| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
The following information was gained by scanning the program of the continuing education course in Bürgenstock Hotels and Resorts which took place from September 17th - 19th. Misspellings can occur and might lead to errors as regards content. Please let us know if that is the case somewhere so we can correct it. 
Lecturers Dr C. Lukas Bohny, M.D. Program THURSDAY, SEPTEMBER 17TH, AFTERNOON
FRIDAY, SEPTEMBER 18TH, MORNING
Seminar on cranial and sacro-occipital technique Anatomy, Physiology, Pathology
FRIDAY, SEPTEMBER 18TH, AFTERNOON Seminar on cranial and sacro-occipital technique Anatomy, Physiology, Pathology (continued)
Cranial palpation Workshop Hand utilisation techniques & cranial rhythmic identification Lecture and partial workshop Designed to give a comprehensive description of the vault sutures interarticular unions. This lecture is laden with video slides to endow the practitioner with a working knowledge toward their manipulative strategies Hotel Palace Hotel Palace, Dining Room The Nomad'sland Orchestra will accompany us through the evening SATURDAY, SEPTEMBER 19TH, MORNING Invalidity Insurance in the Swiss Health System
The Federal Invalidity Insurance and its development from the point of view of the Federal Office for Social Insurance ?Invalidity Insurance: practical aspects ? Quality of Care
Quality management in health care: the point of view of the Federal Office for Social Insurance Quality of Care: what is it? Evidence based medicine / chiropractic Continued Medical Education: self-assessment procedure Outcome management tools in chiropractic Hotel Palace, Dining Room SATURDAY, SEPTEMBER 19TH, AFTERNOON Quality of care (continued)
1999 THE CONTINUING EDUCATION COURSE WILL BE HELD SEPTEMBER 9 - 11 IN MONTREUX
Abstracts The Federal Invalidity Insurance and its development from the point of view of the Federal Office for Social Insurance The Invalidity Insurance was introduced in 1959 by constitutional decision. Its purpose is to guarantee a reasonable existence in case of invalidity, be it by professional reintroductory measures or by a basic financial allocation (a pension-wage). It is financed by income based premiums and by public monies. Besides the annuity and compensation, in cases of severe handicap or helplessness, the insurance provides medical, professional and educational measures for reinstatement and supportive equipment. It contributes to institutions for the lodging and busying of invalids as well as to organizations offering invalidity aid. Also included are medical treatments of certain congenital affections up to the age of 20. For the Invalidity Insurance the reinstatement is of utmost importance: it does not only serve to avoid pensions, but increases the self-consciousness and self-esteem of the invalids. The notion of invalidity incorporates a medical (health damage) and an economical component (loss of earning power) that are linked. The conception of health damage in the insurance sense is elucidated. Entitlement to insurance assistance presupposes a careful medical evaluation of every single case. For this, the Insurance depends on the knowledge and experience of all medical persons practicing in our country. Concomitantly it has its own medical service which will be discussed elsewhere. The actual financial problems of the Invalidity Insurance clearly mirror the social situation and challenge the economy, politics and the population for solidarity with invalid co-citizens.
Outcome management tools in chiropractic There is an increasing emphasis today on quality assurance in all branches of health care. Assessment of quality of care embraces both measures of the process of care, i.e. audit, and measures of the outcome of care, i.e. what actually happens to patients. In addition to providing information on quality of care, outcome measures can be used to evaluate the efficacy of treatment regimes in everyday practice. This presentation will introduce outcome measures appropriate for use in pain patients which are relevant, reliable, valid and responsive to change, and which are feasible and practical for use in the clinical setting. Documenting patient outcomes in routine practice, as opposed to investigation in the research setting, is seen as a mechanism for enabling the clinician to contribute to the chiropractic knowledge base. The strengths and weaknesses of this approach will be discussed.
