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new health care occupations.

Scientific research in the health fields, like scientific research in
general, has evolved from the work of lone investigators in solitary
laboratory settings to large collaborative projects that are intra- and
interinstitutional, interdisciplinary, national, and international in scope. A
century ago leading scientists primarily worked alone or with a small staff
in one laboratory. Today scientists in the vanguard serve as principal
investigators of collaborative networks of research teams that span vari-
ous institutions and include a broad cross section of occupations. These
large-scale collaborative approaches have now become the norm for
research in the health fields.'^

The team approach to scientific research and patient care has special
implications for higher education. In the past fifty years, the introduction
of many new occupations in the health fields has had a major impact on
post-secondary educational institutions in the United States. At the same
time that existing postsecondary educational institutions have expanded
instructional programs to accommodate changing occupations in the
health fields, new types of specialized educational institutions have
evolved. The number of vocational schools specializing in the health
technologies and the number of community colleges with programs for
ancillary health occupations have greatly increased.

The AMA, the American Dental Association, and several specialty
societies have largely been responsible for initiating certificate and degree
programs in the new allied health occupations at a variety of institutions.
Professional organizations in the fields of radiology and pathology in
particular have taken the lead in developing certificate programs for allied
health personnel in their respective fields. Professional, undergraduate,
and graduate schools have introduced many more specialized degree
programs in the health fields at the bachelor's, master's and doctoral
degree levels.

Early in the twentieth century, educational institutions specializing in
the health fields also became more involved in research. In the post-
World War II years, the federal government, largely through the National
Institutes of Health, allocated vast and unprecedented amounts of funding
for conducting research and training research personnel in the health
fields. With the infusion of postwar funding came major new incentives
for research at educational institutions and health care delivery facilities.



118 EDUCATIONAL INSTITUTIONS AND PROGRAMS FOR HEALTH OCCUPATIONS



Institutions with instructional programs in the health fields expanded
both physically and intellectually to accommodate these funding opportu-
nities. Special components for research evolved at the departmental level
in the basic and applied clinical sciences divisions. Eventually these insti-
tutions became centers for research in addition to being centers for
education and patient care.

The factors that have been most responsible for altering the occupa-
tions in the health fields have also had the greatest influence on changing
educational institutions and instructional programs in the health fields.
Advances in science and technology, the rise of ancillary care, reliance on
technology in both research and patient care, the introduction of third-
party reimbursement for health services, heightened social and economic
concerns, grant and contractual funding for research, and tighter regula-
tory controls are among the key factors that have transformed not only
the occupations but also the instructional programs in the health fields.
These factors have contributed to the increase in and the diversity of
occupations and programs.

From the middle to the latter part of the twentieth century, develop-
ment in instructional programs has been commensurate with major
changes in the health care system. As the activities of health care have
expanded in scope and become more highly specialized, instructional pro-
grams have had to keep in close step. Programs in ancillary and technologi-
cal training have increased significantly over the past two decades. At the
same time, graduate specialization in the health, social, biological, and life
sciences has been on the rise. Within schools of nursing, dentistry, phar-
macy, and public health, programs now range from the paraprofessional to
the doctoral levels, and schools of medicine are establishing doctoral pro-
grams in some life and biological sciences fields. Many of these educational
institutions have also added programs in health policy, finance, and admin-
istration. In the latter part of the twentieth century, legislation and govern-
mental funding continue to have a significant impact on instructional
programs in the health fields. The passage of the Medicare Act in 1965
opened the door for many new occupations, and the equal opportunity
legislation of the past three decades has afforded many new educational
opportunities to ethnic minorities, women, the economically underprivi-
leged, and the physically challenged.

The complexities and costs of late twentieth-century health services
have led to demands for more intensive quality and cost controls. As a
result, several new disciplines have emerged in the following areas: health
policy and planning, health economics, health services research, and
health administration. These highly technical areas of specialization play
an increasingly important role in the activities of organizing, financing.



