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valent as determined by the department in a clinical laboratory approved by the department shall be required; or
(b) Grdauation from a college or university maintaining standards equivalent, as determined by the department, to those institutions accredited by the Western Association of Schools and Colleges, or an essentially equivalent accrediting agency, with a baccalaureate and a major in one of the biological sciences or essential equivalent as may be determined by the department plue one year as a clinical laboratory technologist trainee or equivalent as determined by the department in a clinical laboratory approved by the department. One year of practical experience in a public health laboratory may be accepted if such experience or if unversity or college courses included practical work in clinical biochemistry and hematology; or
(c) A minimum of three years of experience as a clinical laboratory technologist trainee or the equivalent as determined by the department doing clinical laboratory work embracing the various fields of clinical laboratory activity in a clinical laboratory approved by the department and 60 semester hours or equivalent quarter hours of university or college work in which are included the following courses, or essential equivalent as may be determined by the department; general inorganic chemistry—8; quantitative analysis-3; basic biological science-8; bacteriology-4. Additional college or university work which includes courses in the fundamental sciences may be substituted for two of the three years of experience in the ratio of 30 semester hours or equivalent quarter hours for each year of experience; provided, however, that individuals seeking admission to the examination on or after January 1, 1965, shall meet the prerequisites specified in subdivisions (a) or (b) of this section, or the prerequisities as set forth by the Council of Medical Education and Hospitals of the American Medical Association and the Board of Registry of Medical Technologists of the American Society of Clinical Pathologists, and the American Society of Medical Technologists, or equivalent accreditation body approved by the Department of Public Health, provided, however, that the total or combined time of college or university work and practical training and experience in an approved clinical laboratory be not less than five years or as specified in subdivision (a).
Experience as a clinical technician in any branch of the armed forces of the United States may be considered equivalent to the experience as a clinical laboratory technologist trainee, if such experience as a technician is approved by the board. Each year of training and experience as a clinical technician in such armed forces shall be equivalent to 15 semester hours, which shall be credited to the minimum number of hours required to qualify for registration as a clinical laboratory technologist trainee. The semester hours acquired in this manner shall not be in organic chemistry, quantitative analysis, basis biological science, and bacteriology, unless these courses have been completed at a college, university, or institution maintaining standards equivalent, as determined by the department, to those institutions accredited by the Western College Association or an essentially equivalent accrediting agency. The maximum number of hours granted shall not exceed 60 semester hours or its equivalent.
ITEM 3: EXHIBITS RELATED TO DR. ELSIE A. GIORGI'S STATEMENT*
EXHIBIT A. PROPOSAL FOR A COMMUNITY HEALTH PLANNING FOUNDATION
I. THE NEED
For a very long time in Medicine, we know much better than we do. The gap between technology and its clinical application becomes ever wider in spite of a very generous National budget. Our great potential for comprehensive care is dissipated through duplication and lack of coordination. Addition of numerous isolated, poorly thought out programs, have only served to escalate costs and add to the chaos and ferment.
What is needed is a new health care delivery model, which makes optimum use of what is already there, through coordination and unification, and simultaneously promotes dynamic health education towards improved health practices and proper use of health care services.
Advanced medical science has succeeded in the virtual eradication of a hard core of disease predominantly responsive to antimicrobial therapy and surgical
.See statement, p. 686.
extirpation. What is left are the degenerative, neoplastic, metabolic, and emotional disruptions—all very possibly linked in causation—for which there are no cures. Thus mortality figures improve, while morbidity increases.
The inseparability of man from his genetic inheritance and his total environment; and the need to treat all if we are to produce optimum function and total health-is becoming increasingly mandatory as the diseases of stress become more and more predominant.
Total health planning of this order, requires a degree of technologic competence, not within the scope of an isolated medical sector, trained mainly in the biologic. It requires a broad scoped multi and interdisciplinary-consortium approach.
An enlightened public—recipient of health care services—demands change. Harried providers of services are ready for it. Large consumers such as labormanagement, government and industry threaten outright planning, ownership, and direct rendering of services. The Congress has mandated change and has recommended regional adaptation and partnership planning. The time was never so propitious. There is a great need to define and relegate the role of all involved and concerned if we are to plan most effectively.
Figure I depicts a suggested relegation of roles :
Planning by (interdisciplinary con- Philanthropy (or Government): sortium)
health care planning foundation. Demonstration--Innovation
Government (Public health), other pub
lic and private health agencies. Implementation
Association of Practitioners in consul
tation with Health Care Planning In
stitute. Financial support--
Investment groups. Initial outlays (loans)
Individual and large consumers: Self
paid and/or health insurance. Research and education.