Quality management in health care: the point of view of the Federal Office for Social Insurance Quality management is the direct responsibility of the providers of health care. The federal government seeks its role in prescribing specific products, tools and all the details of quality management implementation. We see its role much more as a supporter and enabler. Relevant aspects of quality management in health care are the quality of access to health care, the appropriateness of diagnostic and therapeutic procedures, the quality of processes and outcomes and the satisfaction of the patients. Special attention has to be given to the quality of interaction between the providers of health care. Our criteria for the evaluation of quality contracts are based on the concept of a continuous quality improvement. In a first step the providers of health care should build up a structured improvement process. Improvement has to be planned and managed. A continuous monitoring of some key performance indicators is then needed to report periodically on the results of improvement programs.
Continued Medical Education: self-assessment procedure As a result of more learning and leading to greater competence, Continued Medical Education (CME) of the General Practitioners (GPs) allows them to improve their performance, and finally, to have better patient outcome. Giving better care by means of CME is very hard to prove. But the use of an entire course of the Medical Audit cycle could bring that proof. CME is an ethical duty and individual responsibility for every practising doctor throughout his professional life. Art. 58 of the KVG/LAMal and the Réglementation pour la formation continue of the FMH makes CME almost mandatory for the GPs in Switzerland. At the very least, the GP must keep a record of his CME activities. What does a professional organization do with these records? There are two ways to proceed: 1) Set an obligatory number of hours of CME and sanction those practitioners who do not manage to reach the prescribed requirement (Top-Down System). 2) Collect and analyse the records anonymously and publish the results so that each member can compare his with that of his peers (Buttom-Up System). With this system, the participation is secured while there is no compulsion nor penalties of relicensure. It has already been chosen by the Swiss GP Organisation: cf the 1997 Joumal d'assurance de qualité. In conclusion, a self-assessment procedure permits the professional organization to control and improve the CME of its members, all while respecting the law and assuring the confidentiality of every individual.
Quality of care: what is it? Care providers, patients and payers tend to give different meanings to the terms quality and quality of care. Such a variation is quite expected and legitimate because these terms encompass many elements. However, there are at least two definitions that are internationally recognized. One of them has been established by the U.S. Institute of Medicine (IOM), the other by the International Organization for Standardization (ISO). These definitions will be discussed, as well as the various dimensions and aspects related to quality of care. The main principles of quality management will be briefly described, including quality control, quality assurance, quality indicators and audits. The usual categories proposed by Donabedian (structure, process and outcome) will also be explained. Certification and accreditation Accreditation can be defined as an act of voluntary submission to review by external agents. The participating organization is assessed against specific standards and the review is undertaken by peers who can assist in ensuring that the organization meets the standards of the professional group to which it belongs. Certification has a similar meaning, but it applies mainly to the process by which a company's quality systems and processes are evaluated to determine ISO 9001 or 9002 or 9003 compliance. The evolution of accreditation of health care organizations in North America and the history of certification in the industrial sector will be shortly presented. The standards, the scope, the survey procedures and the objectives of both accreditation and certification will be discussed. An overview of the current situation in Europe and Switzerland will be given.
Chiropractic in the age of computer technology While basic chiropractic principles and procedures have either remained unaltered or evolved slowly over the last decades, information technology has advanced at lightning speed. In a traditionally low technology medicinal field such as chiropractic, why is it important to keep up with this development? In what perspective can computers help to improve the quality of care in our profession? The presentation provides some visual examples of how practitioners and patients can benefit from modern communication means. The issues addressed include knowledge acquisition through the internet, digital medical data transmission, internet banking, public relations and patient education.
