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PubMed2005

Hospital and health plan liability in granting privileges for endoscopy.

In December 1992, the American College of Gastroenterology (ACG) published a legal opinion which had been developed by the nationally renowned litigation law firm, Williams & Connolly, which has long served as ACG's litigation counsel. The opinion set forth potential litigation liabilities/risks that hospitals incur if they are negligent in their credentialing practices and enable undertrained physicians to perform endoscopy in their inpatient and outpatient facilities. The opinion was published as part of a broader joint effort by ACG and the American Society for Gastrointestinal Endoscopy (ASGE) that resulted in ASGE's Guidelines on Appropriate Training for GI Endoscopy together with the legal opinion on undertrained endoscopists being circulated to all of America's hospitals. Much has changed in both the practice of medicine and the law, since 1992. The two societies decided to join forces again to update these materials. The ACG legal opinion was expanded to also provide guidance about liability of insurance plans when they indicate preferences as to where and by whom procedures should be performed. Some of the key findings from the liability update section of this joint effort follow.

Certification↗
PubMed2005

Expert witness malfeasance: how should specialty societies respond?

There is little doubt that severe distortions are present in the legal adjudication of professional medical liability. The medical expert witness plays an important, often crucial, role in the medical liability cases. The expert assesses medical information, interprets and explains medical uncertainty, medical research, and customary practice for a nonscientific jury, and offers an expert level opinion as to whether the standard of medical care was met. When expert witnesses not merely disagree, but misrepresent data, misrepresent their background credentials and expertise, and offer egregiously false testimony, the legal process is violated and verdicts may be distorted. Many medical and surgical professional organizations, including the American Medical Association, have adopted programs that provide guidelines for members who serve as medical expert witnesses in professional liability cases. The American Association of Neurological Surgeons (AANS) was the first to develop a program to deal with irresponsible expert witness testimony. That program involves a published code of conduct, which outlines the expectations of society regarding expert witness testimony, and potential consequences for noncompliance. To date, the AANS program has withstood court challenge, in fact, has received judicial praise. Other medical societies, including the American College of Gastroenterology (ACG), have reviewed efforts by others and are considering developing their own programs.

American Medical Association↗
PubMed1999

Risk to tourists posed by wild mammals in South Africa.

BACKGROUND: One of South Africa's principal tourist attractions is the opportunity to encounter Africa's large mammals in the wild. Attacks by these mammals can be exceptionally newsworthy with potentially deleterious effects on tourism. Little is known about the risk of injury and death caused by wild mammals to visitors to South Africa's nature reserves. The aim of this study was to determine the incidence of fatal and nonfatal attacks on tourists by wild mammals in South Africa and to ascertain avoidable factors, if any. METHODS: Commercial press records covering all South African Newspapers archived at the Independent Newspapers' central library were systematically reviewed for a 10-year period, January 1988 to December 1997 inclusive, to identify all deaths and injuries to domestic and international tourists resulting from encounters with wild mammals in South Africa. All of these incidents were analyzed to ascertain avoidable factors. RESULTS: During the review period seven tourists, including two students from Thailand and a German traveler, were killed by wild mammals in South Africa. Three of the four deaths ascribed to lions resulted from tourists carelessly approaching prides on foot in lion reserves. A judicial inquiry found that the management of a KwaZulu-Natal Reserve was culpable for the remaining death. Tourist ignorance of animal behavior and flagrant disregard of rules contributed to the two fatalities involving hippopotami. The unusual behavior manifested by the bull elephant responsible for the final death, resulted from discomfort caused by a dental problem to this pachyderm. During the same period there were 14 nonfatal attacks on tourists, including five by hippo, three by buffalo, two by rhino, and one each by a lion, leopard, zebra and musth elephant. Only the latter occurred while the visitor was in a motor vehicle. Tourist ethological naivete and failure to determine the experience of trail guides prior to travel, resulted in inadvertent agonistic behavior, unnecessary risk-taking and avoidable injury. CONCLUSIONS: This retrospective study has shown that attacks on tourists by wild mammals in South Africa are an uncommon cause of injury and death. Sensible precautions to minimize this risk include remaining in a secure motor vehicle or adequately fenced precincts while in the vicinity of large mammals, rigidly observing nature reserve instructions, never approaching animals that appear ill, malnourished, displaying aggressive behavior traits or female wild mammals with young, and demanding adequately trained and experienced game rangers when embarking on walking trails. Any behavior that might be construed as antagonistic and which could provoke an attack by large mammals should be avoided (e.g., driving directly at a lion). Visitors need to be informed of classic signs of aggression, in particular in elephants, which will allow timely avoidance measures to be taken. The risk-enhancing effect of excessive alcohol intake is undesirable in the game reserve setting, as is driving at high speed after dusk in areas where hippos graze. Local advice on personal safety in wildlife reserves and the credentials of trail guides should be obtained from lodge or reserve management, tourism authorities or the travel industry prior to travel to game reserves.

