QUALITY IN COMPLEMENTARY & ALTERNATIVE MEDICINE
INTRODUCTION (Copyright 2006, D. Kailin)
Complementary and alternative medicine (CAM) is a term applied to a vast array of theories and practices - over 300 by some counts - extending from within to well beyond the margins of biomedicine (Whorton, 2002). The focus and use of the term CAM is delimited here to a leading set of five medical arts: acupuncture and oriental medicine; chiropracty; homeopathy; massage and bodywork; and naturopathy. They are characterized by distinctive non-biomedical theoretic frameworks, by breadth of application to many conditions, and by alternative providers. These arts have moved appreciably from the margins toward mainstream social, legal, and medical acceptance over the last two decades.
Quality is the encompassing theme. Biomedicine is facing a crisis of quality, with avoidable errors of commission and omission causing an alarming number of injuries and deaths (IOM, 2000). Quality is also at issue in the provision of timely and truly efficacious interventions; in the handling of information and the management of services; in the ecological and social impacts of services; in the compassion and the meaningfulness of care; and in the fairness of medical economic exchanges. The quest for quality embarks on securing competence in requisite performances, while adroitly preventing harm, and then extends on toward excellence.
Quality is currently at issue in CAM due to CAM’s entry into a mainstream of medical practice characterized by burgeoning technological, financial, and regulatory complexity. CAM is progressively included in hospitals, managed care organizations, community clinics, and private practices. More health insurers are reimbursing for CAM services. Provider networks are adding panels of CAM practitioners. New measures of accountability come with these changes.
Part of that accountability is for regulatory compliance, a middling, fateful, and defining star in the constellation of quality. The increasing complexity of the regulatory environment greatly favors large organizations with administrative specialists. Small CAM practices can achieve comparable compliance, and this text indicates precisely how. Mastering the web of regulations (despite encountering its galling features) is more than a demanding personal choice for admission to, and retention in, the market. CAM professions collectively face the difficult choice to develop cultures of regulatory compliance. This text provides guidance toward compliance, without forfeiting the heart and soul of healing.
Regulatory compliance, and (more broadly) quality standard conformance, exact initial and ongoing costs. But non-compliance, and quality deficiencies, usher in major liabilities. Costs associated with securing quality should be framed as business investments. Returns on well chosen investments in comprehensive quality management are on the order of 17:1 (ISO, 2005, vii). Attending to quality makes good business sense.
Legal and regulatory strictures on medical practice mandate a minimum bar of quality. To fall below that bar is to invite dire individual and professional consequences. An achievable second (and higher) bar of quality is defined by voluntary quality standards. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2004), the Accreditation Association for Ambulatory Health Care (AAAHC, 2004), the International Organization for Standardization (ISO, 2005), and a number of other professional and governmental quality improvement organizations have promulgated such standards. The spirit and direction (though not the letter and extent) of voluntary quality standards have influenced this work.
There is yet a third bar of quality, drawn from a groundbreaking assessment of the core purposes of primary care (Kailin, 2002). A framework of seven core purposes indicates fundamental and legitimate ends of health services. Quality can be evaluated on the basis of fulfillment of these core purposes. A number of core purposes are overshadowed in biomedicine, and are ostensibly better served in CAM practices. Readers will find this discussion (in Ch 12.5) to be most engaging, as it bears on the brightest stars in the constellation of quality.
CAM practices are not automatic paragons of quality, solely by dint of offering natural therapies. The delivery of health services in small practice settings does not guarantee fulfillment of clients’ needs. There is ample room for improvement at the bottom, at the middle, and at the top of the quality bar. I have written not as an unquestioning partisan of CAM, but as a partisan of quality CAM, extending a frankly daunting invitation to professional excellence.
Some readers will decline portions of that invitation, overwhelmed by convoluted regulations and demanding managerial functions. A modicum of culture shock may be experienced initially. Read on, nonetheless, and you will be rewarded with a wealth of easily achievable ways to improve and protect your practice. Learn what federal posters are required, what financial ratios to track, and recent changes in guidance on hand hygiene. Read this book gradually, and then read it again. Knowing the rules facilitates more intelligent play. You will not come away unimproved.
Quality in clinical performance requires the simultaneous bridging of multiple contexts of practice. Contexts of practice are the frames of reference that shape and inform clinical activities. These include functioning as a medical profession (Ch 1), and balancing benefits and risks (Ch 2).
