SOCIETY OF NUCLEAR MEDICINE TECHNOLOGIST SECTION POSITION PAPER ON LICENSURE

*****PREAMBLE*****

In 1981, Congress passed the Consumer-Patient Radiation Health and Safety Act (Public Law

97-35). This act mandated the Secretary of Health and Human Services (HHS) to develop

minimum accreditation and certification standards and to prepare and transmit to the States a

model statute for radiologic procedure safety. This model statute was to provide that:

1. "It shall be unlawful in a State for individuals to perform radiologic procedures unless such

individuals are certified by the State to perform such procedures and;

2. Any educational requirements for certification of individuals to perform radiologic

procedures shall be limited to educational programs accredited by the State."

The act required HHS to issue "final" regulations in 1982. Not until July 1983 did the HHS

publish minimum standards, and were of particular note, "proposed" standards. On August

14, 1985, a suit of noncompliance was filed in U. S. District Court, D. C. by the American

Society of Radiologic Technologists (ASRT) (Plaintiff) against Margaret M. Heckler,

Secretary-HHS and the U. S. Department of Health and Human Services (HHS) (Defendants).

Because of the action filed by the ASRT, final regulations were published on December 11,

1985 in the Federal Register.

***PREAMBLE: POSITION PAPER ON LICENSURE***

According to the Position Paper on Licensure (Revised 6/80and 2/94) of the Society of Nuclear

Medicine Technologist Section (SNMTS), it states that in states which have enacted legislation

to regulate and register radiologic and nuclear medicine technologists, the SNMTS will work to

insure there is appropriate recognition of: Nuclear Medicine Technology Certification Board

(NMTCB), Verification of Involvement in Continuing Education (VOICE), Society of Nuclear

Medicine (SNM) and Society of Nuclear Medicine Technologist Section (SNMTS). In states

that have not adopted such legislation, the SNMTS will proactively participate to supply

accurate data regarding the practice of nuclear medicine technology in that state. It is

imperative that the best interests of the health care community, the state's fiscal condition and

that of nuclear medicine technology be protected.

POSITION PAPER ON LICENSURE Licensure of allied health personnel is a topic of rapidly growing importance to regulatory

agencies at the federal, state, and local levels as well as to professional organizations and its

members. Owing to increasing interest in and concern about licensure, the SNMTS has

developed the following position on licensure for nuclear medicine technologists.

Formed in 1970, the SNMTS is a professional organization embracing scientific and

educational activities, which satisfy its membership needs. The SNMTS is the only

professional organization singularly dedicated to nuclear medicine technology and related

activities. The Technologist Section's ongoing objectives are to maintain the identity and

quality of nuclear medicine technologists and to provide the continuing development,

improvement, and expansion of nuclear medicine technology for the betterment of health care

services.

The SNMTS is committed to assuring adequate education and competency of nuclear medicine

technologists. To guarantee this objective for nuclear medicine technologists, the Section has

provided in-depth activities and on-going involvement in the development of voluntary

certification examinations for nuclear medicine technologists (Addendum A). The Nuclear

Medicine Technology Certification Board, (Addendum B), sponsored by the Section, has

developed and published a comprehensive task analysis of nuclear medicine technology which

is the basis for the NMTCB certification examination and which has been integrated into its

criterion reference examination (Addendum C). The Section has direct input into and has

accepted obligations for the collaborative development of minimum education essentials for

nuclear medicine technology. Additionally, the Section has direct input into and accepted

participatory technology for the Committee on Allied Health Education and Accreditation

(CAHEA) Joint Review Committee on Educational Programs in Nuclear Medicine Technology

(Addendum D). Further, the Section is actively involved in the preparation and conduct of

scientific and educational meetings consisting of approved and documented continuing

educational programs for the nuclear medicine professional.

A. NUCLEAR MEDICINE DEFINED

Nuclear medicine is the medical specialty that utilizes the unique properties of radioactive and

stable nuclides to make diagnostic evaluations of the anatomic or physiologic conditions of the

body and to provide therapy with unsealed radioactive sources. This utilization includes the

administration of radiopharmaceuticals to a patient and the subsequent imaging of its

distribution in organ systems and/or laboratory assay procedures.

The professional role of the nuclear medicine technologist is to assist the licensed physicians in

the conduct and evaluation of clinical procedures, including the preparation, calibration, quality

control and administration of radiopharmaceuticals, as well as the operation of both imaging,

radioassay instruments and computer systems.

