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8324700

C so k a s y , Judith H ag estro m

A NEEDS ASSESSMENT TO DETERMINE THE EMPLOYMENT POTENTIAL
OF A MULTIPLE COMPETENCY HEALTH PRACTITIONER IN SMALL
HOSPITALS IN MICHIGAN

M ich ig a n State University

University
Microfilms
International

300 N. Zeeb Road, Ann Arbor, Ml 48106

Ph.D.

1983

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A NEEDS ASSESSMENT TO DETERMINE THE EMPLOYMENT
POTENTIAL OF A MULTIPLE COMPETENCY HEALTH
PRACTITIONER IN SMALL HOSPITALS IN MICHIGAN

By
J u d i t h Hagestrom Csokasy

A DISSERTATION

Submitted to
Michigan S t a t e U n iv e rs ity
in p a r t i a l f u l f i l l m e n t of the requirements
f o r th e degree of

DOCTOR OF PHILOSOPHY

Vocational and Technical Education
Department o f Curriculum and I n s t r u c t i o n

1983

ABSTRACT
A NEEDS ASSESSMENT TO DETERMINE THE EMPLOYMENT
POTENTIAL OF A MULTIPLE COMPETENCY HEALTH
PRACTITIONER IN SMALL HOSPITALS IN MICHIGAN
By
J u d i t h Hagestrom Csokasy

The primary purpose o f t h i s d e s c r i p t i v e study was to e x p lo r e the
employment p o t e n t i a l of a m u l t i p l e competency h e a l t h p r a c t i t i o n e r in
small h o s p i t a l s in Michigan.

A p r a c t i t i o n e r with m u l t i p l e competencies

was d e fin e d as an in d iv i d u a l who uses s e l e c t e d s k i l l s and knowledge
from two o r more a l l i e d h e a l t h o c cup a ti o n s.
The s u b j e c t s f o r t h i s study were the a d m i n i s t r a t o r s o f small
h o s p i t a l s o f 100 bed c a p a c i t y o r l e s s in Michigan.

An examination of

the da ta o b tain ed from t h e needs assessment survey in stru m e nt i n d i c a t e d
t h a t the m a j o r i t y o f th e h o s p i t a l ' s a d m i n i s t r a t o r s r e p o r t e d they would
choose a jo b a p p l i c a n t with m u l t i p l e competencies over a job a p p l i c a n t
with a s i n g l e competency.
In a d d i t i o n , th e general f i n d i n g s o f the study i n d i c a t e d t h a t :
1.

The respondents t h a t r e p o r t e d they would n o t choose an a p p l i c a n t
with m u l t i p l e competencies, did so because o f s a l a r y e x p e c t a t i o n s .

2.

Hospital a d m i n i s t r a t o r s a r e c u r r e n t l y u t i l i z i n g t h e i r employees in
more than one a re a o f r e s p o n s i b i l i t y .

R e s p i r a t o r y therapy and

ra d i o l o g y were the h i g h e s t ranked primary s k i l l a r e a s , while
e le c t r o c a r d i o g r a m was the most widely s e l e c t e d secondary s k i l l .
3.

In th e f u t u r e , the a d m i n i s t r a t o r s would most l i k e t h e i r p r a c t i t i o n
e r s with m u l t i p l e competencies to possess the following s k i l l
combinations:

J u d i t h Hagestrom Csokasy
F i r s t Choice o f Primary S k i l l

F i r s t Choice o f Secondary S k i l l

A.

R e sp ir a to r y Therapy

Ele ctro cardiogram (EKG)

B.

Surgical Technician

Licensed P r a c t i c a l Nurse (LPN)

C.

Medical Technology

Radiology

0.

Radiology

U l t r a sonography

E.

Physical Therapy A s s i s t a n t

R e s p i r a t o r y Therapy

There i s no r e l a t i o n s h i p between the bed c a p a c i t y o f the f a c i l i t y
o r the popu lation s e r v i c e a r e a o f the f a c i l i t y and the d e s i r e of
the a d m i n i s t r a t o r s to use a p r a c t i t i o n e r with m u l t i p l e competencies.
The respondents were about e q u a l l y d ivid ed concerning the p r e f e r r e d
ed u ca tio n al p r e p a r a t i o n o f a p r a c t i t i o n e r with m u l t i p l e competen­
cies.

Half o f t h e responden ts d e s i r e a r e g u l a r c o l l e g i a t e program,

while the o t h e r res po ndents s e l e c t e d o t h e r types of edu ca tion al
experiences.
The h o s p i t a l a d m i n i s t r a t o r s were about e q u a l l y d iv id e d concerning
the c u r r e n t c r e d e n t i a l i n g o f a l l i e d h e a l t h workers.

Forty-one or

i

f i f t y - f i v e p e r c e n t o f the responden ts were s a t i s f i e d w ith the
c u r r e n t c r e d e n t i a l i n g mechanism.

The remaining responden ts d e s i r e d

a change in t h e c r e d e n t i a l i n g p r o c e s s .

This d i s s e r t a t i o n i s d e d ic a te d to my p a re n ts and my s i s t e r Nancy, f o r
a l l o f t h e i r love and su p p o rt shared with me through th e y e a r s ; and to
my husband David who never l o s t f a i t h in my a b i l i t y to complete the
do cto ral program.

ACKNOWLEDGEMENTS

With deep a p p r e c i a t i o n , I wish to thank my committee members:
P rofessors Donald Meaders, Louis Romano, and Robert Poland.

A spe cia l

thank you to Pro fe sso rs Richard Gardner and B i l l i e T. Rader, who were
always ready to o f f e r i n s p i r a t i o n and guidance s i n c e the beginning o f
my do cto ral program.
I would a ls o l i k e to thank the a d m i n i s t r a t i o n and s t a f f o f the
,

School o f A llie d Health a t F e r r i s S t a t e College.

Especially

Dean Aaron L. Andrews and Acting Dean Duane Addleman, who were both
su pp o rtiv e in allowing me to have r e l e a s e time and to u t i l i z e c o ll e g e
resources.
Appreciation i s a ls o extended to my f r i e n d and t y p i s t ,
Norma Larne r, who a s s i s t e d me with e d i t i n g and provided encouragement
to the end.

TABLE OF CONTENTS

Chapter

Page

I

INTRODUCTION............................................................................................
Growth o f A l l ie d Health Occupatio ns.........................
Role o f Credentia l i n g ...................................................................
Problems o f Small and Rural H o s p i t a l s ................................
R e s p o n s i b i l i t y o f A llie d Health E d ucation ...........................
Statem ent o f th e Problem............................................................
Research Q u e stio n s.........................................................................
Need f o r t h e Stud y.........................................................................
S i g n i f i c a n c e o f the Stud y........................................
Basic Assumptions f o r the Stu d y ...................
Terms and D e f i n i t i o n s ...................................................................
L im ita tio n s of the S tud y............................................................
Summary o f C hapte r.........................................................................
Overview o f Other C h a p te r s ........................................................

1
1
3
4
5
6
7
8
9
10
11
13
14
15

II

REVIEW OF LITERATURE...........................................................................
Credential ing o f A l l ie d Health P r a c t i t i o n e r s ..................
Se ction I :
H i s t o r i c a l Development...............................
S ection I I : The Current S t a t e o f C r e d e n t i a l i n g . . .
Multip le Competency Health Care Workers..............................
Needs Assessment.............................................................................
Survey Research Methodology......................................................
The S t r e n g th o f Survey Rese arch.............................................
The Weaknesses o f Survey R esearch.........................................
Development o f the Q u e s t i o n n a i r e ...........................................
Summary o f C ha p te r.........................................................................

16
16
16
23
26
29
34
35
35
36
37

III

RESEARCH METHODOLOGY...........................................................................
P o p u l a t i o n ..........................................................................................
Development o f the I n s t r u m e n t ..................................................
O b j e c t i v e s ..........................................................................................
Research Q u e s t i o n s .........................................................................
Face V a l i d i t y ....................................................................................
Panel o f E x p e r t s .............................................................................
P r o f i l e o f Panel o f E x p e r t s ......................................................
Review- Pro c ed ure .............................................................................
Data G a th erin g..................................................................................
Correspondence..................................................................................
Mailing Sequence.............................................................................
Treatment o f the Data...........................
Summary o f C hapte r.........................................................................

38
38
39
39
41
42
42
44
44
45
45
46
46
47

iv

V

IV

FINDINGS...................................................................................................
Response R a t e s ...............................................................................
The F i n d i n g s ..................................................................
Se ction I:
Background I n f o r m a t io n ...........................
Section I I :
S t a f f i n g .........................................................
S e l e c t i o n o f P e r s o n n e l ........................................................
M ultip le Competency P r a c t i t i o n e r s ................................
Se ction I I I : Education and t r a i n i n g n e e d s

V

SUMMARY, CONCLUSIONS, RECOMMENDATIONS, AND
REFLECTIONS............................................................................................
Summary of th e F i n d i n g s ............................................................
C on c lu sio ns......................................................................................
Summary..............................................................................................
Recommendations.............................................................................
Recommendations Based on the F i n d i n g s ...............................
Recommendations f o r Future Rese arc h ...................................
R e f l e c t i o n s ......................................................................................
C re d en tia l i n g ...........................................................................
Information Concerning M u ltip le Competency
P r a c t i t i o n e r s .....................................................................

48
48
49
49
52
52
54
65
68
69
73
74
75
75
77
78
78
79

APPENDICES
Appendix A
Survey Q u e s t i o n n a i r e ...................................................................

82

Appendix B
Correspondence...............................................................................

86

Appendix C
Names and Addresses o f H o s p i t a l s .........................................

90

Appendix D
Department o f Health and Human Sciences
Proposed R u l e s .........................................................................

94

BIBLIOGRAPHY...........................................................................................................

99

GENERAL REFERENCES

103

TABLES

TABLE

Page

1

Response to Survey by Bed C a pac ity ................................................

49

2

Bed Capacity o f the F a c i l i t y and Willingness
o f the Adm inis trator to U t i l i z e M ultiple
Competency Health P r a c t i t i o n e r s ......................................................

50

Population Serv ice Area and A d m i n i s t r a t o r 's
Desire to U t i l i z e M ultiple Competency Health
P r a c t i t i o n e r s ............................................................................................

51

Adm inis trators who would Choose Job Applicants
with Multiple Competencies................................................................

53

Reasons why Adm inis trators Avoid Hiring
Multiple Competency Health P r a c t i t i o n e r s . . . ............................

54

Adm inis trators Cu rrently U t i l i z i n g Health Care
P r a c t i t i o n e r s in More Than One Area o f
R esponsibility
...............................................................................

55

S k i l l Areas in which M ultiple Competency
P r a c t i t i o n e r s P r e s e n t ly S e r v e ..........................................................

57

S k i l l s Adm inis trators Perceive a Multiple
Competency Health P r a c t i t i o n e r should Possess
with R e sp ira to ry Therapy as the Primary S k i l l ........................

59

S k i l l s Adm inis trators Perceive a Multiple
Competency Health P r a c t i t i o n e r should Possess
with Surgical Technician as a Primary S k i l l ............................

50

S k i l l s Ad m in is tr ators Perceive a M ultiple
Competency Health P r a c t i t i o n e r should Possess
with Medical Technology as a Primary S k i l l ..............................

61

S k i l l s Adm inistrators Perceive a Multiple
Competency Health P r a c t i t i o n e r should Possess
with Radiology as a Primary S k i l l .................................................

62

3

4
5
6

7
8

9

10

11

vi

vii
12

13
14
15

S k i l l s A d m inistra tors Perceive a M ultiple
Competency Health P r a c t i t i o n e r should Possess
with Therapy A s s i s t a n t as a Primary S k i l l ..............................

63

Additional Desired S k i l l Combinations f o r
P r a c t i t i o n e r s with M u ltip le Competencies................................

64

Methods P r e f e r r e d by A d m in is tra to rs f o r Educating
a Multip le Competency Health P r a c t i t i o n e r ..............................

66

P r e f e r r e d Changes in the C r e d e n tia lin g
P r a c t i c e s o f A l l i e d Health P r a c t i t i o n e r s ................................

67

L I S T OF FIG U RES

Figure
1

Page
The Curriculum Development Cycle
Using a Needs Assessment Base..........................................................

vi i i

33

Chapter I
INTRODUCTION

The outlook f o r h e a l t h s e r v i c e s and changing h e a lth manpower
u t i l i z a t i o n p a t t e r n s . . . p o i n t to an i n c r e a s i n g need f o r
personnel who can fu n c tio n in a v a r i e t y o f s e t t i n g s and
e x e r c i s e a wide range o f s k i l l s . (National Commission on
A l l ie d Health Education, 1980:153)
The goal which d i r e c t e d the r e s e a r c h e r during t h i s study was to
determine the employment p o t e n t i a l o f a m u l t i p l e competency h e a l th
p r a c t i t i o n e r in small and r u r a l h o s p i t a l s in Michigan.

For use in t h i s

s t u d y , a m u l t i p l e competency h e a l th p r a c t i t i o n e r was defined as an
ind iv idu a l who uses s e l e c t e d s k i l l s and knowledge from two or more
a l l i e d h e a l th o c c u p a tio n s.

The need f o r such a person has been

i d e n t i f i e d by various l e a d e r s in the h e a l t h care f i e l d (Blayney, 1982;
Kinsinger, 1980; Lugenbesl, 1980) and appears to be an outgrowth o f
the ever changing American h e a l th system.
Growth o f A llie d Health Occupations
The rapid expansion o f the h e a l t h care f i e l d and the r e s u l t a n t
in c r e a s e in re q u i r e d c e r t i f i e d h e a l t h occupa tions r e f l e c t s th e changes
in s o c i e t a l a t t i t u d e s and t e c h n o lo g ic al in n ovations during r e c e n t
years.

Rapid, ongoing changes in s c i e n t i f i c and medical knowledge have

r e s u l t e d in advances t h a t have g r e a t l y a l t e r e d the a v a i l a b i l i t y and
delivery of health care se rv ic e s.

For example, the progress from the

2

disc ov ery o f gamma r a d i a t i o n to x -ray d i a g n o s is and thera py led to a
d i a g n o s t i c and t h e r a p e u t i c tool f o r the ph ysic ia n p r a c t i t i o n e r .

In

t u r n , t h i s has led to t h e development o f a s p e c i a l t y f o r medical
p r a c t i c e ( R a d io l o g i s t ) as well as g e n e r a t i n g a number o f a l l i e d h e alth
occu pations ( e . g . Radiographer and Nuclear Medicine T e c h n o lo g i s t ) .
In the a l l i e d h e a l t h p r o f e s s i o n s , t h e number and d i v e r s i t y of
occupational groups continues to i n c r e a s e .

The c r i t e r i a f o r e s t a b l i s h ­

ment o f a job c ateg ory or o ccu p a tio n , r e p o r t s Martin (1980), have o f t e n
been based on the d isc ov ery o f a new medical t r e a t m e n t , a newly
disc overed d i s e a s e , new machine, o r the need f o r a new a s s i s t a n t f o r
one o f the ever i n c r e a s in g number o f phy sicia n s p e c i a l t i e s .

The

i d e n t i f i c a t i o n o f s k i l l s and th e development o f jobs which has r e s u l t e d
in newly c r e a t e d a l l i e d h e a l th o c c u p a ti o n s , appears to have come about
w ithout o v e r a l l d e s i g n , c on tro l or c o o r d i n a t i o n .

According to Friedman

(1981:47), "This has r e s u l t e d in a l l i e d h e a l t h workers who a r e narrowly
t r a i n e d and o f t e n h ired f o r s p e c i f i c t a s k s . "
As new a l l i e d h e a l t h occupations have emerged, p r o f e s s i o n a l
o r g a n i z a t i o n s have developed to r e p r e s e n t the needs and i n t e r e s t s o f
the occupational groups.

Such o r g a n i z a t i o n s seek to gain r e c o g n i t i o n

and p r o f e s sio n a l i d e n t i t y by i n c r e a s i n g e ducational requirements and
r a i s i n g the l e v e l s o f p r o f e s s i o n a l c r e d e n t i a l i n g .

Approximately e i g h t

o f every ten a l l i e d h e a l th occupations a re now r e p r e s e n te d by p r o f e s ­
siona l a s s o c i a t i o n s .

(Galambos, 1979:6)

The newly formed National

Commission of Health C e r t i f y i n g Agencies (1980) warned t h a t the
i n c r e a s in g number o f a l l i e d h e a l t h p r o f e s s i o n a l o r g a n i z a t i o n s seeking
c r e d e n t i a l i n g had reached a c r i t i c a l l e v e l .

3

Role o f C r e d e n t ia l in g
C r e d e n t ia l in g was o r i g i n a l l y designed as a mechanism o f q u a l i t y
assurance e s t a b l i s h e d by a p u b lic agency to i n d i c a t e to an employer
and the pu b lic t h a t an in d iv id u a l had met s p e c i f i c requirements
n ecessary f o r the p r a c t i c e o f a p a r t i c u l a r o c c u p a tio n .

However, the

c r e d e n t i a l i n g pr ocess no longer appears to be accomplishing t h a t g o a l.
P o t t e r (1981), o f the Michigan Hospital A s s o c ia t io n , i d e n t i f i e s the
c r e d e n t i a l i n g mechanism o f a l l i e d h e a l th occupations as the number one
" a r t i f i c i a l b a r r i e r " to e f f e c t i v e u t i l i z a t i o n o f personnel in Michigan
hospitals.

P o t t e r s t a t e s , "since 60% o f t h e h o s p i t a l ' s t o t a l

o p e ra t in g budget i s a l l o c a t e d to p a y r o l l , the h o s p i t a l employer should
be involved in the development o f c r e d e n t i a l i n g sta n d ard s f o r the
employee and c u r r i c u l a f o r e d ucational programs."

(personal communi­

c a t i o n June 6, 1981)
There is a growing concern t h a t as p r o f e s s i o n a l o r g a n i z a t i o n s
have gained s t a t u s and p o l i t i c a l power, they have lobbied s u c c e s s f u l l y
f o r s t a t e and fed e ral l e g i s l a t i o n to d e f i n e n o t only t h e ed u ca tio n al
experiences n e c e ssa r y , but th e c r e d e n t i a l i n g mechanism f o r p r a c t i c e .
The r e s u l t i s t h a t p r o f e s s i o n a l o r g a n i z a t i o n s a re having in creased
power to c o n tro l the type o f c r e d e n t i a l i n g a person must have in o r d e r
to perform a c e r t a i n t a s k .

This lobbying e f f o r t i s manifes ted in the

c r i t e r i a f o r reimbursement o f t h i r d p a rty payments ( i . e . , Medicare and
Medicaid).

In o r d e r f o r a h o s p i t a l to be reimbursed f o r s e r v i c e s to a

Medicare and/or Medicaid r e c i p i e n t , the s p e c i f i c s e r v i c e must have been
performed by a p r a c t i t i o n e r desi gnated as " q u a l i f i e d " by Medicare and
Medicaid e s s e n t i a l s .

For example, i f the h o s p i t a l expects to be paid

f o r a s p e c i f i c l a b o r a t o r y t e s t , the t e s t can only be performed by a

4

l a b o r a t o r y t e c h n o l o g i s t c r e d e n t i a l e d by the National Asso cia tio n o f
C l in i c a l Laboratory S c i e n t i s t , the l a b o r a t o r y t e c h n i c i a n s p r o f e s sio n a l
organization.

Such r u l e s and r e g u l a t i o n s e x e r t a powerful in f lu e n c e

and l i m i t the ways in which h o s p i t a l s may e f f e c t i v e l y u t i l i z e t h e i r
p e rso nn el.

The members o f the American Hospital A s s o c i a t i o n 's Council

on Human Resources have expressed concern over the r e s t r i c t i o n s o f the
f l e x i b l e use o f personnel when they s t a t e t h a t :
C r e d e n t ia l in g (Licensur e) by i t s very n a tu re r e s t r i c t s the
f l e x i b l e use o f p e rs o n n e l. Technology, s e r v i c e r equ ire m e n ts ,
a v a i l a b i l i t y and o t h e r f a c t o r s may n e c e s s i t a t e a realignment
o f fu n ctio n s not p o s s ib l e under l i c e n s u r e . In the p a s t ,
p r o t e c t i o n f u n c t i o n s through l i c e n s u r e laws has led to the
fragmentation and p r o l i f e r a t i o n o f o c cu p a tio n s. S ociety can
no longer a f f o r d t h i s waste o f r e s o u r c e s . (1980:2)
All h o s p i t a l s a r e becoming i n c r e a s i n g l y concerned about the
problem o f a l l i e d h e a l th p r a c t i t i o n e r u t i l i z a t i o n , bu t the dilemma
appears to be e s p e c i a l l y s e r i o u s in the small and r u r a l h o s p i t a l .
Problems o f Small and Rural H o sp itals
The problem o f m aintainin g p a t i e n t s e r v i c e s w ith o ut i n c r e a s in g
s t a f f i n g c o s t s i s a t r o u b l i n g problem f o r a l l h o s p i t a l s , but i s
e s p e c i a l l y c r i t i c a l in the small h o s p i t a l .

The l e a d e r s in o r g a n i z a ­

t io n s advocating c r e d e n t i a l i n g and high l e v e l s o f p r a c t i t i o n e r
s p e c i a l i z a t i o n appear to be unaware o f what r u r a l America i s l i k e .
Most small h o s p i t a l s , says Friedman (1981:48) "maintain adequate
s e r v i c e s with a minimum number o f f u l l time personnel and might b e n e f i t
from being allowed to u t i l i z e t h e i r personnel in innovative ways."
As i s well documented in small h o s p i t a l s , personnel a re needed fo r
primary c a r e ; few can a f f o r d to a t t r a c t f u l l - t i m e s t a f f members who are
highly s p e c i a l i z e d .

The National Commission on A llie d Health

5

Education (1980:75) r e p o r t s "the small h o sp ita l needs a core s t a f f to
provide b asic s e r v i c e s , in such a re as as l a b o r a t o r y , x - r a y and
r e s p i r a t o r y th e r a p y . "
One small h o s p i t a l a d m i n i s t r a t o r explained t h a t her f a c i l i t y
solved the problem in s t a f f i n g by t r a i n i n g t h r e e s t a f f members with an
a d d i t i o n a l competency.

"Using people in t h i s way has enabled our

h o s p i t a l to pay expenses without i n c u r r i n g a d e f i c i t in the areas
where we u t i l i z e a m u l t i p l e competency p r a c t i t i o n e r . "

(Lugenbeel,

1980:74)
Other small h o s p i t a l s might b e n e f i t from employing an a l l i e d
h e a lth p r a c t i t i o n e r with an a d d i t i o n a l competency.

There appears to

be a need f o r the ed uca tio nal i n s t i t u t i o n s which prepare a l l i e d h e a lth
personnel to ex p lo re ways to meet the various s t a f f i n g needs o f the
small and r u r a l h o s p i t a l .
R e s p o n s i b i l i t y of A l l ie d Health Education
The development o f a l l i e d h e alth education has t r a d i t i o n a l l y
followed the demand f o r new a l l i e d h e a l th o ccu p a tio n s.

This has r e ­

s u l t e d in p r a c t i t i o n e r s who a r e o f t e n t r a i n e d f o r s p e c i f i c tas k s in
response to a new medical trea tm e n t o r a newly c r e a t e d physician
specialty.

As t h es e narrowly t r a i n e d h e a l th p r a c t i t i o n e r s p r o l i f e r a ­

t e d , the d e l i v e r y o f h e a l th care has become i n c r e a s i n g l y s p e c i a l i z e d
and d i v e r s i f i e d .
The National Commission on A llie d Health Education (1980),
acknowledging the p a s t t r a d i t i o n s o f preparing highly s p e c i a l i z e d
p r a c t i t i o n e r s , i s concerned t h a t the tendency to c r e a t e new a l l i e d
h e a l t h occupations seems to c o n ti n u e .

The commission has c a l l e d f o r a

6

"concerted e f f o r t on th e p a r t o f e d u c a t o r s , p r o f e s s i o n a l a s s o c i a t i o n s
and a c c r e d i t a t i o n bodies" (p. 177) , to seek a l t e r n a t i v e ways o f meet­
ing h e a l th manpower needs.
In response to the expansion o f highly s p e c i a l i z e d p r a c t i t i o n e r s ,
various l e a d e r s in the h e a l th c are f i e l d (Blayney, 1982; Kinsing er,
1980; Lugenbeel, 1980) have c a l l e d f o r a l l i e d h e a l t h ed ucato rs to
develop educational programming t h a t would allow a s t u d e n t to develop
competencies in more than one a l l i e d h e a l t h occupational r o l e .

This

would prepare a h e a l th p r a c t i t i o n e r who would be able to fun ction in
more than one categ o ry o f job d e s c r i p t i o n .
Thus, the study was undertaken by t h i s r e s e a r c h e r to determine i f
a d m i n i s t r a t o r s o f small h o s p i t a l s would employ a m u l t i p l e competency
a l l i e d h e a l th p r a c t i t i o n e r .

A h e a l th p r a c t i t i o n e r who would be

prepared to "function in a v a r i e t y o f s e t t i n g s and e x e r c i s e a wide
range o f s k i l l s " .

(National Commission on A llie d Health Education,

1980:153)
Statement of the Problem
This study sought to answer the general q u e s t i o n :

What i s the

p o t e n t i a l f o r employment o f h e a l th c are p r a c t i t i o n e r s with m u ltip le
competencies in small h o s p i t a l s in Michigan?

One method proposed by

le a d e r s in the f i e l d o f a l l i e d h e a l th education to provide more
e f f e c t i v e u t i l i z a t i o n o f a l l i e d h e a l t h personnel i s to pr epare h ealth
care providers in two or more h e a l th occupation a r e a s .
The need f o r a m u l t i p l e competency in d iv id u a l has obvious
im p lic a tio n s f o r i n s t i t u t i o n s which educate and t r a i n a l l i e d h e a l th
practitioners.

I f such i n s t i t u t i o n s a r e to provide employees to meet

7

changing human res o u r c e needs, then information must be gathered from
h e a l th care a d m i n i s t r a t o r s reg ard in g the s p e c i f i c h e a l t h p r a c t i t i o n e r
needs o f t h e i r r e s p e c t i v e i n s t i t u t i o n s .

The National Committee on

A llie d Health Education and A c c r e d it a ti o n o f the American Medical Asso­
c i a t i o n r e c e n t l y approved the c r e a t i o n o f a ta s k fo r c e to study the
concept o f a m u l t i p l e competency a l l i e d h e a l t h e du cational program.
Prospectiv e employers o f m u l t i p l e competency h e a l t h p r a c t i t i o n e r s are
to be surveyed to a s c e r t a i n the employment p o t e n t i a l o f such
individuals.
Research Questions
The r e s e a r c h e r was d i r e c t e d by the followin g q u e s t io n s :
1.

Would a d m i n i s t r a t o r s o f small h e a l th c a r e f a c i l i t i e s choose
job a p p l i c a n t s with m u l t i p l e competencies?

2.

Do a d m i n i s t r a t o r s in some small h e a lth care f a c i l i t i e s avoid
h i r i n g a m u l t i p l e competency h e a l t h p r a c t i t i o n e r ?

3.

I f y e s , why?

Do small h e a l th c are f a c i l i t i e s p r e s e n t l y u t i l i z e h e a l th
p r a c t i t i o n e r s in more than one primary area o f r e s p o n s i b i l i t y ?

4.

What a re the s k i l l a re a s in which m u l t i p l e competency h e a l th
»

p r a c t i t i o n e r s p r e s e n t l y serve?
5.

What are the s k i l l a r e a s which a d m i n i s t r a t o r s o f small h e alth
care f a c i l i t i e s p erceiv e a m u l t i p l e competency h e a lth care
p r a c t i t i o n e r should possess?

5.

Is t h e r e a r e l a t i o n s h i p between the bed c a p a c i t y o f the
f a c i l i t y and th e d e s i r e to u t i l i z e a m u l t i p l e competency
h e a lth p r a c t i t i o n e r ?

8

7.

Is t h e r e a r e l a t i o n s h i p between the s i z e o f the population
s e r v i c e area o f the h e a l t h c are f a c i l i t y and the d e s i r e to
u t i l i z e a p r a c t i t i o n e r with a m u l t i p l e competency?