Evidence-based medicine / chiropractic Today, evidence-based medicine (EBM) is one of the most topical issues for discussion amongst medical clinicians, public health authorities, third party payers and medical curriculum planners. EBM is now well established through research centers and dedicated journals within the medical profession in the United States, Canada, and the United Kingdom and is now rapidly expending throughout Europe especially in France, Germany, Italy and Portugal. The philosophical roots of EBM can be traced back to mid 19th century Paris or earlier. However, it has emerged today from the field of clinical epidemiology as a result of the role epidemiology has to play in the treatment and management of individual patients. EBM may be defined as current best evidence in making decisions about the care of individual patients. In practice, this means integrating individual clinical expertise with best available external clinical evidence. Although it is acknowledged that the best external clinical evidence may arise from a variety of different sources, it is generally accepted that the randomized controlled clinical trial (RCT) and systematic reviews of such form the gold standard for evidence. In the clinical setting, the practice of EBM has been described as a process to encourage clinicians to become self-directed, life-long learners. The motivation to engage in such a process is thought to arise from the need to answer questions generated from everyday clinical encounters with patients. To accomplish this, the EBM process consists of: - converting the patient information needs into answerable questions - searching for the best evidence - critically appraising the evidence - applying the best evidence to practice However, EBM is not without controversy and many debates are currently taking place about its validity, reliability and application in clinical practice for individual patient care. Within chiropractic as well as complementary and alternative medical professions, this debate has yet to begin. This presentation will discuss the strengths and weaknesses of EBM, its appropriateness for chiropractic practice as well as introduce an alternative model to help achieve deep, self-directed and reflective learning as well as document change in clinical practice.
Quality control in private practice: how to improve standards of patient care As providers of health care, chiropractors are responsible for the decisions they make in ensuring their patients receive the best and most appropriate service available. Various strategies may be employed in pursuit of the fundamental desire to improve the quality of care given to patients. Those practitioners unaware of the latest fashion in health service management will nevertheless be using the basic principles in their every day work by asking themselves if they are treating patients as well as possible, if there was anything else that could have been done and what changes can be made in the future. To be truly committed to excellence, a framework for adherence to good practice is necessary. Such changes begin with awareness, and implementation is achieved with motivation and support. Individual practitioners can set appropriate standards of care utilising many sources such as research evidence, professional organizations, local needs and Patients Charters. Priority areas of practice can be identified and realistic targets set. Clinical audit methods can help improve patient care in a systematic and objective way involving and benefiting the entire practice team.
Impact of peer review groups. Quality circles on quality of care Background: Under the pressure of steadily rising expenditures for health care, medical systems are undergoing a lengthy process of reorganization, comparable to the historic period of early industrialization. Solo medical practices, like small hospitals, will be replaced by large networks of practices, integrated with hospitals, and systems which can deal with the complexity and financial investments necessary to run these new networks. These systems ultimately need quality management, which is not necessary for the much simpler systems we are used to. But a widespread move to best practice will not be possible without involving clinicians in the processes of organizational change. Aim: This lecture will outline the role and limits of peer review groups or quality circles of care providers as a comprehensive, integrated and co-operative approach to the continuous improvement of all facets of health care. Definitions: Quality circles are on site-unions of professionals committed to a well planned process of mainly prospective, cyclic and structured activities to implement lasting changes and continuous improvement in areas of high priority. This process is based on 1) a co-operative and participative relations culture with emphasis on mutual support which incorporates effective communication and consultation throughout the organization and 2) the use of medical audits and feedback, i.e. a constructive work-up of the gap between prior agreed targets and/or evidence-based criteria/standards, and respective key performance indicators recorded in daily routines by participants. Facilitators proved to be of help for guiding the groups through this stepwise review process. Peer review emphasizes colleagues' support in this approach and is defined as a continuous, systematic and critical reflection by a number of care providers, on their own and colleagues' performance, using (the same) structured procedures, with the aim of achieving continuous improvement of the quality of care. Conclusion: Peer review in small groups or quality circles match the profile of effective behaviour change in health care, as found in the literature. Barriers and problems encountered in establishing quality circles or peer review groups have to be taken into account for a successful internal quality assurance.
Indicators of quality of care in chiropractic Background: Chiropractors are gradually moving out of their isolated position within the health care world to become part of a group of practitioners who all compete for their share of the health care budget. The issue of quality and of how to measure it will therefore soon become a reality for individual practitioners. Discussion: In this presentation, I will discuss how different players (the chiropractor, the patient and the 3rd party player) have different goals in relation to the treatment. Furthermore I will show how one can construct quality indicators in relation to these goals. Conclusion: It is important that the chiropractic profession defines its own standards of care and that regular audits take place, using relevant indicators of quality of care, to ensure that the profession, at large, sticks to these standards. Inability to show that treatment is based on accepted evidence and that the care provided is of acceptable quality will throw us back into the realms of quackery and the free forces of the open market. The appropriate use of quality indicators is therefore an urgent priority.