Government (public health): Philan
II. THE PURPOSE It is proposed that the consortium approach to planning be implemented through non-profit Community Health Planning Foundation, sponsored by philanthropy. There is much precedent for this. Historically, the most significant changes in medicine have been promoted by institutions outside the existing structure. Striking examples are the Flexner report of 1910–1911, supported by the Carnegie Foundation, and the sweeping innovations in education and research, influenced by that report as well as the Rockefeller Foundation.
This is particularly necessary at this point in time, as it becomes increasingly obvious that the current policy makers seem unable or unwilling to take the initiative. Restrictions imposed on government public health units, force them, for the most part, into consultative and fiscal roles. The rigidity of the academie world and its poor motivation towards outright community service. hare perpetuated its interest predominantly in scientific research and education. Organized medicine seems unable to overcome the inertia of “tradition."
Philanthropy seems to be the only vehicle flexible and financially strong enough to undertake this gigantic and much needed task. It is uniinpeded by conflict of interests. It can attract the best minds in the country--those with broad scoped knowledge, experience, and creativity whose feet are on the ground, but not in cement.
III. THE FOUNDATION AT WORK The Foundation will have a three pronged approach-service, research, and education-all very closely interrelated. Figures II and III depict this graphically:
FIGURE II.-Community Health Planning Foundation (Multi- und
Interdisciplinary Consortium) Research:
nity Development. Medical Economics.
Service: Planning for comprehensive Systems Engineering.
health care delivery models (biomediComputer Analysis, Record Keep- cal complex—see fig. III).
ing, Information storage and Re- Biomedical complex: Provides vehicle trieval.
for service, research, and education. Optimum sue of Laboratory Pro
FIGURE III.--The biomedical complex 1. Centers around a single access Ambulatory Care Diagnostic and Treatment Center, rendering pooled paramedical, ancillary, managerial, administrative, and secretarial, at reasonable cost. (Health Care Facility-fixed and/or mobile, depending on population density-to include multiphasic screening.)
2. All services rendered through the personal, (managing) physician, assisted by a Health Care Team, permitting optimum utilization and quality surveillance. Combines best features of solo practice ("one doctor/one patient") with those of group practice (pooling of his personalized services).
3. Expedition of services by "Family Health Agents"--peer related and a new health career-supervised and trained by the Health Care Team. (A Medical Ombudsman--informed family advocate.)
4. Closely related to all institutions—Community ("cottage”) Hospitals; extended and domiciliary care facilities and programs; Medical Center; and education and research. The principle is that of rendering frequently used services locally and less frequently used, more highly specialized and technologic services, through centers-treating the “right patient in the right place at the right time” with free and prompt
transfer. Alternative, improved health care delivery models-regionally adapted-will comprise the laboratory for all components. The model to be demonstrated first is a Biomedical Complex, centering around the Health Core Facility Concept. It is described briefly the Appendix and its accompanying Figures. This model has been chosen because it seems to have a significant measure of universality and replicability. It permits demonstration, research, and education in the framework of service where they rightfully belong if we are to avoid a continued widening gap between them. Each Health Core Facility will serve about 100,000 people, which is numerically very significant.
Figure II indicates the proposed areas of major concern to be addressed. The factor of sheer numbers—the population explosion-demands a systems engineering approach. The highly successful attack against man's formerly predominant enemy-the world of microbes—has shifted emphasis to the physical and chemical world around him--the atmosphere of pollution, crowding, noise and competition for status and recognition.
There is a great need to apply the same type of scientific excellence, so successful against infective and communicable disease, to a study of the edidemiology of our current major offenders degenerative, metabolic, neoplastic and emotional disruptions.
A wider laboratory must be created--one involving the greater mass of our people and the more common pathology-if we are to effectively study, combat and prevent the more frequently occurring diseases rather than just the rare and the exotic. Medical Care is only one factor in the broad gamut involved in Comprehensive and Total Health Care. It can, however, lend itself very well as an opening wedge to all the others.
Centralized computer analysis, data storage and retrieval, and optimum use of laboratory procedures, may well eventually provide us with information permitting determination of priorities for professional time as well as guidelines for prediction of disease valuable tools towards circumvention of manpower shortages and true prevention and prompt restoration to function.
The close interrelationship of the component parts of the Biomedical Complex, permits analysis of the patient from diagnosis to therapy. One of the areas to be explored can include the assembly of consultant expertise in the various medical specialities and sub-specialties, towards the goal of determining the minimal requirements from diagnosis to therapy relative to the more common illnesses (at least 85%). This will serve to insure optimum prevention, treatment and quality of care. It will also be a valuable instrument in determining "reasonable costs" for those illnesses, and can be used as guidelines for reimbursement through prepaid government and other health insurance programs.
Another area of interest will be the creation of a branching type questionnaire, permitting complete data gathering simulating physician history taking. This can then be done either by non-professional personnel or by automated devices—freeing the physician's time considerably, simultaneously permitting a better and more sensible allocation of labor resources.
