little snippet from the strategic plan that the ANA has, which is updated every couple of years. And that really is leaning in to that membership experience, making sure that we have connection with the members, inclusivity, and constant interaction. That we're keeping our ear close to the ground and making sure we understand and deliver back to the membership the services and the requests that they need to be outstanding practitioners. We're also really championing advocacy and influencing legislation, making sure that you're getting reimbursed in parity with what physician anesthesiologists are receiving, and ensuring that you have a right to a full scope of practice, that the hard work and the training that you put into your education is acknowledged and rewarded, and you have the opportunity to be able to practice the full scope of your license within the state that you reside. Born professional development and clinical excellence, making sure that we are delivering back to our patients the absolute highest quality cutting-edge resources involving nurse anesthesiology. And then ensuring organizational excellence, making sure that our organization, the ANA, is a high performance organization, that we're nimble, that we represent strong financial health, good governance, and leading technology. And so these are just a few of the things that we are promoting well into the future that you, me, and all of us are going to benefit from. So some questions here. How can we become an ANA member? Well, registered nurses, nurse anesthesia residents, advanced practice nurses, and certainly active practicing CRNAs. The cost of the ANA membership, it varies depending on on your role. Anywhere from associate to a full member. We did have a recent dues increase, but those dues are now well under $1,000 and will be like that the next couple years. How does the ANA support nurse anesthesia residents? Well, there is a huge list of opportunities. Not only promoting learning and sessions, educational sessions, but all of our meetings have carve-out focused areas for our nurse anesthesia residents. We have committee opportunities, so you can participate as a full-fledged committee. Participate as a full-fledged committee member in the organization and leadership and governance of and direction of our organization. Can you attend an ANA-sponsored meeting or event? 100 percent, and I would strongly, strongly recommend it. It's a wonderful networking opportunity. It's a wonderful opportunity to learn history, to learn about leadership, as well as the art and the science of anesthesiology. And then, as I said already, can residents join ANA committees? Absolutely, yes, and we encourage it, and we promote it, and we welcome you to join those particular operations and committees. As I leave you now at the top of the hour, I want to point out some of the references here for you. If you're interested in learning more about the American Association of Nurse Anesthesiology, please visit its website, aana.com. There, you can learn more about the practice of CRNAs, as well as the membership requirements, and if you choose to, you can enroll as an associate member of the ANA. There are also two books I highly recommend for anyone interested in becoming a nurse anesthesiologist. The first is Watchful Care, A History of America's Nurse Anesthesiologist, written in 1989 by Marianne Bancart, and this really chronicles the development during the nascent years of nurse anesthesiology, all the way up into the late 80s. Paul Worden picks up the second volume in 1989 and continues to present day. Both books are excellent, they're insightful, and they're almost required for all nurse anesthesia residents or anybody who's ready to embark on this incredible transformation from ICU nurse to nurse anesthesiologist. With that said, thank you so much for allowing me to spend an hour with you. Again, welcome. I hope you found that this presentation was informative. Please do review these references and resources. Thank you so much.

American Association of Nurse Anesthesiology

AANA

nurse anesthetists

anesthesia care

veterans

underserved communities

CRNA

advocacy

professional development

Jeff Darna