B. ELEMENTS OF LICENSURE

The following important elements of licensure should be considered:

1. Uniformity and consistency of licensure regulations and reciprocity among all states are

of utmost pragmatic priority. National standards used as criteria for certification,

licensure, employment and requirements for reimbursement (Medicare/Medicaid and

National Health Insurance) are imperative. The Section is actively supporting the

development of national standards for certification as sponsored by the National

Commission of Health Certifying Agencies and the U. S. Department of Health and

Human Services. (Addendum E)

2. In any licensure approach that is initiated, individuals currently employed as nuclear

medicine technologists must be allowed to perform the nuclear medicine technology

procedures for which he has been trained. Fractionalization may result if differently

trained individuals are allowed by law to only perform

procedures on humans or on specimens from humans. Conceptually, a licensure

approach is to assure competency among practitioners. Excluding individuals from the

right to practice is not the answer. Also of practical importance is the mechanism for

licensure of a practitioner of nuclear medicine technology in sparsely populated regions

where one health professional is performing in more than one health occupation (e.g.,

nuclear medicine and diagnostic radiology). A general license may be needed in these

situations.

3. The Technologist Section believes that certification examinations are the central points

of all licensure approaches. Currently, the Nuclear Medicine Technology Certification

Board prepares and administers an examination in nuclear medicine technology and

could provide this examination in a licensure program. The duality of credentialing and

task analysis activities presents a unique and impressive interrelated framework upon

which to evaluate the competency of nuclear medicine technology in the delivery of

health care.

4. Essentials of education and accreditation of educational programs are important facets

in striving for professional competency and should be incorporated into a licensure

approach. The Technologist Section and the Society of Nuclear Medicine are two of

the sponsoring organizations of the Joint Review Committee on Educational Programs

in Nuclear Medicine Technology, which is the review and evaluation body that grants

approval to allied health education programs.

5. Acceptable levels of on-the-job training should be evaluated and included as acceptable

criteria for licensure eligibility. Examinations must be developed in concert with the

minimum educational essentials and task analysis for individuals not qualifying for

voluntary national certification.

6. Demonstration of continued competency should be included in any licensure approach.

Performance assessment methods are means of striving for continued competence.

Continuing education is one of the primary objectives of the Technologist Section and

is considered by the Technologist Section as the first step towards the assurance of

continued competence. The Section implements numerous continuing educational

programs annually on the national, regional and local level. To Verify and assess the

involvement of participants in these educational programs, the Section has implemented

its own system of review and approval of continuing education units (CEU's) as defined

by the Office of Education. This system, Verification of Involvement in Continuing

Education (VOICE) records all VOICE approved activities of a SNMTS member to

account for and document his involvement in SNMTS approved continuing education

activities. Performance assessment methods may include recertification and/or

evaluation techniques such as self-assessment questionnaires. Performance assessment

methods and/or continuing education programs can fulfill the important objectives of

assuring competency.

C. LICENSURE APPROACHES

There are three approaches that can be taken to implement state licensure:

1. Individual state licensure in which each state establishes its own criteria and minimum

standards for educational program accreditation, technologist certification and

licensure.

2. States would be required to adopt federal standards or develop more stringent state

requirements.

3. State licensure through state acceptance and adoption of national certification. The

federal government has assisted in the establishment of the National Commission of

Health Certifying Agencies (NCHCA), a national (non-federal) certification system.

National standards for certification agencies are now being established through a

collaborative effort of the federal government, professional associations, state

governments, recognized certifying organizations and other interested parties.

States implementing licensure should be encouraged to adopt national certification

granted by only those certifying organizations adhering to the certification standards

established by the NCHCA. State licensure boards and certifying agencies should be

encouraged to collaborate in the development of licensure examinations for individuals

within that particular state who do not or cannot meet the eligibility requirements for

national certification.

D. RECOMMENDATION AND POSITION

The first and second approaches are not preferred due to potential unique individual state

requirements and possible interstate non-compatibility or non-reciprocity. The third approach--

state licensure through state acceptance and adoption of national certification--is the most

practical approach. Since this allows for state control and adaptation to fulfill local needs, the

national standards would be adopted by the states, thus maintaining uniformity and consistency

and facilitating reciprocity and mobility between states. State adoption of national standards

would be likely because of requirements for reimbursement under federal health insurance

programs that services must be provided by health professionals who have been licensed or

certified according to national standards. Additionally, this approach also is most amenable to

the incorporation of the elements relating to licensure listed above.