Adolescent↗
PubMedDate not supplied

Maintaining career marketability as a professional nurse.

As we rush around attending to the essentials of our lives (family, friends, clients, employers), what is left? Nursing Forum invites readers to engage in thoughts and activities that may awaken an untouched place. We hope these writings will kindle your personal involvement in something that was previously avoided--because of bias, fear, or uneasiness--in order to stretch your mind and spirit. The ability to be competitive in the shifting marketplace of professional nursing practice is dependent upon a nurse attaining the credentials or experiences being sought. Identifying those knowledges and skills and developing a working plan to achieve them is essential. The Career Development Work Plan presented here is the framework to help do that, and the accompanying Professional File Management system provides the mechanism to monitor and document achievements and abilities over time. This career development approach provides the foundation and preparation nurses will need when presenting themselves to the professional job market.

Career Mobility↗
PubMedDate not supplied

Hospital privileges: who needs them?

Hospital privileges should be seen as a vital part of every nurse practitioner's practice. It allows the nurse practitioner to continue as the primary case manager. It helps to demonstrate the nurse practitioner's competence and credentials and may assist the nurse practitioner in becoming a preferred provider for some insurance companies. To the patients, it shows that the nurse practitioner's scope of practice is truly comprehensive.

Clinical Competence↗
PubMed2003

Preadmission characteristics of advanced practice nursing students.

PURPOSE: To determine the nature of prerequisite experiences of applicants to nurse practitioner (NP) and certified registered nurse anesthetist (CRNA) programs that faculty believe are necessary for success in graduate nursing programs. DATA SOURCES: An exploratory descriptive study based on findings from four focus groups of faculty from four different universities and a written survey mailed to program or admissions directors of a random sample of 50% of the 295 credentialed NP or CRNA programs in the United States. CONCLUSIONS: Themes from the focus groups revealed 20 personal characteristics, 14 professional characteristics, and 9 clinical skills, all of which were used to create a survey instrument. A 33% response rate was achieved (n = 48). Personal characteristics were considered most important, professional characteristics and clinical skills moderately important, and kinds of clinical experience of lesser importance. Length of desired experience ranged from 0 to 5 years, most often 2 years. The most important characteristic under personal was "ethical;" under professional, "clinically competent;" under clinical, "interpersonal communication;" and under clinical experience, "to work in a setting with MD-RN interaction." IMPLICATIONS FOR PRACTICE: Information from this study may be useful for examining admissions policies of advanced practice graduate programs. Faculty were able to articulate the characteristics, proficiencies, and experiences that are likely to produce success in NP and CRNA programs. These desired characteristics need to be translated into meaningful criteria for admission.

Education, Nursing↗
PubMed2007

Preceptor rewards: How to say thank you for mentoring the next generation of nurse practitioners.

PURPOSE: To answer the question how do faculty nurture and reward clinical preceptors and what supports do preceptors require? DATA SOURCES: Data came from the literature and from surveying a purposive sample of 26 faculty members teaching clinical courses and arranging precepted experiences for nurse practitioner (NP) students at 26 public and private institutions across the United States. The vehicles for the survey were personal contact and e-mail. CONCLUSIONS: Schools offer preceptor rewards varying widely in their monetary value, from tuition and continuing education vouchers, verification of hours toward recertification, access to services and events on campus, reduced price or free admission to museums, cultural and sports events, and lectures. Faculty nurture preceptors by nominating them for awards, providing letters of reference, editing manuscripts, and collaborating on research projects. Supports for preceptors from the literature reflected National Organization of Nurse Practitioner Faculties guidelines (2000), and the policies of schools and clinical agencies, such as providing copies of program objectives and student credentials. IMPLICATIONS FOR PRACTICE AND EDUCATION: As NP programs have proliferated, there is increased pressure on faculty to find, nurture, reward, and retain good preceptors. Faculty must continue to work with program and agency administrators to comply with policies and create preceptor rewards to recognize their gifts to us, to our schools, and to the profession.

Awards and Prizes↗
PubMed1998

Rural and urban nonphysician providers in Georgia.