8.

Do the a d m i n i s t r a t o r s o f small h e a l th c a r e f a c i l i t i e s have a
p r e f e r r e d method f o r the e d ucational p r e p a r a t i o n o f m u lt i p le
competency h e a l t h p r a c t i t i o n e r s ?

9.

Do a d m i n i s t r a t o r s p r e f e r to see any change in the c r e d e n t i a l ­
ing p r a c t i c e s o f a l l i e d h e a l th p r a c t i t i o n e r s ?

Need f o r the Study
In the p a s t few y e a r s , the h e a l th c are d e l i v e r y system has w itn es­
sed a r a p i d p r o l i f e r a t i o n o f a l l i e d h e a l th s p e c i a l t i e s , each o f which
has attempted to i d e n t i f y a unique r o l e f o r i t s e l f .

As a consequence,

th e r e appears to be i n s u f f i c i e n t u t i l i z a t i o n o f h e a lth care p e rs o n n e l.
This f a c t o r co ntin u es to c o n t r i b u t e to the a d d i t i o n a l c o s t o f d e l i v e r i n g
h e a l th c a r e .
There i s evidence o f i n t e r e s t in a movement away from the narrow
s p e c i a l i z a t i o n o f the p a s t toward a more g e n er alize d curriculum r e s u l t ­
ing in the p r e p a r a t i o n o f a person in h e a lth c are to perform in more
than one competency a r e a .
In the Future o f A l l i e d Health E ducation, the National Commission
on A llie d Health Education s t a t e d :
The outlook f o r s e r v i c e s and changing h e a l th manpower u t i l i ­
z a t i o n p a t t e r n s . . . p o i n t to an i n c r e a s in g need for
personnel who can f u n ctio n in a v a r i e t y o f s e t t i n g s and
e x e r c i s e a wide range o f s k i l l s . Moreover, the f a c t t h a t the
f u n c tio n s o f many a l l i e d h e a l th p e rs o n n e l , indeed most p e r­
so n n e l, o v e rla p to a s i g n i f i c a n t e x t e n t makes the concept o f
a g e n e r a l i s t both r a t i o n a l and f e a s i b l e . (1980:153)

9

The American Hospital Associa tio n (AHA) recommends t h a t s t u d i e s
be done in each s t a t e to meet the a d d i t i o n a l needs o f h e a l t h care
f a c i l i t i e s and workers.

A needs assessment which in clud es ga th e ring

data from employers i s considered to be the b a s i s o f sound c u r r i c u l a r
revisions.

A key spokesman f o r the AHA s t a t e s :

Too many c u r r i c u l a a r e developed by the ed u cato rs and
p r o f e s s i o n a l o r g a n i z a t i o n s , w itho u t s u f f i c i e n t i n p u t from the
employer or independent p r a c t i t i o n e r . Job sta n dard s develop­
ed without employer i n p u t o f t e n d i s r e g a r d such major f a c t o r s
as c o s t , p r o d u c t i v i t y , and job s a t i s f a c t i o n . (American
Hospital A s s o c ia t io n , 1980:6)
In th ese times o f economic c r i s i s and e s c a l a t i n g c o s t s , i t i s
ne cessary t h a t e du cational i n s t i t u t i o n s take anoth er look a t curriculum
c o n te n t to determine whether "or n o t changes must be made to meet the
needs o f the employers o f v a ri o us h e a l th care i n s t i t u t i o n s .
S i g n i f i c a n c e o f the Study
The study was designed to measure the employment p o t e n t i a l o f a
m u lt i p le competency h e a l th c a r e worker as a f i r s t s t e p toward educa­
t i o n a l program rea lig nm e n t to meet the employer s t a f f i n g needs in
h o s p i t a l s of 100 bed c a p a c i t y o r l e s s in the S t a t e o f Michigan.
The data from t h i s study w ill be o f primary i n t e r e s t to the S t a t e
o f Michigan, the Michigan Hospital A s s o c ia t io n , various s t a t e l i c e n s i n g
a g e n t s , schools o f A l l ie d Health within post -seco ndary i n s t i t u t i o n s ,
P rofe ssio n a l Org aniz ations and in d iv id u a l h e a l th c a r e workers.
The da ta w i l l be reviewed by the Michigan Hospital Association
(MHA) Manpower U t i l i z a t i o n Committee.

The MHA i s aware of the employ­

ment s h o r ta g e s in many h e a l t h f a c i l i t i e s acro ss the s t a t e and o f
a d m i n i s t r a t o r s ' problems as they attem p t to provide q u a l i f i e d h e a l th
workers to meet p a t i e n t needs.

10

Health planning agencies may use the information from t h i s study
to a s s i s t small h o s p i t a l s in long-range p lan n in g .

There i s a g r e a t

need f o r c a r e f u l comprehensive p lan nin g, but too o f t e n , small h o s p i t a l s
lack the fin a n c e s to su p p ort such s t u d i e s .

The ch alle n g e o f the 1980's

in thes e i n s t i t u t i o n s i s to match h e a l th s e r v i c e s to the changing
p op u latio n s.

A m u l t i p l e competency person could be used in many are as

and in varying combinations, depending on the s p e c i f i c need.
S t a t e l i c e n s i n g boards and c e r t i f y i n g agencies may fin d these
survey r e s u l t s use ful to exp lo re expanded job d e s c r i p t i o n s .

The

r e s i s t a n c e by p r o f e s s i o n a l o r g a n i z a t i o n s to d i s c u s s the m u l t i p l e
competency concept has managed to keep most edu cational i n s t i t u t i o n s
from e x p lo rin g the i d e a .

As a r e s u l t , because o f the p r o t e c t i o n o f

each p r o f e s s i o n a l o r g a n i z a t i o n d i r e c t e d toward i t s are a*o f knowledge,
most c e r t i f y i n g boards o f the a l l i e d h e a lth occupations continue to
move t h e i r o r g a n i z a t i o n s toward more s p e c i a l i z a t i o n .
Data from the r e s e a r c h may be u t i l i z e d by educato rs a t various
educational i n s t i t u t i o n s t h a t are seeking to modify e x i s t i n g programming
to meet the needs o f c u r r e n t l y employed h e a l th c are p r a c t i t i o n e r s .

By

means o f a c on tin uing educational program, p r a c t i c i n g a l l i e d h e a lth
p r o f e s s i o n a l s could expand t h e i r knowledge base and develop a d d it i o n a l
occupational s k i l l a r e a s .
Basic Assumptions f o r the Study
This study was based upon the following assumptions:
1.

There a re personnel needs which involve change in educational
p r e p a r a t i o n which employers a re w i l l i n g to i d e n t i f y and r e p o r t .

11

2.

A study o f t h i s n a t u r e , d i r e c t e d to a d m i n i s t r a t o r s in small
and r u r a l h o s p i t a l s , would provide useful information about
the p o t e n t i a l employment o f a m u l t i p l e competency h e a l th
practitioner.

3.

The respondents to a mailed survey in stru m e n t w ill be f o r t h ­
r i g h t , honest , and candid in t h e i r r e s p o n s e s .

Terms and D e f in i t io n s
D e f in i t io n s o f key terms used in t h i s study a r e provided f o r a
common b a s i s o f un d e rstand ing .
1.

Allied Health - A term g e n e r a l l y a p p lie d to occupations whose
primary fu n c tio n i s to provide h e a l t h s e r v i c e s or to promote
health.

(National Commission A llie d Health Education,

1980:1)
2.

A llie d Health Personnel The term a l l i e d h e a l th personnel in clu des i n d i ­
v id u a ls t r a i n e d a t the a s s o c i a t e , b a c c a l a u r e a t e ,
masters o r do cto ral degree level in h e a l th care
r e l a t e d s e r v i c e s ( i n c l u d in g s e r v i c e s r e l a t e d to the
i d e n t i f i c a t i o n , e v a l u a t i o n , and pr eventio n o f
d i s e a s e s and d i s o r d e r s , d i e t a r y and n u t r i t i o n s e r ­
v i c e s , h e a l t h promotion, r e h a b i l i t a t i o n and he alth
systems management), bu t who a r e not graduates o f
schools o f medicine, o s t e o p a t h y , d e n t i s t r y ,
v e t e r i n a r y medicine, optometry, p o d i a t r y ,
c h i r o p r a c t i c , pharmacy o r nursing ( D e f i n i t i o n
accepted by the National Commission on A llie d
Health Education and the Board o f D irec to rs o f the
American S o ciety o f A llie d Health P r o f e s s io n ,
1980).

3.

Competency - The a b i l i t y ( in c lu d in g knowledges, s k i l l s and/or
a t t i t u d e s ) to perform a s p e c i f i c t a s k s u c c e s s f u l l y (als o
called a s k i l l ).

12

4.

C r e d e n t ia l s - That which gives t i t l e to b e l i e f o r confidence.
In A l l i e d H e alth , i t i s used as an assurance o f q u a l i t y t h a t
p r a c t i t i o n e r s a r e q u a l i f i e d to perform the r o l e s and
f u n c t i o n s o f t h e i r o c c u p a tio n s.

This can be done by e i t h e r

l i c e n s i n g or c e r t i f i c a t i o n , which have been d e fi n e d by the
U.S. Department o f H e alth , E ducation, and Welfare.
A.

(1978)

Licensure
The process by which an agency o f government g r a n t s
permission to an ind ivid ua l to engage in a given occupa­
t i o n upon f i n d in g t h a t t h e a p p l i c a n t has a t t a i n e d the
minimal degree o f competency necessary to ensure t h a t
th e p u b l i c h e a l t h , s a f e t y , and w e l fa r e w i l l be reaso nably .
well p r o t e c t e d .

B.

C ertification
The pro cess by which a non-governmental agency o r
p r o f e s s i o n a l o r g a n i z a t i o n g r a n t s r e c o g n i t i o n to an
i n d iv id u a l who has met c e r t a i n predetermined q u a l i f i c a ­
t i o n s s p e c i f i e d by t h a t agency o r o r g a n i z a t i o n .

5.

Hospital - In accord with the p r o v i s i o n s of Act 368, Public
Acts of 1978, as amended, a h o s p i t a l i s :
a f a c i l i t y o f f e r i n g i n p a t i e n t , o v e rn i g h t c a r e , and
s e r v i c e s f o r o b s e r v a t i o n , d i a g n o s i s , and a c t i v e
tr e a tm e n t o f an in d iv i d u a l with a m edica l, s u r g i c a l ,
o b s t e t r i c , c h r o n i c , o r r e h a b i l i t a t i v e c o n d itio n
r e q u i r i n g the d a i l y d i r e c t i o n o r su p e r v i s i o n o f a
p h y s i c ia n . The term does not in clude a h o s p i t a l
l i c e n s e d , or o p erated by th e Department o f Mental
Health ( D i r e c t o r y , Bureau o f H o s p i t a l s , Ja n u ary ,
1981, p. 1)

6.

Need - The gap between what i s and what ought to b e .
(Kaufman and E n g lish , 1979:37)

13

7.

Needs Assessment - A formal process f o r determining perceived
gaps between p r e s e n t and d e s i r e d outcomes.

A c r i t i c a l step

to a s s u r e t h a t problem-solving process i s v a l i d , u s e f u l , and
im p o rtan t.

I t g a th e r s information about i n s t i t u t i o n s which

a r e c u r r e n t l y in place and o p e r a t i n g (such as t r a i n i n g
o r g a n i z a t i o n s , f e d e r a l o r s t a t e a g e n c i e s , school? o r school
d i s t r i c t s ) and attem pts to i d e n t i f y gaps in s o c i e t a l
s i t u a t i o n s to which a l t e r n a t i v e methods (such as education
o r t r a i n i n g ) might be r e s p o n s i v e .

(Kaufman and E n g lish ,

1979:39)
8.

M u ltiple Competency Health P r a c t i t i o n e r - A member o f a
h e a l t h c a r e team who p oss esse s s k i l l s and knowledge from two
o r more a l l i e d h e a l t h o c c u p a tio n s.
Respiratory therapy.

For example:

Radiology/

(Nebraska Department o f Education,

1980:1)
L im ita tio n s o f the Study
This study was l i m i t e d by th ose problems r e l a t e d to a mailed
survey q u e s t i o n n a i r e , g e n e r a l i z e a b i l i t y , and the type o f information
gathered from the h o s p i t a l a d m i n i s t r a t o r s .
1.

Only c h i e f a d m i n i s t r a t o r s were surveyed.

( I f employees had

been s e n t t h e i n s t r u m e n t , the da ta might have been d i f f e r e n t )
2.

Since the p op u latio n f o r t h i s study were the c h i e f adminis­
t r a t o r s o f a l l h o s p i t a l s o f 100 bed c a p a c i t y o r l e s s in the
S t a t e o f Michigan, the r e s e a r c h r e s u l t s may be g e n e r a l i z e a ble to only th ose h e a l t h c are f a c i l i t i e s in geographic are as
which have s i m i l a r a l l i e d h e a l th manpower needs.

14

3.

This study di d no t i n clu de q u e stio n s about the
u t i l i z a t i o n o f p e rs o n n e l ; n e i t h e r did i t in clu de a t a s k
analysis.

4.

This study was n o t designed to pr ovide f u t u r i s t i c employ­
ment p r o j e c t i o n s .

Summary o f Chapter
This c h a p t e r c o n t a i n s a d e s c r i p t i o n o f the problems small h o s p i t a l s
f ac e in s t a f f i n g of a l l i e d h e a l t h p e rs o n n e l .

I t appears t h a t c u r r e n t

p r a c t i c e s w it h in th e v a rio u s c r e d e n t i a l i n g agen cies a r e p r e s e n t i n g a
b a r r i e r to a l l i e d h e a l t h a d m i n i s t r a t o r s as they a ttem p t to a l l e v i a t e
s t a f f i n g s h o r ta g e s through t h e in n o v a tiv e and f l e x i b l e u t i l i z a t i o n of
e x i s t i n g p e rs o n n e l.
Various l e a d e r s in t h e a l l i e d h e a l t h f i e l d have s t a t e d t h a t they
b e l i e v e t h a t t h e development o f a h e a l t h p r a c t i t i o n e r with m u l t i p l e
competencies may be one s o l u t i o n to th e s t a f f i n g problems o f the small
hospital.

The a d m i n i s t r a t o r s o f such f a c i l i t i e s could b e n e f i t from

being allowed to use t h e i r a l l i e d h e a l t h personnel to f u n c t i o n in two or
more a l l i e d h e a l t h s p e c i a l t y a r e a s .

Thus, th e study was undertaken to

measure the employment p o t e n t i a l of a m u l t i p l e competency h e a l t h
p r a c t i t i o n e r in small h o s p i t a l s in Michigan.
The r e s e a r c h q u e s t io n s focus on t h e info rmation n ecessary f o r
a l l i e d h e a l t h ed uca tio nal program p lan nin g.

The primary goal o f the

study was to determine whether a d m i n i s t r a t o r s in small h o s p i t a l s in
Michigan p e rc e iv e a m u l t i p l e competency p r a c t i t i o n e r to be an a l t e r n a ­
t i v e to conventional a l l i e d h e a l t h s t a f f i n g p r a c t i c e s .

15

Overview of Other Chapters
In Chapter I I , t h e p e r t i n e n t l i t e r a t u r e i s reviewed.

The f i r s t

s e c t i o n o f t h e c h a p t e r d e a l s with t h e c r e d e n t i a l i n g o f a l l i e d h e a l th
p e rso n nel.

Se c tio n two e xp lore s th e p o t e n t i a l use o f a m u l t i p l e

competency h e a l t h p r a c t i t i o n e r .

The t h i r d s e c t i o n e x p la in s the

importance o f a needs assessment as a necessary tool f o r e f f e c t i v e
curriculum d e s i g n , and t h e l a s t s e c t i o n i s r e l a t e d t o survey r es ea r ch
methodology.
Chapter I I I c o n ta in s a d e s c r i p t i o n o f t h e r e s e a r c h procedures
used to g a t h e r inform ation concerning t h e employment p o t e n t i a l o f
m u l t i p l e competency personnel in small h o s p i t a l s in Michigan.

This

in cludes the methods used f o r s e l e c t i n g t h e p o p u l a t i o n , the procedures
f o r developing t h e survey in s t r u m e n t , and an overview o f the tr e a tm e n t
o f th e d a t a .
Chapter IV c o n ta in s the f i n d i n g s with an a n a l y s i s o f the data
gath ered from the a d m i n i s t r a t o r s .
Chapter V c o n ta in s a summary o f t h e r es ea r ch f i n d i n g s , c o n c lu sio n s,
recommendations, and i m p l i c a t i o n s f o r f u t u r e r e s e a r c h .

In a d d i t i o n ,

the r e s e a r c h e r p r e s e n t s some r e f l e c t i o n s on t h i s study and i t s f i n d i n g s .

Chapter I I
REVIEW OF THE LITERATURE

The review o f the l i t e r a t u r e i s or ganized under fo ur major head­
i ngs:

1)

C r e d e n t ia l in g o f a l l i e d h e a l t h p r a c t i t i o n e r s ; 2)

competency h e alth p r a c t i t i o n e r s ; 3)
curriculum d esign; and 4)

Multiple

Needs assessment as a b a s i s o f

Survey r e s e a r c h methodology.

C r e d e n tia lin g o f A l l ie d Health P r a c t i t i o n e r s
The c r e d e n t i a l i n g o f a l l i e d h e a l t h p r a c t i t i o n e r s i s divid ed i n to
two s e c t i o n s .

Section 1 reviews t h e h i s t o r i c a l development o f the

c r e d e n t i a l i n g p r o c e s s , and Section 2 w i l l e x p lo r e c r e d e n t i a l i n g and i t s
impact upon c u r r e n t a l l i e d h e a l th employee u t i l i z a t i o n .
Se ction I :

H i s t o r i c a l Development.

The following opposing s t a t e ­

ments by two key spokesmen in n a tio n a l h e a l t h c are a r e i n d i c a t i v e of the
controversy surrounding the whole are a o f a c c r e d i t a t i o n / c r e d e n t i a l i n g
o f f a c i l i t i e s and personnel in providing h e a l t h c a r e s e r v i c e s to the
p u b l ic .

P rofe ssor Nathan Hersey, r e s e a r c h p r o f e s s o r o f Health Law a t
4

the U n iv e rs ity of P i t t s b u r g h , w r i t e s :
The major e f f e c t o f our mandatory l i c e n s i n g system o f p r o f e s ­
siona l and occupational s p e c i a l i s t s in the h e a l t h f i e l d i s to
e s t a b l i s h a r i g i d c a t e g o r i z a t i o n o f personnel t h a t tends to
i n t e r f e r e with the o r g a n i z a t i o n o f s e r v i c e s to meet the demand
o f p a t i e n t s e r v i c e s . (1964:1)
An opposing view o f c r e d e n t i a l i n g i s held by J . W. Cashman, a noted
Health Systems Analyst, when he s t a t e s :
16

17

L ic en su re, c e r t i f i c a t i o n and a c c r e d i t a t i o n have b a s i c a l l y
s i m i l a r o b j e c t i v e s : to e s t a b l i s h sta nd ard s o f q u a l i t y f o r
medical c are s e r v i c e s , and through a process o f i n s p e c t i o n ,
e d u c a tio n , and c o n c i l i a t i o n , to encourage and a s s i s t
i n s t i t u t i o n s to meet and maintain the stan d ards and improve
the q u a l i t y o f c a r e they p r o v id e . (1967:26)
Since the c r e d e n t i a l i n g process i s viewed as a major c o n s t r a i n t
upon the v e r s a t i l e use o f a l l i e d h e a l t h p e r s o n n e l , a review o f the
l i t e r a t u r e was made to explo re the h i s t o r i c a l development o f the
credentialing issue.

I t i s important to understand how the c r e d e n t i a l -

ing process has become so i n f l u e n t i a l in mandating the q u a l i f i c a t i o n s
an a l l i e d h e a l t h worker must p o s s e s s .
A spokesman f o r the American Hospital Asso cia tio n (AHA) a ddre ss es
the c r e d e n t i a l i n g i s s u e when he w r i t e s about the c o n tr o l c r e d e n t i a l i n g
has gained over the t h i r d p a rt y payment o f s e r v i c e s to h o s p i t a l s .
A r e c e n t r e p o r t issue d by th e Council o f Human Resources s t a t e s :
The economic e f f e c t s o f l i c e n s i n g laws f o r h e a l t h and o t h e r
occupations must be noted. The a n a l y s i s o f in creased
h o s p ita l c o s t s o f f e r s some i n d i c a t i o n o f the e f f e c t o f s a l a r y
demands where t h e r e i s l e g i s l a t i v e r e c o g n i t i o n o f h e a lth
oc cu p a ti o n s. Since t h i s i s an era o f f u n c t i o n a l and knowledge
s p e c i a l i z a t i o n , the time may come soon when an i n d iv id u a l will
need f o u r or f i v e l i c e n s e s to perform a l i m i t e d s e r v i c e and
hi s s a l a r y demands w ill i n c r e a s e a c c o rd ing ly i f p r e s e n t tren ds
a r e follow ed. (American Hospital A s s o c ia t io n , 1980:4)
The e a r l i e s t e f f o r t a t p u b l ic r e g u l a t i o n o f h e a l t h c a r e in the
United S t a te s came in the form o f l i c e n s i n g p h y s i c i a n s .

Shryrock in

Medical Licensing in America, 1650 to 1965, found t h a t in 1649 in the
Province o f Mass achusetts, b a re ly twenty ye ars a f t e r i t s o r i g i n a l
s e t t l e m e n t , physicians or o t h e r s "who were employed a t any time about
the body o f men, women o r c h i l d r e n , f o r the p r e s e r v a t i o n o f l i f e or
h e a l t h " , were l i c e n s e d .

No such persons were to p r a c t i c e "without the

advice and consent o f such as a r e s k i l l f u l in the same a r t ( i f such may

18

be had) o r a t l e a s t some o f the w i s e s t and g r a v e s t then p r e s e n t . "
Those who ignored the r e g u l a t i o n could be fin ed by th e c o u r t .

(19 67: i i )

Nearly 160 ye ars passed between passage o f th e f i r s t l i c e n s i n g law
in New York in 1760 and 1917 when th e l a s t s t a t e , Alaska, took a c t i o n .
(Somers, 1969:77)

Of the e stim a te d 3,500 p h ysic ia n s in the United

S t a t e s in 1775, only 400 held medical d e g re e s .

S u b s t a n t ia l changes

were not made in the p r e p a r a t i o n o f p h y sic ia n s and the q u a l i t y of
medical education u n t i l well i n to the t w e n ti e t h c e n t u r y .

(G oldstein

& Horowitz, 1977:25)
By the beginning o f th e t w e n ti e t h c e n t u r y , the American Medical
Associa tio n (AMA) was becoming concerned about the p r o l i f e r a t i o n o f
inadequate medical sc hools and the poor s t a t e o f b a sic medical educa­
tion for physicians.

The AMA then began to e x e r t a r o l e in demanding

q u a l i t y education and volunte ered to r a t e medical sc h o o l s , placin g them
in t h r e e c a t e g o r i e s on the b a s i s o f performance.

This move was met

with g r e a t h o s t i l i t y by the p r o f e s s i o n and the s c h o o l s ; however, the
Carnegie Foundation stepped in to su pport th e p o s i t i o n o f the AMA on
q u a l i t y education and commissioned Abraham Flexnor, a non-medical
educa tor to do a study o f medical e d u c a ti o n .

F l e x n o r 's r e p o r t was

published in 1910 a f t e r he v i s i t e d every medical school in the United
S t a t e s and Canada.

In his book, the Flexnor Re port, i n t h e c h a p t e r

t i t l e d R eco n s tru c tio n , he r a i s e s q u e stion s concerning the r i g h t s of
s t a t e s to r e g u l a t e medical ed u ca tio n :

19

. . . the community through r e g u l a t i o n unde rtakes to abridge
the freedom o f p a r t i c u l a r i n d i v i d u a l s to e x p l o i t c e r t a i n
c o n d it i o n s f o r t h e i r personal b e n e f i t . S o c i e t y f o r b i d s a
company o f p h y sic ia n s to pour o u t upon th e community a horde
o f i l l - t r a i n e d p h y s i c i a n s . Their l i b e r t y i s indeed c l i p p e d .
Reorganization along r a t i o n a l l i n e s involves the s t r e n g t h e n ­
i n g , n o t the weakening o f democratic p r i n c i p l e s , because i t
tends to provide th e c o n d it i o n s upon which w e l l- b e in g and
e f f e c t u a l l i b e r t y depend. (1910:142)
Somers, (1969:232) a medical s o c i o l o g i s t c i t e s the p u b lis h in g o f
th e Flexnor Report as one o f t h e " g r e a t d a te s in r e c e n t h i s t o r y o f
medical c a r e " .

The Flexnor Report on medical education marked the

beginning o f t h e e ra o f s c i e n t i f i c medicine and o f i n s t i t u t i o n a l
medicine.

This study h i g h l i g h t e d t h e need f o r reform and generated

p ub lic concern and a c t i o n toward improving the poor s t a t e o f medical
schools.

Goldstein & Horowitz (1977) b e l i e v e the Flexnor Report not

only r e s u l t e d in improved education f o r ph y sic ia ns and in b e t t e r
h o s p i t a l f a c i l i t i e s , b u t a l s o brought a decrea se in the p h y s i c ia n /
patient ra tio .

The end r e s u l t o f the r e p o r t was AMA's su pport f o r a

system of s e l f - r e g u l a t i o n t h a t ended in t h e a c c r e d i t a t i o n of medical
sc h o o l s .

S t a t e l e g i s l a t u r e s l a t e r began e s t a b l i s h i n g medical p r a c t i c e

a c t s which r e q u i r e d gradu atio n from an a c c r e d i t e d school as t h e b a sic
q u a l i f i c a t i o n to s i t f o r the s t a t e ph y sicia n l i c e n s u r e exam ination.

In

1913 the AMA Council o f Medical Education began i n s p e c t i n g h o s p i t a l s
and su b seq u en tly published i t s l i s t o f h o s p i t a l s approved f o r r e s i d e n t
training.
The f i r s t involvement o f t h e American Medical A sso c ia tio n in
a c c r e d i t a t i o n o f programs f o r h e a l t h c a r e workers, o t h e r than p h ysic ia n s
came in 1932 when they agreed to c o o perate with occu pational t h e r a p i s t s .
Through th e ne xt two de cades, fo u r more programs were added.
1960's and 1970's saw a p r o l i f e r a t i o n o f a c c r e d i t e d programs.

The
Of the

20

27 s e t s o f E s s e n t i a l s f o r Program A c c r e d i t a t i o n developed by t h e Com­
m i t t e e on A l l i e d Health A c c r e d i t a t i o n and Education (CAHEA) s i n c e 1930,
"22 p e rc e n t were adopted b efore 1960, 22 p e rc e n t during th e 1960‘s and
56 p e rc en t s i n c e 1970."

(Hoistrom, 1976:4)

With t h e advent o f more h e a l t h p r a c t i t i o n e r s b esides th e r o u t i n e
p h y s i c i a n s , nurse s and p h a rm a c ists, p r o f e s s i o n a l o r g a n i z a t i o n s began to
demand more autonomy in t h e i r education and in s e t t i n g t h e i r own pro­
fessional credentialing standards.

The r a t i o o f p h y sic ia n s and o t h e r

a l l i e d medical workers, as they were then c a l l e d , was changing.

In 1967

the American S o ciety o f A l l i e d Health p r o f e s s i o n s was formed to provide
a forum f o r a l l o f th e a l l i e d h e a l t h workers to come t o g e t h e r to d isc u ss
e d u c a tio n , p u b l ic and p r i v a t e a c c r e d i t a t i o n , c l i n i c a l f a c i l i t i e s and the
r o l e o f t h e independent p r a c t i t i o n e r .