Spinal-cranial morphology and physiology A review of the relationships between osseous, meningeal and neuronal structures and their role in the cranio-sacral respiratory rhythms The meninges are comprised of three distinct tissue layers. The outermost layer is a thick fibrous sheath known as the dura mater. Most anatomy texts will agree that the dura is lightly connected along the spinal canal but place the significant firm attachments at the foramen magnum, posterior body of cervical two and second sacral segment 1,2. It has only been as recent as 1996 that studies have established its attachments throughout the canal as more substantial than previously believed 3,4. The two inner layers are the thin middle arachnoid mater and the somewhat tougher internal pia mater. Although these layers initially appear to be autonomous they do in fact integrate along various longitudinal planes of the spinal canal. The pia mater encases the spinal cord and laterally projects the dentate ligament to segmentally anchor itself and the arachnoid to the dura. The arachnoid mater in turn feeds back into the pia's anterior and posterior midline by projecting a continuous fibrous sheath known as the arachnoid septum. Converging at the foramen magnum the endosteal and periosteal cranial meninges join the spinal meninges to form a continuous open channel between the cranium and the sacrum. The meninges are kept tense by the constant positive pressure of cerebrospinal fluid and activated into a rhythmic motion by four distinct impulses. The first two are the primary respiratory and cranial rhythmic impulses. Although very little is known about the source that generates both of these rhythmic impulses, their existence has been recorded by Viola Frymann in her study on cranial rhythmic motion 5. The third rhythm is derived from the influences of the pulmonary diaphragm as it moves the abdominal viscera against the pelvic floor and transforms pneumatic pressure into hydrokinetic waves of cerebrospinal fluid. The fourth rhythm or cardiac is generated under the influence of cardiac output as blood courses through the central perivascular canals. 1.Romanes GJ, editor, Cunningham's Textbook of Anatomy. 11th ed. London, Oxford University Press, 1972:6934 2. Gray H, Gross CM, eds., Anatomy of the human body 29th (Am) ed. Philadelphia; Lea 8 Febiger, 1973:883 3. Shinomiya K, Dawson J, Spengler DM, Konrad P, Blumenkopf B, An analysis of the posterior epidural ligament role on the cervikal spinal cord. spine, September 1996, 21(18):pp.2081-88 4.Bashline BD, Bilott JR, Ellis JP, Meningovertebral ligaments and their putative significance in low back pain Journal of Manipulative and Physiological Therapeutics, Nov-Dec 1996, 19(9):pp. 592-6 5.Frymann VM, A study of the rhythmik motions of the living cranium. J Am Osteopathic Assoc. 1971; 70:92845 Anatomy & physiology of cranial motion A look into the various intercranial rhythmic motions and their effects upon the brain, meninges and cranial bones The cranial chamber that encases the brain and meninges is maintained at a positive fluid pressure to preserve meningeal tension and neuronal protection. To regulate against excessive pressures which might interfere or damage these structures, a feedback reflex is transmitted through the superior cervical ganglion by the hypothalamic-intermediate lateral neutron feedback system. The increased sympathetic output is transmitted to the blood-brain-barrier in the choroid plexuses and decreases the production of cerebrospinal fluid 1 until the fluid levels drop below their normal pressure variances. As the vault swells and contracts to the rhythmic pulsations of the brain and cerebrospinal fluid, the meninges respond with tensile force to influence the motion of the skull bones. The human skull consists of 22 separate bones. Embryologically each bone emerged from either membrane, cartilage or a combination of both Gray's Anatomy 2. The siginificance of this is that cranial bones derived from membrane have a greater propensity toward pliability, whereas those that develop from cartilage appear to take on a more supportive role. Sutherland 3, DeJarnette 4, and Retzlaff EW 5 noted that each bone was capable of independent motion. However, through sutural afffiliation, they collectively produce a specific overall global motion to the cranium when subjected to the intercranial hydrokinetic rhythms of neuronal and cerebrospinal fluid pulsations. Guided by the sutures, morphological articular characteristics and the tension reciprocal membranes of the meningeal tissues, the midline structures are predominantly coerced through cycles of flexion and extension whereas lateral structures are forced into external and internal rotations. 