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Joint Review Committee on Educational Programs in Nuclear Medicine Tech-
nology

Accreditation Committee, American Physical Therapy Association

Joint Review Committee for Ophthalmic Medical Personnel, Joint Commission on
Allied Health Personnel in Ophthalmology

Accreditation Committee for Perfusion Education

Accreditation Review Committee on Education for the Physician Assistant

Joint Review Committee on Education in Radiologic Technology

Joint Review Committee for Respiratory Therapy Education

Accreditation Review Committee on Education in Surgical Technology

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



instructional programs for occupations in the health fields. In addition, the
JCAHO makes specific recommendations for educational programs in the
following areas: child and adolescent health, diagnostic radiology services,
dietetic services, emergency services, infection control, library services,
medical records, medical staff, nursing services, pathology and medical
laboratory services, services for patient and family, pharmaceutical ser-
vices, physical rehabilitation services, radiation oncology services, respira-



IMPACT OF REGULATORY ENVIRONMENT ON INSTRUCTIONS L PROGRAMS 129



tory care services, social work services, special care units, and surgical and
anesthesia services. ^^



THE IMPACT OF THE REGULATORY ENVIRONMENT ON
INSTRUCTIONAL PROGRAMS

Regulatory requirements play a major role in shaping curricula and
defining programs. The regulatory activities that control programs and
institutions in many instances interact with the regulatory activities that
control the practice of occupations in the health fields. Knowledge of the
regulatory environment is particularly important because regulatory re-
quirements carry many stipulations regarding the generation, mainte-
nance, and disposition of documentation.

LICENSURE

State licensing boards in the health fields are the authoritative bodies that
grant permission to institutions to perform designated functions, and to
individuals to practice specific occupations and assume particular titles.
Each state has licensing boards in numerous health occupations. Licen-
sure is intended as a means of quality control for practicing in the health
occupations and operating health care deliver facilities. Meant to offer
society a measure of protection from incompetent practitioners and inade-
quate health care delivery facilities, licensure governs the rights of indi-
viduals to practice and of institutions to operate.

To ensure that graduates have smooth entry into the work force,
instructional programs for the health occupations adapt curricula to meet
standards for licensing in their particular state. Whereas certificate pro-
grams tend to address only the specific licensing requirements of the state
in which the program is located, degree programs usually aspire to meet
the national norm in licensing standards, affording their graduates more
professional mobility at the entry level. Most schools, however, have
instructional programs that go far beyond the minimum licensing require-
ments, and rarely do students from accredited institutions fail license
examinations. Because standards for licensure vary from one state licens-
ing board to another, efforts are under way to introduce standardized
licensing examinations for a number of occupations in the health fields.
Greater standardization should help normalize curricula and create
greater mobility for graduates.

Since 1915 the National Board of Medical Examiners has assumed a



1 30 EDUCATIONAL INSTITUTIONS AND PROGRAMS FOR HEALTH OCCUPATIONS



leadership role in providing testing services for licensing physicians. Its
mission includes preparing and administering high-caliber qualifying ex-
aminations; cooperating with state examining boards, state boards, and
other bodies involved in educating and evaluating personnel in the health
fields; engaging in ongoing research to assess the quality of education in
the health fields and to improve the precision of their assessment tech-
niques; and providing educational outreach regarding their testing meth-
odologies and procedures.

In recent years the National Board has engaged in cooperative projects
with other health professionals. Major instances of collaboration have
occurred with the National Commission on the Certification of Physician
Assistants and the National Council of State Boards of Nursing. ^^

CERTIFICATION

Although licensure is required by law, certification is a voluntary process
in the health fields. Specialty boards of professional organizations set
standards and regulate the certification process. Even though it is volun-
tary in concept, board certification is a widespread requirement for em-
ployment in the health occupations. By also setting standards for the
curricula and accreditation of instructional programs, specialty boards
have significantly influenced both specialized education and practice in
the health fields. Specialty boards determine length of training, scope, and
content of courses. Board certification, which is especially important for
advancement in academia, is also a significant factor in setting fee sched-
ules and in the third-party reimbursement process.



