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Traditional medicine, professional monopoly and structural interests: a Korean case.

Oriental medicine (OM) is a widely practised traditional healing modality across the East Asian countries. The typical operating mode of traditional medicine in the region is characterized by a relatively stable, though asymmetrical, relationship with the biomedically-oriented health care system with a varying degree of collaboration. The present paper looks at the major conflict between OM and pharmacy in South Korea in the 1990s. Most of the discussions over the so-called 'Hanyak Punjaeng'(OM vs pharmacy dispute) have so far been carried out in the perspective of interest/pressure group politics. But this paper presents an alternative analysis about the genesis, process and resolution of the dispute. It is argued that Robert Alford's 'structural interests' model, rather than the conventional pluralist perspective, offers the most plausible explanation of the conflict. Three key findings are ascertained. First, a sectional, inter-professional conflict can erupt into a major social cataclysm beyond the confines of health care services, an unlikely incident of a 'low politics' case becoming a 'high politics' affair. Second, a bipartite professional monopoly based on the principle of professional credentialism came to be established. Third, the dispute brought about a notable change in the structural power distribution between the corporate rationalizer and professional monopolist.

Competitive Behavior↗

Does low individual operator coronary interventional procedural volume correlate with worse institutional procedural outcome?

OBJECTIVES: To assess the relation between individual operator coronary interventional volume and incidence of complications, the in-hospital outcome at a single, moderate volume urban academic center was prospectively collected over a 3-year period. BACKGROUND: A minimum of 75 coronary interventions/operator per year may be required in the future to obtain formal certification. However, few data exist regarding individual operator volumes and procedural outcome. METHODS: Between January 1993 and December 1995, 1,389 consecutive procedures were performed or supervised by nine geographic full-time operators: 171 (12.3%) utilized various devices, and 350 (25.2%) involved multivessel coronary intervention. Left ventricular ejection fraction was 59 +/- 15% (mean +/- SD), and there were 1.7 +/- 0.7 vessels diseased (with > or = 70% stenosis). Clinical indications included stable angina in 22.5% of cases, unstable angina in 31.9%, acute myocardial infarction (MI) in 2.9%, post MI in 20.6%, shock or acute heart failure in 3.0% and restenosis in 19.1%. In the last consecutive 857 lesions in 655 cases, 20.7% type A, 55.5% type B and 23.8% type C lesions were categorized before coronary intervention. RESULTS: Average yearly operator volume ranged from 26 to 83 cases (mean 51 +/- 26). Each operator has performed a total of 590 +/- 268 coronary interventions, with 10.0 +/- 4.3 years of coronary interventional experience. The mean angioplasty volume rating for the nine operators was 180 +/- 37 (> 170 considered adequate). The in-hospital major complication rate was 1.4% (95% confidence interval 0.7% to 1.893%) for all coronary interventions, including death in 3 patients, bypass surgery in 13, arrhythmia in 3 and Q wave MI in 2. To ascertain how these outcomes compared with standard measures of coronary interventional outcome, four previously published registries were reanalyzed in a similar manner. The rate of complications in the present study was found to be significantly lower than that of the 1992-1993 Society for Cardiac Angiography and Intervention registry (1.9%, n = 19,594, p < 0.05 [excludes ventricular arrhythmias]), the 1994 American College of Cardiology database (3.9%, n = 38,963, p = 0.001), the Mid-America Heart Institute outcome in 1988 (2.3%, n = 5,413, p = 0.02) and the 1985-1986 National Heart, Lung, and Blood Institute Registry (7.2%, n = 1,801, p = 0.001). Odds ratios and 95% confidence intervals showed the outcome in the current study to be at least comparable to the standard registries. CONCLUSIONS: Despite individual operator volumes below those currently being considered for credentialing, the overall institutional outcome was excellent in a diverse and complex patient population.

Academic Medical Centers↗

Guidelines for privileges in arthroscopic surgery.