The reader will first encounter a number of management plans, statutes, quality organizations, and regulatory agencies as we move into the several contexts of a clinical facility. Access requirements, and management plans for utilities, safety, emergencies, and fire are covered in Ch 3 and Ch 4. Chemical hazard communications standard, infection control, respiratory protection standard, and bloodborne pathogens standard plans are explained in detail in Ch 5. Ch 6 takes up medical equipment issues, including autoclaves, clinical laboratory tests, diagnostic x-ray devices, and lasers. Ch 7 discusses security, and conveys the complex Health Insurance Portability and Accountability Act (HIPAA) regulations on information privacy and security.
The basics of business planning and human resources are the subjects of Ch 8, while Ch 9 penetrates the terrain of billing and insurance claims. Medico-legal constructs, duties of care, and liabilities engage Ch 10. Then Ch 11 enters the realm of the Food & Drug Administration (FDA). In this context, we offer a medication and dietary supplement management plan.
We arrive at the heart of the matter in Ch 12, the provision of care. The opening sections reflect standards of care by reference to documentation standards. A section on the healer’s art explores the process of care, how care is given. The chapter closes with an essay on core purposes, pointing out seven dimensions of the complex exchange negotiated in health care.
Quality improvement, a significant context in its own right, is broached in Ch 13. Hospital-based practice (a relatively recent option) is the topic of Ch 14. The text closes with Ch 15 on standard procedures for equipment decontamination, housekeeping, and hand hygiene.
Links to Internet sites are provided as indispensable and authoritative educational extensions. On the text’s website, www.qualityincam.com, you will find products (some free, some for a fee) including forms, management plan templates, and links to reference documents and quality improvement organizations. Errata and updates are also found there. Critiques and suggestions are welcomed.
The presumptive setting (other than in Ch 14) is a CAM practice employing one to several clinicians and clerical staff, operating in a business occupancy, and treating out-patients. The text serves current CAM clinicians, as well as CAM students in practice management, ethics, and clinical orientation courses. Readers trained in other CAM arts (or in biomedicine) will find much that applies to their own quest for quality.
It is crucial to note that I do not presume to set official standards of practice for diverse CAM professions. Those standards are promulgated by relevant professional organizations and licensing agencies. This text does not fully or officially convey the standards of JCAHO, AAAHC, ISO, or any other quality improvement organization. Consult guides from those organizations, and consider their certification processes. The interpretations of federal regulations, though carefully researched, are not the authorized statements of any federal agency. Readers are advised to additionally consider State regulations, as the scope is delimited to the federal level. Kindly recall while perusing the denser portions of this tome that I am only the messenger, conveying rules and regulations (whether admirable or appalling) that are not of my making.
I am deeply grateful for the kindness of the many individuals who have shared their expertise with me. My interpretations have been guided by the counsels of employees of federal and State agencies, by medical administrators and insurance executives, and by biomedical and CAM clinicians. Some material was adapted from Acupuncture Risk Management (Kailin, 1997). A special note of thanks to Jean Achterberg, D.C., Richard Felten, Jerry Kantor, Connie Koshewa, J. Robert Rapcinski, and Jim Whorton. Many an infelicitous phrase and incomplete thought have been caught and rectified by the keen eye of my esteemed colleague, Michael Pope. As author, I retain final accountability for remaining errors. I am beholden as ever to family and friends for support in this endeavor.
The quality process goal is to continuously improve CAM practices, with risk reductions and better outcomes for patients, practitioners, and the organizations hosting them. The concurrent challenge is to preserve the integrity of CAM within the multiple contexts of American medicine. This quest for quality with integrity does not end. The arduous path I commend will lead you to contend with the force of habit, the inertia of complacency, and the defense of denial. The drive toward the provision of higher quality services (despite such formidable obstacles) betokens a keen professionalism. That element is essential for manifesting the benefits of CAM, and further developing the potential of integrative medicine.
David C. Kailin Corvallis, OR July, 2006
Citations
AAAHC 2004. Accreditation handbook for ambulatory health care.
Wilmette, IL: AAAHC, Inc.
IOM 2000. To err is human - Building a safer health system. Institute of Medicine
Washington, D.C.: National Academies Press.
ISO 2005. International Workshop Agreement 1. Quality Management Systems -
Guidelines for process improvements in health service organizations. Geneva: ISO.
www.iso.org
JCAHO 2004. Standards for ambulatory care 2004. Oakbrook Terrace, IL: Joint
Commission Resources.
Kailin DC 2002. Quality of learning in primary care: A social systems inquiry.
unpublished doctoral dissertation, Oregon State Univ. Corvallis OR.
Kailin DC 1997. Acupuncture risk management. Corvallis, OR: CMS Press.
Whorton JC 2002. Nature cures - The history of alternative medicine in America.
NY: Oxford University Press. p.xiii.
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