TYPES OF INSTRUCTIONAL PROGRAM

Programs for occupations in the U.S. health care system exist either as
freestanding institutions, as components of college or university systems,
or as divisions within professional schools. Universities and colleges pre-
pare students for many types of health care occupation through accredited
graduate or undergraduate degree programs. Typical graduates of these
programs are occupational therapists (who earn a bachelor's degree in
occupational therapy), physical therapists (who earn a bachelor's or a
master's degree in physical therapy), physician assistants (who earn a
bachelor's or master's degree or a professional certificate), and pharma-
cists (who earn either a bachelor's or doctor of pharmacy degree, depend-
ing on the area of pharmacy in which they intend to practice). Profes-



FUNCTIONS OF INSTITUTIONS THAT CONFER CREDENTIALS FOR OCCUPATIONS 131



sional schools in dentistry, medicine, and other fields require undergradu-
ate education as a prerequisite to admission. ^^

A considerable number of instructional programs, such as those pre-
paring physician assistants, physical therapy assistants, phlebotomists,
dental hygienists, and nurses, are offered as associate degree programs at
two-year community and junior colleges. Two-year community, junior,
and technical colleges as well as some specialized institutions also offer
degree and certificate programs for specialized clerical personnel and
technicians. In addition, two-year community colleges offer degree pro-
grams that prepare individuals for further training in one of the health
care occupations.

Specialized degree programs often exist within a professional school.
For example, some schools of public health offer, in addition to a master's
degree in public health, a master's degree in health administration, and
many physician assistant training programs are located in medical schools
or in schools of allied health. Some ancillary care workers, such as
radiologic technologists, receive training in specialized short-term training
schools and programs or at vocational technical institutions. These pro-
grams are either freestanding or based in a university, college, or hospital.
Another type of specialized program is the continuing education program,
now required by many health care professions as a condition of maintain-
ing licensure. Continuing education is discussed in detail later in this
chapter.

The records of institutions with instructional programs in the health
fields contain vital data and information that are regularly used by the
institutions, faculty, and students to meet evidential requirements for
accreditation, licensing, and certification. Archivists responsible for main-
taining the records of these institutions should give special consideration
to the various evidential uses of these records. They should also consider
the primary resource value of the vast range of records from these
institutions that may be viable for ongoing studies in the health, life,
biological, and social sciences in some areas of the humanities.



FUNCTIONS OF INSTITUTIONS THAT CONFER CREDENTIALS FOR
OCCUPATIONS IN THE U.S. HEALTH CARE SYSTEM

The primary function of a health educational or training institution is to
prepare individuals for occupations in the health care system. Closely
related to the education function are the functions of research and patient
care. At an academic health center, the three functions of education.



1 32 EDUCATIONAL INSTITUTIONS AND PROGRAMS FOR HEALTH OCCUPATIONS



biomedical research, and patient care are interdependent. Administration,
including financial management, human resource management, informa-
tion management, and facilities management, is also a function of educa-
tional institutions, just as it is a function of all institutions and organiza-
tions.



EDUCATION

Education for health care professionals may be divided into four levels:
undergraduate education, graduate education, postgraduate education,
and continuing education. Not every health care occupation requires all
four levels. The focus of most instructional programs is to prepare their
graduates to meet and maintain professional licensing requirements. At
graduation, an institution confers credentials on students, but this creden-
tialing alone does not enable an individual to practice. In nearly every
occupation involving patient care, program graduates must also obtain a
license or certificate before they are permitted to practice. Therefore, in
preparing students to practice nursing, medicine, or dentistry, for exam-
ple, an instructional program must impart high professional standards and
include a curriculum that will enable students to qualify for licensing or
certification.

Postgraduate education is required for practicing medicine and for
specialized practice in the fields of dentistry, nursing, optometry, phar-
macy, podiatry, and veterinary medicine. After graduation from medical
school, physicians must complete an internship, lasting one or two years,
in an accredited graduate medical education program. After the intern-
ship, physicians usually complete a residency in the specialty in which
they intend to practice.

Most physicians who practice a specialty seek certification by a spe-
cialty board, although board certification is not required for specialized
practice. Board certification helps to legitimize a specialist's practice by
ensuring that the physician meets certain qualifications and has the
credentials needed to obtain and maintain certification. Eighty-five per-
cent of physicians specialize in one of twenty-three specialties.-^^ Some
newer areas of specialization include preventive medicine, family medi-
cine, and community medicine. Dentists, nurses, optometrists, pharma-
cists, physician assistants, podiatrists, and veterinarians may also special-
ize. In most of the health care professions, licensing boards and state
governments require additional education and practical training for spe-
cialized practice.

Many health care professions require continuing education as a con-
dition of maintaining a license to practice. For example, in the medical



FUNCTIONS OF INSTITUTIONS THAT CONFER CREDENTIALS FOR OCCUPATIONS 133



profession, twenty-three states require continuing medical education
(CME) credits for re-registration of a physician's license to practice medi-
cine. Ten specialty boards require CME credits for recertification. Eight
state medical societies and seven specialty societies require CME credits as
a condition of membership.'*^

The role of the educational institution in continuing education is to
host or coordinate continuing education courses and to confer the credits.
The institution selects the speakers and determines the course content.
The courses and programs are often underwritten by a commercial ven-
ture such as a drug company.