This report sets forth flexible guidelines to be used by hospitals or surgery centers to define privileges in arthroscopic surgery. The Arthroscopy Association of North America recognizes that the completion of a residency program, fellowship training, or hands-on workshop does not, per se, guarantee competence in arthroscopic surgery. The demonstration of an applicant's technical and motor skills by direct observation is a vital component of the credentialing process. Threshold criteria of state licensure, completion of surgical residency training, documentation of prior experience, and existing orthopaedic surgical privileges are defined. Levels of complexity of arthroscopic procedures are divided as basic and advanced.

Arthroscopy↗

Promoting the nurse practitioner role in managed care.

Managed care poses opportunities for nurse practitioners, providing they successfully negotiate new health care systems. This requires being familiar with Medicaid waivers and state policies regarding health insurance. In addition, knowledge of credentialing and compensation mechanisms under managed care enhances nurse practitioners' ability to forge provider roles. Because of the overlap between priorities of nurse practitioner practice and managed care, nurse practitioners have the potential to strengthen their roles as primary and specialty care providers in traditional and nontraditional settings.

Credentialing↗

Nursery privileging for pediatric nurse practitioners.

Developing a nursery privileging policy for pediatric nurse practitioners (PNPs) in a hospital that has not previously used PNPs in this capacity requires a clear understanding of the issues, a well-thought-out plan, and a win-win approach. Current trends in privileging of PNPs are summarized. The credentialing and privileging processes are defined, and the relationships that PNPs must establish with medical and administrative staff are explored. Five steps PNPs should take before requesting nursery privileges along with approaches to managing conflict are suggested. A case example involving the creation of a nursery privileging policy is included.

Credentialing↗

Joint Commission World Symposium on Improving Health Care Through Accreditation.

BACKGROUND: Throughout the world, in developed and developing countries alike, governments, payers, employers, and consumers desire means of holding providers accountable for the quality of care purchased and delivered. To explore the relevance and value of accreditation systems for meeting these various needs, the Joint Commission on Accreditation of Healthcare Organizations (Oakbrook Terrace, III) cosponsored a "World Symposium on Improving Health Care Through Accreditation," in Barcelona, Spain, July 8-10, 1999. To sharpen the issues involved in improving health care worldwide, the program was organized around debates focusing on four provocative propositions. Each pair of keynote debaters was followed by a reactor panel, audience discussion, and balloting. PROPOSITIONS: 1. No single set of quality standards is appropriate for universal use in health care organizations; 2. Health care financing mechanisms provide the primary incentives and disincentives to deliver high-quality health care; 3. Effective health system reform must be legislated and encompass reliance on the private sector; and 4. An accreditation system that includes professional credentialing and evidence-based practice will improve health care outcomes. SUMMARY: There was much agreement that emphasis on accountability has stimulated dramatic growth in internal (organizational) quality management programs, external (cross-organizational) benchmarking with comparative data, and accreditation or certification.

Accreditation↗

Houston Conference: need for more fundamental knowledge in neuropsychology.

Two training models in neuropsychology have been recently proposed (Guidelines of the INS-Division 40 Task Force on Education, Accreditation, and Credentialing, Clin. Neuropsychol. 1: 29-34, 1987; Hannay, H. J. et al., Anh. Clin. Neuropsychol. 13: 157-250,1998). When comparing both educational models, similarities but also differences are found. According to the Houston Conference model--but not to the former model--neuropsychology represents a specialty of psychology. In the Houston Conference training model, applied knowledge is overtly emphasized, whereas fundamental or basic knowledge in neuropsychology appears weak. The proposed program does not seem to provide sufficient emphasis and background knowledge in (1) History of neuropsychology, (2) Neuropsychological syndromes, and (3) Neuropsychology theory.

Credentialing↗

Rethinking education in psychology and psychology in education. The inaugural Education Leadership Conference.