Nonphysician providers make valuable contributions to health care in rural areas. This study examines provider and practice characteristics, location preference, and reasons for location preference among Georgia nurse practitioners (NPs), certified nurse midwives, and physician assistants (PAs) (N = 1,079). Data collected through a statewide survey revealed that providers were concentrated in urban areas. Rural providers tended to be older, less educated, possess fewer specialty credentials, and were employed longer than urban providers. NPs were significantly more likely to prefer smaller communities, and PAs were significantly more likely to prefer larger communities. Providers who preferred smaller communities were likely to practice in rural and urban areas, but providers who preferred larger communities were substantially more likely to practice in urban areas. Providers who preferred smaller communities were significantly more likely to mention the importance of community dynamics, while providers who preferred larger communities were significantly more likely to mention professional context.

Adult↗
PubMed2006

Modeling the mental health workforce in Washington State: using state licensing data to examine provider supply in rural and urban areas.

CONTEXT: Ensuring an adequate mental health provider supply in rural and urban areas requires accessible methods of identifying provider types, practice locations, and practice productivity. PURPOSE: To identify mental health shortage areas using existing licensing and survey data. METHODS: The 1998-1999 Washington State Department of Health files on credentialed health professionals linked with results of a licensure renewal survey, 1990 US Census data, and the results of the 1990-1992 National Comorbidity Survey were used to calculate supply and requirements for mental health services in 2 types of geographic units in Washington state-61 rural and urban core health service areas and 13 larger mental health regions. Both the number of 9 types of mental health professionals and their full-time equivalents (FTEs) per 100,000 population measured supply in the health service areas and mental health regions. FINDINGS: Notable shortages of mental health providers existed throughout the state, especially in rural areas. Urban areas had 3 times the psychiatrist FTEs per 100,000 and more than 1.5 times the nonpsychiatrist mental health provider FTEs per 100,000 as rural areas. More than 80% of rural health service areas had at least 10% fewer psychiatrist FTEs and nonpsychiatrist mental health provider FTEs than the state ratio (10.4 FTEs per 100,000 and 306.5 FTEs per 100,000, respectively). Ten of the 13 mental health regions were more than 10% below the state ratio of psychiatrist FTEs per 100,000. CONCLUSIONS: States gathering a minimum database at licensure renewal can identify area-specific mental health care shortages for use in program planning.

Geography↗
PubMed2004

Trends in family therapy supervision: the past 25 years and into the future.

This investigation repeats a survey of American Association for Marriage and Family Therapy (AAMFT) Approved Supervisors done in 1976 and 1986. Despite negative contemporary contextual influences, the AAMFT Approved Supervisor credential is still attractive to the same percentage of the AAMFT clinical membership as formerly and reflects in general the demographic characteristics of marriage and family therapists (MFTs) in clinical practice. Across the last quarter century there has been a steady increase in female AAMFT Approved Supervisors and those with terminal master's degrees. These and other trends are discussed with a view toward what supervision is becoming and what it needs to become.

Aged↗
PubMedDate not supplied

A multidisciplinary QA program for enteral nutrition in high-risk patients.

An increase in elderly patients and severity of illness rates means greater use of nasogastric feeding tubes for both high-risk acutely ill and chronically ill patients. When the QA screening process at Booth Memorial Medical Center revealed a certain percentage of complications with small bore, weight-tipped feeding tubes inserted through the nares, a multidisciplinary peer review committee (MPRC) was formed to review the enteral nutrition program. After a literature review to determine possible complications, the MPRC identified lung perforations due to tube misplacement, tube feeding aspiration into the lungs leading to possible aspiration pneumonia, and an internal tip separation from the tube product failure. Unconscious incubated patients on ventilators were shown as at high risk for feeding tube misplacement in an initial MPRC patient study. A second study evaluated several different feeding tube products in the medical, respiratory and surgical ICU. The MPRC established a credentialing process for physician assistants, interns and residents in feeding tube placement. The MPRC proceedings were presented to the hospital-wide QA committee for review, endorsement and recommendations on all policy and procedure changes. The conclusions were that a more concerted effort must be made to improve medical management and encourage ongoing education in the administration of enteral feedings to high-risk patients.

Cost-Benefit Analysis↗
PubMedDate not supplied

The integration of a QA/RM program in a rural healthcare obstetrical service.