(Holder, 1981)

As a l l i e d h e a l t h moved i n to a more co hesive u n i t , the AMA began to
c o l l a b o r a t e with the i n d iv id u a l o r g a n i z a t i o n to comprise the " l a r g e s t
a c c r e d i t i n g consortium in the United S t a t e s with r e s p e c t to the number
of p r o f e s s i o n a l o r g a n i z a t i o n s , programs and s t u d e n ts g r a d u a t e d . "
A l l i e d Health Education D i r e c t o r y , 1979:10)

(The

In c o l l a b o r a t i o n with "47

medical s p e c i a l t i e s and a l l i e d h e a l t h o r g a n i z a t i o n s , and with th e
numerous review committees, CAHEA, o f t h e AMA, a c c r e d i t s programs f o r
25 a l l i e d h e a l th o c c u p a ti o n s ."
Some o f the c r i t i c i s m d i r e c t e d a t t h e whole process o f a c c r e d i t a ­
t i o n / c r e d e n t i a l ing i s d i r e c t e d toward t h e AMA and t h e i r heavy in v olv e­
ment in the p r o c e s s .

But t h e r e a re a ls o o t h e r f a c t o r s in the c u r r e n t

s t a t u s of a c c r e d i t a t i o n which a r e cause f o r concern.

McNulty s t a t e s

p a r t o f t h e fragm enta tion and "the f r a y i n g around the edges" o f the
a c c r e d i t a t i o n mechanism i s due t o :

21

1) th e s t r u g g l e o f p r o f e s sio n a l o r g a n i z a t i o n s to gain inde­
pendence f o r them se lves, 2) t h e move i n to s p e c i a l i z a t i o n and
the l a r g e i n c r e a s e in numbers o f th e types o f h e a l th
o c c u p a tio n s, and 3) i n t e r e s t o f t h e government in p r o t e c t i n g
and c o n t r o l l i n g Medicare and Medicaid to th e p o i n t o f becom­
ing i n c r e a s i n g l y involved in monitoring s e r v i c e s rendered in
education and in s e t t i n g c r i t e r i a f o r sta nd ard s o f p r a c t i c e .
(1980:66)
The area o f i n c r e a s i n g s p e c i a l i z a t i o n o f the new and emerging occupa­
t io n s i s o f v i t a l concern to a l l h e a l t h workers.

This movement toward

s p e c i a l i z a t i o n i s causing h e a l t h c a r e c o s t s t o e s c a l a t e as new
s p e c i a l i s t s emerge and t h i r d p a rt y payers a ttem p t to mandate who may
perform s p e c i f i c d u t i e s .

Cohen w r i t e s :

perhaps more c r i t i c a l than the number o f p hy sic ia n s i s the
f a i l u r e w it h in t h e system to r e g u l a t e type and number o f
s p e c i a l i s t s , t h e i r geographic l o c a t i o n . . . No s i n g l e
agency has y e t accepted r e s p o n s i b i l i t y f o r determining the
type and number o f s p e c i a l i s t s and a l l i e d h e a l th workers
needed. (1977:26)
Martin (1980:2) s t a t e s t h a t in a l l i e d h e a l t h t h e r e has been a g r e a t
variety of sp e c ia liz a tio n .

"Often t h i s s p e c i a l i z a t i o n i s based on

such th in g s as t h e d isc o very o f a new tec h n iq u e , a tr e a tm e n t m odality ,
a new discovered d i s e a s e , a new machine, o r a new a s s i s t a n t f o r one
o f the ph ysicia n s p e c i a l t i e s . "

P e l l e g r i n o , one o f the n a t i o n ' s keenest

spokesman f o r t h e h e a l t h p r o f e s s i o n , sums up the c o n f l i c t s and problems
in he alth care manpower t h i s way:
The re a l i s s u e i s how to bring about some convergence in
f u n c t i o n and numbers. The p r e s e n t course o f unguided p ro­
l i f e r a t i o n i s s o c i a l l y untenable and f i s c a l l y unsu pportable.
(1977:27)
As a l l i e d h e a l th employees have i n c r e a s e d , so have the problems of
c r e d e n t i a l i n g such employees.

The i s su e s of c r e d e n t i a l i n g i s now

viewed by many as a primary cause o f in creased h o s p i t a l c o s t s .

Through

22

the c r e d e n t i a l i n g p r o c e s s , h o s p i t a l s a re mandated by t h i r d pa rty
payers to use only employees with c e r t a i n c r e d e n t i a l s f o r c e r t a i n
functions.
In o r d e r to p r o t e c t the p u b l i c , "the h e a l th p r o f e s s i o n s have be­
come obsessed with c r e d e n t i a l s " .

(M artin, 1980:10)

In a d d i t i o n to the

a c c r e d i t a t i o n o f edu ca tion al programs, they turned to l i c e n s u r e by the
s t a t e and c e r t i f i c a t i o n by the p r o f e s s i o n s .

Licensure was a public

s e c t o r fu n ctio n in c o n t r a s t to a c c r e d i t a t i o n which was a p r i v a t e s e c t o r
function.
Although l i c e n s u r e was accomplished through examinations gen­
e r a l l y prepared by n o n -ed u c ato rs, the r i g h t to take an exam
was based on completion o f an educational program t h a t was
a c c r e d i t e d . This combination e s t a b l i s h e d the precedent f o r
p r i v a t e a c c r e d i t a t i o n to se rv e a pu b lic f u n c t i o n . (Martin,
1980:18)
C e r t i f i c a t i o n was l a t e r developed by the p r o f e s s i o n a l o r g a n i z a t i o n s to
examine a h e a lth c are worker f o r the competence t h a t i d e n t i f i e d a
sp ecialist.

"The a l l i e d h e a l th p ro f e s s i o n s followed the medical school

with t h ree l a y e r s o f c r e d e n t i a l i n g ; namely, a c c r e d i t a t i o n , l i c e n s u r e and
certificatio n ."

( M artin, 1980:12)

Many p r o f e s s i o n a l o r g a n i z a t i o n s pro­

moted l e g i s l a t i o n to d e f i n e in d e t a i l the are a o f p r a c t i c a l competence
and the scope o f c are to be p r a c t i c e d by each group.
The complex system o f c r e d e n t i a l i n g r e g u l a t i o n in h e a l th c a r e ,
while f o s t e r e d by the p r o f e s s i o n s , received sa n c t i o n o f government
through s t a t e and f e d e r a l laws.

As new p r o f e s s i o n a l groups developed

e x p e r t i s e , they have demanded i n c r e a s i n g a u t h o r i t y to govern t h e i r
educational e x p e r ie n c e , and t h e i r p r o f e s sio n a l competence.

They have

used the whole c r e d e n t i a l i n g process to in c r e a s e wages and improve t h e i r
public image.

(Goldst ein & Horowitz, 1977)

This " i n t e r - p r o f e s s i o n a l

23

fragm enta tion" o f h e a l t h care e d u c a ti o n , a c c r e d i t a t i o n and o t h e r forms
o f c r e d e n t i a l i n g a ls o has led to open c o n f l i c t s between t h e p r o f e s s i o n s .
(K i n s i n g e r, 1980:13)
Se ction I I :

The C urrent S t a t e o f C r e d e n t i a l i n g .

The fed e ral

government has s h i f t e d i t s emphasis away from th e production o f more
manpower t o solving t h e problem o f geographical and p r o f e s s i o n a l mal­
d i s t r i b u t i o n o f manpower.

(Ruhe, 1980)

A concensus o f opinion i s

forming t h a t the c u r r e n t laws o f l i c e n s u r e o f h o s p i t a l personnel i s
o b s o l e te and more o f a "hindrance than a h e l p . "

( C l a r k , 1980)

( K in sin g e r, 1973)
The whole dilemma o f c r e d e n t i a l i n g a f f e c t s a l l h o s p i t a l s , b u t the
sm a ll, r u r a l h o s p i t a l has p a r t i c u l a r problems in terms o f s a l a r i e s ,
r e c r u i t i n g and r e t a i n i n g c r e d e n t i a l e d p r a c t i t i o n e r s .

Friedman, i n t e r ­

viewing small h o s p i t a l a d m i n i s t r a t o r s , w r i t e s about t h e i r concerns:
I f something i s n ' t done t h e p r o l i f e r a t i o n o f t h e s p e c i a l t y
groups w ill mean t h e demise o f t h e small h o s p i t a l . I t h in k
people advocating high l e v e l s o f s p e c i a l i z a t i o n a re simply
unaware o f what r u r a l America i s l i k e . . .
In terms o f the claim t h a t more highly t r a i n e d and educated
personnel ensure b e t t e r q u a l i t y j u s t does not add up. None
o f t h e h o s p i t a l s in our system have ever been sued and i f
our c a r e had been so poor I am su r e we would have by now . . .
From an employer's p o i n t o f view, I have seen no c o r r e l a t i o n
between e f f e c t i v e outcome and t h e c r e d e n t i a l s t r e n d . There
i s no documentation o f whether a p e r s o n ' s work i s b e t t e r and
w ill continue to be b e t t e r because he holds a d egre e. There
has been no study t h a t has proven t h a t a l l the c r e d e n t i a l i n g
r e s u l t s in b e t t e r p a t i e n t c a r e . (1981:48-49)
Thus, c r e d e n t i a l i n g i s r e s t r i c t i n g t h e use o f personnel and prev entin g
small h o s p i t a l s from so lvin g t h e i r own problems such as " c o r r e c t i o n of
high tu r n o v e r r a t e s , jo b d i s s a t i s f a c t i o n , r e l a t i v e l y low wages and
l i m i t e d upward m o b i l i t y . "

(G oldstein & Horowitz, 1977:12)

24

At a r e c e n t Forum on National A c c r e d i t a t i o n o f A l l i e d Health
Education, Mr. William C u l b e r t s o n , an a d m i n i s t r a t o r o f a small h o s p i t a l ,
recounted the following sequence o f e vents in volv ing th e c e r t i f i c a t i o n
f o r emergency s e r v i c e s :
Let me t e l l you about a problem in Ohio and what problems a re
developing and what I t h i n k w i l l e v e n t u a l l y happen because o f
the c e r t i f i c a t i o n p r o c e s s . About f i v e o r s i x y e a r s ago, the
fed e ral government gave t h e s t a t e money to e s t a b l i s h some
type o f emergency medical s e r v i c e s . Here i s what happened.
People r i d i n g in t h e ambulances as v o l u n t e e r s had to be
c e r t i f i e d in a 90-hour t r a i n i n g program t o be an EMT.
A second program running 500 hours was in tr o d u c e d . The p e r ­
son i s then q u a l i f i e d as a paramedic and can do c e r t a i n
procedures not covered in EMT t r a i n i n g .
What has happened t o t h e "good Samaritan" who used to help in
emergency s i t u a t i o n s ? His s t a t u s i s now q u e s t i o n a b l e .
I f an EMT answers your c a l l
l i f e t h a t only a paramedic
tro u b le ? Proba bly, i f t h e
though you would have died

and does something to save your
i s supposed t o do, i s he in
r e s u l t s a r e not p e r f e c t , even
i f he h a d n ' t t r i e d t o be h e l p f u l .

Now, a f t e r f i v e y e a r s , EMT's have to be r e c e r t i f i e d every
t h r e e y e a r s . Local squads a re having t r o u b l e because i t
again r e q u i r e s 27 hours o f t r a i n i n g and a l l squad members'
o r i g i n a l c e r t i f i c a t e s d o n ' t need to be renewed a t th e same
time.
In most i n s t a n c e s , t h e s e r v i c e has been s t a f f e d by v o l u n t e e r s ,
b u t in c i t i e s where the volume o f s e r v i c e w a r r a n t s , i t has
been s t a f f e d with paid employees, u s u a l l y paramedics.
With the t i g h t e n i n g up o f t h e c e r t i f i c a t i o n p r o c e s s , we w ill
probably see v o l u n t e e r departments going under and th e p u b l ic
demanding a paid s e r v i c e .
In ru ral a r e a s , where t h e r e i s a 15 to 30 thousand po p ulation
in a county, what do you t h in k the response time would be i f
t h e r e i s only one squad in the county?
The c o s t o f 365-day, 24-hour-a-day s t a f f i n g i s e stim ate d to
exceed $150,000 p e r squad.

25

Because o f th es e problems, un les s the r u l e s a r e changed, I
t h in k we w ill see a demise o f v o l u n te e r programs. The r e s ­
ponse time in many a r e a s w ill i n c r e a s e d r a m a t i c a l l y . I f and
when somebody a r r i v e s , you w i l l probably be b e t t e r cared f o r .
The c o s t o f h e a l t h c a r e w i l l i n c r e a s e .
The c e r t i f i c a t i o n pr ocess seems to be most importan t in the h e a lth
c a r e f i e l d ; i t has been a bonanza f o r the e d u c a t o r s ; and probably the
b i g g e s t a l l y i s the medical m a l p r a c t i c e s i t u a t i o n t h a t e x i s t s in the
United S t a t e s today.

( C u lb e r tso n :

1980:157-158)

In 1977, the National Commission of Health C e r t i f y i n g Agencies
(NCHCA) was formed as a v o l u n ta r y o r g a n i z a t i o n to a tt e m p t to deal with
t he complex problems o f p rep a rin g and c e r t i f y i n g h e a l t h c a r e p e rs o n n e l .
The agency recommends case monitoring o f the Reagan Adm inistratio n as
i t a tte m p ts to d e r e g u l a t e h e a l t h c a r e .

Would d e r e g u l a t i o n mean an end

to r u l e o f law; l i c e n s u r e , a n t i t r u s t and c i v i l r i g h t s laws?

Each

p r o f e s s i o n a l group must monitor l e g i s l a t i o n c a r e f u l l y to p r o t e c t t h e i r
interests.

A commission r e p o r t concludes:

Deregulation o f h e a l t h w i l l occur slowly and may only margin­
a l l y a f f e c t the system. I n ste a d o f d i r e c t i n g h o s p i t a l
a d m i n i s t r a t o r s who to h i r e f o r s p e c i f i c f u n c t i o n s , the
government w ill allow a d m i n i s t r a t o r s t h e i r own b e s t judgments
as o u t l i n e d in v o l u n ta r y a g e n c i e s , such as th e J o i n t Commis­
sion on A c c r e d i t a t i o n o f h o s p i t a l s . (1980:i i i )
Besides the economic changes f o r e c a s t , t h e r e a re o t h e r i s s u e s being
d iscu ssed on the n a ti o n a l scene r e l a t i n g to the whole a c c r e d i t a t i o n /
c r e d e n t i a l i n g pro ce ss .
1.

How to measure the competence o f an i n d i v i d u a l . (NCHCA
B u l l e t i n , 1980:3) Licensure alo ne does not gu arantee
competence. (AHA Guidelines on l i c e n s u r e o f Health Care
Personnel, 1980)

2.

I n s t i t u t i o n a l a c c r e d i t a t i o n - a l l o f the g rad uates o f c e r ­
t a i n ed u ca tio n al i n s t i t u t i o n s would be considered
competent and t h e i r c r e d e n t i a l s would be a u to m a t i c a ll y
accepted with no f u r t h e r exam ination. Romer,(1974) s t a t e s

26

the b e s t p r o t e c t i o n of t h e q u a l i t y o f h e a lth personnel
i s no t l i c e n s u r e , c e r t i f i c a t i o n o f a c c r e d i t a t i o n , but
r a t h e r educ ational p r e p a r a t i o n , both academic and
practical.
3.

I n s t r u c t i o n a l l i c e n s u r e - Personnel l i c e n s u r e and
l i c e n s u r e o f a c l i n i c a l c are f a c i l i t y could merge i n to a
s i n g l e r e g u l a t o r y program governing both the p rov isio n
o f personal h e a l t h and medical s e r v i c e s . (Somers, 1969;
Friedman, 1981)

4.

How o f t e n should l e g i s l a t i v e bodies review the laws and
sugge st r e v i s i o n to r e f l e c t the c u r r e n t p r o f e s sio n a l or
occupational requirements o f an e n t r y level h e a l th care
p r a c t i t i o n e r . (Kinsin ger, 1980) A major component in
the e f f o r t to in tr o d uc e g r e a t e r pu b lic a c c o u n t a b i l i t y
i n to the r e g u l a t i n g process i s the c r e a t i o n o f a mech­
anism f o r c o o r d i n a t i n g , a d v i s i n g , mediating and reviewing
fu n ctio n s r e l a t e d to h e a l t h p e rso n nel.

Because o f the c o n tr ov e rsy surrounding the whole issu e o f a l l i e d
h e a l th a c c r e d i t a t i o n / c r e d e n t i a l i n g , no s i n g l e summary state m ent o f the
review o f l i t e r a t u r e would s u f f i c e .

The whole f i e l d o f h e a l th care i s

dynamic and many diverg ing opinions view the 1980's as a decade o f
convergence o f i d e a s .

The AHA Council on Human Resources (1981:6)

commenting on the c u r r e n t s t a t e o f a l l i e d h e a l th c r e d e n t i a l i n g sa ys:
"Licensure laws should c o n t r i b u t e sound s o l u t i o n s and should not
s u b s t i t u t e o b s t a c l e s to the d e l i v e r y o f h e a l th c a r e . "

This s t a t e s

s u c c i n c t l y what should be the ideal r o l e o f the c r e d e n t i a l i n g process
of each h e a l th c are p r a c t i t i o n e r .
'

Multiple Competency Health Care Workers
A thorough review o f th e l i t e r a t u r e revealed a pa u city of informa­
t i o n concerning the use of m u l t i p l e competency h e alth c are personnel in
t o d a y 's system o f h e a l th c a r e .

Munroe and Schumann, w r i t i n g about

small h o s p i t a l s ' need to s u r v i v e , provide new ideas concerning the
d i s t r i b u t i o n , r e c r u i t m e n t , r e t e n t i o n and u t i l i z a t i o n o f p e rs onnel:

27

In th e f u t u r e , h o s p i t a l s w ill need to use n u r s e s , p h ysic ia n s
a s s i s t a n t s and o t h e r a l l i e d h e a l t h p r o f e s s i o n s in inn o vativ e
ways. Many h o s p i t a l s w ill need to use multi-competency
t e c h n i c i a n s t o supplement a v a i l a b l e personnel in departments
such as l a b o r a t o r y , r a d i o l o g y , ECG, physical th era p y and
r e s p i r a t o r y t h e r a p y . (1980:101)
In a speech on t h e changing t r e n d s in h e a l th c a r e , Kinsinger s t a t e s :
Narrowly t r a i n e d t e c h n i c i a n s have m u l t i p l i e d and g r e a t new
numbers o f .personnel have been added t o the n a t i o n ' s manpower.
I t i s e a s i e r to develop a new occupation than to modify one
which a lr e a d y e x i s t s . A developing idea i s to experiment
with curriculum t h a t o f f e r s t h e a l l i e d h e a l th g rad u a te m u l t i ­
ple competencies. (1980:11)
The American Hospital A s so c ia tio n has developed a t a s k f o r c e to
study the u t i l i z a t i o n o f m u l t i p l e competency h e a l t h c a r e workers.

In a

d is c u s s io n with Clark, Chairman o f the Task Force, t h i s r e s e a r c h e r
asked what were the r e s u l t s o f a nation-wide survey t o study the need
f o r m u l t i p l e competency personnel..

He r e p l i e d :

The need f o r multi-competency, o r m u l t i - s k i l i e d a l l i e d h e a l th
p r a c t i t i o n e r s has become i n c r e a s i n g l y a p parent in underserved
small r u r a l h o s p i t a l s , neighborhood c l i n i c s , and p r i v a t e
p r a c t i c e s e t t i n g s where a small number but wide v a r i e t y o f
m edically r e l a t e d t a s k s a r e performed. The a l t e r n a t i v e o f
employing s i n g l e - s k i l l e d a l l i e d h e a l t h p r o f e s s i o n a l s i s
i n f e a s i b l e , p r i m a r i l y because o f d i f f i c u l t i e s in r e c r u i t i n g
and r e t a i n i n g q u a l i f i e d p r a c t i t i o n e r s , e i t h e r because
i n s u f f i c i e n t work volume makes the s a l a r y paid a s i n g l e ­
s k i l l e d p r a c t i t i o n e r i n s u p p o r ta b le or because t h e volume o f
work i s i n s u f f i c i e n t to provide job s a t i s f a c t i o n o r p r o f e s ­
sional challe ng e f o r s i n g l e - s k i l l e d p r a c t i t i o n e r s . (Personal
Communication, June 7, 1981)
A study done by t h e American Medical A sso c ia tio n and th e American
Academy o f Family P r a c t i c e and r e p o r t e d by Clark surveyed randomly
chosen small h o s p i t a l and p hy sic ia n s o f f i c e s na ti o n -w id e.

The con­

c lu s io n s o f the study i n d i c a t e a s t r o n g , developing i n t e r e s t in the
concept o f a m u l t i p l e competency worker.

28

These s t u d i e s i n d i c a t e t h a t multi-competency t e c h n i c i a n s are
a v i a b l e and important component o f th e h e a l t h - c a r e d e l i v e r y
team. They a r e mainly employed by s m a l l , r u r a l h o s p i t a l s with
fewer than 100 beds and by one and two p h y sic ia n p r a c t i c e s .
The most common methods o f t r a i n i n g t e c h n i c i a n s c o n s i s t of
o n - t h e - j o b t r a i n i n g in the h o s p i t a l s and p r e c e p t o r i a l t r a i n ­
ing by p h y s i c i a n s , p a r t i c u l a r l y in t h e r u r a l s e t t i n g .
H o s p ita ls and p hysicia ns noted t h a t they would c o n s i d e r
h i r i n g t e c h n i c i a n s i f they were a v a i l a b l e ; 50% of the r e p o r t ­
ing p hy sic ia n s noted t h a t multi-competency t e c h n i c i a n s a r e not
r e a d i l y a v a i l a b l e . (1980:6)
Clark c o n t i n u e s , th e "bottom l i n e " shows t h a t i t i s f i n a n c i a l l y more
f e a s i b l e to h i r e th es e t e c h n i c i a n s , and a l s o t h a t t h e r e i s not always
enough work to keep two l ic e n s e d personnel busy in a small h o s p i t a l or
physician's o f f i c e .

Performance a r e a s most f r e q u e n t l y noted by

respondents c o n s i s t e d o f :
Nursing ( o f f i c e ) , l a b o r a t o r y , e le c t r o c a r d i o g r a m , medical 1
recor ds (in su r a n c e forms, e t c . ) , p a t i e n t e d u c a tio n , v i s i o n
t e s t i n g , x - r a y , pulmonary f u n c t i o n t e s t i n g , and audiometry.
Additional r e s e a r c h w ill be necessary to d e l i n e a t e the t a s k s ,
develop a p r o f i l e and c r e a t e a d e f i n i t i v e job d e s c r i p t i o n f o r
the multi-competency t e c h n i c i a n s . (1980:7)
In a l e t t e r o f in q u ir y by the AMA s e n t to v ario us s t a t e medical
s o c i e t i e s to a s c e r t a i n t h e i r pe rc ep tio n o f the need f o r multi-competency
t r a i n e d p e rs o n n el, most o f t h e South Dakota responses expressed concern
f o r p r o l i f e r a t i o n o f an o th er a l l i e d h e a l th s p e c i a l t y and the problem i t
would cause in the a c c r e d i t a t i o n pr o c e ss .

A w r i t e r from North C a ro lin a,

who a ls o responded to the AMA survey, wrote:
My own opinion i s t h a t t r a i n i n g in t h i s area o f m u l t i p l e
competencies i s n e i t h e r needed nor d e s i r a b l e . The t r a i n i n g
in th e s e a re a s i s v a r i a b l e because in d iv id u a l h o s p i t a l s a re
so v a r i a b l e . To "formalize" such t r a i n i n g would only
complicate t h i n g s . (1980:39)
The National Commission on A llie d Health Education (1980) recommends
t h a t a few c r i t i c a l q u e stio n s need to be answered concerning the use of
a m u lt i p le competency employee.

These q u e stion s r e l a t e to s e l e c t i o n of

29

competency q u a l i f i c a t i o n s , how to maintain high q u a l i t y education with­
o u t e x ce ssiv e len gth enin g o f p r e p a r a t i o n , and what a re a p p r o p r i a t e
c r e d e n t i a l i n g mechanisms.

J . Douglas Coleman, P r e s i d e n t o f Associated

Hospital S e rv ice s o f New York emphasized the need to develop a l t e r n a ­
t i v e ways o f providing p e rs o n n e l .

Another a s p e c t o f the h e a l th care

economy t h a t needs c a r e f u l study i s g r e a t e r use of paramedical and sub­
p r o f e s sio n a l personnel

. . .

"A breakthrough i s long overdue".

(1978:

146)
In summary, a c o l l a b o r a t i v e approach between education and
p ro viders o f h e a l t h s e r v i c e s is necessary to supply the a l l i e d h e a l th
workers needed f o r the f u t u r e .

The h e a l th c a r e system needs workers

who a r e competent, e f f i c i e n t and c o s t e f f e c t i v e .
Needs Assessment
Numerous d e f i n i t i o n s o f Needs Assessment may be found by w r i t e r s
in the f i e l d o f curriculum development.

However, in g e n e r a l , the term

i s used to d e s i g n a t e a process f o r i d e n t i f y i n g and measuring gaps
between what i s and what ought to be.

Research methods f o r a s s e s s in g

needs a r e becoming e s s e n t i a l t o o l s f o r edu cational d e c i s i o n making and
academic planning.

Kaufman (1975) defined a needs assessment as a

sy ste m atic study to i d e n t i f y i f a need e x i s t s , and i f s o , to v a l i d a t e
the e x i s t i n g need, o r gap between "what i s " and "what should be".
English and Kaufman in Needs Assessment:

A Focus f o r Curriculum

Development (1979:12) s t a t e t h a t the ste p s to a needs assessment
r evolve around a simple model.
between two i n d i c e s .
s t a t u s quo.

A need i s a gap, or a discrepancy

That i s , a f u t u r e d e s i r e d c o n d it i o n and the

The concept o f a "need" define d as a gap was f i r s t used by

30
\

Ralph Tyler in h is h i s t o r i c work on th e development o f curriculum a t
the U n i v e rs i ty o f Chicago in the e a r l y f i f t i e s .

In h i s course on Basic

P r i n c i p l e s o f Curriculum and I n s t r u c t i o n , Tyler wrote:
S tu d ies o f the l e a r n e r su g g e st e du ca tion al o b j e c t i v e s only
when th e in form atio n about the l e a r n e r i s compared with some
d e s i r a b l e s t a n d a r d s , some co nce ption o f a c c e p t a b l e norms, so
t h a t th e d i f f e r e n c e between the p r e s e n t c o n d it i o n o f the
l e a r n e r and th e a c c e p t a b l e norm can be i d e n t i f i e d . This
d i f f e r e n c e o r gap i s what i s g e n e r a l l y r e f e r r e d to as a need.
(1950:5-6)
E a r l i e r d e f i n i t i o n s f o r "need" included gaps in p rocess es while
l a t e r work o f Kaufman and Corrigan emphasize the concept as r e l a t i n g to
only gaps or outcomes.

(Kaufman, 1975)

The concept o f needs a s s e s s ­

ment was developed i n t o a lo ng er proce ss o f systems a n a l y s i s in the
l a t e s i x t i e s in Operation PEP 9 ( P r e p a r a t i o n o f Educational Planners)
in CaVifornia.

(E nglish and Kaufman, 1979:12)

The need to develop c u r r i c u l a which i s r e l e v a n t i s o f v i t a l
importance in a l l i e d h e a l t h e d u c a ti o n .

There i s i n c r e a s in g p r e s s u r e

from members, c e r t i f y i n g a g e n c i e s , p r o f e s s i o n a l o r g a n i z a t i o n s , and
a d m i n i s t r a t o r s o f h e a l t h c a r e f a c i l i t i e s toward developing educ ational
programs which w ill meet f u t u r e h e a l t h c a r e need s.
Curriculum may be defined as "the planned substanc e f o r intended
learners".

(S n e lb ec k er, 1974:141)

Finch and Crunkilton in Curriculum

Development in Vocational and Technical Edu cation, d e f i n e curriculum a s :
the sum o f the l e a r n i n g a c t i v i t i e s and ex p erien ce t h a t a
s t u d e n t has under th e a u sp ice s o r d i r e c t i o n s o f t h e sch o o l.
(1979:7)
A r e c e n t p u b l i c a t i o n o f the American Hospital Asso cia tio n supports
f u t u r e planning by r e a l i s t i c assessment o f the job market.