The inaugural Education Leadership Conference was convened by the American Psychological Association (APA) in October 2001 to provide a forum for groups and organizations across all levels of education and training to address issues of mutual concern, to promote a shared disciplinary identity among education and training leaders in psychology, and to influence public policy regarding education in psychology and psychology in education. Participants from 23 national education and training organizations, 25 APA divisions, and national credentialing organizations in psychology identified 8 major issues for education and training in psychology and addressed a number of specific questions relevant to ongoing work of the Board of Educational Affairs.

Credentialing↗

Best practice guidelines in pediatric/adolescent weight loss surgery.

OBJECTIVE: To establish evidence-based guidelines for best practices in pediatric/adolescent weight loss surgery (WLS). RESEARCH METHODS AND PROCEDURES: We carried out a systematic search of English-language literature in MEDLINE on WLS performed on children and adolescents. Key words were used to narrow the field for a selective review of abstracts. Data were extracted, and evidence categories were assigned according to a grading system based on established evidence-based models. Eight pertinent case series, published between 1980 and 2004, were identified and reviewed. These data were supplemented with expert opinions and literature on WLS in adults. RESULTS: Recommendations focused on patient safety, reduction of medical errors, systems improvements, credentialing, and future research. We developed evidence-based criteria for eligibility, assessment, treatment, and follow-up; recommended surgical procedures based on the best available evidence; and established minimum guideline requirements for data collection. DISCUSSION: Lack of adequate data and gaps in knowledge were cited as important reasons for caution. Physiological status, comprehensive screening of patients and their families, and required education and counseling were identified as key factors in assessing eligibility for surgery. Data collection and peer review were also identified as important issues in the delivery of best practice care.

Adolescent↗

Specialized staff and equipment for weight loss surgery patients: best practice guidelines.

OBJECTIVE: To provide evidence-based guidelines on the specialized personnel, equipment, and physical plant required for safe and effective care of severely obese weight loss surgery (WLS) patients. RESEARCH METHODS AND PROCEDURES: We examined MEDLINE (Ovid and PubMed) and the Cumulative Index of Nursing and Allied Health Literature for articles on facilities resources for care of WLS patients published in English between January 1980 and March 2004. We queried several web sites for appropriate references; these included the Agency for Healthcare Research and Quality and the American College of Surgeons. The majority of reference material was descriptive and not specific to facilities resources for WLS patients. We identified a substantial body of literature on the general subject of patient safety; three of these articles were used to develop recommendations on the use of technology for medical error reduction. All other recommendations are based on 11 expert opinion reports. RESULTS: We recommended adequate training and credentialing for all medical staff; dedicated support and administrative personnel; and specialized interventional, diagnostic, operating room, and transport equipment. We specified needed adaptations to the physical plant and developed evidence-based guidelines for medical error reduction and systems improvements. DISCUSSION: Specialized resources and dedicated staff are needed to protect the health of WLS surgery patients and staff. Adaptations include preoperative preparation for safe means of patient transport; techniques of anesthesia and intraoperative exposure; provisions for postoperative recovery; and measures to assure postoperative patient safety, hygiene, and comfort.

Credentialing↗

Scope of practice in renal nutrition.

Clinical standards for practice in renal nutrition can vary dramatically from region to region, state to state, and clinic to clinic, and are greatly affected by the policies of several governing bodies. This review explores the factors that influence practice patterns among renal dietitians and examines the current American Dietetic Association's Scope of Dietetics Practice Framework for its applicability to kidney disease. Lastly, this article discusses current strategies for establishing a scope of practice in renal nutrition and evaluates licensure and credentialing issues that impact standards for practice across the various regions of the United States.

Credentialing↗

Optimal training strategies for carotid stenting.

Future participation in the treatment of carotid occlusive disease is dependent on training to perform carotid stent placement. Reviewed herein are strategies for training in carotid stenting. Included in this discussion are; the skills required for carotid stenting, the carotid stent learning curve, a comparison of training and credentialing, and the roles of simulators, courses, and hands-on experience in carotid stent training.

Angioplasty↗

Endovascular training of vascular surgeons: have we made progress?