CLASSIFICATION OF OCCUPATIONS IN THE U.S. HEALTH CARE SYSTEM 119



and regulating the health fields. Various programs in these disciplines
have arisen at the master and doctoral levels in educational institutions
including schools of public health, business schools, and schools and
departments of public policy, economics, and administration.

The social sciences have also had a major impact upon the health
professions. In the past fifty years, many new occupations that emanated
from the social sciences have evolved in the health fields. Professional
specialization has largely occurred in the following areas: health behavior,
ethics, history of health care, social determinants of health, social analysis
of health care, environmental health, environmental engineering, occu-
pational health, international health, and health education. Archivists
need to be aware of the importance of documenting these educational
programs because these new disciplines are playing a strategic role in
shaping the present and future directions of the health fields. ^^

Despite the concentrated institutionalization of education and train-
ing in the health occupations, individual instructional programs are still
largely controlled by external forces — by professional, educational, and
medical associations, legislative bodies, and governmental agencies. As in
the earlier apprenticeship tradition, professional health associations func-
tion somewhat as the medieval guilds did in defining criteria and setting
standards for skilled work and ethics of practice; they establish the criteria
for each field's specialized educational requirements.^^ Legislative bodies
and governmental agencies represent the public interest by defining the
suitability of these programs and monitoring their compliance with edu-
cational standards and regulations.

Because the incorporation of instruction with patient care can in some
instances raise the cost of care, many health care delivery facilities have
resisted or severed affiliations with instructional programs and educa-
tional institutions. Health care reforms that emphasize cost containment
may require that new sources of funding be found for the practical
training of health care professionals.



CLASSIFICATION OF OCCUPATIONS IN THE U.S. HEALTH CARE
SYSTEM

The U.S. Department of Labor has defined sixteen broad areas in which
most health care occupations are clustered. (See Table 5-2.) Three basic
types of occupation can be found in each of these categories:

1 . Service occupations deal primarily with the delivery of technical and
clinical services.



1 20 EDUCATIONAL INSTITUTIONS AND PROGRAMS FOR HEALTH OCCUPATIONS



TABLE 5-2 Areas in which most of the health care occupations are clustered

Clinical laboratory services

Dentistry

Dietetics and nutrition

Education

Health information and communication

Health services administration

Medicine

Nursing

Pharmacy

Psychology

Science and engineering

Social work

Technical instrumentation

Therapeutic Services

Veterinary medicine

Vision care

Source: Data from U.S. Department of Labor, Employment and Training Administration; and
U.S. Department of Healtfi, Education, and Welfare, Health Resources Administration.
Health Careers Guidebook (Washington, D.C.: U.S. Department of Labor, 1979)



2. Educational and research occupations deal primarily with pedagogical
activities and scientific studies. In the health fields, education and
research are inextricably bound together. Researchers frequently
teach their area of specialization, and many educators also engage
in some aspect of clinical or scientific research.

3. Combined occupations involve the delivery of services in addition to
education and research and are represented mainly by faculty in
academic health centers, who are frequently engaged in patient
care as well as research and education.

According to classifications of the Department of Education, prepara-
tion for occupations in the U.S. health care system is concentrated primar-
ily in two broad educational fields — the health professions and related
sciences and the biological sciences/life sciences.'^ The health professions
and related sciences encompass the highly specific training programs for
service occupations as well as related research occupations. They include
groups of instructional programs that prepare individuals to provide



CLASSIFICATION OF OCCUPATIONS IN THE U.S. HEALTH CARE SYSTEM



121




FIGURE 5-1 A class in gross and microscopic anatomy for nursing students,
taught by Dr. Florence Sabin, the first woman to reach the rank of full professor in
the Johns Hopkins University School of Medicine, circa 1915. Source: Alan Mason
Chesney Medical Archives, Johns Hopkins Medical Institutions



patient care, or related research and support services, to individuals or
groups. ^° The category of biological sciences/life sciences programs in-
cludes instructional programs that describe the scientific study of living
organisms and their systems. Specialized programs in the biological and
life sciences prepare students mainly for occupations in basic scientific
research and education. Many of these basic science occupations are
directly or indirectly part of the U.S. health care system. By providing
basic instruction in the preclinical sciences, programs in the biological
sciences also play an important role in the curriculum of specialized
programs in the health sciences. Biological and life sciences programs
prepare students primarily for occupations in laboratory research. (See
Table 5-3 for a classification of fields in the health professions and related
sciences, and Table 5-4 for a classification of fields in the life sciences and
biological sciences.)