31

too many curriculums a r e developed by the educato rs and
p r o f e s sio n a l o r g a n i z a t i o n s without s u f f i c i e n t in p u t from the
employer o r independent p r a c t i t i o n e r . . . d i s r e g a r d such
major f a c t o r s as c o s t , p r o d u c t i v i t y , and job s a t i s f a c t i o n .
Since 50% of a h o s p i t a l ' s t o t a l o p e ra tin g budget i s a l l o c a t e d
to p a y r o l l , employers should be involved in t h e development
o f sta n d ard s and c u rr i c u lu m s . (1980:4)
Warren Perry (1978), in h i s address to the S o c i e t y o f A llie d Health
P r o f e s s i o n s , spoke o f the h e a l t h systems o f the f u t u r e which w ill be
l a r g e l y a f f e c t e d through a r e v i s i o n and r e s t r u c t u r i n g o f e x i s t i n g
educational programs to accommodate th e new requirements o f t h e h e a lth
system y e t to be.

A curriculu m developer must r e s e a r c h the jo b r e q u i r e ­

ments f o r e f f e c t i v e e d uca tio n al plan ning .

(M e h allis , 1980)

Curriculum

c o n te n t must focus on n e ce ssa r y program outcomes so t h a t gr ad uates may
1 o b t a i n ga in fu l employment.
Decaro su pp o rts t h a t purpose o f needs assessment when he s a i d :
the i n i t i a l s t e p in e s t a b l i s h i n g ^ a n y course o f study in a
t e c h n ic a l c a r e e r ( a s s o c i a t e degree l e v e l ) i s determining the
s k i l l s t h a t a g rad ua te must possess f o r su ccessfu l employ­
ment. There i s general agreement t h a t t h e s e s k i l l s should
r e f l e c t the needs o f th e p r o f e s s i o n i n which the graduate
i s to be employed. At b e s t , needs o f a p ro f e s s io n a re
derived from t h e advice o f a panel o f e x p e r t s in the f i e l d .
At w o r s t, they a re based upon the experience o f a s i n g l e
c o n s u l t a n t o r f a c u l t y member. Although needs so de rived may
r e f l e c t the s k i l l s r e q u i r e d by a p r o f e s s i o n , they have a
f a i r l y high p r o b a b i l i t y o f being d e f i c i e n t . (1978:31)
Myron (1978:64) proposed t h a t a c o l l e g e has the r e s p o n s i b i l i t y to
maximize "the congruence between i t s s e r v i c e s and programs and the
educational needs and a s p i r a t i o n s o f a l l population groups in i t s
service are as."
E. A. Campbell p o i n t s o u t t h a t importance o f a needs assessment
when he s a y s :

32

Education, to be e f f e c t i v e , must se rve the people who l i v e ,
work, and play in a p a r t i c u l a r environment . . . I f the
ed u catio n i s to be meaningful and a s s i s t the s t u d e n t toward
gainful employment, a l l l e v e l s o f education must ste p back
and take a long, hard look. Educators should determine i f
stu d e n ts and community needs a r e being met. A needs a s s e s s ­
ment i s v i t a l . (1978:40)
The need to r e l a t e s t u d e n t l e a r n i n g to employers needs and demands o f
the jo b market i s extremely im p o rtan t.

In o r d e r f o r a needs assessment

to be s u c c e s s f u l , sound c u r r i c u l a r planning must follow with a l o g i c a l ,
syste m atic sequence.
English & Kaufman (1975:50) have developed a model e n t i t l e d The
Curriculum Development Cycle Using a Needs Assessment Base.
Figure 1)

(See

The needs assessment base i s r e a l i t y , the base u t i l i z e d to

determine the needs ( o r outcome gaps, such as employer n e ed s) .
needs may be divided i n t o two c a t e g o r i e s .

The non-agreed upon needs

a r e l a i d a s i d e to be reviewed by the assessment p r o c e s s .
upon needs a re placed in p r i o r i t y o r d e r .

The

The agreed

From the p r i o r i t y needs

s e l e c t e d f o r a c t i o n , the o b j e c t i v e s , both f o r l e a r n i n g as well as
management, a re developed.
From the two c a t e g o r i e s of management, c u r r i c u l a i s planned and
l a t e r implemented.

During the implementation st a g e o f curriculum

development, t h ere i s a planned p ro cess o f formative e v a l u a t i o n .

The

r e s u l t s o f the formative e v a l u a t i o n can serve to r e v i s e the implementa­
t i o n pro ce ss , as needed.

When the curriculum i s f u n ctio n in g and

r e v i s i o n s introduc ed from the form ative e v a l u a t i o n , two types of
e v a l u a t i v e process may take p l a c e .

The auth ors i d e n t i f y the summative

e v a l u a t i o n as one where o b j e c t i v e s o r accomplishment i s a s s e s s e d .

The

goal f r e e e v a l u a t i o n c o n s i s t s o f a s s e s s i n g the u n a n ti c i p a te d r e s u l t s .
Information received from both types o f e v a l u a t i o n may be used to

33

REALITY
_____

Learner
Needs

Educator
Needs

S o c iety
Needs

Agreed Upon
Needs

Requirements f o r
Minimal Survival

Ncn-agreed
Upon Needs

Needs Placed in
P r i o r i t y Order

S e lec te d Needs

Management
Objectives

Learning
Objectives

Curriculum
Planning

Dsvelopmi
Curriculum
Implementation
Formative
Evaluation

Goal-free
Evaluation

Figure 1.

The Curriculum Development Cycle Using a
Needs Assessment Base

34

r e f i n e or r e v i s e the t o t a l system a t any p o i n t in t h e development
p ro ce ss .

This model could be a useful tool f o r e d uca tors in any

occupational f i e l d as they g a th e r information from a needs assessment
and pr epare to u t i l i z e thes e data to b uild r e l e v a n t c u r r i c u l a .
Survey Research Methodology
The use o f surveys as a means o f ga th e rin g da ta a r e useful fo r
d e s c r i p t i v e , e x p la n a t o r y , and e x p l o r a t o r y purposes.

They a r e used

p r i m a r i l y in s t u d i e s t h a t have in d iv id u a l people as u n i t s o f a n a l y s i s .
(Babbie, 1975)

The survey may se rve as an a p p r o p r i a t e tool in g a t h e r ­

ing information under c o n d itio n s i d e n t i f i e d by Warwick and Lininger
(1975).

When the d e s i r e d information i s " r ea so n a b le, s p e c i f i c and

f a m i l i a r " to the respondents and when the r e s e a r c h e r has c o n s i d e r a b le
p r i o r knowledge o f th e p a r t i c u l a r problems and the range o f responses
l i k e l y to emerge.

Isa ac and Michael (1981:128) inclu d e four guiding

p r i n c i p l e s o f survey r e s e a r c h which a r e e s s e n t i a l f o r educato rs to use
in a s s e s s i n g needs and s e t t i n g goals f o r curriculum plan nin g.

These

p r i n c i p l e s s t a t e t h a t a l l surveys should be:
1.

Systematic - C a r e f u lly planned and executed to i n s u r e
a p p r o p r i a t e c o n te n t coverage and sound, e f f i c i e n t data
collection.

2.

R e p rese ntative - Closely r e f l e c t the s e l e c t e d p o p u la tio n .

3.

Ob jectiv e - Insure t h a t the data are as ob se rvab le and
e x p l i c i t as p o s s i b l e .

4.

Q u a n t if i a b l e - Yield data t h a t can be expressed in numerical
terms.

35

There a r e c e r t a i n g u i d e l i n e s and concepts the r e s e a r c h e r must be
aware o f when doing survey r e s e a r c h .

Warwick and L in inger have s t a t e d

s u c c i n c t l y the s t r e n g t h s and weaknesses o f survey r e s e a r c h .
The S t r e n g th o f Survey Rese arch:
1.

They a r e useful in g e t t i n g opinions o f p o pu latio ns
sc atte re d geographically.

2.

They a re f l e x i b l e because much information can be o b t a i n e d .

3.

Because the same qu e stio n s a re asked each p e rso n , t h e r e i s
s t r e n g t h to measurement.

Asking each person the same

q u e stio n s allows th e r e s e a r c h e r to impute the same i n t e n t to
a l l respondents g iv in g a p a r t i c u l a r response .
4.

Economy and s t a n d a r d i z a t i o n a r e p o s s i b l e as compared to
interviews.

5.

There i s a l a c k o f i n t e r v i e w e r b ias in the s e l f - a d m i n i s t e r e d
questionnaire.

The Weaknesses o f Survey Rese arch;
1.

Generally a r e s e a r c h e r seldom tap s what i s most a p p r o p r i a t e
to many respondents by d esign in g q ue stio n s t h a t w ill be a t
l e a s t minimally a p p r o p r i a t e to a l l resp on d en ts.

2.

Tends to be s u p e r f i c i a l by comparison with in te r v ie w i n g s in c e
the r e s e a r c h can seldom deal with the c o n te n t o f s o c i a l l i f e
o r develop the feel f o r the t o t a l s i t u a t i o n .

3.

Although f l e x i b l e in one sense (amount o f information t h a t
can be o b t a i n e d ) , surveys r e q u i r e t h a t an i n i t i a l study
design remain unchanged throughout the e n t i r e r e s e a r c h .

36

4.

There i s an a r t i f i c i a l i t y i n h e r e n t in surveys.

Since surveys

cannot measure so c i a l a c t i o n , they can only c o l l e c t s e l f r e p o r t s o f o p in io n s a t a given time.

The a c t o f studying a

given time may a f f e c t t h e r e s p o n d e n t 's o p in io n .

(1975:114)

Development o f the Q u e stio n n a ir e
The f i r s t s t e p in the procedure o f developing a q u e s t i o n n a i r e f o r
survey purposes i s to l i s t s p e c i f i c o b j e c t i v e s to be achieved by the
questionnaire.

(Borg & G a l l , 1979; Babbie, 1975)

O b je c tiv e s must be

d e fin e d a t th e beginning o f the study to f a c i l i t a t e d e c i s i o n making
regarding each s e c t i o n o f th e sample c o n s t r u c t i o n o f the q u e s t i o n n a i r e ,
and methods f o r a n aly zing t h e d a t a .

(Sheps, 1979)

Once the. o b j e c t i v e s a r e e s t a b l i s h e d and the survey in stru m e n t i s
designed , p r i o r t o m ailin g th e f i n a l i n s t r u m e n t , i t i s important to
check fac e v a l i d i t y o f t h e in str u m e n t.

I n d i v i d u a l s o r a v a l i d i t y panel

from a pop u latio n s i m i l a r to th e group o f s u b j e c t s chosen f o r t h e
r e s e a r c h , should be s e l e c t e d to check t h e f a c e v a l i d i t y o f th e survey
instru m e n t.

DiVesta, (1954) and Borg & G a l l , (1979) s t a t e th e panel o f

e x p e r ts should review t h e survey in stru m e n t f o r c l a r i t y , ease o f comple­
t i n g t h e i n s tr u m e n t, ambiguity o f q u e s t i o n s , and i n s t r u c t i o n s .

After

the f a c e v a l i d i t y procedure i s completed, th e q u e s t i o n n a i r e i s ready to
be a dm in istere d to t h e s e l e c t e d s u b j e c t s .
Other useful techn iq u es i d e n t i f i e d by Babbie (1975:131) i s to
su ggest d e a d l in e d a te s f o r completion o f the instrument and the use o f
green paper f o r th e p r i n t i n g o f t h e q u e s t i o n n a i r e .

37

Non-respondents.

The tel ep hone c a l l to non-respondents Is an

e f f e c t i v e measure to secure a higher response r a t e *

Warwick and

Lininger (1975) see the telephone follow-up as an economical way to
ensure a higher res ponse r a t e .

Eckland (1965) advocates the use o f the

telephone to c o n t a c t th ose f a i l i n g to respond, and Wiseman (1973) found
t h a t a telephone follow-up can s u b s t a n t i a l l y i n c r e a s e th e response r a t e
a f t e r the second m ailin g and r e s u l t in a more e f f e c t i v e inst rument
return.
Summary o f Chapter
The review o f the l i t e r a t u r e included the h i s t o r i c a l development
o f a l l i e d h e a l t h c r e d e n t i a l i n g and i t s in f lu e n c e upon a l l i e d h e a l th
education and the c u r r e n t u t i l i z a t i o n o f p e rs o n n e l .

The m u lt i p le

competency h e a l t h personnel review covered t h e p o t e n t i a l use o f such
employees and the personal opinion o f key l e a d e r s in the f i e l d o f
a l l i e d h e a l th ed u catio n concerning t h e i r u t i l i z a t i o n .

Also included was

a l i t e r a t u r e review o f c u r r e n t information reg ardin g needs assessment as
a necessary tool f o r sound cu rriculu m b u i l d i n g .

Survey r es ea r ch

l i t e r a t u r e as a means o f g a th e r in g data f o r the needs assessment
completed the l a s t s e c t i o n o f t h i s c h a p t e r .

Chapter I I I
RESEARCH METHODOLOGY

The resea rch f o r t h i s d e s c r i p t i v e study was designed to measure
the employment p o t e n t i a l o f an in divid ua l with m u l t i p l e competencies in
small h o s p i t a l s in Michigan.

One method proposed by l e a d e r s in the

f i e l d o f a l l i e d h e a l t h educa tion t o provide more e f f e c t i v e h e a lth
manpower u t i l i z a t i o n in small h o s p i t a l s was to prepare p r a c t i t i o n e r s in
two o r more a l l i e d h e a l t h occupation a r e a s .

An employee with m u l t i p l e

competencies who has th e a b i l i t y t o f u n c t i o n in two o r more occupational
s p e c i a l t y are as might be one p o s s i b l e s o l u t i o n to t h e personnel s h o r t ­
ages seen in small h o s p i t a l s .
Included in t h i s c h a p t e r on r es ea r ch methodology i s a d e f i n i t i o n of
the p o p u l a t i o n , the process used in t h e development of the needs a s s e s s ­
ment survey i n s tr u m e n t, da ta g a th e r in g p roce d ures, and an overview of
the procedures used f o r th e d a ta a n a l y s i s .
Population
The population f o r t h i s study was the c h i e f a d m i n i s t r a t o r o f every
h o s p ita l o f 100 bed c a p a c i t y o r l e s s in the S t a t e o f Michigan.

All o f

the h o s p i t a l s used in the study were l i c e n s e d by Medicaid and Medicare
and as such, f u n ctio n under a l l c o n s t r a i n t s and g u i d e l i n e s as mandated
by fed e r a l r e g u l a t i o n s .

There were a t o t a l o f 94 h o s p i t a l s which met

these c r i t e r i a .
38

39

Development o f th e Instrument
The procedure f o r developing th e da ta g a th e r in g instrum ent included
the estab lis h m en t o f t h e o b j e c t i v e s , development o f th e r e s e a r c h ques­
t i o n s , and use o f a panel o f e x p e r t s to review t h e in stru m e nt.
Objectives
The development o f a l i s t o f s p e c i f i c o b j e c t i v e s to be achieved by
the instrument was o f v i t a l importance e a r l y in the r e s e a r c h p ro ce ss .
The survey instru ment was designed as a means to g a t h e r da ta to provide
information concerning the employment p o t e n t i a l o f a m u l t i p l e competency
h e a l th p r a c t i t i o n e r .
1.

The o b j e c t i v e s were:

To determine i f small h o s p i t a l s would employ a p r a c t i t i o n e r
with m u l t i p l e competencies.

2.

To determine i f small h o s p i t a l s were c u r r e n t l y u t i l i z i n g
p r a c t i t i o n e r s with m u l t i p l e competencies.

3.

To determine what combination o f s k i l l s small h o s p i t a l s would
l i k e h e a l th p r a c t i t i o n e r s with m u l t i p l e competencies to
p oss ess.

4.

To determine what e d u c a t i o n a l / t r a i n i n g experien ces small
h o s p i t a l s would l i k e a v a i l a b l e to t r a i n a p r a c t i t i o n e r in
o r d e r to develop an a d d it i o n a l competency.

5.

To determine i f c u r r e n t c r e d e n t i a l i n g o f h e a l th c a r e p r a c ­
t i t i o n e r s a f f e c t the a d m i n i s t r a t o r s ' d e c i s i o n s to employ
persons with m u l t i p l e competencies?

The survey in strum ent was then designed with a s e r i e s o f qu e stio n s
to meet the s t a t e d o b j e c t i v e s .
sections.

The q u e stio n s were arranged i n to t h r e e

40

S ection I , Background Information - was designed t o g a t h e r th e
demographic info rmation about the h e a l t h care f a c i l i t y .
Se c tio n I I , S t a f f i n g - was designed to g a t h e r inform ation about
whether o r not small h o s p i t a l a d m i n i s t r a t o r s would u t i l i z e a person
with m u l t i p l e competencies.

Also covered in t h i s s e c t i o n was what

combination o f s k i l l s an a d m i n i s t r a t o r would l i k e a m u l t i p l e competency
p ra c titio n e r to possess.

Question number f i v e on th e survey in stru m en t

was designed s i m i l a r t o t h e m u l t i p l e competency t e c h n i c i a n q u e s t i o n n a i r e
developed by t h e American Hospital A s soc ia tio n Survey o f Small and
Rural H o s p i t a l s .

( C l a r k , 1980:2)

All o t h e r q u e stio n s were designed

s p e c i f i c a l l y f o r t h i s stu d y .
Se c tion I I I , E du cation/Train ing - was designed to g a t h e r informa­
t i o n concerning t h e a d m i n i s t r a t o r s ' p r e f e r e n c e f o r se vera l a l t e r n a t i v e s
to prepare persons with m u l t i p l e competencies.

This s e c t i o n a ls o

included a q u e stio n which asked f o r p r e f e r e n c e s reg a rd ing t h e c r e d e n t i a l
ing o f i n s t i t u t i o n s o r th e p r o v i s i o n f o r i n s t i t u t i o n a l l i c e n s i n g o f
employees.
The in strum ent was p r i n t e d on a s i n g l e s h e e t o f 11" x 17" paper
and folded to form a sta n d a r d 8-1/2" x 11" format t h a t provided two
pages, f r o n t and back, o r a t o t a l o f fo u r s i d e s .
l i g h t green colored paper.

I t was p r i n t e d on

(A sample survey in strument i s provided in

Appendix A)
A general comment s e c t i o n which allowed the a d m i n i s t r a t o r s an
o p p o r tu n ity to express a d d it i o n a l comments not covered on the
q u e s t i o n n a i r e was pro vided .

In a d d i t i o n , a s e c t i o n was included where

a d m i n i s t r a t o r s were o f f e r e d an o p p o r t u n it y to r e q u e s t a b s t r a c t s o f the
study by l i s t i n g t h e i r names and a d d re s s e s .

41

Research Questions
The study pro vid es inform ation to answer t h e nine major r e s e a r c h
questions.

The l o c a t i o n o f the d a ta from s p e c i f i c p a r t s o f the

q u e s t i o n n a i r e i s shown below.
Source o f Data from
Instrument
Section

Data from Research Questions
1.

Would a d m i n i s t r a t o r s o f small h e a l th

Question
3

c a r e f a c i l i t i e s choose job a p p l i c a n t s
with m u l t i p l e competencies?
2.

Do a d m i n i s t r a t o r s in some small h e a l th
care f a c i l i t i e s avoid h i r i n g a m u l t i p l e
i

competency h e a l t h p r a c t i t i o n e r ?

If

y e s , why?
3.

Do small h e a l t h c a r e f a c i l i t i e s

6A

p resently u t i l i z e health p ra c titio n e r s
in more than one primary a re a o f
responsibility?
4.

What a r e t h e s k i l l a r e a s in which
m u l t i p l e competency h e a l t h p r a c t i t i o n e r s
p r e s e n t l y serve?

5.

What a r e t h e s k i l l a r e a s which adminis­
t r a t o r s o f small h e a l t h c a r e f a c i l i t i e s
p e rc e iv e a m u l t i p l e competency h e alth
care p r a c t i t i o n e r should possess?

6B

42

6.

Is t h e r e a r e l a t i o n s h i p between
the bed c a p a c i t y o f the f a c i l i t y and

and

the d e s i r e to u t i l i z e a m u l t i p l e
competency h e a l t h p r a c t i t i o n e r ?
7.

Is t h e r e a r e l a t i o n s h i p between the
s i z e o f th e p op ulation s e r v i c e area

and

o f the h e a l t h c a r e f a c i l i t y and the
d e s i r e to u t i l i z e a p r a c t i t i o n e r with
m u l t i p l e competencies?
8.

Do the a d m i n i s t r a t o r s o f small h e a lth
c a r e f a c i l i t i e s have a p r e f e r r e d method
f o r the e du ca tio nal p r e p a r a t i o n o f
m u l t i p l e competency h e a l t h
practitioners?

9.

Do a d m i n i s t r a t o r s p r e f e r to see any
change in the c r e d e n t i a l i n g p r a c t i c e s
of a ll i e d health p r a c titio n e r s ?

Face V a l i d i t y
The fac e v a l i d i t y o f th e survey in strum ent was checked by using a
panel o f e x p e r t s r e p r e s e n t i n g a wide range o f a l l i e d h e a l th occupations
and e x p e r t i s e .
Panel o f Experts
A p o rtion o f the panel o f e x p e r t s were s e l e c t e d from a pop ulatio n
s i m i l a r to those s u b j e c t s to be used in the r e s e a r c h s t u d y .

The

remaining panel members were s e l e c t e d because o f t h e i r i n t e r e s t and
background in a l l i e d h e a l th occupational a r e a s , demographics or survey

43

i nstrum ent d e s i g n .
were:

1)

C onsi deratio ns for s e l e c t i o n o f the f i r s t group

Geographical l o c a t i o n :

the h o s p i t a l s were ne ar the

r e s e a r c h e r to allow f o r personal i n t e r v i e w s ; 2)

Bed c a p a c i t y :

the

a d m i n i s t r a t o r s were from h o s p i t a l s with bed c a p a c i t i e s s i m i l a r to those
used in th e stu d y; and 3)

Expert ise o f a d m i n i s t r a t o r s :

the

a d m i n i s t r a t o r s had an i n t e r e s t in and the p r o f e s s i o n a l e x p e r t i s e
necessary to provide a sound c r i t i q u e o f the survey i n s tr u m e n t.
The second group, composing the panel o f e x p e r t s , were s e l e c t e d
because o f t h e i r background and i n t e r e s t s i n :
specialty areas:

1)

A llie d h e a l th

th es e people had s u f f i c i e n t knowledge and e x p e r t i s e

in the occu pational a re a s which were l i s t e d on the survey in s t r u m e n t ;
2)

Demographics:

the person provided a s s i s t a n c e with determining the

s i z e s o f the population s e r v i c e a r e a s ; and 3)
d e sig n:

Survey instru ment

th ese e x p e r ts provided a s s i s t a n c e on the d e s i g n , lay o u t and

format of the survey i n s t r u m e n t .

Included as members o f the panel were

h o sp ita l a d m i n i s t r a t o r s , Michigan Hospital Associatio n o f f i c e r s and
committee members, a l l i e d h e a l t h educational program d i r e c t o r s , a l l i e d
h e a lth f a c u l t y , persons s p e c i a l i z i n g in demographics and survey
in strument development.
checking f o r v a l i d i t y .

A t o t a l o f n in eteen persons were involved in

44

P r o f i l e o f Panel of Experts
Small h o s p i t a l a d m i n i s t r a t o r s (one a d m i n i s t r a t o r
possessed m u l t i p l e competencies in rad iolo gy and
laboratory s k i l l s )

2

Michigan Hospital Associatio n

2

Officers

Michigan Hospital Asso cia tio n Standing Committee
on Small and Rural H o s p i t a l s . All members of
which a d m i n i s t e r small h o s p i t a l s

7

A llie d Health

Educational Administrators

1

A llie d Health

Educational Program D irec tors

2

A llie d Health

Faculty

2

S p e c i a l i s t s in Demographics

1

S p e c i a l i s t s in Survey Instrument Design

2

Total

19

Review Procedure
The follow ing s t e p s were developed to f a c i l i t a t e the implementation
o f the survey instrument review procedure.
Step 1:

At the f i r s t m a i l in g , the panel o f e x p e r ts were requested

to complete th e survey instrum ent and submit comments on:
A. la y o u t and general design
B. number and arrangement o f questions
C.

general i n s t r u c t i o n s to the s u b j e c t s

D. ambiguity and s e n s i t i v i t y o f the questions
Step 2:

The panel members' responses were noted and changes

implemented.
Step 3:

The panel members were again requested to respond to the

rev is ed survey instrument and t h e i r responses were no ted .

45
Step 4:

The f i n a l survey instrum ent r e f l e c t e d t h e changes as

i n d i c a t e d by the r ev ie w ers .
Data Gathering
The following procedures were designed to g a t h e r the d a ta f o r the
needs assessment.
Correspondence
A survey in strum en t and cover l e t t e r were mailed to the 94 adminis­
t r a t o r s of h o s p i t a l s o f 100 bed c a p a c i ty o r l e s s in th e S t a t e o f
Michigan.

The names and addre sses were ob tain ed from th e 1981

Direc to ry o f H o s p ita ls publis hed by t h e Michigan Department o f Public
«

Health and were v a l i d a t e d f o r accuracy with the 1982 Michigan Hospital
A sso c ia tio n D i r e c t o r y o f l i c e n s e d h o s p i t a l s .

(The names o f the

h o s p i t a l s a r e l i s t e d i n Appendix B)
The cover l e t t e r expla in ed the purpose o f th e s t u d y , how the
t a b u l a t e d d a ta were to be used and defined a m u l t i p l e competency h e a l t h
practitioner.

Mr. Donald P o t t e r , D i r e c t o r o f Health P o l i c y f o r the

Michigan Hospital A s so c ia tio n was instrumental in se curing the endorse­
ment and f u l l suppor t o f the Michigan Hospital A sso c ia tio n Committee on
Smaller H o s p i t a l s .

Reference to t h i s endorsement was included in the

f i r s t paragraph o f t h e cover l e t t e r .

(A copy o f a l l correspondence i s

included in Appendix C)
When the a d m i n i s t r a t o r s completed th e survey instrument and
re tu r n e d i t , a thank you l e t t e r was mailed.

A sp e c ia l follow-up

l e t t e r prepared f o r t h e non-respondents was mailed two weeks a f t e r the
i n i t i a l m a ilin g .

I f t h e a d m i n i s t r a t o r s f a i l e d to respond two weeks

46

a f t e r t h e second m a i l i n g , a telep hone c a l l was made to e l i c i t the
info rmation and complete t h e survey in str u m e n t.
Mailing Sequence
The survey in strum ents and l e t t e r s were mailed o u t in the fo llo w ­
ing sequence.
Number o f Survey
Instruments Returned
Event

Date

N

%

February 15, 1982

F i r s t Mailing
A. Survey Instrum ent and
B. Cover L e t t e r

45

48

March 5, 1982

Second Mailing
A. Thank You L e t t e r o r
B. Survey Instrum ent and
L e t t e r to non-respond­
e n ts

18

19

12

13

75

80

March 20, 1982

A.
B.

Telephone Call to
Non-respondents
Third Survey In strument
Mailed i f req u e ste d

Total Returns
Respondents.

The names and ad d re sses o f the respondents were

noted and thank you l e t t e r s were mailed immediately.
Non-Respondents.

I f no r e p l y was r e c e i v e d two weeks a f t e r the

i n i t i a l m a i l i n g , a second l e t t e r and survey in stru m en t were s e n t to the
non-respondent.

I f no response was rec eiv e d two weeks a f t e r t h e second

m a i l in g , a telephone c a l l was made to the non-respondents and they
were requested to e i t h e r respond to th e survey a t t h a t time v i a the
telephone o r to complete a t h i r d survey in stru m ent which was mailed o u t
immediately.

47

Treatment o f the Data
When the survey in stru m e n ts were r e t u r n e d , the d a ta were compiled
r e s p e c t in g g u i d e l i n e s pu b lis hed in the l i t e r a t u r e .
Recording o f t h e D a ta .

When a l l o f t h e survey instruments were

r e t u r n e d , the d a ta were recorded on a m aste r survey instrument ready to
be t a b u l a t e d .
Tabulation o f th e Data.

The da ta were t a b u l a t e d and or gan ized

i n t o t a b l e s f o r visual p r e s e n t a t i o n in Chapter IV.
S t a ti s t i c a l Analysis.