The rapid evolution of catheter-based technologies during the last 5 years has created a critical need for development of effective resident level and postgraduate education programs in both open and endovascular techniques and associated cognitive and clinical skills. Currently, significant variability exists in endovascular training formats and in the number of endovascular procedures performed during the course of a graduate or postgraduate program. Little information on the quality of these programs exists and in the subsequent practice patterns of the trainees. This report reviews recommended credentialing requirements, training paradigms, and the growing experience of vascular surgical trainees since 2000.

Catheterization↗

Training and educational approaches to minimally invasive surgery: state of the art.

Current training in minimally invasive surgery (MIS) is inadequate given the demands of patients on practitioners and the number of surgeons and residents who still need to be trained. The training that is provided is neither widespread nor is it standardized, resulting in graduate surgeons with a wide range of competence. There is little guidance in what a training program needs to be effective. We provide a brief review of the state of the art of MIS training with some emphasis given to training methods including perceptual motor training, MIS learning laboratories, virtual reality, evaluation and assessment, cost, simulation fidelity, credentialing, certification, privileging, and ergonomics. We conclude that the state of the art is left wanting.

Certification↗

Mediocrity is no standard: searching for self-respect in Clinical Neuropsychology.

While medicine moved from a training based in proprietary schools to university-based education and board specialty examinations during the early part of this century, psychology has seemed to move in the opposite direction during the past 20 years. Clinical Neuropsychology, as a specialty, has established training and practice guidelines, and more recently, produced an integrated model of education and training, not unlike the models developed by medicine and its specialties. Nevertheless, there are pressures within the field of Psychology in general, and Clinical Neuropsychology in particular, to abrogate standards and weaken credentials. These pressures are seen as stemming from prioritizing the interests of the practitioner over the needs of the patient and the profession. The thesis is presented that upholding standards leads to the benefit of the patient and the long-term health of the profession.

Credentialing↗

The acupuncture wars: the professionalizing of American acupuncture--a view from Massachusetts.

Since the 1970s acupuncturists in the United States have confronted the dilemma of how to define themselves not only as practitioners in relation to an evolving Americanized version of Chinese medicine but also with respect to definitions of biomedical professional identity, which are currently in flux. The central issue is that of professionalization. This study traces the process of professionalization through the initial reception of the modality; the first steps toward specialized training; and the further steps through professional associations, credentialing, and licensing. This process takes place within the broader social frame of fluctuating definitions of biomedical professionalism. It is within this context that acupuncturists are assessing role definition, status, and compensation. Part of the process also involves the renewed use of the clinical trial and the potential co-opting of acupuncture. The potential for resistance is tied in with alliances with holistic physicians and with acupuncturists' own defense of pluralism.

Acupuncture↗

Policy for therapeutic acupuncture in an academic health center: a model for standard policy development.

Acupuncture as a therapeutic modality offers multiple applications. Its effectiveness coupled with its general acceptance by conventional health care professionals makes it one of the first complementary and alternative medicine (CAM) modalities to be incorporated in an integrative approach to care. However, few centers that offer acupuncture have written standard policies to regulate its use. This lack of standard policies may impede provision of quality care, serve as a barrier to cross-institutional data collection and clinical application of that data, and may put health care professionals and institutions at risk when credentialing or malpractice liability has not been clearly addressed. Here we present a policy for acupuncture, created by a diverse group of health care professionals at the University of Michigan Health System. It may function as a generalizable template for standard policy development by institutions incorporating acupuncture.

Academic Medical Centers↗

Managing managed care through accreditation standards.

Accreditation is emerging as a dominant strategy for ensuring accountability and basic quality of services in managed care organizations. Knowledge of accreditation standards can help social workers interact effectively with managed care companies when requesting services for clients and appealing denials. Familiarity with patient's rights protections, the appeals process, and provider credentialing guidelines can help protect social workers as well as clients from unfair decisions by managed care organizations. This article provides an overview of managed care accreditation standards and strategies for integrating this knowledge into advocacy efforts.

Accreditation↗