The Biomedical Complex can become a very valuable field laboratory for education at all levels, and for creation of new careers designed towards use of non-professionals to perform those parts of the daily tasks now done repeatedly by professionals-not requiring their skills. This is also a very important means of improved allocation of manpower resources.
Other projects will undoubtedly be undertaken as the need for them becomes apparent.
The table of Organization for the Foundation will be decided upon as soon as possible. It should be kept in mind however, that since Medical Care is only a part of the entire gamut of Total Health Care Services, the medical sector should not predominate. Indeed, since the main emphasis will be on improved allocation of resources and the effect of man's genetic and physical environment on his total wellbeing, the non-medical expertise sector must play a very prominent role, at least equal to that of the medical sector. Continued education of the staff on an inter and intra-departmental basis is essential.
A Board of Directors will assist the staff in policy making and program plan. ning. Their participation must be meaningful and not merely tokenism.
Publications of findings will be as frequent as feasible in order to disseminate information as well as to promote the institution of similar programs by others.
The Foundation will be non-profit. However, within these limits, it can still apply for grant awards, and can charge consultation fees whenever feasible.
IV. RELATIONSHIP OF PROGRAMS TO EXISTING SERVICES AND INSTITUTIONS Every attempt should be made to prevent duplication. Services will be added only when those existing in the community are inadequate or inefficient. Every effort will be directed towards meaningful affiliation with existing facilities and programs.
It is proposed that the Foundation be free standing, in order to circumvent the rigidity which is too often associated with the academic world. Preferably, the relationship with professional schools and other institutions, will be through affiliation of its staff, rather than of the Foundation.
There is little doubt that well organized, broad scoped planning of this type, will be of great benefit to both consumers and providers of services. The general public will benefit through improved, quality oriented services. Large consumers such as labor-management, industry, and Government, will benefit greatly through improved quality and lowered costs. The Foundation can serve as a valuable resource to these large consumer groups, as well as to indigent groups in deprived areas, and others such as Geriatric Residence plans, who are constantly in need of consultation for health care planning and who currently hare no one to turn to.
As usual, there may well be some who will feel economically threatened. However, these should be very few, since the proposed plan preserves the concepts of “one patient/one doctor," and free enterprise. Preliminary discussions indicate acceptance and approval of the medical sector, including professional schools, private practitioners, organized medicine and labor-management. The planned approach is not disruptive. It carries with it the better components of the past, is pertinent to the present, and has meaning for the future.
Recruitment of key staff (executive level).
Selection of board
Designing of health core facility.
Establishing relationships towards creation of biomedical complex.
Implementation of health core facility
large consumer groups. Phase IV (continuing-starting after second year): Designing research and
demonstration projects by staff and by invitation of others (grants to be ac
cepted whenever feasible). Phase V (after all components functioning): Teaching and education, including
It should be noted that service will be rendered within two years at the latest. Publications will be encouraged throughout all phases. There should be careful documentation of the process as well as content of the data related to service, education and research.
VII. FUNDING A sizable basic permanent fund will have to be maintained if we are to attract the best people. Additional funds will come from consultation fees and grant awards. The Foundation will maintain a non-profit status throughout, but will serve profit as well as non-profit groups.
Some thought should be given to starting with "seeding" planning funds required to complete Phase I, in order to establish a larger and more permanent budget.
VIII. CONCLUSION As far as we know, there is no precedent for a Health Care Planning Foundation such as we envision. If such an institute were formed, it could set a precedent for establishing innovative health care delivery models and new associative and assistive health careers, designed towards improved quality and lowered costs of care, through circumvention of the duplication, fragmentation, shortages, and inequities which currently exist. In reality, it might well precipitate a much needed clinical revolution, counterpart of the scientific revolution promoted by the Flexner report of 1910–1911.
As justification, we need only remember that we are at least fifty years behind in our health care delivery system, as pointed out by the renowned Dr. William Welch in 1926, when he bemoaned the widening gap between scientific advances and their clinical application. There has really been no major change since Dr. Flexner's monumental work in 1911. His expectations that quality care would be a natural concommitant of scientific and educational excellence, have not been fulfilled.
It is hoped that philanthropy will again supply the resources and become the unifying force towards implementation of a scientific and systematic approach to the rapidly deteriorating Health Care of our Nation, and thus preserve its heritage for excellence and humanism.
EXHIBIT B. A UNIFIED HEALTH CARE DELIVERY SYSTEM
(Excerpted from address by Dr. Giorgi to the Southern California Hospital Council)
A true challenge to an effective, acceptable Health Care Delivery Model is to preserve the very important concept of "one patient-one doctor", simultaneously permitting comprehensiveness and quality care at reasonable cost. For successful care, there must be a personal “managing" physician who sees the patient