A dense network of controls and standards governs occupations in the
health fields. Occupations involving patient care or research with human



1 22 EDUCATIONAL INSTITUTIONS AND PROGRAMS FOR HEALTH OCCUPATIONS



TABLE 5-3 Classification of fields in the health professions and
related sciences

Chiropractic

Communication disorders sciences

Community health services

Dentistry

Heahh and medical administrative services

Health and medical aides and assistants

Health and medical diagnostic and treatment services

Health and medical laboratory technologies/technicians

Health and medical preparatory programs

Medical basic sciences

Medical clinical services

Medicine

Mental health

Nursing

Optometry

Ophthalmic/optometric services

Osteopathic medicine

Pharmacy

Podiatry

Public health

Rehabilitation/therapeutic sciences

Veterinary medicine

Miscellaneous health sciences and allied health services (acupuncture and oriental
medicine, medical dietetics, medical illustration, naturopathic medicine,
psychoanalysis)

Source: Data from Robert L. Morgan, E. Stephen Hunt, and Judith M. Carpenter, Classification
of Instructional Programs (Washington, D.C.: U.S. Department of Education, 1991)



subjects are the most tightly controlled and heavily regulated, from the
education and training phase through credcntialing and practice. Controls
are exerted largely through the following four means: ( 1 ) establishment of
criteria and standards for accrediting instructional programs, educational
institutions, and health care delivery facilities; (2) licensure, (3) certifica-
tion; and (4) regulations and legislation governing practice.

Accreditation is "the process by which an authorized agency or organi-



CLASSIFICATION OF OCCUPATIONS IN THE U.S. HEALTH CARE SYSTEM 1 23



TABLE 5-4 Classification of fields in the life and biological sciences

Anatomy

Biochemistry

Biology

Biological immunology

Biometrics

Biophysics

Biostatistics

Biotechnology

Botany

Cell and molecular biology

Cytology

Ecology

Embryology

Epidemiology

Evolutionary biology

Genetics, plant and animal

Immunology

Marine/aquatic biology

Microbiology/bacteriology

Molecular biology

Mycology

Neuroscience

Nutritional sciences

Parasitology

Pharmacology

Physiology

Plant physiology

Psychology

Radiation biology/radiobiology

Toxicology

Virology

Zoology

Source: Data from Robert L. Morgan, E. Stephen Hunt, and Judith M. Carpenter, Classification
of Instructional Programs (Washington, D.C.: U.S. Department of Education, 1990)



1 24 EDUCATIONAL INSTITUTIONS AND PROGRAMS FOR HEALTH OCCUPATIONS



zation evaluates and recognizes a program of study or an institution as
meeting certain predetermined qualifications or standards."^' Licensure is
"the process by which an agency of government grants permission to
persons meeting predetermined qualifications to engage in a given occu-
pation and/or to use a particular title; or, grants permission to institutions
to perform specified functions within their jurisdiction. "^-^ Certification is
"the process by which a nongovernmental agency or association grants
recognition to an individual who has met certain predetermined qualifica-
tions specified by that agency or association. "^^

The most comprehensive sets of legislation governing health care prac-
tice are the Medical Practice Acts of the several states. This is "legislation
valid within each state which defines and regulates the practice of medicine
including qualifications for licensure within its jurisdiction." In some states
the practice of physician's assistants, and other licensed health manpower is
also regulated by the medical practice act.-^^ In addition all states have
legislation entitled Nurse Practice Act, governing the practice of nursing.