Since t h e e n t i r e i d e n t i f i e d pop u latio n was

surveyed, a l l o f th e r e s e a r c h q u e stio n s were analyzed using only
d e s c r i p t i v e s t a t i s t i c a l pro cedures.
Summary o f Chapter
A mailed survey instru m e n t was t h e chosen means to g a t h e r t h e da ta
f o r t h i s needs assess ment.

The f i r s t s t e p in the process o f survey

instrum ent development was th e e s t a b l is h m e n t o f c l e a r l y defined
objectives.

Face v a l i d i t y o f the in strum ent was e s t a b l i s h e d by a group

o f e x p e r t s w i t h in th e f i e l d s o f a l l i e d h e a l t h , a l l i e d h e a l t h education
and a d m i n i s t r a t o r s o f h e a l t h care f a c i l i t i e s .
The survey instruments were mailed to th e 94 c h i e f a d m i n i s t r a t o r s
o f each small h o s p i t a l o f 100 bed c a p a c i ty o r l e s s in the S t a t e o f
Michigan.

I f the a d m i n i s t r a t o r s f a i l e d to respond to th e second m a i l ­

i n g s telep hone follow-up was done to encourage t h e non-respondents to
complete th e in str u m e n t.

When the d a ta were t a b u l a t e d , t h e a n a l y s i s was

done by using frequency and p e rc en ta g es .

CHAPTER IV
FINDINGS

This c h a p te r p r e s e n t s an a n a l y s i s o f the responses g a th e red from
th e Michigan h o s p i t a l a d m i n i s t r a t o r s who responded to t h i s survey.
There were a t o t a l o f 94 persons surveyed in t h i s study which r e p r e s e n t ­
ed the e n t i r e po pu lation o f c h i e f a d m i n i s t r a t o r s o f Michigan h o s p i t a l s
housing a 100 bed c a p a c i t y o r l e s s .

The data have been analyzed and are

p resen ted in th e t a b l e s which a re arranged t o follow in sequence with
the research questions.

Most o f the t a b l e s a r e designed to p r e s e n t the

number o f response s (N), f r e q u e n c i e s (F) and perc entages (%) plus t o t a l s .
Percentages may no t t o t a l 100% due t o e r r o r s in rounding o f f the
numbers.

Two t a b l e s p r e s e n t a m a tr ix diagram f o r v i s u a l i z a t i o n o f the

d i v e r s e respo n ses.
Response Rates
A t o t a l o f 63 o u t o f 94 survey instrum ents were r e t u r n e d by mail
with

an a d d i t i o n a l 12 a d m i n i s t r a t o r s responding to a telephone follo w -up.

Since the response r a t e to th e in stru m en t was v o l u n t a r y , the number of
respondents answering each q u e stion w ill vary.
A t o t a l o f 75 o r e ig h t y p e rc e n t o f the a d m i n i s t r a t o r s responded to
the q u e s t i o n n a i r e .

However, 100 p e rc e n t o f the a d m i n i s t r a t o r s from the

h o s p i t a l s with 25-49 beds responded while only 62 p e rc e n t of th e adm­
i n i s t r a t o r s from h o s p i t a l s with 50 to 74 beds responded, as shown in

48

49

Table 1.

The r e s u l t o f t h i s study was t h e r e f o r e in flu enced l a r g e l y by

h o s p i t a l s with g r e a t e r than 25 but fewer than 100 beds.
TABLE 1
RESPONSE TO SURVEY BY BED CAPACITY

Number o f Questionnaires
Sent

Completed

Percent
Completed

8

7

87.0

25- 49 .

29

29

100.0

50- 74

27

17

62.0

75-100

30

22

73.0

94

75

79.0

Number o f Beds

Less than 25

Totals

The Findings
The nine res e a r c h q u e stion s were used to o rgan ize the f i n d i n g s .
The questio ns were regrouped under t h r e e general he adings, which follow
the sequence o f q u e stio n s on the survey in stru m e n t:
in form atio n , 2)
Section I :

S t a f f i n g , 3)

Background

Education and t r a i n i n g o f s t a f f .

Background I n f o r m a t io n .

with demographic i n fo rm a tio n.

1)

Two res e a r c h qu estio ns d e a l t

The q uestio ns concerning bed c a p a c i t y o f

the f a c i l i t y and the population s e r v i c e are a o f the f a c i l i t y were
r e l a t e d to the w i l l i n g n e s s of the a d m i n i s t r a t o r s to employ a p r a c t i t i o ­
ner with m u lt i p le competencies.

50

RESEARCH QUESTION #1:

Is t h e r e a r e l a t i o n s h i p between th e bed
c a p a c i ty o f the f a c i l i t y and th e d e s i r e
to u t i l i z e a m u l t i p l e competency h e a l th
practitioner?

The da ta c o l l e c t e d to determine r e l a t i o n s h i p s between t h e bed c a p a c i ty
o f the f a c i l i t y and th e w i l l i n g n e s s to h i r e an in d iv idu a l with m u l t i p l e
competencies i s p res en te d in Table 2.

The a d m i n i s t r a t o r s who responded

to t h i s questio n provided responses which showed t h a t 57 o r 78 p e rc e n t
would u t i l i z e m u l t i p l e competency h e a lth p r a c t i t i o n e r s , while 16 or 22
p e rc e n t would n o t .

The usage o f m u l t i p l e competency h e a l t h p r a c t i t i o n e r s

by a d m i n i s t r a t o r s does not appear to change as t h e number of beds in a
f a c i l i t y i n c r e a s e o r d e cr ea se .
TABLE 2
BED CAPACITY OF THE FACILITY AND WILLINGNESS OF THE
ADMINISTRATOR TO UTILIZE MULTIPLE COMPETENCY
HEALTH PRACTITIONERS
(N-73)

W illingness to U t i l i z e a
M ultip le Competency Health
Practitioner
Bed Capacity
of F a c i l i t y

Would Employ

Would Not Employ

F

%

F

%

5

8

2

3

25- 49 beds

23

31

6

8

50- 74 beds

13

17

4

5

75-100 beds

16

22

4

5

57

78

16

22

Less than 25 beds

Total

51
RESEARCH QUESTION #2:

Table

3 p r e s e n t s the

size of

Is t h e r e a r e l a t i o n s h i p between the s i z e
o f t h e po pulation s e r v i c e a re a o f the
h e a l th f a c i l i t y and t h e d e s i r e to u t i l i z e
a p r a c t i t i o n e r with m u l t i p l e competencies?
da ta c o l l e c t e d r e p r e s e n t i n g th e two v a r i a b l e s :

po p ulation c e n t e r served and w i l l i n g n e s s t o h i r e job a p p l i c a n t s

who possessed m u l t i p l e competencies.

F i f t y - s e v e n a d m i n i s t r a t o r s o r 78

p e rc e n t s t a t e d t h a t they would h i r e a job a p p l i c a n t with m u l t i p l e
competencies.

A d m in is tra to rs o f s e r v i c e a re a s o f l e s s than 1,000

people were the only group evenly d i v id e d , in a l l o t h e r s e r v i c e are as
the a d m i n i s t r a t o r s chose t h e m u l t i p l e competency h e a l t h p r a c t i t i o n e r
much more o f t e n .
TABLE 3
POPULATION SERVICE AREA AND ADMINISTRATOR'S DESIRE TO
UTILIZE MULTIPLE COMPETENCY HEALTH PRACTITIONERS
(N-73)

A d m i n i s t r a t o r ' s Desire to U t i l i z e a
M ultip le Competency Health P r a c t i t i o n e r
Population o f S e r v ic e
Area

Would Employ
F

%

F

1

%

Less than 1,000 people

1

1.000 to 10,000 people

21

29

4

5

10.000 to 25,000 people

20

27

6

8

G re ater than 25,000 people

15

20

5

7

57

78

16

22

Total

1

Would Not Employ

1

52

Se c tion I I :

S taffing.

In S e c tio n I I , the a d m i n i s t r a t o r s were

req u e ste d to respond to q u e stio n s on t h e survey in stru m en t concerning:
1) S e l e c t i o n o f personnel and 2) What s k i l l combinations would they
d e s i r e a p r a c t i t i o n e r w ith m u l t i p l e competencies t o p o ss e s s.
S e l e c t i o n of P e r s o n n e l .
s e l e c t i o n o f p e rso nn el.

Two r e s e a r c h q u e s t io n s d e a l t with the

The f i r s t q u e s t io n was r e l a t e d to th e w i l l i n g ­

ness of t h e a d m i n i s t r a t o r s to choose a jo b a p p l i c a n t with e i t h e r a
s i n g l e o r m u l t i p l e competency.

I f the a d m i n i s t r a t o r s responded t h a t

they would choose a jo b a p p l i c a n t with only t h e s i n g l e competency, they
were then i n s t r u c t e d to go to q u e s t io n 4 on the survey in s t r u m e n t , which
req uested inf or mation concerning the reasons they would not h i r e a
person with m u l t i p l e competencies.
RESEARCH QUESTION #3:

Would a d m i n i s t r a t o r s in small h e a l t h c a r e
f a c i l i t i e s choose job a p p l i c a n t s with
m u l t i p l e competencies?

The m a j o r i t y o f th e res pondents s t a t e d they would s e l e c t a h e a l t h
p r a c t i t i o n e r with m u l t i p l e competencies.

Table 4 i l l u s t r a t e s th e 74

responses to r e s e a r c h q u e s t io n number 3.

F i f t y - n i n e o r 80 p e r c e n t o f

t he respondents r e p l i e d t h a t they would choose a jo b a p p l i c a n t with
m u l t i p l e competencies.

F i f t e e n o r 20 p e r c e n t s t a t e d t h a t they would

choose a job a p p l i c a n t with a s i n g l e competency.

53
TABLE 4
ADMINISTRATORS WHO WOULD CHOOSE
JOB APPLICANTS WITH MULTIPLE COMPETENCIES
(N=74)

Pr eferen ce f o r Job Appl icant

F

%

Would choose a job a p p l i c a n t with
m u l t i p l e competencies

59

80

Would choose a job a p p l i c a n t with
s i n g l e competency

15

20

74

100

Total

RESEARCH QUESTION #4:

Db a d m i n i s t r a t o r s in small h e a l t h c a r e
f a c i l i t i e s avoid h i r i n g a m u l t i p l e
competency h e a l t h p r a c t i t i o n e r ? I f y e s ,
why?

A t o t a l o f f o u r t e e n o u t o f a p o t e n t i a l f i f t e e n respondents perceived
various problems i f they were to h i r e a p r a c t i t i o n e r with m u l t i p l e
competencies, as shown in Table 5.

Seven o r 50 p e r c e n t o f those r e s ­

ponding to t h i s q u e stion f e l t t h a t s a l a r y e x p e c t a t i o n s would be the
most s e r i o u s problem i n h i r i n g a m u l t i p l e competency h e a l t h p r a c t i t i o ­
ner.

Two o f th e v a r i a b l e s , union demands and i n t e r - p e r s o n a l

r e l a t i o n s h i p s , were each s e l e c t e d by f o u r o f th e a d m i n i s t r a t o r s .
Four respondents made comments in th e c atego ry " o t h e r " .
comments were:
competency"; 2)

1)

Their

"Scheduling problems--!ong term problems with

"We have pr ogressed beyond j a c k - o f - a l l - t r a d e s ,

m u l t i p l e competencies i s not a new con ce p t" ; 3)

"Individua l would work

in only most needed sp e cia lty -w o u ld need only one d i s c i p l i n e " ; 4)

"I

54
have done i t myself and have employed such a person; t h e r e i s too much
c o n f l i c t about which t a s k t o perform f i r s t " .
TABLE 5
REASONS WHY ADMINISTRATORS AVOID HIRING
MULTIPLE COMPETENCY HEALTH PRACTITIONERS
(N=14)

Perceived Problems in Hiring
M u ltip le Competency Health
Practitioners

F

Pe rcent o f Those
Responding to Question

S a lary E xpectations

7

50

6

43

Credenti a l i ng Agenci es

5

36

Union Demands

4

29

I n t e r - p e r s o n a l R e la ti o n s h ip s

4

29

Other

4

29

Not as q u a l i f i e d

i

*The respondents were requ e ste d to s e l e c t as many o f the problems as
a p p li e d to t h e i r personal s i t u a t i o n .
M ultip le Competency P r a c t i t i o n e r s .
with m u l t i p l e competency p r a c t i t i o n e r s .

Three r e s e a r c h q u e stio n s d e a l t
Research q u e stion number f i v e

was concerned with the c u r r e n t use o f p r a c t i t i o n e r s with m u l t i p l e
competencies.

Research qu e stion s s i x and seven d e a l t with what combina­

t i o n s o f s k i l l s do such p r a c t i t i o n e r s c u r r e n t l y p o s s e s s , and what
combinations o f s k i l l s would a d m i n i s t r a t o r s d e s i r e a p r a c t i t i o n e r with
m u l t i p l e competencies t o possess in the f u t u r e .

55

RESEARCH QUESTION #5:

Do small h e a l t h c are f a c i l i t i e s p r e s e n t l y
u t i l i z e h e a l th p r a c t i t i o n e r s in more than
one primary area o f r e s p o n s i b i l i t y ?

I t can be seen from Table 6 t h a t 72 h o s p i t a l a d m i n i s t r a t o r s responded
to t h i s r e s e a r c h q u e s t i o n .

Forty o r 56 p e r c e n t o f the respondents

rep o rted t h a t they employ persons with m u l t i p l e competencies while the
remaining 32 or 44 p e rc e n t do n o t .

In the f a c i l i t i e s t h a t r ep o r te d

p r e s e n t l y u t i l i z i n g i n d i v i d u a l s with m u l t i p l e competencies, 71 p e rc e n t
o f the 75-100 bed c atego ry u t i l i z e them while 48 p e rc e n t o f the 25-49
bed s i z e c ateg o ry u t i l i z e such a person.

In the 0-24 and 50-74 bed

s i z e c a t e g o r i e s t h a t r e p o r t e d , 50 p e rc e n t responded t h a t they do
u t i l i z e i n d i v i d u a l s with m u l t i p l e competencies.
TABLE 6
ADMINISTRATORS CURRENTLY UTILIZING HEALTH CARE
PRACTITIONERS IN MORE THAN ONE AREA OF RESPONSIBILITY
(N=72)

Hospital Bed Size
Employer P r a c t i c e

0-24

25-49

50-74

75-1QQ

Total

?

%

?

F %

F

F

U t i l i z e p r a c t i t i o n e r s in
more than one area of
responsibility

3

50

14

48

8

50

15

71

40 56

Do not u t i l i z e p r a c t i t i o n e r s
in more than one area o f
r e s p o n s i b i 1i t y

3

50

15

52

8

50

6

29

32 44

%

%

%

56
RESEARCH QUESTION #6:

What a r e the s k i l l are as in which
m u l t i p l e competency h e a lth p r a c t i t ­
io n ers p r e s e n t l y serve?

Table 7 i s a m atrix p r e s e n t i n g d a ta in suppor t o f an answer to r e s e a r c h
qu estio n number 4.

A t o t a l o f 69 a d m i n i s t r a t o r s l i s t e d 33 v a rio u s s k i l l

combinations in which h e a l t h p r a c t i t i o n e r s with m u l t i p l e competencies
a r e p r e s e n t l y employed.

R e sp ir ato r y therapy and r a d io lo g y t e c h n ic i a n s

a r e the most o f t e n l i s t e d a r e a s f o r a primary s k i l l with 19 each.
were a number o f s i n g l e e n t r i e s
(EKG) was the most o f t e n

f o r primary s k i l l s .

There

Electrocardiogram

chosen are a f o r a secondary s k i l l with 17

selections.
RESEARCH QUESTION § 7 :

What a re th e s k i l l a re as which adminis­
t r a t o r s o f small h e a l th c a r e f a c i l i t i e s
p e rc eiv e a m u l t i p l e competency h e alth
c a r e p r a c t i t i o n e r should possess?

Tables 8 through 13 w ill be used to i l l u s t r a t e the data from res e a r c h
question 7.

Tables 8 through 12 w ill p r e s e n t the f i r s t and second

choice o f a secondary s k i l l a re a f o r the l i s t e d primary s k i l l a r e a .
Table 13 i s in the form o f a matrix and shows the various s k i l l combina­
t i o n s , both primary and secondary s k i l l a r e a s , t h a t were d e s i r e d by
a d m i n i s t r a t o r s but which were not l i s t e d on the survey in stru m e n t.
The survey q u e s t io n n a ir e

l i s t e d f i v e primary s k i l l a r e a s :

A.

R e sp ir ato r y th e r a p y ,

Table 8

B.

Surgical t e c h n i c i a n ,

Table 9

C.

Medical t e c h n o l o g i s t , Table 10

D.

Radiographer, Table 11

E.

Physical therapy a s s i s t a n t , Table 12

The respondents were to choose a f i r s t and second choice o f the d e s i r e d
secondary s k i l l to accompany the s t a t e d primary s k i l l .

Based on t h e i r

57
TABLE 7
SKILL AREAS IN WHICH MULTIPLE COMPETENCY
PRACTITIONERS PRESENTLY SERVE
(N=41)

Total

1
1

6
4
2

1
3

2

2
1

2

3
3
1

1
1

1
1
1

1
1
1
1
1
1
1
1
1
19 19

11

8

4

3

2

1

1

1

Total

Pharmacist

Maintenance

Med. Tech.

Aide
Nurse's

Emergency

Medicine

1

Nuclear

5

Practical

8

Licensed

Nurse
Lab

Registered

2
7

Medical

Electrocardiogram (EKG)
U ltra sonoqraphy
Pulmonary Function/EKG
Nuclear Medicine
Radiographer
Medical Lab
Central Supply
Pulmonary Function
Ul tra sonography/Nuc. Med
R e sp ir ato r y Therapy
Surgical Technician
Anesthesia
Audiometry
Building S e c u ri t y
Emergency Medical Tech
Employee Development
Health Education
M a te r ia ls Management
P a t i e n t Education
Purchasing Agent
Radiographer/EKG
Weiqht Control

Respiratory

Radiology

Tech

Secondary S k i l l

Therapy

Nurse

Primary S k i l l

17
8
6
5
5
4
3
3
3
2
2
1
1
1
1
1
1
1
1
1
1
1
69

58

p r o j e c t i o n s o f f u t u r e h e a l t h s e r v i c e needs, the res pondents were asked
i f t h e r e were o t h e r competency combinations they would d e s i r e f o r t h e i r
f a c i l i t y and t h e s e d a ta a r e p res en te d in Table 13.
Since th e d a ta f o r r e s e a r c h q u e s tio n 7 i s p r e s e n te d in 6 t a b l e s , a
summary o f tho se f i n d i n g s i s presen te d f o r c l a r i f i c a t i o n .

When r e s p i r a ­

t o r y th erapy was l i s t e d as the primary s k i l l , f o r t y - s e v e n p e rc e n t o f the
respondents chose e l e c t r o c a r d i o g ra m ( EKG) as t h e f i r s t choice o f a
secondary s k i l l .

S i x t y - t h r e e p e r c e n t o f the res po ndents s e l e c t e d a

l i c e n s e d p r a c t i c a l nurse as t h e i r f i r s t choice o f secondary s k i l l to
accompany t h e primary s k i l l o f s u r g i c a l t e c h n i c i a n .

F i f t y - o n e p e rc e n t

of th e respondents chose rad io log y as t h e i r f i r s t choice o f a secondary
s k i l l to accompany t h e primary s k i l l o f medical technology.

When r a d i o ­

logy was l i s t e d as t h e primary s k i l l , f i f t y - t h r e e p e r c e n t o f the
respondents s e l e c t e d u l t r a sonography as the f i r s t choic e o f a secondary
sk ill.
Forty-seven p e r c e n t o f th e respondents s e l e c t e d r e s p i r a t o r y th erap y
as the f i r s t choice o f secondary s k i l l s to accompany th e primary s k i l l
o f physical th erapy a s s i s t a n t .
The m atrix p res en te d in Table 13 shows t h a t t h e most commonly
l i s t e d primary s k i l l a re a was r e g i s t e r e d nurse (RN) and l i c e n s e d
p r a c t i c a l nurse (LPN).
p a t i e n t e d u ca tion .

The most commonly s e l e c t e d secondary s k i l l was

59

R e sp ir a to r y therapy as a primary s k i l l i s shown in Table 8.
Twenty-three o r 47 p e rc e n t o f th e respondents s e l e c t e d e le c tr o c a r d io g ra m
as t h e i r f i r s t choice f o r a secondary s k i l l , while n u c le a r medicine and
u l t r a sonography was l i s t e d by only one ind ivid ua l in each c a s e .

Twenty

a d m i n i s t r a t o r s o r 49 p e r c e n t s e l e c t e d e le c tr o c a r d io g ra m as t h e i r second
choice while none o f t h e respondents s e l e c t e d th e v a r i a b l e s n u c le a r
medicine or u l t r a sonography.
No respo ndent s e l e c t e d " other" as a f i r s t c h o ic e , while 2 persons
o r 5 p e rc e n t s e l e c t e d i t as a second choice and l i s t e d e le ctro ca rd io g ra m
and nur sing as t h e i r need.
TABLE 8
SKILLS ADMINISTRATORS PERCEIVE A MULTIPLE COMPETENCY
HEALTH PRACTITIONER SHOULD POSSESS WITH
RESPIRATORY THERAPY AS THE PRIMARY SKILL
(N=49)

F i r s t Choice
Secondary S k i l l

Second Choice

F

%

F

%

Electrocardiogram

23

47

20

49

Pulmonary Function

20

41

17

41

Laboratory

4

8

2

5

Nuclear Medicine

1

2

0

0

U l t r a sonography

1

2

0

0

Other

0

0

2

5

60

Surgical t e c h n i c i a n as a primary s k i l l i s shown in Table 9.
Twenty-seven o r 63 p e r c e n t o f th e respondents s e l e c t e d l i c e n s e d p r a c t i ­
cal nurse (LPN) as t h e i r f i r s t choice f o r a secondary s k i l l , while only
one, o r two p e r c e n t , in d iv id u a l s e l e c t e d th e v a r i a b l e e le c tr o c a r d io g ra m .
In the second c h o ic e , twenty-two o r 73 p e rc e n t o f t h e a d m i n i s t r a t o r s
s e l e c t e d c e n t r a l supply, while only one ind iv idu al s e l e c t e d the v a r i a b l e
"other" and l i s t e d o b s t e t r i c s .
TABLE 9
SKILLS ADMINISTRATORS PERCEIVE A MULTIPLE COMPETENCY
HEALTH PRACTITIONER SHOULD POSSESS WITH
SURGICAL TECHNICIAN AS A PRIMARY SKILL
(N=43)

F i r s t Choice
Secondary S k i l l

Second Choice

F

%

27

63

5

17

Central Supply

15

35

22

73

Electrocardiogram

1

2

7

Other

0

Licensed P r a c t i c a l

Nurse

2
0

F

1

%

2

61

Table 10 i l l u s t r a t e s medical technology as a primary s k i l l a r e a .
In the f i r s t choice c a t e g o r y , twenty o r 51 p e r c e n t o f the a d m i n i s t r a t o r s
s e l e c t e d r a d i o l o g y , while one o f the responding a d m i n i s t r a t o r s s e l e c t e d
the v a r i a b l e e le c t r o c a r d i o g ra m .

One o f the respondents s e l e c t e d the

v a r i a b l e "other" which was l i s t e d as t o x i c o l o g i s t .
TABLE 10
SKILLS ADMINISTRATORS PERCEIVE A MULTIPLE COMPETENCY
HEALTH PRACTITIONER SHOULD POSSESS WITH
MEDICAL TECHNOLOGY AS A PRIMARY SKILL
(N=39)

F i r s t Choice
Secondary S k i l l

Second Choice

F

%

F

%

Radiology

20

51

4

13

E le c t r o c a r d i ogram

11

28

9

28

Nuclear Medicine

4

10

7

22

Pulmonary Function

3

8

7

22

R e sp iratory Therapy

1

3

4

13

Other

0

0

1

3

62

Radiology as a primary s k i l l i s portrayed in Table 11.

Twenty-

four or 53 p e rc e n t o f th e respondents s e l e c t e d u l t r a sonography as t h e i r
f i r s t choice f o r a secondary s k i l l a r e a , while no respondent s e l e c t e d
the s k i l l o f pulmonary f u n c t i o n , r e s p i r a t o r y th erap y o r " o t h e r " .
F if tee n or 41 p e rc en t o f the a d m i n i s t r a t o r s s e l e c t e d n u c le a r medicine
as t h e i r most d e s i r e d second choice f o r a secondary s k i l l , while no
respondent s e l e c t e d pulmonary fu n c tio n or " o t h e r " .
TABLE 11
SKILLS ADMINISTRATORS PERCEIVE A MULTIPLE COMPETENCY
HEALTH PRACTITIONER SHOULD POSSESS WITH
RADIOLOGY AS A PRIMARY SKILL
(N=45)

F i r s t Choice

Second Choice

Secondary S k i l l

F

%

F

%

Ultra Sonography

24

53

5

14

Medical Technology

11

24

6

16

Nuclear Medicine

6

15

15

41

Electrocardiogram

4

9

8

22

R e sp iratory Therapy

0

0

3

8

Pulmonary Function

0

0

0

0

O ther

0

0

0

0

63

Physical therapy a s s i s t a n t i s pr esented as the primary s k i l l in
Table 12.

Eighteen o r 47 p e r c e n t o f the respondents s e l e c t e d r e s p i r a ­

to r y therapy as t h e i r f i r s t choice f o r a secondary s k i l l , while four or
10 p e rc ent o f the i n d i v i d u a l s s e l e c t e d the v a r i a b l e " o th e r " and l i s t e d
occupational therapy a s s i s t a n t and u l t r a sonography.

In the second

choice c a t e g o r y , twelve or 43 p e r c e n t o f t h e a d m i n i s t r a t o r s s e l e c t e d
r e s p i r a t o r y t h e r a p y , while only 2 i n d i v i d u a l s s e l e c t e d medical t e c h ­
nology.
TABLE 12
SKILLS ADMINISTRATORS PERCEIVE A MULTIPLE COMPETENCY
HEALTH PRACTITIONER SHOULD POSSESS WITH
PHYSICAL THERAPY ASSISTANT AS A PRIMARY SKILL
i

"""

1

(N=38)

F i r s t Choice
Secondary S k i l l

Second Choice

F

%

F

%

R e sp iratory Therapy

18

47

12

43

Electrocardiogram

11

29

10

36

Medical Technology

5

13

2

7

Other

4

10

4

14

64
TABLE 1 3
ADDITIONAL DESIRED SKILL COMBINATIONS FOR
PRACTITIONERS WITH MULTIPLE COMPETENCIES
(N-21)

Medical Records
Physical Therapy
Patient Education
|
Audiometry
Business Office Superv.
Medical Lab
Nuclear Medicine
Occupational Therapy
Pharmacy Technician
Pulmonary Function
Respiratory Therapy
Speech & Language Pathology
S tatistician
Ultra sonography

P a t i e n t Education
Audiometry & Vi si si on
Tes tinq
Medical Lab
Discharge Planninq
Q u a lity Assurance
Radiographer
C ertified Athletic
Trainer
C e r t i f i e d Orth
Community Health Aide
Computer
Exercise Physiology
I n f e c t i o n Control
L ib ra ry S k i l l s
LPN
Medical Records
Occupational Therapy
Personnel D irec to r
Purchasing Agent
R e s p i r a t o r y Therapy
Speech Aide
S t a f f Education
U ltra sonography

3

3

Total

9

Secondary S k i l l Area

6
1

1
1
1
1

Total

LPN/RN

Primary S k i l l Area

1

1
1

1

1
1
1

1
1
1
1
1
1
1
1

1
1
1
1
1
1
1
1

1
1
1
1
1
1
1

1
1
1
1
1
1
1
5 4

3 2 1

1 1 1 1 1

3
3
2
2
2 ...

1 1 1

1

1

65
Table 13 p r e s e n t s a m atrix diagram of the respondents d e s i r e d
combinations of t h e i r perceived f u t u r e needs f o r m u l t i p l e competency
p e rs o n n e l.