Continuing education is designed to broaden the knowledge and
upgrade the skills of practitioners throughout the course of their careers.
Because of ongoing and extensive change in the health fields, continuing
education has evolved as a principal means of keeping graduates current
with the latest developments in their professions. In some instances the
accrual of continuing education credits is a requirement for maintaining
licensure and certification. A number of states have introduced legislation
that requires personnel in a range of occupations, including nursing and
medicine, to earn a stipulated number of continuing education credits per
year to maintain their licensing and certification to practice.

Overall, the quality of preparatory education in the health fields is still
considerably higher than that of the emerging area of continuing educa-
tion. More rigorous controls are in place for preparatory education than
for continuing education because no single mechanism exists to monitor
the quality of continuing education systems in the health fields. Evalua-
tion of continuing education is done on a voluntary basis and credits are
issued on verification of attendance. In recent years both federal agencies
and professional associations have become more actively involved in
setting standards for continuing education in an effort to improve its
overall quality.

Although continuing education is still largely a voluntary process, it is
rapidly expanding out of market demand. Even where legislation and
regulatory requirements do not require continuing education, enrollment
figures are high. Students voluntarily requesting evaluation of their
course work is a particularly significant characteristic of continuing educa-
tion programs offered by educational institutions.'^ The American College
of Physicians self-assessment exam is an example of physicians' need and
regard for self-evaluation. Personnel in the health occupations, especially
those at academic health centers, appear to be highly motivated by the
ongoing need to retool and to learn new skills and procedures. A clear
consensus exists among personnel in the health fields regarding the need
for relevant and high-caliber continuing education courses.



1 34 EDUCATIONAL INSTITUTIONS AND PROGRAMS FOR HEALTH OCCUPATIONS



In recent years professional associations, legislative bodies, and gov-
ernment agencies have entered the debate over controls and standards for
continuing education in the health fields, declaring that the relationship
between commercial sponsorship and continuing education is not
healthy. In 1990 the U.S. Senate's Committee on Labor and Human
Resources held hearings on the role of pharmaceutical companies in
continuing education. At about this time the AMA released guidelines on
gifts to physicians from industry. These guidelines were readily adopted
by the Pharmaceutical Manufacturers Association. In addition, the Ac-
creditation Council for Continuing Medical Education and the Food and
Drug Administration recently introduced guidelines designed to limit drug
companies' control of the content of the continuing education courses that
they fund.'^

RESEARCH

Research plays an integral role at institutions of higher education. Federal
research grants and contracts are a key source of funding for institutions of
higher education, particularly those involved with the health care system.
The need to obtain external support for research has changed the charac-
ter of educational institutions in the health fields — particularly medical
schools — over the past four decades. Entry into the competition for re-
search funding has forced these institutions to expand administrative
activities and set new institutional agendas. ^^ Because tuition for profes-
sional degree programs in the health fields usually falls short of true costs,
there is extensive cross subsidy of teaching from research funding and
patient care revenues. Research funding is used to pay the salaries of
faculty members, for the education of graduate students, and for equip-
ment, among other things. It has created a new set of loyalties for faculty,
who feel more obligated to their funding source (e.g., a governmental
agency, foundation, or corporation) than to their institution.''^ As a result,
confusion often exists at educational institutions over the ownership of
research records. The granting agencies, principal investigators, and the
institutions where the research activities are conducted share responsibil-
ity for the maintenance of these records. Because most grants are awarded
to institutions and not to individuals, however, the institutions have
ownership rights to any equipment purchased by grant funds and to the
products of research. Furthermore, because the institutions usually have
ownership rights over the physical research records and their intellectual
content, they may determine the policies governing retention and use of
these records. For instance, when principal investigators move to other



FUNCTIONS OF INSTITUTIONS THAT CONFER CREDENTIALS FOR OCCUPATIONS 135



institutions, they are usually required to deposit the original records at the
institution where the research was conducted and take copies with them.

In deciding which institutions and which research projects to fund,
funding agencies play a critical role in the fate of these institutions.
Although the awards are based on peer review, the decisions of these
agencies greatly influence what research is done, where it is done, and
who does it. Success or failure to obtain research funding may alter the
direction of instructional programs and may cause individual departments
to thrive or wither at an institution. At academic health centers in particu-
lar there is concern that the pre-eminence of the research function may
skew the direction of education and patient care.^^

In addition to conducting research, faculty at institutions of higher
education with instructional programs in the health sciences train stu-
dents for research occupations. A considerable amount of time, effort, and
money is put into training researchers. Individuals planning a research
career in the life and biological sciences usually seek a Ph.D. degree, which
could be earned from a program based in a medical school, a health
sciences school other than a medical school (e.g., a school of nursing or
public health), or a university. Those planning a research career in the
health sciences seek either a Ph.D or an M.D. degree. Some researchers
hold combined M.D. and Ph.D degrees, including graduates of Medical
Scientist Training Programs. Students who seek careers in public health
and areas such as health policy and theory also earn graduate level
degrees. (For a comprehensive discussion of research institutions and the
research function, see Chapter 4.)