Another factor that affects instructional programs is the eligibility of
the programs' graduates for third-party reimbursement and their ability to
qualify in the competition for research grant funding. Service and re-
search occupations that become ineligible for third-party reimbursement
or fail to qualify to obtain grant funding usually have difficulty surviving.
The pressure to meet professional standards for practice and to qualify for
research funding or reimbursement of services are among the major
economic forces that shape these instructional programs.

For the purpose of focusing this discussion, we have limited it to
occupations with two or more of the following characteristics:

• Inclusion in the U.S. Department of Labor's categorization of
occupations in the health fields (see Table 5-3);

• Existence of accredited instructional programs for the occupation;

• Recognition by legal, regulatory, and professional bodies of the right
to practice the occupation;

• Eligibility of the occupation for either direct or indirect third-party
reimbursement for services;

• Inclusion of the occupation on biomedical research teams; and

• Eligibility of the occupation for funding by research grants and
contracts.

Occupations in the U.S. health care system are hierarchical and highly
structured, ranging from the professional to the paraprofcssional. The
instructional programs for these occupations and the institutions in which
the programs are based are equally diverse. In addition the range of



THE ROLE OF ACCREDITATION IN DEFINING INSTRUCTIONAL PROGRAMS 125



credentials conferred by institutions with instructional programs is both
extensive and varied.



THE ROLE OF ACCREDITATION IN DEFINING INSTRUCTIONAL
PROGRAMS

In the United States, accreditation is a major process that links nearly all
instructional programs in the health fields. Accreditation occurs at both
the institutional and the program level. To be accredited, the institutions
and the specialized programs at them must meet the exacting standards of
official accrediting bodies. These bodies not only set criteria for accredita-
tion but also confer accreditation status on institutions and programs. In
the United States accreditation is voluntary in concept. Yet, because
accreditation status is tied directly to the eligibility to receive governmen-
tal and private funds, the pursuit of accreditation has become imperative
for the survival of institutions and programs. As a result, accreditation
standards play a large role in the design and administration of instruc-
tional programs for occupations in the health fields.

Accreditation requirements account in large part for the standardiza-
tion of instruction for specific occupations, which occurs primarily at the
program level rather than at the institutional level. Basic requirements for
specific degrees and training certificates are similar in all institutional
settings. Because of accreditation standards, the curricula of specialized
instructional programs tend to be both occupation- and discipline-specific.
For instance, as a result of highly standardized nationwide requirements
for nursing diploma programs, the types of core courses required for a
diploma are essentially the same in every R.N. program.

The 1993 edition of the Council of Postsecondary Accreditation Membership
Directory (the last edition before COPA voted itself out of existence)
includes fifty-five associations. Twelve of the associations are responsible
for institutional accreditation, the remaining forty-three are responsible
for accrediting specialized programs at institutions of postsecondary edu-
cation. Of the twelve associations that accredit institutions, ten are respon-
sible for accrediting institutions that have programs for occupations in the
health fields. (See Table 5-5.) Six of these associations for institutional
accreditation are regional associations. Thirty-three of the forty-three
associations that accredit specialized programs are devoted to programs
for occupations in the U.S. health care system. (See Table 5-6.) The
AMA's Committee on Allied Health Education and Accreditation serves as
an umbrella agency for nineteen review committees, each representing



1 26 EDUCATIONAL INSTITUTIONS AND PROGRAMS FOR HEALTH OCCUPATIONS



TABLE 5-5 Associations that accredit postsecondary educational institutions

National Associations

Accrediting Bureau of Health Education Schools

Career College Association
Accrediting Commission for Independent Colleges and Schools;
Accrediting Commission for Trade and Technical Schools

National Home Study Council

Accreditation Council for Continuing Medical Education

Regional Associations

Middle States Association of Colleges and Schools (Delaware, District of Columbia,
Maryland, New Jersey, New York, Pennsylvania, Puerto Rico, Virgin Islands)

New England Association of Schools and Colleges (Connecticut, Maine, Massa-
chusetts, New Hampshire, Rhode Island, Vermont)