A t o t a l o f 21 a d m i n i s t r a t o r s l i s t e d 29 o r 33 s e p a r a t e s e t s

of s k i l l s .

The most commonly l i s t e d primary s k i l l was LPN/RN (9) and

the most commonly l i s t e d secondary s k i l l was p a t i e n t education ( 6 ) .

In

a d d i t i o n , t h e r e was a wide range o f o t h e r primary and secondary s k i l l
a re as i n d i c a t e d , which r e f l e c t the d i v e r s e needs o f the in div id u a l
small h o s p i t a l .
Section I I I :

Education and t r a i n i n g needs.

This s e c t i o n o f the

survey instrument requ ested information r e l a t e d to res ea rch q u e stio n s
number 8 and 9.

The a d m i n i s t r a t o r s were re q u ested to respond to the

p r e f e r r e d method o f education p r e p a r a t i o n o f a p r a c t i t i o n e r with
m u l t i p l e competencies.

The second qu estio n in t h i s s e c t i o n d e a l t with

information concerning the p r o f e s sio n a l c r e d e n t i a l i n g process as i t
i n f lu e n c e s e f f e c t i v e employee u t i l i z a t i o n .
RESEARCH QUESTION #8:

Do the a d m i n i s t r a t o r s o f small h e a l th
c a r e f a c i l i t i e s have a p r e f e r r e d method
f o r the educa tional p r e p a r a t i o n o f
m u l t i p l e competency h e alth p r a c t i t i o n e r s ?

Table 14 i l l u s t r a t e s the responses o f r es ea r ch q uestio n number 8.
They were asked to s e l e c t a f i r s t and second choice to the types of
educa tional experience they p r e f e r r e d in o r d e r to prepare m u l t i p l e
competency h e a lth p r a c t i t i o n e r s .

Sixty-seven people s e l e c t e d a f i r s t

c h o ic e, while only 54 s e l e c t e d a second choice.

T h i r t y - f i v e o r 52

p e rc ent of the respondents who l i s t e d a f i r s t choice s e l e c t e d r e g u l a r
c o l l e g i a t e lev e l programming as th e p r e f e r r e d method to pr epare m u lt i p le
competency h e alth p r a c t i t i o n e r s .

Twenty-two or 41 p e rc e n t o f those who

l i s t e d a second choice d e s i r e d t h a t a m u l t i p l e competency h e a l th

66

p r a c t i t i o n e r should be prepared through c l a s s e s in t h e i r f a c i l i t i e s
o f f e r e d by an o u t s i d e i n s t i t u t i o n .

Only f o u r o r 6 p e rc e n t o f those

responding f e l t t h a t t r a i n i n g should be provided by t h e i r own in-house
s t a f f , while f i v e o r 9 p e rc e n t o f those givin g a second choice s t a t e d
t h a t r e g u l a r c o l l e g i a t e le v e l programming was t h e d e s i r e d method to t r a i n
a m u l t i p l e competency h e a l t h p r a c t i t i o n e r .
t h e v a r i a b l e " other" and s t a t e d :

Two a d m i n i s t r a t o r s s e l e c t e d

1) "depends on p o s i t i o n to be t r a i n e d

f o r " and 2) "based on i n d iv id u a l ne eds."
TABLE 14
METHODS PREFERRED BY ADMINISTRATORS FOR EDUCATING
A MULTIPLE COMPETENCY HEALTH PRACTITIONER
(N=67)

F i r s t Choice

Second Choice

Educational Experience

F

%

F

%

Regular A sso cia te o r Baccalaure a t e lev e l c o l l e g i a t e programs

35

52

5

9

Continuing education programs
in your geographic are a

19

28

21

39

Trained by an o u t s i d e i n s t i tu tio n t h a t presents classes
in your f a c i l i t y

7

10

22

41

Trained by your in-house s t a f f

4

6

6

11

O th er

2

3

0

0

67

RESEARCH QUESTION #9:

Do a d m i n i s t r a t o r s p r e f e r to see any
change in the c r e d e n t i a l i n g p r a c t i c e s
o f a l l i e d h e a l th p r a c t i t i o n e r s ?

The p refe ren c e o f a d m i n i s t r a t o r s f o r changes in the c r e d e n t i a l i n g
p r a c t i c e o f a l l i e d h e a l t h p r a c t i t i o n e r s i s shown in Table 15.

Fo rty -

one o r 55 p e rc e n t o f t h e a d m i n i s t r a t o r s responding f e l t t h a t t h e r e was
no need t o change t h e p r e s e n t c r e d e n t i a l i n g process f o r a l l i e d h e a l t h
practitioners.

Nine o r 12 p e rc e n t o f the a d m i n i s t r a t o r s would p r e f e r a

c r e d e n t i a l i n g process t o allow h o s p i t a l s to c e r t i f y th e competency o f
t h e i r employees.
Three o r 4 p e r c e n t o f th e a d m i n i s t r a t o r s responded with w r i t t e n
comments to th e v a r i a b l e " o t h e r " :

1) "I su pp ort t h e Michigan Hospital

Associa tio n p o s i t i o n " ; 2) "A uniform c r e d e n t i a l i n g proce ss o r s t a t e
c r e d e n t i a l i n g with common g u i d e l i n e s to allow people to be recognized
f o r r e s p o n s i b i l i t i e s , educational requirements and c on sid er consumer
needs", and 3) "There should be ano th er way to look a t pe ople ."
TABLE 15
PREFERRED CHANGES IN THE CREDENTIALING PRACTICES
OF ALLIED HEALTH PRACTITIONERS
(N=75)

C r e d e n tia lin g P r a c t i c e

F

%

No change in the c r e d e n t i a l i n g process

41

55

Educational i n s t i t u t i o n a c c r e d i t a t i o n

24

33

Hospital i n s t i t u t i o n l i c e n s u r e

9

12

Other

3

4

77

104

Total

C hapter V

SUMMARY, CONCLUSIONS, RECOMMENDATIONS, AND REFLECTIONS

The primary purpose o f t h i s d e s c r i p t i v e study was to explo re the
employment p o t e n t i a l o f a h e a l th p r a c t i t i o n e r with m u l t i p l e competencies
in small h o s p i t a l s in Michigan.

For use in t h i s s t u d y , a m u l t i p l e

competency h e a l th p r a c t i t i o n e r was defined as an i n d iv id u a l who uses
s e l e c t e d s k i l l s and knowledge from two o r more a l l i e d h e a l t h occupa­
tions.

The need to exp lo re the p o t e n t i a l employment of the

p r a c t i t i o n e r with m u l t i p l e competencies i s supported by v ariou s l e a d e r s
in a l l i e d h e a l th e d u c a ti o n .

While many i n s t i t u t i o n s appear to be

s u f f e r i n g from a shortage o f a l l i e d h e a l th worke rs, the la c k of person­
nel seems to be most acu te in the small h o s p i t a l .
The small h o s p i t a l s provide f o r consumer h e a l t h c a r e needs which
are o f t e n considered to be r o u t i n e and r a t h e r l i m i t e d in scope.

These

s e r v i c e s , however, a r e being performed by h ig h ly s k i l l e d t e c h n i c i a n s ,
who because o f the requirements of c r e d e n t i a l i n g a g e n c i e s , a r e narrowly
specialized.

Large h o s p i t a l s and medical c e n t e r s have s u f f i c i e n t case

loads to be ab le to use the re q u ir e d s p e c i a l i z e d a l l i e d h e a l th person­
n e l , but small h o s p i t a l s o f te n do not have s u f f i c i e n t case loads to
f u l l y u t i l i z e th e same category o f p e rs o n n el.
The a d m i n i s t r a t o r s o f t h es e f a c i l i t i e s could b e n e f i t from being
a b le to use t h e i r a l l i e d h e a l th personnel in f l e x i b l e ways t h a t would

68

69

permit them to f u n c t i o n in two o r more h e a l t h s p e c i a l t y a r e a s .

Not only

would t h i s allow the small h o s p i t a l to remain economically v i a b l e , but
more i m po rtantly would enable t h e f a c i l i t y to o f f e r a f u l l range o f
e s s e n t i a l s e r v i c e s d e s p i t e th e l i m i t e d number o f a v a i l a b l e h e a l t h prac­
t i t i o n e r s in the v a ri ou s s p e c i a l t y a r e a s .
I t was e s t a b l i s h e d through a review o f c u r r e n t l i t e r a t u r e t h a t on
a n a tio n a l s c a l e , a personnel sho rta g e e x i s t s in small h o s p i t a l s .

It

was n e c e s s a r y , t h e r e f o r e , to confirm through d e s c r i p t i v e d a t a , whether
h o s p i t a l a d m i n i s t r a t o r s in Michigan perceived the m u l t i p l e competency
h e a l t h p r a c t i t i o n e r as an a l t e r n a t i v e to conventional s t a f f i n g p r a c t i c e s .
The s u b j e c t s f o r t h i s study were the a d m i n i s t r a t o r s o f small
h o s p i t a l s o f 100 bed c a p a c i t y o r l e s s in Michigan.

An examination of

the da ta c o l l e c t e d from the needs assessment survey i n s t r u m e n t , i n d i c a t ­
ed t h a t th e m a j o r it y o f the h o s p i t a l a d m i n i s t r a t o r s re p o r te d they would
choose a job a p p l i c a n t with m u l t i p l e competencies over a jo b a p p l i c a n t
with a s i n g l e competency.
To o b t a i n the d a t a needed f o r making recommendations on th e employ­
ment p o t e n t i a l o f a h e a l t h p r a c t i t i o n e r with m u l t i p l e competencies, nine
res e a r c h q u e stio n s were examined.

The remainder o f t h i s c h a p t e r focuses

on the f i n d in g s from the r e s e a r c h q u e s t i o n s , the conclusions based on
the f i n d i n g s , recommendations, and th e personal r e f l e c t i o n s o f the
researcher.
Summary o f th e Findings
In Chapter IV was p resente d t h e f i n d i n g s from th e data c o l l e c t e d
f o r the needs assess ment.
q u e stio n s as fo llo w s:

These da ta a r e now summarized by r e s e a r c h

70

RESEARCH QUESTION #1:

I s t h e r e a r e l a t i o n s h i p between the bed
c a p a c i ty o f t h e f a c i l i t y and the d e s i r e
to u t i l i z e a m u l t i p l e competency h e a lth
practitioner?

There does no t appear t o be a r e l a t i o n s h i p between t h e bed c a p a c i ty of
t h e i r r e s p e c t i v e h e a l t h f a c i l i t i e s and whether o r n o t t h e a d m i n i s t r a t o r s
would employ a h e a l t h p r a c t i t i o n e r with m u l t i p l e competencies.
RESEARCH QUESTION #2:

Is t h e r e a r e l a t i o n s h i p between the s i z e
o f t h e p op ulation s e r v i c e are a o f the
h e a l t h c a r e f a c i l i t y and t h e d e s i r e to
u t i l i z e a p r a c t i t i o n e r with m u l t i p l e
competencies?

There does no t appear t o be a r e l a t i o n s h i p between t h e population
s e r v i c e a re a o f the f a c i l i t y and the d e s i r e o f the a d m i n i s t r a t o r s to
employ a p r a c t i t i o n e r with m u l t i p l e competencies.
RESEARCH QUESTION #3:

Would a d m i n i s t r a t o r s o f small h e a lth
c a r e f a c i l i t i e s choose job a p p l i c a n t s
with m u l t i p l e competencies?

The a d m i n i s t r a t o r s had a p o s i t i v e response to t h e choic e of a job
a p p l i c a n t with m u l t i p l e competencies.

F i f t y - n i n e or e i g h t y p ercen t of

the respondents s t a t e d they would s e l e c t a h e a l th p r a c t i t i o n e r with
m u l t i p l e competencies, r a t h e r than a p r a c t i t i o n e r with a s i n g l e
competency.
RESEARCH QUESTION #4:

Do a d m i n i s t r a t o r s in some small h e a l th
care f a c i l i t i e s avoid h i r i n g a m u lt i p le
competency h e a l t h p r a c t i t i o n e r ? I f y e s ,
why?

Approximately 20 p e rc e n t o f the a d m i n i s t r a t o r s i n d i c a t e d they would
avoid h i r i n g a p r a c t i t i o n e r with m u l t i p l e competencies.

S alary

71

e x p e c ta ti o n s were s e l e c t e d by the seven o r f i f t y p e rc en t o f th ose who
responded to t h i s q u e s t i o n .

The second h i g h e s t reason s t a t e d f o r not

h i r i n g such a p r a c t i t i o n e r was t h a t they be lie v e d t h e p r a c t i t i o n e r with
m u l t i p l e competencies was not as q u a l i f i e d as t h e p r a c t i t i o n e r with a
s i n g l e competency.
RESEARCH QUESTION #5:

Do small h e a l th c a r e f a c i l i t i e s p r e s e n t l y
u t i l i z e h e a l t h p r a c t i t i o n e r s in more than
one primary are a o f r e s p o n s i b i l i t y ?

F i f t y - s i x p e rc e n t o f the h o s p i t a l a d m i n i s t r a t o r s responded t h a t they
were c u r r e n t l y u t i l i z i n g a p r a c t i t i o n e r in more than one a re a of
responsibility.

F o r t y - f o u r p e rc e n t o f the a d m i n i s t r a t o r s responded

t h a t they did no t u t i l i z e t h e i r personnel in more than one area o f
responsibility.
RESEARCH QUESTION #6:

What a r e th e s k i l l a r e a s in which m u l t i p l e
competency h e a l th p r a c t i t i o n e r s p r e s e n t l y
serve?

Hospital a d m i n i s t r a t o r s a r e c u r r e n t l y using t h e i r employees in varying
combinations.

R e sp ir a to r y Therapy and rad io lo g y were t h e h i g h e s t

ranked primary s k i l l a r e a s .

Electrocardiogram followed c l o s e l y by

ultraso nogra phy were th e most widely u t i l i z e d secondary s k i l l s .

The

a d m i n i s t r a t o r s l i s t e d t h i r t y - t h r e e va rio u s s k i l l combinations which
t h e i r a l l i e d h e a l t h p r a c t i t i o n e r s p r e s e n t l y p o ss es s.

The d i v e r s e s k i l l

combinations on th e m atrix diagram (se e page 57) r e f l e c t the highly
i n d i v i d u a l i z e d employment needs o f each i n s t i t u t i o n .
RESEARCH QUESTION #7:

What a r e th e s k i l l a r e a s which adminis­
t r a t o r s o f small h e a l th c a r e f a c i l i t i e s
p e rc e iv e a m u l t i p l e competency h e a l th
care p r a c t i t i o n e r should possess?

72

The s k i l l a re a s which a d m i n i s t r a t o r s would l i k e t h e i r p r a c t i t i o n e r with
m u l t i p l e competencies t o possess a r e as f ollo w s:

Forty-seven p e rc e n t

o f the respondents chose e le ctr o ca r d io g ra m as t h e i r f i r s t choice o f a
secondary s k i l l to accompany th e primary s k i l l a re a o f r e s p i r a t o r y
t h era p y.

When s u r g i c a l t e c h n i c i a n was l i s t e d as the primary s k i l l ,

s i x t y - t h r e e p e rc e n t o f the respondents s e l e c t e d l i c e n s e d p r a c t i c a l
nurse as t h e i r f i r s t choice o f a secondary s k i l l .

F i f t y - o n e p e rc e n t of

the a d m i n i s t r a t o r s would l i k e t h e secondary s k i l l of rad io lo g y to
accompany the primary s k i l l o f medical technology.

When radiology was

l i s t e d as th e primary s k i l l , f i f t y - t h r e e p e rc ent o f t h e respondents
chose the secondary s k i l l o f ultraso nography as t h e i r f i r s t c h o ic e.
Forty-seven p e rc e n t o f the respondents s e l e c t e d r e s p i r a t o r y therapy as
t h e i r f i r s t choice o f a secondary s k i l l to accompany the primary s k i l l
o f physical therapy a s s i s t a n t .

To accompany th e primary s k i l l o f r e g i s ­

t e r e d o r l ic e n s e d p r a c t i c a l n u r s e , th e a d m i n i s t r a t o r s d e s i r e d the
p r a c t i t i o n e r to develop the secondary s k i l l o f p a t i e n t edu catio n .
RESEARCH QUESTION #8:

Do a d m i n i s t r a t o r s o f small h e alth care
f a c i l i t i e s have a p r e f e r r e d method f o r
the p r e p a r a t i o n o f a m u l t i p l e competency
health p rac titio n er?

F ifty-tw o p e rc e n t o f t h e a d m i n i s t r a t o r s p r e f e r r e d , as a f i r s t c h o ic e,
to have a m u l t i p l e competency h e a l th p r a c t i t i o n e r educated in a r e g u l a r
c o l l e g i a t e program.

Continuing education programs was the second most

o f t e n s e l e c t e d v a r i a b l e in the f i r s t choice c ateg o r y .
RESEARCH QUESTION #9:

Do a d m i n i s t r a t o r s p r e f e r to see any
change in the c r e d e n t i a l i n g p r a c t i c e s
o f a l l i e d h e a l th p r a c t i t i o n e r s ?

73

The a d m i n i s t r a t o r s ' response to the c r e d e n t i a l i n g i s s u e was mixed.
Forty-one or f i f t y - f i v e p e rc e n t d e s i r e d no change in the c r e d e n t i a l i n g
mechanism of a l l i e d h e a l t h p r a c t i t i o n e r s .
would l i k e to see a change.

However, f o r t y - n i n e p e rc en t

T heir responses were di vid ed between

e ducational i n s t i t u t i o n a c c r e d i t a t i o n and h o s p i t a l i n s t i t u t i o n a l
warranty.
Conclusions
Based upon th e f i n d i n g s o f t h i s stu d y , th e following conclusions
were formulated:
1.

A d m in is tra to rs o f small h e a l th care f a c i l i t i e s would choose a
job a p p l i c a n t who possessed m u lt i p le competencies.

2.

The bed c a p a c i t y o f th e h e a l t h care f a c i l i t y was not r e l a t e d
to the d e s i r e to u t i l i z e a m u l t i p l e competency h e a l th
practitioner.

3.

The population s e r v i c e area o f th e h e a l t h c a r e f a c i l i t y was
not r e l a t e d t o t h e d e s i r e to u t i l i z e a p r a c t i t i o n e r with
m u lt i p le competencies.

4.

Those a d m i n i s t r a t o r s who would not h i r e h e a l t h p r a c t i t i o n e r s
with m u l t i p l e competencies i n d ic a t e d t h a t the m u l t i p l e
competency p r a c t i t i o n e r would expect a higher s a l a r y than one
with a s i n g l e competency.

5.

A.

Small h o s p i t a l a d m i n i s t r a t o r s who u t i l i z e h e a l t h p r a c t ­
i t i o n e r s in more than one a re a o f r e s p o n s i b i l i t y were
u t i l i z i n g them in a wide v a r i e t y of s k i l l combinations.

B.

A d m in is tra to rs of small h o s p i t a l s were c u r r e n t l y u t i l i z i n g
the employees in more than one are a of r e s p o n s i b i l i t y .

74

The most common combination was t h e primary s k i l l of
r e s p i r a t o r y th erap y and rad iolo gy with th e secondary s k i l l
o f e le c t r o c a r d i o g ra m .
6.

Small h o s p i t a l a d m i n i s t r a t o r s p r e f e r r e d f u t u r e h e a l t h p r a c t ­
i t i o n e r s to be prepared to fu n ctio n in more than one
occupa tional a r e a .

7.

The responden ts were about e q u a l ly divid ed concerning the
p r e f e r r e d e d u ca tio n al p r e p a r a t i o n o f a p r a c t i t i o n e r with
m u l t i p l e competencies.

Half o f th e respondents d e s i r e a

r e g u l a r c o l l e g i a t e program, while the o t h e r respondents
s e l e c t e d o t h e r types o f educational e x p e r ie n c e s .
8.

The h o s p i t a l a d m i n i s t r a t o r s were about e q u a lly d ivid ed con­
cerning th e c u r r e n t c r e d e n t i a l i n g o f a l l i e d h e a l t h workers,
while some o f the respondents were s a t i s f i e d with th e c u r r e n t
c r e d e n t i a l i n g mechanism.

The remaining respondents d e s i r e d a

change in t h e c r e d e n t i a l i n g p r o c e s s .

No concensus was reached

on any p a r t i c u l a r changes to be made.
Summary
Based on th e f i n d i n g s o f t h i s s t u d y , i t i s c l e a r t h a t th e adminis­
t r a t o r s of small h o s p i t a l s were c u r r e n t l y u t i l i z i n g h e a l t h p r a c t i t i o n e r s
in more than one occupational area and would p r e f e r to h i r e a job a p p l i ­
c a n t who possessed m u l t i p l e competencies.

In a d d i t i o n , t h e s e same

a d m i n i s t r a t o r s p r e f e r r e d a t r a d i t i o n a l c o l l e g i a t e educational experience
to prepare a p r a c t i t i o n e r with m u l t i p l e competencies, but were divid ed
on t h e need to a l t e r t h e p r e s e n t c r e d e n t i a l i n g p r a c t i c e s .

RECOMMENDATIONS
This s e c t i o n on recommendations i n c l u d e s : 1) recommendations
based on t h e f i n d i n g s , and 2) recommendations f o r f u t u r e r e s e a r c h .
Recommendations Based on t h e Findings
1.

A l l i e d h e a l t h e d u ca tio n al i n s t i t u t i o n s should implement pro­
grams to pr ovide ed uca tio nal ex perien ces f o r a l l i e d h e a l th
p r a c t i t i o n e r s to develop m u l t i p l e competencies.

According to

t h e co n clusio ns drawn from the r e s e a r c h f i n d i n g s , t h e r e i s a
mixed response as to which type o f e ducational program i s
desired.

A p r e - s e r v i c e educational program o r continuing

e d u ca tio n al e x p erien c es may be developed t o meet t h e i n d i v i ­
d u a li z e d needs o f t h e h o s p i t a l s .
The model designed by English and Kaufman, which i s
p resen te d in Chapter I I o f t h i s s t u d y , would be one p o s s i b l e
guide to fo llo w in program development.

The model would be

a p p l i c a b l e t o e i t h e r a r e g u l a r p r e - s e r v i c e a s s o c i a t e or
b a c c a l a u r e a t e degree program o r a c o n tinuing education program
o f f e r e d in t h e geographic are a o f th e h e a l t h c a r e f a c i l i t y .
A c o ntin u in g e du catio n program could be designed to serve
two p o t e n t i a l p o pu latio n groups:
A.

Since t h e a d m i n i s t r a t o r s r e p o r t e d t h a t they were c u r r e n t l y
u t i l i z i n g t h e i r employees in more than one occupational
competency a r e a , t h i s group o f employees may d e s i r e to
update t h e i r dual s k i l l a r e a s .

B.

There may be employees c u r r e n t l y working in the h o s p i t a l s
who would d e s i r e t o develop an a d d i t i o n a l competency

through con tinu ing education experien ces designed to meet
t h e i r s p e c i f i c needs.
A p r e - s e r v i c e educational program could be designed to
serve tho se s t u d e n t s who, upon e n t e r i n g c o l l e g e f o r the f i r s t
tim e, d e s i r e to e n t e r i n t o a curriculum designed to pr epare a
m u l t i p l e competency h e a l t h p r a c t i t i o n e r .
The response o f t h e a d m i n i s t r a t o r s appear to group the d e s i r e d
competency s k i l l a r e a s i n t o a l o g i c a l c l u s t e r o f s k i l l s which
would enable a curriculum to be developed in an or ganized and
cohesive fo rm at.

A curriculum developer should c o n s i d e r the

follo w in g primary and secondary s k i l l combinations as s e l e c t e d
by t h e ad m in istrato rs!.
F i r s t choice of
primary s k i l l

F i r s t choice o f
secondary s k i l l

A.

R e s p i r a t o r y Therapy

Electrocardiogram (EKG)

B.

Surgical Technician

Licensed P r a c t i c a l Nurse (LPN)

C.

Medical Technology

Radiology

D.

Radiology

Ultrasonography

E.

Physical Therapy
A ssistant

R e s p i r a t o r y Therapy

Hospital A s s o c ia t io n s should u t i l i z e t h e da ta from t h i s study
in o r d e r to be a b le t o a s s i s t th e small h o s p i t a l in u t i l i z i n g
t h e i r employees more e f f e c t i v e l y .

An understanding o f what

o t h e r h o s p i t a l s a r e doing may prove he lp fu l to t h e ho sp ital
a d m i n i s t r a t o r seeking s o l u t i o n s to s t a f f i n g problems.
The s p e c i f i c p r o f e s s i o n a l o r g a n i z a t i o n s r e p r e s e n t i n g the
various a l l i e d h e a l t h occupation al s k i l l a re a s should review

77

t h es e da ta as they e s t a b l i s h o r recommend the c r i t e r i a f o r the
c r e d e n t i a l i n g of a l l i e d h e a l t h p r a c t i t i o n e r s .
Recommendations f o r Future Research
1.

F u rthe r r e s e a r c h should be conducted t o s p e c i f i c a l l y i d e n t i f y
the combinations of s k i l l a re a s which would have t h e g r e a t e s t
demand by p o t e n t i a l employers.

This e x p l o r a t o r y study has

i d e n t i f i e d a wide range of p o s s i b l e occupational combinations,
but new r e s e a r c h i s r eq u ire d to i d e n t i f y those combinations
most h igh ly d e s i r a b l e . ' Once a study o f t h i s type i s com­
p l e t e d , a t a s k a n a l y s i s should be conducted t o determine
a ctual employment s k i l l s , .
2.

F u r th e r r e s e a r c h should be conducted to exp lo re the p o s s ib l e
c o n f l i c t s w it h in the c r e d e n t i a l i n g mechanism.

The l i t e r a t u r e

seems t o i n d i c a t e t h a t the c o n s t r a i n t o f c r e d e n t i a l i n g i s a
f a c t o r which i n h i b i t s a d m i n i s t r a t o r s from using t h e i r person­
nel in f l e x i b l e ways.

Most o f the a d m i n i s t r a t o r s ' responses

to the survey q u e s t i o n n a i r e i n d i c a t e d a d e s i r e not to change
the current cred en tialin g process.

What a r e the f a c t o r s t h a t

in flu e n c e t h e s e data?
3.

The study should be r e p l i c a t e d in o t h e r s t a t e s t h a t have
s i m i l a r a l l i e d h e a l t h manpower needs as th ose in Michigan.
The l i t e r a t u r e seems to i n d i c a t e t h a t e f f e c t i v e employee
u t i l i z a t i o n i s a nation-wide problem.

A data base ought t o be

e s t a b l i s h e d in o t h e r s t a t e s concerning u t i l i z a t i o n o f a l l i e d
h e a l t h personnel and to determine i f a m u l t i p l e competency
h e a l th p r a c t i t i o n e r would be a r e l e v a n t s o l u t i o n to t h e i r
perceived needs.

78

4.

This study should be r e p l i c a t e d in t h r e e to f i v e y e a r s to
determine i f th e u t i l i z a t i o n a n d /o r d e s i r e f o r m u l t i p l e
competencies h e a l t h p r a c t i t i o n e r s has changed.

This informa­

t i o n would be useful to schools o f a l l i e d h e a l th as they
prepare g radu ates f o r f u t u r e employment.

Included in such a

study should be the reasons why some a d m i n i s t r a t o r s would
avoid h i r i n g a p r a c t i t i o n e r with m u l t i p l e competencies.

The

b a r r i e r s l i s t e d by some o f th e a d m i n i s t r a t o r s may make i t
d i f f i c u l t f o r t h e p r a c t i t i o n e r to f i n d employment in a l l
hospitals.
R e f!e ction s
The r e s e a r c h e r o f f e r s the following r e f l e c t i o n s on t h i s study and
i t s findings.

The two s u b j e c t s disc u sse d in t h i s s e c t i o n in clu d e 1) the

i s s u e o f c r e d e n t i a l i n g , and 2) key persons on the n a tional scene o f
a l l i e d h e a l th education who a re involved with m u l t i p l e competency h e alth
practitioners.
Credentialing.

The mixed response o f th e a d m i n i s t r a t o r s to the

q uestio n on t h e survey instrum ent which d e a l t with t h e c r e d e n t i a l i n g o f
a l l i e d h e a lth workers, was a s u r p r i s e .