1.Lindvail M, Edvinsson L, Owman C, Sympathetk nervous control of cerebrospinal fluid production from the choroidplexus, Science, July 1978; vol. 201:176-8. 2.Gray H, Gross CM, eds., Anatomy of the human body, 29th (Am) ed. Philadelphia; Lea & Febiger, 1973:110-12 3.Sutherland WG, The Cranial Bowl, Minnesota, Free Press Company, 1939 4.DeJarneKe MB, Cranial Manual, Nebraska City, Nebraska; Sacro Occipital Technique, 1979-80 5.Retzlaff EW, Michael DK, Cranial bone mobility, J Am Osteopathic Assoc.1975; 74:869-73
Cranial palpation Hand utilization techniques & cranial rhythmic identification This section is dedicated to developing the practitioner's hand manipulative dexterity and palpatory skills to identify the four cranial rhythmic impulses. When applying cranial manipulative procedures, the practitioner should always approach the subject with a work soft contact. To insure this, the session will begin with an exercise to identify the soft hand touch. The following exercises will target pressure application identification and hand manipulative applications. Each attendee will receive one air filled balloon and will remain seated as they are directed through the exercise protocol. The purpose of this exercise is to impart a working understanding of hand applications to address multidirectional maneuvers. Cranial rhythmic identification: Following the hand application exercises, the attendees will be divided into two groups and paired up. Group A will act as the practitioner while group B will be the simulator subjects. Group B will sit comfortably in chairs while group A contacts their group B partner's head for the exercise. Simulation exercise one: Group A will take the temporal pulse of group B. Although this is called a simulation exercise, it is in fact feeling for the actual blood rhythm. The group A participants will be asked to notice the strength, deep, rhythm regularity and speed. Simulation exercise two: Is to simulate the cranial motion facilitated by pulmonary inhalation. Simulation exercise three: Is to simulate pulmonary inhalation with primary respiratory impulse expansion and contraction. Simulation exercise four: Is designed to imitate the cranial rhythmic impulses. Upon completion of the four exercises, the groups will switch places and the exercises will be repeated. Morphology of the cranial vault sutures Designed to give a comprehensive description of the vault sutures interarticular unions, this lecture is laden with video slides to endow the practitioner with a working knowledge toward their manipulative strategies In the human skull, each bone is segregated from the other by articular seams known as sutures. For years anatomists believed that sutures functioned as primary growth regions of the skull and served no purpose other than to hold the skull together 1,Z3. However, recent studies now question the old theories and suggest the sutures developed to permit independent cranial bone motion throughout the skull. In 1956, Pritchard demonstrated the existence of five tissue layers and vascular vessels residing within the suture's articular seams 4. He further suggested that they form a strong bond of union between adjacent bones and allow for slight articular motion. In 1971, Baker reported the movement of the cranial bones along the sutures with the application of maxillary arch expansion s. Other studies such as those performed by Retzlaff & Michael 6, Kostopoulos & Keramidas 7, Wood 8, Pavlin 9, Derman 10, Kragt 11, Moss 12 and Mc Elhanely 13, all suggest the presence of allowable motion within the sutures of the human skull. Because the skull is essentially a closed structural unit, access to the internal structures via the suture's articular unions would seem to be an obvious mode of entry. This is substantiated by the internal meninges infiltration through the suture's articular seam to become the external periosteum of the cranial vault. With this relationship in mind, it becomes apparent that manipulative applications to the external cranial structures can transmit through the sutures to alter the structure around and through the brain (Pick, 1994)14. When viewed topographically, the articulations