North Central Association of Colleges and Schools (Arizona, Arkansas, Colorado,
Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, New
Mexico, North Dakota, Ohio, Oklahoma, South Dakota, West Virginia, Wiscon-
sin, Wyoming)

Northwest Association of Schools and Colleges (Alaska, Idaho, Montana, Nevada,
Oregon, Utah, Washington)

Southern Association of Colleges and Schools (Alabama, Florida, Georgia, Ken-
tucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee,
Texas, Virginia)

Western Association of Schools and Colleges (American Samoa, California, Guam,
Hawaii, Trust Territory of the Pacific)

Source: Data from Council on Postsecondary Education, COPA Membership Directory (Washing-
ton, D.C.:COPA, 1992)



professional organizations collaborating in the accreditation of programs
in designated allied health fields. ^^ (See Table 5-7.) The principal accredi-
tation group for schools of medicine is the Liason Committee on Medical
Education, a joint committee of the AMA and the Association of American
Medical Colleges. The Accreditation Council for Continuing Medical Edu-
cation, an arm of the AMA, accredits institutions to approve continuing
education credit hours.

Because programs for the health occupations are located in educa-
tional institutions and in health care delivery facilities, the accreditation of
health care delivery facilities also plays an important role in the accredita-
tion of instructional programs. The Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) also participates in the accreditation of



THE ROLE OF ACCREDITATION IN DEFINING INSTRUCTIONAL PROGRAMS 1 27



TABLE 5-6 Associations that accredit specialized programs in the
health fields

Accrediting Bureau of Health Education Schools (medical assistant and medical
laboratory technician)

Accrediting Commission on Education for Health Services Administration

American Association for Counseling and Development

American Council on Pharmaceutical Education

American Dental Association (dentistry and dental auxiliary programs)

American Dietetic Association

American Medical Association

Committee on Allied Health Education and Accreditation
Liaison Committee on Medical Education (with AAMC)

American Optometric Association

American Osteopathic Association

American Physical Therapy Association

American Podiatric Medical Association

American Psychological Association

American Speech-Language-Hearing Association

American Veterinary Medical Association

Association of American Medical Colleges

Liaison Committee on Medical Education (with AMA)

Council on Accreditation of Nurse Anesthesia Educational Programs

Council on Chiropractic Education

Council on Education for Public Health

Council on Rehabilitation Education

Council on Social Work Education

National Accreditation Commission for Schools and Colleges of Acupuncture and
Oriental Medicine

National Confederation of State Medical Examining and Licensing Boards

National League for Nursing

Boards of Review for Baccalaureate and Higher Degree, Associate Degree,
Diploma, and Practical Nursing Programs

The Committee on Allied Health Education and Accreditation (CAHEA) functions as an
umbrella agency for nineteen review committees, each representing professional organiza-
tions collaborating in the accreditation of programs in designated allied health fields (see
Table 5-7)

Source: Data from Council on Postsecondary Education, COPA Membership Directory (Washing-
ton, D.C.: COPA, 1992)



1 28 EDUCATIONAL INSTITUTIONS AND PROGRAMS FOR HEALTH OCCUPATIONS



TABLE 5-7 Review committees under the AMA's Committee on Allied Health
Education and Accreditation

Accreditation Review Committee on Education for the Anesthesiologist's Assis-
tant

Committee on Accreditation of Specialist in Blood Bank Schools, American Asso-
ciation of Blood Banks

Joint Review Committee on Education in Cardiovascular Technology

Cytotechnology Programs Review Committee, American Society of Cytotech-
nology

Joint Review Committee on Education in Diagnostic Medical Sonography

Joint Review Committee on Education in Electroneurodiagnostic Technology

Joint Review Committee on Educational Programs for the EMT-Paramedic

National Accrediting Agency for Clinical Laboratory Sciences

Curriculum Review Board, American Association of Medical Assistants'
Endowment

Accreditation Review Committee for the Medical Illustrator

Council on Education, American Health Information Management Association


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Online LibraryJoan D KrizackDocumentation planning for the U.S. health care system → online text (page 14 of 26)