A more d i r e c t mandate f o r change

of the c r e d e n t i a l i n g pro cess was expected.
In d i s c u s s i o n o f t h e f i n d in g s with various members o f th e panel of
e x p e r t s , i t was agreed t h a t th e c u r r e n t s t a t e o f c r e d e n t i a l i n g o f a l l i e d
h e a lth p r a c t i t i o n e r s i s a major b a r r i e r to e f f e c t i v e employee u t i l i z a ­
tion.

A p o s s ib l e reason f o r the mixed response of the a d m i n i s t r a t o r s

could be t h e i r own p r o f e s s i o n a l background.

In Michigan, many o f the

small h o s p i t a l a d m i n i s t r a t o r s a r e , them selves, c r e d e n t i a l e d a l l i e d

79

he alth p r a c t i t i o n e r s .

The a d m i n i s t r a t o r s ' personal involvement in the

c r e d e n t i a l i n g process may have unconscious ly introduced b i a s i n to the
way they perceived the c r e d e n t i a l i n g process o f a l l i e d h e a l t h personnel
should be conducted.
There a re now a c t i v i t i e s tak in g p la c e on the n a ti o n a l scene which
may remove the b a r r i e r s o f c r e d e n t i a l i n g o f a l l i e d h e a l t h p r a c t i t i o n e r s .
P r e s i d e n t Reagan has r e c e n t l y assigned a t a s k f o r c e to r e v i s e the Con­
d i t i o n s of P a r t i c i p a t i o n f o r h o s p i t a l s .

The proposed changes w i l l be a

p a r t o f the Department o f Health and Human S e r v i c e s ' plan to reduce
Medicare and Medicaid requirements and to s i m p li f y r e g u l a t i o n s r e l a t i n g
to small h o s p i t a l s .

Guidelines a l r e a d y proposed would permit more f l e x ­

i b l e use of personnel and would allow the h o s p i t a l a d m i n i s t r a t o r s to
make d e c i s i o n s as to who may be q u a l i f i e d to perform c e r t a i n t a s k s .
These newly proposed r u l e s were r e l e a s e d in Ja nu ary , 1983 and the
Department i s now r e q u e s t i n g response s from a l l i n t e r e s t e d p a r t i e s .
copy o f the g u i d e l i n e s a re enclosed in Appendix D)

(A

I f these g u i d e l i n e s

a re acc epted , i t would appear they would g r e a t l y f a c i l i t a t e the use of
h e a lth p r a c t i t i o n e r s with m u l t i p l e competencies.
Information Concerning M u ltiple Competency P r a c t i t i o n e r s .

The

most d i f f i c u l t p a r t o f developing t h i s study was th e lack o f informa­
tio n concerning a l l i e d h e a l t h p r a c t i t i o n e r s with m u l t i p l e competencies.
Because t h i s e n t i r e s u b j e c t i s r e l a t i v e l y new, t h e r e was l i t t l e in the
l i t e r a t u r e to provide in form a tion .

Much time and e f f o r t was spent in

c o n ta c tin g key people in the f i e l d of a l l i e d h e a l t h e d u ca tion .

The

following information may be o f help to t h e r e a d e r who i s i n t e r e s t e d in
pursuing the concept o f a m u l t i p l e competency p r a c t i t i o n e r .

80

As o f t h i s w r i t i n g , I am aware o f two programs in th e United
S t a t e s which a r e c u r r e n t l y o f f e r i n g e d ucational e x p e r ie n c e s to prep are
h e a l th p r a c t i t i o n e r s in more than one a l l i e d h e a l t h occupational a r e a .
Information about t h e s e two programs, l o c a t e d in I l l i n o i s and Alabama,
may be obtained from c o n ta c t i n g the f ollow ing :
Archie Lugenbeel, P r o j e c t D i r e c t o r
Rural A l l i e d Health Manpower P r o j e c t
The School o f Technical Careers
Southern I l l i n o i s U n i v e rs i ty
Carbondale, I l l i n o i s
Keith Blayney, Dean
M ultip le Competency C l i n i c a l Technician
Program
School o f Community and A l l i e d Health
U n i v e rs i ty o f Alabama in Birmingham
Birmingham, Alabama
The Committee on A l l i e d Health Education and A c c r e d i t a t i o n (CAHEA)
o f th e American Medical A s so c ia tio n has developed a t a s k f o r c e to study
the use o f p r a c t i t i o n e r s with m u l t i p l e competencies.

The d i r e c t o r of

t h i s p r o j e c t , Dr. C l a r k , was w i l l i n g t o share t h e mission s ta te m e n t o f
the committee.

He a l s o provided me with the study and r e s u l t s completed

by CAHEA and t h e American Academy o f Family P r a c t i c e concerning t h e r o l e
o f m u l t i p l e competency p r a c t i t i o n e r s .

His addre ss i s :

Dr. Wallace C la r k , A s s i s t a n t D i r e c t o r
Department o f A l l i e d Health
Education and A c c r e d it a ti o n
American Medical A sso c ia tio n
535 N. Dearborn
Chicago, I l l i n o i s
Dr. Robert K in sing e r, Vice P r e s i d e n t o f the Kellogg Foundation,
provided info rmation t h a t was helpful concerning th e i n i t i a l concept of
the p r a c t i t i o n e r with m u l t i p l e competencies.

The foundation was

81

instru m ental in funding B layney's o r i g i n a l work in Alabama.
c o n t a c t Dr. Kinsing er a t t h e followin g a d d re ss:
Dr. Robert K i n sin g e r , Vice P r e s i d e n t
W. K. Kellogg Foundation
B a t t l e Creek, Michigan

You may

APPENDICES

APPENDIX A
SURVEY QUESTIONNAIRE

82

MULTIPLE COMPETENCY ALLIED HEALTH PERSONNEL SURVEY
all responses will be kept strictly confidential
GENERAL DIRECTIONS:

Please complete ALL sections that apply by lilling in the blank or placing an "X”
in the appropriate box. Your (rank response is very important in order that the
School of Allied Health may plan relevant programs.
SECTION I — BACKGROUND INFORMATION

1. What is the total number of beds in your facility? (Not including Long Term Care beds)
□ 0-24
2.

□ 25 - 49

□ 50 - 74

□ 75 - 100

□ More than 100

Your facility is located in a population service area of:
□ less than 1,000 people
□

1,000 to 10,000 people

□

10,000 to 25,000 people

□ more than 25,000 people
SECTION II — STAFFING
DEFINITION OF A MULTIPLE COMPETENCY PERSON: A MEMBER OF'A HEALTH CARE TEAM WHO
USES SELECTED SKILLS AND KNOWLEDGE FROM TWO OR MORE TRADITIONAL HEALTH OCCU­
PATIONS. FOR EXAMPLE: RADIOLOGY/RESPIRATORY THERAPY.

3.

If you had to choose between two job applicants would you choose:
□ A professionally trained individual who possess multiple competencies and is credentialed in each skill area.
(Go to Question 5)
□ A professionally trained individual who possess one competency and is credentialed in only that area. (Go to
Question 4)

4. If you would not hire a person with multiple competencies, is it because you anticipate problems in the following
areas? (Check as many as apply)
□

Union demands

□ Salary expectations
□ Credentialing agencies
□ Qualifications of applicant
□ Inter-personal relationships among employees
□ Other_______________________________________________________________________________
(please specify)
If you answered Question 4, Please go to Question 6.

83

5.

Please identify the secondary skill area that would most closely match your needs for a Multiple Competency
Technician with the specified primary skills. Identify your first and second choices ONLY by placing a 1 and 2 in
the appropriate space.

PRIMARY SKILL AREA

SECONDARY SKILL AREA

A.

Respiratory Therapy

□
□
□
□
□
□
□

B.

Surgical Technician

□
□
□
□
□

LPN
EKG
Central Supply
Other ______
Other ______

C.

Medical Technologist

□
□
□
□
□
□
□

EKG
Radiology
Nuclear Medicine
Pulmonary Function
Respiratory Therapy
Other ____ :_____
Other __________

D.

Radiographer

□
□
□
□
□
□
□
□

EKG
UltraSonography
Medical Technology
Nuclear Medicine
Pulmonary Function
Respiratory Therapy
Other ___________
Other ___________

E.

Physical Therapy Assistant

□
□
□
□
□

EKG
Medical Technology
Respiratory Therapy
Other ___________
Other ___________

EKG
Lab
Nuclear Medicine
Pulmonary Function
Ultra Sonography
Other ----------------------Other ______________

84

F.

Based on your projections of future health services, are there other competency combinations that you would
prefer for your facility? (e.g. Audiometry, Medical Records, Patient Education, Vision Testing) If so, please
identify in the space below.
PRIMARY SKILL AREA

6.

SECONDARY SKILL AREA

A. Do you currently employ anyone with multiple competencies?
□ Yes - How many?_______ (Proceed with Question 6)
□ No (Go to Question 7)
B.

Identify their Primary and Secondary Skill Areas.
PRIMARY SKILL AREA

C.

SECONDARY SKILL AREA

Identify, problems, if any in employing multiple competency personnel.

SECTION III • EDUCATION/TRAINING
7.

In reality, the restraints of accreditation, licensure and certification mandate how individuals must be prepared
educationally. Assuming, however, that there were no restraints on the educational preparation for multiple
competency employees, how would you like to see them prepared for your particular facility? Identify your first
and second choices ONLY by placing a 1 and 2 in the appropriate box.
□ Trained by your in-house staff.
□ Trained by an outside educational institution that presents classes in your facility.
□ Continuing education programs in your geographic area.
□

Regular associate or baccalaureate level collegiate programs.

□ Other (please specify)___________________________________________________________________

85

8.

Professional credentialing of Health Care Employees continues to be widely discussed. In order to have more
effective health manpower utilization in your facility would you prefer to see:
□ Educational Institutional Accreditation • The educational institution would certify graduates as competent and
there would be no national examination.
□ Hospital Institution Licensure • Through a self-designed system a hospital would certify that their employees
are competent and there would be no national examination.
□ No change in the credentialing process of health personnel.
□ Other (please specify)___________________________________________________________________

9.

Would you like an abstract of the results from this study?
□ No
□ Yes-N am e_________________________________
Title

____________

•

_______ _

Address_______________________________

C ity___________________________________________________________ Zip.
Comments and/or suggestions:___________________________________________________

THANK YOU FOR YOUR COOPERATION
A PRE-ADDRESSED STAMPED ENVELOPE IS PROVIDED FOR YOUR CONVENIENCE

Judith A. Csokasy
Ferris State College
School of Allied Health
Big Rapids, Michigan 49307

APPENDIX B
CORRESPONDENCE

86

R i a l A ^ o sp rtal
111

l i l i associate

8215 W est St. Jo sep h Hlghwev
Lansing, Michigan 48917
15171323-3443
Patric E. Ludwig
Prssldan-

February
Fourth
19 8 2

Judith A. Hagestrom-Csokasy
7420 East Nine Mile Road
Big Rapids, MI
49307
Dear Judy:
I am pleased to convey to you the support provided by the Michigan Hospi­
t a l Association Committee on Smaller Hospitals r e l a t i v e to your d i s s e r ta tio n
survey instrument and the general topic to which i t is d irec ted .
As expectdd, the Committee was concerned about the p oten tial complexity
and time associated with completion of the survey instrument, however, a f te r
clo s e examination i t was not f e l t th a t the instrument was excessively complex
or would req uire s ig n ific a n t amounts of time on the p arts of adm inistrators to
app rop riately complete i t . The Committee was most supportive of your research
and you should fe el free in your cover l e t t e r s associated with d i s t r i b u ti o n of
the survey instrument to point out th a t the instrument has been reviewed by
the Michigan Hospital Association Committee on Smaller Hospitals and endorsed
in i t s in ten t and completion encouraged.
I should also point out th a t several of the Committee members had some
r e c o lle c tio n of receiving a sim ilar survey in the not too d is t a n t p a s t. They
were not sure whether the survey came from an educational i n s t it u t i o n or an
individual in vestig atin g the s im ilar area, however, you should be aware th a t
there are apparently sim ilar i n t e r e s t s out there somewhere.
I have attached to th is l e t t e r the copy of the survey Instrument th at you
sent as i t looks lik e a workup th a t you may be able to use in your fin a l
d r a f t . I have made a couple of changes on the document with my pen th at will
provide c l a r i t y in terms of understanding on the p a rt of hospital adm inistra­
to rs from my perspective.

87

Judith A. Hagestrom-Csokasy
February 4, 1982
Page Two

Best wishes to you with your work and if I can
on t h i s e n t i r e to p ic, please advise meand I will
you out.
I would most c e r t a i n l y be in tere ste d in
fi n a l work and also o ff e r to serve as a reviewer
d i s s e r t a t i o n i f you think th a t would be h elpfu l.
With best regards,

Oonald P. P otter
Director
Department of Health Policy Development
DPP:llw
Enclosure

1

be of fu rth e r help
do whatever I can
receiving a copy
of i n i t i a l d ra fts

to
to
of
of

you
help
your
your

88

Dear

The School of A llied Health a t F e rr is S ta te College with fu l l support of the
Small Hospital Committee of the Michigan Hospital Association is conducting
a survey to determine the p ro je c te d need and c u rre n t u t i l i z a t i o n of m ultiple
competency h e a lth ca re workers fo r the s t a t e s small ho sp ital systems. As a
Michigan Health Care Leader, your response i s invaluable fo r the fu tu re
pre p ara tio n of Michigan's h e a lth p ro fe ss io n a ls .
For purpose o f t h i s study, a h e a lth care worker with m u ltiple competencies
is defined as:
A member of the h ea lth c a re team who uses s e le c te d s k i l l s and
knowledge from two o r more t r a d i t i o n a l h ea lth occupations and
p ro fessio ns. (For example: radiology and c l i n i c a l laboratory
sk ills).
The enclosed q u estion naire should be completed and returned in the stamped
se lf-a d d re sse d envelope no l a t e r than April 8. Your individual responses
w ill be kept in s t r i c t e s t confidence as the r e s u l t s w ill only be presented
in the form of ta b u lated t o t a l s . I f you d e s ire an a b s t r a c t copy of the
r e s u l t s , p lease complete the ap p ro p riate s ec tio n a t the end of the question­
n aire .
Thank you fo r your cooperation in t h i s most worthwhile p r o je c t.
S incerely,

Ju d ith A. Csokasy
Associate Professor
Enclosure
cac: 3/8774

89

MULTIPLE COMPETENCY HEALTH PERSONNEL QUESTIONNAIRE

Thank you for responding to the recent questionnaire concerning
multiple competency health personnel from the School of Allied Health
at Ferris State College. The responses you gave will soon be analyzed
and will provide valuable information for the future planning of
Michigan's Health Care System.
If you requested an abstract it will be mailed to you as soon as the
tabulated data is available.
Sincerely,

Judith A. Csokasy
Associate Professor
gv/2 0404

APPENDIX C
NAMES AND ADDRESSES OF HOSPITALS

COUNTY

FACILITYNAM
E

STREETADDRESS

CITY

LICENSED
BED
ZIP CODE CAPACITY

* CERTIFICATIONS*
M
EDICARE MEDICAID

Alger

Hunising Heaorial Hosp.

Sand Point Road

Hunising

49862

40

X

X

Allegan

Allegan General Hospital
Coaunity Hospital
Pipp Coaaunity Hospital

555 Linn Street
130tb Avenue
411 Naoai Street

Allegan
Douglas
Plainwell

49010
49406
49080

71
31
45

X
X
X

X
X
X

Arenac

*Standish Coaaunity Hosp

805 West Cedar

Standish

48658

81

X

X

Baraga

*Baraga County Heaorial

770 N. Main Street

Lanse

49946

67

X

X

Barry

Pennock Hospital

1009 W. Green Street

Hastings

49058

92

X

X

Benzie

Paul Oliver Heaorial Hosp

224 Park Avenue

Frankfort

49635

40

X

X

Berrien

Unity Hospital
Coaaunity Hospital

1301 Main Street
541 N. Main Street

Buchanan
Watervliet

49107
49098

42
70

X
X

X
X

Calhoun

Battle Creek Sanitariua
Oaklavn Hospital
Albion Dept, of Hospitals

197 N. Washington
200 N. Madison St.
809 W. Erie Street

Battle Creek
Marshall
Albion

49017
49068
49224

75
77
89

X
X
X

X
X
X

Cass

Lee Heaorial Hospital

420 W. High Street

Dowagiag

49047

74

X

X

Charlevoix

Beaver Island Med Ctr
Charlevoix Hospital

Lake Shore Drive

St. Janes
Charlevoix

49782
49720

3
44

X

X
X

Clare

Clare Osteopathic

104 W. Sixth Street

Clare

48617

64

X

X

Clinton

Clinton Heaorial Hosp.

805 S. Oakland Street

St. Johns

48879

76

X

X

Dickinson

Anderson Heaorial

Main Street

Norway

49B70

19

X

X

Eaton

Eaton Rapids Coon Hosp
Hayes Green Beach Hosp

1500 S. Main Street
321 E. Harris

Eaton Rapids
Charlotte

48827
48813

41
46

X
X

X
X

Genesee

Wheelock Heaorial Hosp

7280 State Road

Goodrich

48438

53

X

X

Gladwin

Gladwin Hospital

455 S. Quarter St.

Gladwin

48624

42

X

X

CITY

LICENSED
BED
CAPACITY

* CERTIFICATIONS*
M
EDICARE MEDICAID

COUNTY

FACILITYNAM
E

Gogebic

Grand View Hospital

U S 2 Box 708

Ironwood

4993B

72

X

X

Gd Traverse

Traverse City Osteo Hosp

550 Munson Avenue

Traverse City

49684

81

X

X

Hillsdale

Hillsdale Cob b Hltb Ctr

168 S Howell Street

Hillsdale

49242

86

X

X

Houghton

Calumet Public

205 Osceola

Lauriua

49913

70

X

X

1100 S. Van Dyke
170 N. Caseville Rd.
First & Broad Street

Bad Axe
Pigeon
Harbor Beach

48413
48755
48441

93
47
67

X
X
X

X
X
X

Huron

Huron Heaorial Hospital
* Scheurer Hospital
* Harbor Beach Cob b Hosp

STREETADDRESS

ZIP
CODE

Ingham

Mason General Hospital

800 E. Columbia St.

Mason

48854

42

Ionia

Belding Co b b Osteo Hosp
Ionia County Men Hosp

1534 V. State Street
479 Lafayette Street

Belding
Ionia

48809
48846

56
77

Iosco

Tawas St. Joseph Hosp

M-55 and Court St.

Tawas City

48763

65

Iron

Crystal Falls Cob b Hosp
Iron County General Hosp

Michigan and Third
Ice Lake Road

Crystal Falls
Iron River .

49920
49935

35
38

X
X

X
X

Jackson

Jackson Osteo Hosp

121 Seyaour Avenue

Jackson

49202

75

X

X

Kalamazoo

Franklin Coaaunity Hosp

13326 North Blvd.

Vicksburg

49097

50

X

X

Box 37 419 S. Coral

Kalkaska

49646

21

X

X

235 Wealthy St., S.E.

Grand Rapids

49503

80

X

X

High Street

Nortbport

49670

94

X

X

X
X
X
X

X
X
X
X

Kalkaska
Kent
Leelanau

* Kalkaska Mea Hltb Ctr
Mary Free Bed Guild
* Leelanau Heaorial Hosp

Lenawee

Addison Coos Hosp Autb
Herrick Heaorial Hospital
Morenci Area Hospital
Thorn Hospital

421 N. Steer Street
500 E. Pottawatoaie
Sims Highway
458 Cross Street

Addison
Tecuaseb
Morenci
Hudson

49220
49286
49256
49247

24
76
33
25

Livingston

Brighton Hospital

12851 Grand River

Brighton

48116

63

X
X

VO

H*

LICENSED

* CERTIFICATIONS ••

CITY

ZIP
CODE

BED
CAPACITY

MEDICARE

SOZ W. Harrie

Newberry

4986B

74

X

Hackinac Strts Hlth Ctr

220 Burdette Street

St. Ignace

49781

21

Haconb

Harrison Coaaunity Hosp
Coaaunity Hosp Foundation
McNaaara-Warren Como Hosp
Kern Hospital

26755 Ballard Road
806S0 Earle Hea Hvy
4050 E. Twelve Mile
21230 Dequindre

M l . Cleaens
Alaont
Warren
Warren

48043
48003
48089
48091

96
48
54
54

X
X
X
X

X
X
X
X

Manistee

Heaorial Hosp of Manistee
West Shore Coam Hosp

Rogers Heaorial Hvy
1465 E. Parkdale Ave

Onekeaia
Manistee

49675
49660

24
95

X
X

X
X

Hason

Heaorial Hosp-Mason Co

One Atkinson Drive

Ludington

49431

95

X

X

Mecosta

Mecosta Heaorial Hosp
Mecosta Co Gen Hosp

122 Pierce Street
405 Winter

Stanvood
Big Rapids

49346
49307

36
74

X
X

X
X

Menominee

Menoainee Co-Lloyd Hosp

1110 Tenth Ave

Henoainee

49858

78

X

X

301 N. Main Street
H 46 West
4th and Washington

Sheridan
Edaore
Lakeview

48884
48829
48850

42
30
94

X
X
X

X
X
X

COUNTY

Luce

FACILITY NAME

* Helen Newberry Joy Hasp

STREET ADDRESS

MEDIC

X

Hackinac

Montcalm

Sheridan Coaaunity Hosp
Tri County Coam Hosp
4 Kelsey Heaorial Hospital

X

Muskegon

Heritage Hospital

3020 Peck Street

Muskegon Hgts

49440

46

X

X

Newaygo

Gerber Heaorial Hosp
Grant Coaaunity Hospital

South Sullivan St
41 Lake Street

Freaont
Grant

49412
49327

87
32

X
X

X
X

Oakland

Madison Coaaunity Hosp
Straith Heaorial Hosp

30671 Stephenson Hvy
23901 Lahser Road

Madison Hgts
Southfield

48071
48075

37
45

X
X

X
X

Oceana

Oceana Hospital Assn
Lakeshore Coaaunity Hosp

611 E. Main Street
72 S. State Street

Hart
Shelby

49420
49455

36
35

X
X

X
X

Ogeaaw

Tolfree Heaorial Hospital

335 E. Houghton Ave

West Branch

48661

92

X

X

Ontonagon

La Croix Hospital
Ontonagon Meaorial Hosp

Hain Street
Seventh Street

White Pine
Ontonagon

49971
49953

18
41

X
X

X
X

COUNTY

FACILITYNAM
E

STREETADDRESS

CITY

ZIP
CODE

LICENSED
BED
CAPACITY

* CERTIFICATIONS *
M
EDICARE MEDICAID

Otsego

-Otsego County Meaorial

825 N. Center Street

Gaylord

49735

76

X

X

Ottawa

Zeeland Coan Hospital

129 Taft Street, S.

Zeeland

49464

61

X

X

Russell Meaorial Hosp
^Rogers City Hospital

201 North Pine
555 N. Bradley Hwy

Onaway
Rogers City

49765
49779

17
95

X
X

X
X

Presque Is

St. Clair

River District Hospital
Yale Coaaunity Hospital

4100 S. River Road
420 North Street

St. Clair
Yale

46079
48097

68
39

X
X

X
X

SL. Joseph

Sturgis Hospital
Three Rivers Hospital

916 Myrtle Avenue
214 Spring Street

Sturgis
Three Rivers

49091
49095

94
72

X
X

X
X

3559 Pine Street
120 Delaware Street
2770 Main Street

Deckerville
Sandusky
Harlette

48427
48471
48453

25
49
91

X
X
X

X
X
X

520 Main Street

Hanistique

49854

55

X

X

Sanilac

Deckerville Coan Hospital
McKenzie Meaorial Hosp
*Kirlette Coaaunity Hosp

Schoolcraft Schoolcraft Heaorial Hosp
Tuscola

Caro Coaaunity Hospital
Hills & Dales Gen Hosp

401 N. Hooper Street
4675 Hills Street

Caro
Cass City

48723
48726

50
65

X
X

X
X

Van Buren

South Haven Coaa Hosp

955 S. Bailey Street

South Haven

49090

82

X

X

Washtenaw

Saline Coaaunity Hospital

400 W. Russell

Saline

48176

82

X

X

Chelsea Coaaunity Hosp

775 S. Main Street

Chelsea

48118

97

X

X

Dearborn Medical Center
Lynn Hospital
Bedford Coaaunity Hosp
Sidney A Suaby Mea Hosp

10151 Michigan Avenue
25750 W. Outer Drive
25210 Grand River Ave
234 Visger Road

Dearborn
Lincoln Park
Detroit
River Rouge

48126
48146
48240
48218

65
76
72
93

X
X
X
X

X
X
X
X

Wayne

* LICENSURE INCLUDES LONG TERM CARE UNIT

APPENDIX D
DEPARTMENT OF HEALTH AND HUMAN SCIENCES PROPOSED RULES

94
Federal R egister / V ol. 48. No. 2 / T uesday, January 4. 1983 / Proposed R ules
I I 80.592-2. -3. -4. and -5 are not
operated ae designed. Including periods
when a flare pilot light doee not nave a
flame.
(4) Datea of startups and shutdowns of
tha closed vent systems and control
devices required in I I 60.592-2, -3, -4,
apd-S.
(e) The following information
pertaining to all compressors and
fugitive emission sources subject to the
requirements in IS 60.592-2, -3, -4, and
-7 shall be recorded in a log that la kept
in a readily accessible location:
(1)(i) A Ust of identification number*
for ftigitiva emission sources that the
owner or operator electa to designate for
no detectable emissions under the
provision* of | | 60.8Q2-2(e), -3(1), and
-7(f).
(U) The designation of these source*
as aubject to the requirement* of
I I 60.59Z-2(e), -3(1), or-7(f) shall be
signed by the owner or operator.
(2) A list of source identification
number* for pressure relief devices
required to comply with 1 60.592-1
(3)(i) The datea of each compliance
test required in | | 60.592-2(a), -3(1), -4,
and -7(1).
(il) The background level measured
during each compliance test.
(ill) The maximum instrument reading
measured at tha source during each
compliance test
(4) A list of identification number* for
fugitive emission sources that are in
vacuum service.
(f) The following information
pertaining to all valves subject to the
requirements of | | 60.592-7 (g) and (h)
shall be recorded in a log that I* kept in
a readily accessible location:
(1) A list of identification numbers fof
valves that are designated as unsafe to
monitor, an explanation for each valve
stating why the valve is unsafe to
monitor, and the plan for monitoring
each valve.
(2) A list of identification numbers for
valves that are designated a* difficult to
monitor, an explanation for each valva
siating why the valva is dimculi io
monitor, and tha expected date for
monilo.inu each valve.
(g) Tha following information shall be
recorded in a log that is kept in a readily
accassible location:
(1) Design critorion required in
1 60.592—
2(d)(5) and 160.S92-3(e)(2) and
an explanation of the design criterion;
and
(2) Any changes to this criterion and
the reason* for this change.
(h) The provisions of | | 60.7 (b) and
(d) do not apply to affected facilities
subject to this aubpart.
(Sec. 114 of tha Clean Air Act as amended (42
U.9.C. 7414).)

f 60.597 Haporttngrequtramewia.
(a) An owner or operator electing to
comply with the provision* of I I 60.5931 and -2 shall notify the Administrator
of the alternative standard selected 90
days before implementing either of the
provisions.
(b) The provisions of 100.8(d) do not
apply to affected facilities aubject to tha
provisions of this subpart except that an
owner or operator shall notify the
Administrator of the schedule for the
initial performance testa 30 days before
the initial performance testa.
(Sea 114 of the Clean Air Act as amended (42
U.S.C. 7414))

299

IP* Doe. * w e M ad I * * * * U a * |

In commenting, pleas* refer to BPP519-P.
If you prefer, you may dpliver your
comments to Room 300-G. Hubert H.
Humphrey Building, 200 Independence
Ave.. Washington, D.C.. or to Room 132,
East High Rise, 6323 Security Boulevard,
Baltimore, Maryland 21207.
Comments will be available for public
Inspection as they are received,
beginning approximately three weeks
after publication, in Room 300-G of the
Department's Office at 200
Independence Ave., S.W., Washington,
D.C 20201, on Monday through Friday of
each week from 8:30 a.m. to 5:00 p.m.
(202-245-7890).