Obstetrical services in a rural healthcare setting have special problems because the number of deliveries per month is below 100, with some facilities averaging fewer than 10 to 15 births per month. Medical resources may include obstetricians, pediatricians, or family practitioners, but not necessarily all three. Because it is not cost-effective to staff an obstetrical unit 24 hours a day when a low census is the norm, staffing patterns may be atypical and creative. The development of an effective credentialing system for both nursing and medical staffs is the first component of a QA/RM plan. Nursing staff play a vital role in modifying potential risk. When nurses do not routinely provide care on a unit, an efficient quality assurance plan is vital. Components of the plan must include staffing patterns and ratios, policies and procedures, and documentation. QA indicators should address both volume and outcome-oriented clinical indicators. Medical follow-up when indicated should also be part of the plan. Ongoing communication among team members and utilization of outside resources can assist in promoting an effective program. Although obstetrics is an area where the potential for risk exposure remains great, it is possible to create an efficient, practical risk management system.

Communication↗
PubMedDate not supplied

Competency assessment and performance improvement for healthcare providers.

This article discusses the implications of designing a comprehensive competency assessment program for healthcare providers. Increased liability for providers, institutions, and liability carriers is providing the impetus for change. Current methods to evaluate competency are limited; most methods include requirements that simply validate licensure and credentials. This article discusses the literature that supports methods for evaluating competency by assessing skills and proctoring. The author proposes a three-part model to ensure that competency assessment and performance improvement is the mainstay of an organization's quality management program. The model includes (a) a skills assessment inventory, (b) a standards review to promote compliance, and (c) a peer review program. Included are samples from two comprehensive skills inventories designed for orientations for physicians and nurses.

Clinical Competence↗
PubMedDate not supplied

The facility site review process for MCOs: clinical versus nonclinical reviewers.

Managed care organizations (MCOs) conduct provider facility site reviews to promote quality standards in office practice operations and to comply with such regulating agencies as the Joint Commission, various payers, and the Michigan Department of Community Health and statutes such as the Michigan Occupational Safety and Health Act. The results of the facility site reviews are incorporated into the credentialing and recredentialing decision processes for individual practitioners and provider organizations. This study sought to compare the facility site reviews conducted by nurse reviewers who were experienced in quality management of managed care with site reviews conducted by nonclinical staff. In 9 of the 22 sites, the nurse reviewers' scores more accurately represented the primary care physicians' compliance with existing standards and regulations than did those reported by the nonclinical reviewers. This study supports the recommendation that facility site reviews be conducted by nurses experienced in the quality management of managed care.

Data Collection↗
PubMed1999

What do neurologists think about their role in neuroimaging training and practice?

In 1996, a survey of the members of the American Academy of Neurology revealed the following facts and opinions: (1) On an average month, each respondent ordered 15 computed tomography, 22 magnetic resonance imaging, 13 ultrasound and 1 single-photon emission computerized tomography studies. (2) Most respondents did not read their own studies for reimbursement, but relied on their own reading for patient management. (3) Respondents felt that neurologists are appropriate specialists to read imaging studies; however, they favored certification for neurologists credentialed in neuroimaging. (4) Organized neurology should provide certification in neuroimaging for neurologists with appropriate training and defend their right and their need to practice neuroimaging, including endovascular procedures.

Diagnostic Imaging↗
PubMed2000

Protecting patients by training physicians in fluoroscopic radiation management.

During the past 15 years, developments in x-ray technologies have substantially enhanced the ability of practitioners to treat patients using fluoroscopically guided interventional techniques. However, many of these procedures require a greater use of fluoroscopy and serial imaging (cine). This has increased the potential for radiation-induced dermatitis, epilation, and severe radiation-induced burns to patients. It has also increased the potential for radiation injury and radiation-induced cancer in personnel. This work will describe a number of the cases that have appeared in the literature and current recommendations and credentialing requirements of various organizations whose members use fluoroscopy. Finally, a program for implementing training of physicians in radiation management as a means of reducing the risk of injury to patients and personnel is recommended.

Burns↗
PubMed2000

Is nanotechnology dangerous?

As co-founder and chief scientist of Sun Microsystems, Bill Joy can match technophile credentials with anybody on the planet. So when he argued that research into nanotechnology and other fields should be stopped before it wipes out humanity, humanity took notice. But most researchers think he's overstating the case.

Medical Laboratory Science↗
PubMed1971

The American general practitioner in hospital.

In the U.S.A. and Canada full access of general practitioners to hospital beds and facilities is regarded as an essential privilege of their work. All hospital constitutions require a review of the credentials of staff applicants and continuing evaluation of their performance. Staff appointment carries administrative as well as clinical responsibilities and hospital work occupies a considerable proportion of the general practitioner's day. The disciplinary machinery for safeguarding standards is strict by comparison with British hospital practice.This system produces an obvious excellence of clinical standards, postgraduate education, and communication between specialist and general practitioner and is attractive to the more able young British graduate. A pilot experiment of hospital staffing on North American lines in one of our new district general hospitals would be a worthwhile proposition.

Accreditation↗