PATIENT CARE

Educational institutions with instructional programs for health care occu-
pations are involved in patient care, usually through affiliation with a
health care delivery facility. Most instructional programs include a practi-
cal component that involves the student interacting with patients in a
supervised setting. The administrative relationship between an educa-
tional institution and a health care delivery facility determines the degree
to which the educational institution is also a health care delivery facility.
For example, in many academic health centers practicing physicians hold
appointments on the hospital staff and are faculty of the school of medi-
cine. The faculty's clinical professional activities provide revenue for the
school and educational opportunities for students. Where the organiza-
tional relationship is very close, administrative distinctions between the
educational institution and the health care delivery facility tend to blur. As



1 36 EDUCATIONAL INSTITUTIONS AND PROGRAMS FOR HEALTH OCCUPATIONS



a result, documentation of the activities of the facuhy and student trainees
may be generated in both the hospital and medical school.

INSTITUTIONAL ADMINISTRATION

Educational institutions and health care delivery facilities with instruc-
tional programs in the health fields have especially complex administra-
tive responsibilities because education in the health fields is densely
regulated. A significant portion of the budgets of these institutions is
devoted to administrative overhead, including salaries and the costs of
storage and management of evidential materials that must be retained for
legal and regulatory requirements.^^

In general, the chief sources of income for most institutions with
degree and certificate programs in the health fields (public, private, or
church-operated) include revenue from clinical services, research and
teaching grants, tuition, gifts, and endowments. Public- and church-
operated institutions receive operating appropriations from the bodies
that own them, and they obtain funding though the usual sources of
patient fees, grants, gifts, tuition, and endowments. Privately operated
institutions compete in both the private and public sector for funding.

The extensive collaboration between educational institutions and
health care delivery facilities in patient care, research, and teaching
account for many complexities over the jurisdiction of documentation.
Much of the collaboration is interdepartmental and also intra- and interin-
stitutional. Some collaborative activities are local and regional in nature,
but many are national or international in scope. Support for these activi-
ties usually comes from a wide variety of funding sources.

The administration of institutions with educational programs in the
health fields is largely decentralized yet strongly hierarchical, with a clear
distribution of responsibility and authority. Usually these institutions have
governing boards, a chief operating officer and central administrative staff,
and departmental chiefs with administrative staffs. Because of the impor-
tance of effective regulatory compliance, the administrative structure of
these institutions has been designed to distribute administrative responsibil-
ity to the appropriate location of activity. Whereas the institutions are legally
responsible for the administration of grants, they place direct responsibility
on the departments that receive the grants to administer them according to
the appropriate requirements. In turn the departments place the burden of
responsibility on the principal investigators to uphold the terms of their
award. These institutions emphasize individual responsibility in research as
well as in patient care and education.



THE ROLE OF ACADEMIC HEALTH CENTERS 1 37



At institutions with instructional programs in the health fields, the
individual departments have considerable power and authority. Scientific
departments generate funding through grants, patents, and technical
licensing; clinical departments generate revenue from fees for services. As
a result of their capacity to generate income, the clinical and scientific
departments have significant leverage with the central administration of
their institution.



THE ROLE OF ACADEMIC HEALTH CENTERS

Because of the need to integrate academic studies and research with
practical training, specialized centers have evolved that combine institu-
tions of higher education with health care delivery facilities. The academic
health center is the venue where these two types of institution come
together and where much of the education for the health professions
occurs. The three functions of education, research, and health care deliv-
ery (i.e., patient care and health promotion) converge at academic health
centers.

As defined by the Association of Academic Health Centers, an aca-
demic health center includes "a school of medicine (allopathic or osteo-
pathic), a teaching hospital, and at least one additional health education
program (structured as a school or college or functioning within other
units of the center)." An academic health center operates either as a
component of a university, as part of a state university system, or as a
freestanding institution.'^ The governance structures of academic health
centers vary greatly.

In one model, institutions are governed by a board and chief execu-
tive officer of the medical center to whom the hospital director, dean of
the school of medicine and deans of the other schools report. (Duke, the


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Online LibraryJoan D KrizackDocumentation planning for the U.S. health care system → online text (page 15 of 26)