M.UMQ

FOR n iim M t INFORMATION CONTACTS

4M M 04I

DEPARTMENT OF HEALTH AND
HUMAN SERVICE8
Haatth Care Financing Administration
42 CTR Parts 405,450,452,453,454,
455,455,457, and 455

Alan Spielman, Acting Director,
Division of Standards and Certification,
OCP. BPP, 1-0-3 Dogwood East, 1840
Gwynn Oak Avenue. Baltimore, Md.
21207(301)604-3775.
SUaeUM tM TARV MFORtSATtON:

A. Background
Conditions of Participation
■MtMSSTw WMI ■W OKSM I r f v v n H I I v i
(Condition*) is tha term used for the
p . , «d g a|. - ■ ^
an
a s —a
*a
m——
C U IM IU O ftl OT PM IIU t|M uO f1 ro c
requirements that hospitals must meat in
as
««-»notpnaw
order to participate in the M edicare and
Medicaid programs. These requirement*
AOtMCY: Health Cara financing
are based on sectioh 1861 (e), (f), and (g)
Administration (HCFA), HHS.
of the Social Security Act (the Act); the
Acnosc Proposed rule.
utilization revisw provisions in section
1814(a)(7). 1801(k). 1903(g) of the A ct
iu maaRv; We are proposing a general
and the general rulemaking authority in
revision of the Condition* of
section* 1102 and 1571 of the A ct
Participation for hospital*. Tha
Condition* are those requirements that
Tha current requirements for
hospitals must meet in order to
participating hospital* are presented as
participate In tha Medicare and
21 Conditions, containing 128 Standards,
Medicaid programs (title* XVIII and XIX and are located In the existing Federal
regulations at 42 CFR Part 405, Subpart
of tha Social Security Act). This
proposed rule is part of tha
j. There has bean no substantial revision
Department's regulatory relief efforts
of the Conditions since they ware first
and is designed to radium Federal
published in 19*6 , despite changes in tha
requirement*, simplify and clarify
state of the art.
regulations, and provide maximum
On |une 20,1980, the Department
flexibility in administration, while
published a notice of proposed
protecting patient health and safety.
rulemaking (NPRM) proposing a revision
of the hospital Conditions (45 FR 41794).
PATH; To assure consideration,
Subsequent to this publication, HCFA
comments should be submitted by
Initiated a process of regulatory reform
March 7.1953.
as part of tire Secretary's efforts to
a ddress : Addresa comments in writing
reduce tha burden of Federal .
to: Administrator, Health Cara
regulations. Therefore, the June 20, i960
Financing Administration, U&
NPRM wa* not prepared for final rule.
Department of Health and Hunan
We
established criteria for reviewing
Services, Attention: BPP-619-P, P.O. Box
the existing Conditions applicable to
17073, Baltimore. Maryland 21235.
hospitals. Those criteria are as follows:.
In addition please address a copy of
1. Requirements should be necessary
your comments on the information
to protect the health and safety of
collection requirements to: Office of
patient*.
Information and Regulatory Affairs,
2. Tha Conditions should contain only
Office of Management and Budget,
provisions authorised by the statute.
Room 3208, New Executive Offlca
Building, Washington, D.C. 20503,
3. Requirements should not
Attention: Desk Officer for HHS.
unnecessarily overlap with similar

95

300

Federal R egister / VoL 48, N o. 2 / T uesday, Januaiy 4, 1083 / Proposed R ules

requirements enforced by other Federal. hospital actively evaluate Its services.
State, or local government programs.
Tha Condition Is sufficiently flexible to
4.
Requirements should permit
permit a variety of assessment
maximum flexibility for facility
mechanisms and plans, but would place
compliance.
responsibility on the hospital for
As a result of our review, we have
ensuring that quality of care is an.
decided to proceed with another
ongoing goal. Further, we would clarify
proposed rule. These proposals are
that the hospital is accountable for its
intended to simplify and clarify
services provided under contract. In
requirements, to focus on patient care,
recognition of high patient-risk areas,
to emphaalxe outcome rather than tha
we are proposing to elevate certain
means used to achieve those ends, to
Standards to tha Condition level (a.g„
promote cost containment while
Surgical Services, Anesthesia Services,
maintaining quality care, and to achieve Infection Control). This would place
more effective compliance with Federal
greater emphasis on the certification
requirements. The basic function of tha
process in these areas.
Conditions in protecting pationt's health
2. Generally, we replaced most
and safety has been maintained, and in
prescriptive adminstrative requirements
some areas, such as the new Conditions, with language that was elated la terms
and Standards that have been elevated
of expected outcome. For example,
to Conditions, enhanced. We have
mandatory committsea and committee
considered and, as appropriate,
meetings would be deleted from tho
provided for the comments received to
governing body and medical staff
the 1080 NPRM. In developing the final
Conditions ( II 482.12 and 482J22).
rule, we will base our decisions on this
Instead, tha objective that was intended,
proposed rule, and on comments
e.g.. good and direct governance, would
spedfically submitted in response to its
be stated in postive terms.
publication.
3. Next, we would balance the need
B. General Approach to Proposed Rula for personnel to have certain credentials
against hospital accountability and
The hospital Industry is heavily
flexibility in determining personnel
regulated in this country. In addition to
requirements. Recognizing that
Federal regulations, hospitals are
personnel achieve competency through
subject to substantial State inspection
many routes (education, training, ana
through licensure programs. Further,
experience), we would frequently place
nationally recognized atondards of
the responsibility on the hospital for
practice are well accepted and ate
choosing its own staff and delineating
adhered to generally through the
staff responsibilities (e.g., Radiology,
voluntary accreditation process.
Medical Records).
Recognizing the ecrutiny under which
This in no way diminishes our interest
hospital care Is provided, we believe it
in high standards for hospital personnel.
is appropriate to eliminate unnecessary
When, in our view, specific degrees or
regulation in the existing conditions of
experience would be necessary to the
participation. We also believe that it Is
provteion of safe care the Condition
important to modernize the regulations
woutd-clearly state those requirements.
in light of significant changes in the
4. In most Conditions, we would
organizational structure of hospitals and
delete specific references to adequate
the dramatic technological
and aafe facilities in favor of a general
advancements since 1065. At the same
comprehensive statement under the
time, we are aware that it is necessary
physical environment Condition
to impart sufficient flexibility into the
(1 482.4). In those areas of the hospital
regulations to allow thair application to
both the smallest rural faciiily and to the requiring special concern for safe
practices, such as Nuclear Medicine
most modem urban hospital centers.
services and Radiologic services, we
Therefore, in the framing of these
would maintain specific language to
proposals, we used the following
assure additional protection.
approach.
1.
First'we were careful to assure that 5. We would delete most of ths
our attempts to eliminate unnecessary
references to "Departments" by using
regulation, and provide hospitals with
the more encompassing term “services".
greater flexibility, would not adversely
This would be done in order to clarify
affect patient health and safety.
that a hospital's organizational structure
Consequently, In our view, certain key
would not determine whether or not
additions and modifications would be
services would be subject to the
necessary to underscore the hospital's
Conditions. Further, use of the term
accountability for the services II
"services” would avoid any implied
provides. For example, we are proposing suggestion that hospitals should
a new Condition, Quality Assurance
organize their services into formal
(} 482.21) that would require that the
“Departments".

We believe that the numerous
proposed modifications and deletions to
the regulations would result in an
Improved set of Conditions of
Participation. We believe that the
proposed language of the regulations
offers better protection to our
beneficiaries. At the same time,
hospitals, when functioning properly,
should be administratively unburdenod
by the Conditions of Participation. We
would like to mention, however, that
hospitals accredited by the JCAH (the
majority of the 8200 accredited
hospitals) will be affected by.JCAH's
similar efforts to lessen overly
prescriptive requirements while
increasing administrative flexibility. The
(CAN'S revised standards will focus, as
do our proposed Conditions, on
provision of quality care more than on
the means of achieving i t Although we
comment on each draft of JCAH'e
proposed revisions, (CAH's efforts are
not directly linked to ours; that is, the
adoption of new JCAH standards will be
unrelated to the possible
Implementation of new Medicare
Hospital Conditions.
C. Proposed Revisions
1. Compliance with State and Local
Laws. Section 1881(e)(7) of the Act
addresses State and local licensure
requirements. If State or local lawa
provide for the licensing of hospitals, the
Act requires the hospital to ba licensed
or to be approved by the appropriate
State or local licensing authority as
meeting the standards for licensure.
Current regulations at 42 CFR 405.1020
restate these statutory requirements and
expand upon them by requiring
compliance with all relevant laws (e.g..
laws relating to staff licensure,
postmortem examinations,
communicable diseases). We are
proposing to revise these regulations
(see f 482.11) by simply restating
statutory requirements and deleting
other requirements. The regulations
would also require hospitals to comply
with applicable Federal laws.
2. Governing Body. Under the revised
Condition relating to the governing body
(see proposed f 482.12] we would make
these changes:
a.
Bylaws, meetings, committees,
liaison. The current provisions
regarding bylaws, meetings, committees,
and liaison (42 CFR 405.1020(aHd))
would be deleted since we consider
them unnecessarily prescriptive. Wa
believe that it is not necessary for
Federal regulations to address these
specific administrative issues. Rather,
these provisions should fall under the

96
Federal R egister / V ol. 48, N o. 2 / T uesday, January 4. 1963 / P roposed R ules
discretion of Individual facility
Current regulations at 42 CFR 4i>5.1021(J)
management.
expand upon the statutory requirement
b.
Medical Staff. Currant regulationa We are proposing (see proposed
(42 CFR 405.1021(e)) specify the datalla
1482.12(d)) to modify the regulations by
of tha rolatlonahlp between tha
simply incorporating the basic
governing body and tha medical itaff.
provisions contained in the statute.
Wa are proposing to reviie theee
g.
Contracted Service*. The use of
regulation* to Indicate almply that tha
contracted services in hospitals has
medical ataff moat be accountable to tha increased dramatically since 1088.
governing body and be organized under
Today, services frequently provided
bylaw* aa required by Sectlon'1861(a)(3) through contractual arrangements
of tha A ct (Sea proposed 1481.12(a).)
includs nursing, phsrmucy, emergency,
a Hoepital Aaminietrator.
dietary, laboratory, and radiology. Our
Regulationa at 42 CFR 400.1021(1) and (g) concern regarding these contracted
apecify that tha governing body muat
servicea is twofold. First although tha
appoint a hoapltal administrator,
serviess might be subject to survey
describe (he qualifications for this
under other Conditions (e.g., 1 48243,
position, and apecify the details of how
Nursing; 1 482.28 Pharmacy), it is
tha administrator should perform thla
difficult to survey for all aspects of these
function. We are proposing to revise
services when thy are not provided on
these regulationa by eliminating
the hospital premises. For example,
education and experience raquirsmenta
hospital food may be prepared
applicable to an administrator. Proposed elsewhere, and certain ancillary
regulationa at 1482.12(b) would simply
servicea may be provided off-site.
require tha Governing Body to appoint
Second, comments received as a
an Administrator or Chief Executive
result of the 1B80 NPRM highlighted the
officer responsible for administration of fact that there does not appear to be a
the hospital Tha functions would
clear undaralanding, or acceptance, of
remain, but the detail of bow to
the hospital's responsibility tor services
accomplish the tasks would be delated.
provided under contract We would
d. Pnytician Service*. Section
clarify that tha hospital baa ultimate
1861(e)(4) of tha Act mandates that
responsibility for services, whsther they
every patient be under the care of a *
are provided directly, such as by its own
physician. Current regulations (at 42
employses, or by lsasing, or through
CFR 405.1021(h)) require that a hospital
arrangment, such as formal contracts,
have policies to assure patients are
Joint ventures, informal agreement, or
under the care of a physician. We are
shared services. Because many
proposing (see f 482.12(c)) to requite
contracted services are Integral to direct
that patient* actually be under a
patient cars and a n important aspecta
physician's cars, not merely to require
of health and safety, a hospital cannot
that the hospital have an established
abdicate Its responsibility simply by
policy. We would also relocate carrant
providing that service through a contract
with an outside resource. For purposes
requirements for a health history and
physical examination to thla Standard
of assuring adequate care, the nature of
because these are tha responsibility of
tha arrangment between tha hospital
the attending physician.
and tha "contractor’1ia irrevelant
Tha term "physician", as it is defined
As a result of the increased reliance
in 1 482.3, would include all
on contracting for temporary nursing
practitioners provided for by Section
personnel by hospitals, we would
1881(r) of the A ct Thus, the use of tha
include specific requirements to ensure
term ‘‘physician" in regulations will be
that hospitals provide adequate
consistent with its use in the statute.
supervision and evaluation of tha
However, individual hospitals would
clinical activities of non-employee
faSaia the authority to ueianiuiia who
licensed mining personnel (see
has admitting pitvilsaso in their hoapltal. 148243(b)(6)). This would ensure that
e. PhyticeuPlant Current regulationa
contracted nursing employees are
at 42 CFR 408.1021(1) require that tha
required to perform at tha same level of
governing body be sctlvely involved in
competence as nurses employed directly
maintaining the physical plant We are
by the hospital
proposing to deleta this requirement as
h.
Discharge Planning. We are
the intent of the Standard (a safe and
proposing (see 1482.12(f)) to.add a new
effective physical plant) is met through
Standard that requires discharge
planning. We believe this requirement is
other regulations. (See Physical
Environment in current 42 CFR 408.1022, important since discharge planting haa
and proposed 42 CFR 482.41.)
been linked to daoraaaad rataa of
f. im titutional Planning. Sections
hospital readmlssion
1881(e)(8) and 1881(s) of the Act requite
3.
Q uality Amutance. Many of tha
a hospital to have an annual operating
current regulations apecify procedural
budget and capital expenditure plan.
requirements that hospitala must follow

301

to uasure quality care (e.g.,
organisational characteristics,
committee functions, personnel). These
requirements are currently located in
several of tha Conditions (e.g.,
Coveming Body and Medicu staff). We
beliave a focused requirement would
better address qualify of care.
Therefore, we are propoaing to establish
a new Condition on Qualify Assurance
at 1 48241. Wa would require that the
hospital establish a hospital-wide
qualify assurance program aimed at
Identifying and correcting patient care
problems. Specifically, we would requite
that the hospital—
(a) Have a written qualify aaaurance
plan:
(b) Evaluate all organised services,
nosocomial infections, and medication
therapy;
(c) Evaluate all surgery; and
(d) Document dafirdendaa and taka
appropriate remedial action.
4.
Medical Staff. Current regulations
at 42 CFR 408.1022 provide specific
requirementa for medical tuff, such as
requiring very detailed bylaws,
committees, maeWngs, and staff
qualification, fa proposed 1 48242 wa
would delete those provisions that we
now believe to be ovariy preacriptiva or
unnecessary and modify others as
follows:
a. In proposed 148242(a)(1) and (2)
we use tha term "medical ataff*, not
"physicians”. This would grant
maximum flexibility to the hospital in
granting privileges and organising its
professional stall Nurse practitioners
and nurae-eddwivae toe example, could
be granted staff privilege*. Thla reflects
the present hospital trend of extending
patient care responsibilities to
practitioners other than physicians.
We note that proposed 1482.12(c)
would require each patient to be under
the core of a physician. In that ease,
"physician" would be Interpreted as
defined in section 4824 of dlls
regulation; that is. a doctor of medicine,
osteopathy, dentistry, or other
citsd >a that —
b. We would delate the Standard
regarding staff responsibilities to
support hospital policies since such
detail is not necessary for Federal
regulations. Ws would, however, retain
the requirement that bylaws be enforced
(proposed i 482.22(b)).
c. We would deleta tha Standard on
securing autopelas sinoa autopalaa
depend on the consent of next-of-kin,
except whan legally mandated.
d. We would delete requirements
regarding consultations. There is no
indication that consultations, which are
the direct responsibility of the attending

302

Federal R egister / V ol. 4B, N o . 2 / T u esd a y, January 4, 1963 / P roposed Rule*

prescriptive detail*. We would also
physician, are being improperly
overlapping. We are proposing to
conducted.
replace the Condition statement with the modify die personnel Standard to
e. We would combine and simplify
statutory language that requires 24-hour
specify that if the hospital doss not have
requirement* regarding staff
nursing car* given or supervised by a
a staff pharmacist, a designated
appointment*, ataff qualiflcatiune, and
registered nurse. We are proposing to
Individual must have responsibility for
staff officer* (see current 42 CFR
retain requirements on organization,
the day-to-day operation* of the
405.1023(d). (e). and (b|). Proposed
staffing, administration of drugs, and
pharmacy services. We would also
regulationa would require: (1) a well
delivery of care. We would delete
specify that when a pharmacist is not
organized medical ataff accountable to
Standards on working relationships and • available, drugs may be removed only
the governing body for the quality of
stuff meetings because we believe these
by personnel designated by the medical
medical care given to patient*: (2)
issues are best addressed by the
staff or pharmacy.
periodic appraiaala of member* of the
Individual hospitals (see proposed
8. Radiology. Regulations at 42 CFR
ataff; (3) the wanting of clinical
1 482.23).
405.1029 provide that basic radiology
privilege* only to thoae legally,
Section 949 of Pub. L 90-499 provides
service* must be available to patients
profeaalonally. and ethically qualified:
authority to HGFA to temporarily walvs and that these services be provided in
the statutory 24-hour registered nursing
and (4) and individual physician with
accordance with professionally
responsibility for the organisation and
service requirement* for rural hospitals
approved standards for safety and
of 50 or fewer beds. Regulations
conduct of the medical staff. Those
personnel qualifications. We are
requirement* would be maintained since Implementing this law nave been issued proposing (see proposed 1 482.28) to
separately.
there ia evidence that a strong and
reviae the Condition statement to define
6. M edical Records. Section 1801(e)(2)more
responsible medical staff organization 1*
specifically what constitutes
of the Act requires that a hospital
positively related to the provision of
radiological ssrvicaa. We would retain
quality care.
maintain clinical records on sll patients. the basic factors relating to safety
Regulations at 42 CFR 405.1020 currently hazards. We are proposing to revise the
f. The requirements regarding “other
staff" (currant 42 CFR 405.1023(g)) would implement this requirement. This
personnel Standard to require that only
be deleted since they are prescriptive
Condition consists of 10 Standards and
a qualified radiologist, either full or partwithout an apparent relationship to
32 factors, many of which overlap, are
time, supervise the department and
patient health and safety.
inflexible, and are overly prescriptive. In interpret films that requite specialized
g. The requirement on bylaws would
addition, parts of this rule have been
knowledge. The present language had
be simplified. Proposed regulations
made obsolete by changes in
been Interpreted by some to mean that a
would require bylaws that enable the
technology. In proposed S 402.24 we are
radiologist must interpret or reinterpret
medical staff to carry out its
recommending the following changes,
evuty film. Proposed language would
responsibilities, and include a statement the majority of which are intended to
also make it clear that tbs radiologist
of qualification* for admittance to the
focus on outcome-related requirements, - needs to sign reports only of his or her
stuff and responsibilities of each
rather than process-oriented
interpretations.
category of medical staff.
requirements:
We are proposing to allow the
h. Requirements on various specified
a. Preservation.—Y /t would remove
medical staff and the individual
committees (current 42 CFR 405.1023(f)tha reference to statute of limitation*
(o)) would be deleted as unnecessary
end require retention of medical records responsible for radiological services to
designate who is qualified to use
and overly prescriptive. For example,
for 5 years.
radiological apparatus. We would also
the medical ataff should have flexibility
b. Personnel.—Vie would dslste all
modify the Standard on signed report*
in determining whether a medical
specific credential requirements for
to require that records
records committee Is necessary. Also,
medical records personnsb W* have
. . . . of departmental
activities
i]vi1u“ be maintained and that
the Issue of quality of care that formerly seen no evidence that specific ereden tiaW lac*
requirements are Indispendable in .V p V radiological reports and Umsb*
gave rise to the tissue committee
assuring tha quality of the medical f *
preserved for five years. Specific
(current 42 CFR 405.1023(o)) ia now
references to fluoroscopy and radium
provided for under a new Condition,
records.
Quality Assurance (proposed { 482.31).
c. System Details.—We would modify would be deleted since the term
radiology includes these Items.
i. Requirements concerning meetings
these requirements to retain the
9.
la boratories. Current regulations at
(current 42 CFR 4Q5.1023(p)) would be
requirement* that the hospital maintain
42 CFR 405.1028 specify requirement* to
deleted. These meeting*, such as those
a system ensuring prompt location of a
ensure the health end safety of patients
focusing on revtew of clinical work,
patient record by diagnosis and
who are furnished laboratory services in
were Intended to assure quality of care.
procedure: that tha content of the
hospitals. Under currant rules, and these
That intent would be provided for under medical record contains sufficient
the new quality assurance Condition
{imposed rule*, if a hospital arranges for
Information: and that the appropriate
(proposed 1 48221).
aboratory services from an outside
person sign the medical record.
j. Requirements regarding medical
7. Pharmacy. Currant regulations at 42 laboratory, the outside laboratory must
stuff departments and chief* of services
CFR 405.1027 mandat* that
be a Medicare approved hospital or
that are in current 42 CPR 40S.1023(q]
pharmaceutical services be
independent laboratory.
and (r) would be deleted as unnecessary administered in accordance with
The main thrust of the proposed
and not affecting health and safety.
accepted professional principles and
revisions to this Condition is to
5.
Nursing Services. Section 1881(e)(5)recognized standards of practice to
consolidate similar factors, clarify the
of the Social Security Act requires that a assure safe, accurate pharmacological
intent, and establish uniformity in
hospital provide 24-hour nursing ___
regimes for patients. As currently
clinical laboratory requirements. The
services. Current regulations at 42 CFR
written, this Condition limits the
Standards affected by the consolidation
405.1024 Implement this requirement
hospital's ability to establish its own
are: adequacy of laboratory services,
Several of the requirements of this
system for tha control and administation clinical laboratory examinations,
Condition are overly prescriptive,
of drugs. We are proposing (sea 1 482.25) availability of facilities and services,
inflexible, and, in some areas
to eliminate many of the specific and
laboratory report, tissue examination,

F ederal R egister / Vol. 48, N o. 2 / TueadHy. fanuary 4. 1983 / P roposed R ules
and reports of tissue examinations. The
revision would also consolidate all
personnel requirements in a single
Standard in order to eliminate the
ambiguity in qualifications and clarify
the responsibilities of the laboratory
director. Of particular note is the
distinction between those laboratory
services that can be directed by a
laboratory specialist qualified by a
doctoral degree and those laboratory
services that, by their nature, must be
under tha direction of an individual at
the physician level. Additionally, the
preference for American Society of
Clinical Pathologists registry would be
eliminated in order to permit fair
competition for technologist positions by
otherwise qualified non-registered
professionals.
We propose to delete the requirement
fur routing urinalysis and hemoglobin or
hematocrit on admission of each patient.
HCFA has requested Medicare
insurance carriers to stop automatic
payments for a variety of clinical tests
which have sometimes been routinely
performed on all Medicare admissions.
This deletion would ensure that the
regulations would be consistent with
reimbursement actions. Requirements
on participation in staff, departmental,
and clinlcopathic conferences would be
deleted as unnecessarily prescriptive.
We believe such conferences should be
subject to administrative discretion
based on the needs of the individual
facility.
HCFA Is coordinating, with the Food
and Drug Administration and the
Centers for Disease Control of the Publlo
Health Service, future revisions of the
regulations concerning blood banking,
personnel, proficiency testing, and
quatltf control. When this process Is
completed, joint proposals will be
published and the public will be
afforded the opportunity to comment
specifically on these various Issues.
10. Food and Dietetic Services.
Current regulations at 42 CFR 405.1025
provide for the existence of a
professionally staffed dietary
department Integrated into the hospital.
We are proposing to retain a Condition
on food and dietetic services, but to
delete requirements that are overly *
prescriptive and details that are no
longer necessary. (See proposed
S 462.28.)
a. References to requirements for
policies and procedures and the
supervision of the staff would be
deleted.
b. The specific details on the
organisation of the department would be
deleted.
c. The detuiled requirements foj the
facilities of the dietary department

303

would be deleted, and we would provide that the safety and well-being of all
patients are maintained. We nave
fur a general statement under physical
environment (proposed 1482.41(c)(4))
deleted specific reference to isolated
that the kitchen and dietetic services
power since requirements pertaining to
areas must be well-ventilated and
isolated power are contained in the Life
Sufety Code. We would retain the
pruperty equipped and maintained.
d. The specific details relating to
elements addressing emergency power,
therapeutic diets would be deleted.
gas, water, lighting, and obstacle-free
e. The requirement that the director of corridors. All other elements and details
diotetics participate in meetfugs with
would be deleted as redundant.
other department heads would be
b. Currant 42 CFR 405.1022(b)
doleted.
mandates that hospitals comply with the
We believe that this revision would
1907 edition of the Life Safety Code
not lower the quality of the dietetic
(LSC). We are proposing to maintain this
services. Regulationa at proposed
Standard but revise it to update to the
S 462.28(a) would still require a full-time 1981 edition. The 1981 LSC is more
employee to serve as director of the food flexible since it contains more options
services and would continue to require a for compliance than previous editions. A
qualified dietitian on a full-Ume, part"grandfather clause" would provide for
time, or consultation basis.
facilities meeting the 1987 edition of
11. Utilisation Review. Current
LSC.
regulationa at 42 CFR 405.1038 discuss
c. Regulations at 42 CFR 405.1022(dj
the requirements for a hospital
require the hospital to provide adequate
utilization review plan. We are
facilities for diagnostic and therapeutic
{imposing (see 1 482.30) to replace tha
services. We would modify this
anguaga in the current regulation with
provision by specifically requiring
language from the statute. This would
hospitals to provide adequate facilities
eliminate the overly prescriptive and
for all servicea. not just diagnostic and
detailed specifics. The revised rule
therapeutic services. (See proposed
would require the review of admissions,
t 482.41(c)).
durations of stay, and professional
13. infection Control. Current
services, with respect to medical
regulations at 42 CFR 405.1022(c), under
necessity and for tha purpose of
the Condition Physical Environment
promoting the most emdant use of
discuss the sanitary environment of the
facilities and services. Reviews would
be conducted by a hospital committee or hospital In the United States
outside group and written notification of nosocomial (originating in a hospital)
infections occur in approximately 5* of
findings made to the patient the
the patients admitted to acute-cara
physician and tha institution. The
hospitals. This prolongs hospital stay by
regulations would also specify who can
several days on the average, and leads
muke final determinations and the
to more then an extra billion dollars a
timeframe for notification of these
year in direct hospital charges. Because
decisions. Finally, we would retain a
of the enotmlty of the problem, we are
provision found in current regulations
proposing (sea f 482.42) to elevate
that prohibits the committee’s review
infection control provisions to the level
from being conducted by a physician
of a separate Condition of Participation.
who was professionally involved in the
This
proposed revision would place
case being reviewed or who is
more accountability on hospitals to
financially interested In the hospital.
prevent control, and report hospital
(See current 42 CFR 405.1035(e)(3) and
infections, and less emphasis on the
proposed 1482.30(b)).
number of persons necessary to
12. Physical Environment. Section
accomplish the task. The revision would
18Sl(c)(S) of the Act permits the
delete the current requirement for an
Secretary to mandate requirements for
Infection control committee and instead
hospitals relating to the health and
would require designation of an
safety of patients. Some of these
infection control officer(s). This
requirements are found In current
flexibility would give hospitals the
regulations under 42 CFR 405.1022,
option of retaining exlstinjg committees,
which address physical environment
but hospitals with limited staff could
and related Standards. This proposed
comply by the designation of one
rule would provide for the following
revisions:
person. We are also proposing to require
a.
Currant 42 CFR 405.1022(a) containsthat the hospital keep a log to Identify
problems and that Improvement be
many details regarding the functional
features of the physical plant. We are
made when problems are identified.
proposing to revise the requirements to
14. Complementary Services. Current
state that the condition of the physical
regulations at 42 CFR 405.1031 consist of
plant and overall hospital environment
four Standards that represent five
must be developed and maintained so
different services of the hospital. These

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Concensus