that constitute the sutural seams are often deceiving to the eye. Frequently, what appears to be a simple or direct articular junction, may in fact be a complex integration of overlapping beveled surfaces inundated with sockets, ridges and interlocking undercuts. Unfortunately, if the practioner is incognizant of the articulation's concealed characteristics, manipulative attempts can be inhibited by these features and may ultimately result in negating the procedure's therapeutic response. In this session, the accessible sutures of the cranial vault will be dissected and reviewed for their morphological characteristics. Accompanying each suture's description will be a brief explanation of the optimum contacts and manipulative maneuvers to disengage its articular seam. 1.Gray H, Gross CM, eds., Anatomy of the human body, 29th (Am) ed. Philadelphia; Lea & Febiger, 1973:296. 2.Romanes GJ, ed., Cunningham's textbook of anatomy, 11th ed. London; Oxford University Press, 1972:207. 3.Warwick R, Williams PL, eds., Gray's anatomy of the human body, 35th (Br) ed. Philadelphia; W.B. Saunders, 1973:389. 4.Pritchard JJ, Scott JH, Girgis FG, The Structure and Development of Cranial Facial Sutures, J Anat. Vol 90, pp. 73-85 (1956). 5.Baker EG, Alternation in Width of Maxillary Arch and its Relation to Sutural Movement of Crania/ Bones, J Am Osteopathic Assoc. 1971, 70:559-4. 6.Retzlaft EV, Michael DK, Cranial bone mobility, J Am Osteopathic Assoc. 1975; 74:869-73. 7.Kostopoulos DC, Keramidas G, Changes in Elongation of Falx Cerebri during Craniosacral Therapy Techniques Applied on the Skull of an Embalmed Cadaver, J Cranialmandibular Practice 1992; 10:9-12. 8.Wood J, Dynamic response of human and cranial bones; J Biomechanics 1971; 4:1 -12. 9.Pavlin D, Vukicevic D, Mechanical reactions of facial skeleton to maxillary expansion determined by laser holography, Am J Ortho. 1984; 85(6):498-507. 10.Dermant LR, Beerden L, The effects of class 11 elastic force on a dry skull measured by holographic intefferometry. Am J Ortho.1981; 79(3): 296-304. 11. Kragt C, Measurement of bone displacement in a macerated human skull induced by orthodontic force, a holographic study; J Biomechanics 1979, 12:905-10. 12.Moss ML, Extrinsic determination of sutural area morphology in the rat calvania, Acta Anat. 1961; 44:263-72. 13.McElhaneyJ, et al., Mechanical properties of cranial bones, J Biomechanics 1970; 3:495-511. 14.Pick MG, A preliminary sing/e case magnetic resonance imaging investigation into maxillary frontal-panetal manipulation and its short-term effect upon the intercranial structures of an adult human brain; J Manipulative and Physiological Therapeutics 1994; 17(3):168-73.
Patients' perspectives in quality improvement Before trying to improve, ensure and control quality, we have to think about what quality in health care means. Quality has various dimensions. Besides scientific and clinical outcome quality, patients' satisfaction is also an important indicator of the quality of care. Patients' satisfaction does not only depend on the results of care, but also on the way these results are achieved, that means structures and processes as well as individual conditions and expectations. Nevertheless, basic principles can be established. Methods like the systematic questioning of patients, registering complaints, creating an ombudsplace are possible tools for developing a common understanding of quality in health care in a continuous process.
Dr Maurice Theytaz: Invalidity insurance. Practical aspects The law on invalidity insurance defines invalidity as the diminution of earning capacity, presumed to be permanent or of long duration, which results from an impairment of physical or mental health due to congenital disability, sickness or accident. It stipulates the options offered and insists primarily (firstly) on re-adaptation and its numerous allied possibilities (medical and professional measures, special education or other auxiliary means). Disability wages are established only if these measures do not bear fruit. The examination of medical data assumes great importance in precisely stating the severity of the impairment of health and the physical limitations which result from it; this finally sets the level of incapacity in a particular activity. With these elements the disability wage or allowance can be calculated as well as the percentage of invalidity. One page back
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