In conclusion, the Technologist Section believes that the above supported licensure approach is

important as a way of maintaining competency and public protection. In developing licensure,

the interaction of accreditation, certification, continuing education, national standards

development, and licensure must be carefully considered since all of these will have an

important effect on the competency of nuclear medicine technologists and the quality of the

health care they provide.

ADDENDUN A

CERTIFYING EXAMINATIONS

There are currently two voluntary certifying examinations in nuclear medicine technology

given by: The Nuclear Medicine Technology Certification Board (NMTCB) and The American

Registry of Radiologic Technologists (ARRT). The NMTCB is the only certifying agency the

Technologist Section is currently involved with since the Section determined the other agency

was not adequately meeting the certification needs of nuclear medicine technologists. The

successful completion of the NMTCB examination is considered to demonstrate entry level

competence. Satisfactory completion of either of the examinations is frequently considered a

prerequisite for employment as a nuclear medicine technologist.

ADDENDUM B

THE NUCLEAR MEDICINE TECHNOLOGY CERTIFICATION BOARD

The assessment of knowledge and skills necessary for a nuclear medicine technologist to

perform competently is a challenging and critical activity. The necessity for nuclear medicine

technologists to evidence their competence during the remainder of their professional lifetime

is becoming increasingly critical as increasing demands are placed on the health care system.

To meet these challenges, the Nuclear Medicine Technology Certification Board (NMTCB)

was founded and incorporated in 1977 under the initial sponsorship of the Society of Nuclear

Medicine Technologist Section and the Society of Nuclear Medicine.

The primary purpose of the NMTCB is to administer an examination totally relevant to the

competent practice of nuclear medicine technology. To identify knowledge and skills to be

assessed, a comprehensive task analysis has been performed. Based on this analysis,

judgements are made regarding the content and skills to be assessed, the desired statistical

characteristics of the test, and the directions that are provided to the exam item writers. All

material is developed to assess the knowledge needed for competent daily job performance as a

nuclear medicine technologist and is now being assessed through the written certification

examination produced which is administered by the NMTCB and the American College

Testing Program (ACT) in a cooperative effort.

ADDENDUM C

CRITERION REFERENCED EXAMINATIONS

Criterion reference examinations are given to identify candidates for examination who have

achieved a minimum acceptable level at career entry level. Criterion referenced measurement

is concerned with how an individual meets a predetermined minimum level or standard of

performance of an examination as opposed to how he ranks in comparison to the others in the

test group (norm referenced measurement). In other words, the cutoff point for pass/fail is

determined before the test is administered. The nature of the subject matter in nuclear

medicine technology certification examinations, which is related to patient care, dictates that a

predetermined level of minimum acceptable performance should be required rather than the

measurement of differences among individuals.

There are two ways to establish the minimum acceptable level. The first would be to identify

the "required' subject matter of those questions on an examination of at least 200 items. The

large amount of knowledge to be tested and the difficulty of maintaining a consensus of

opinion in all geographic locations, educational institutions, and laboratories as to the

appropriateness of this "required" subject matter would make this approach impractical.

Another way in which a minimum acceptable level can be established is to construct an

examination of questions on a variety of subject matters and levels of difficulty. Each question

can serve as a means of identifying those examinees that have at least a minimally acceptable

level of knowledge and those who are not acceptable. The NMTCB is based on criterion

referenced examination methodology and has administered a fully criterion referenced

examination.

ADDENDUM D

JOINT REVIEW COMMITTEE ON EDUCATIONAL PROGRAMS IN NUCLEAR

MEDICINE TECHNOLOGY

The Joint Review Committee is responsible for evaluation and periodic re-evaluation of

educational program in nuclear medicine technology, including scheduling site evaluations,

designation of evaluator teams, and development of accreditation recommendations.

The Joint Review Committee is composed of representatives from professional associations

that have an interest in nuclear medicine technology. They are: The Society of Nuclear

Medicine, The Society of Nuclear Medicine Technologist Section, American College of

Radiology, American Society of Clinical Pathologists, American Society of Radiologic

Technologists.

ADDENDUM E

THE NATIONAL COMMISSION OF HEALTH CERTIFYING AGENCIES

The effective development of national standards for certification is requiring initial and

collaborative efforts among all bureaus and agencies of the federal government, professional

organizations, state governments, recognized credentialing organizations, and other interested

parties. To this end, the National Commission of Health Certifying Agencies (NCHCA) was

formed in 1977. The SNMTS had an appointed representative on the steering committee which

was the formative group of the NCHCA. The SNMTS and the NMTCB are provisional

members of the commission and the NMTCB had its representative elected to the initial

Executive Council of the NCHCA.