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Perspectives |
Part II. Opportunities for Nonprofessional Workers1 James H. Thrall, MD
1 From the Department of Radiology, Massachusetts General Hospital, MZ-FND 216, Box 9657, 14 Fruit St, Boston, MA 02114. Received April 4, 2006; revision received and final version accepted April 7. Address correspondence to the author (e-mail: thrall.james{at}mgh.harvard.edu).
The Institute of Medicine (IOM) and the Accreditation Council for Graduate Medical Education (ACGME) have put forth initiatives (1,2) for educational reform aimed at improving the outcome of training for health professionals by defining core and general competencies, respectively, designed to help shape values, attitudes, and behaviors rather than simply enumerating facts to be learned. These initiatives have substantial merit (3) and speak to issues that are fundamental to improving the quality and safety of health care delivery and to improving the satisfaction of patients with the delivery system.
However, neither the IOM nor the ACGME have addressed the full extent of the educational and cultural challenges facing the delivery system, because they restrict their focus to health professionals at the top of the delivery pyramid and do not address the educational and cultural challenges posed by the entire health care workforce. In fact, thousands of people come into the health care workforce each year with no formal training for the job they are expected to do. To achieve the ambitious visions of the IOM and ACGME, these workers and thousands more with rudimentary training must be beneficially integrated into the care process and must become culturally aligned with the values underpinning health care delivery.
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COMPOSITION OF THE HEALTH CARE WORKFORCE |
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At the next level of the hierarchy come the "allied health professions." These encompass a wide variety of occupations that have evolved over the years to support the care delivery process, often when a particular function has become well enough defined or understood to stand alone with a specific educational curriculum. For example, in the earliest days of radiology, physicians were responsible for performing exposures and developing films. Later, with better equipment and standardization of procedures, these functions were turned over to the new occupation of radiographer or radiologic technologist with progressive formalization of training, certification, and licensure.
In the current edition of its catalog (4) entitled Health Professions and Education Directory, the American Medical Association lists 65 allied health care occupations and 22 accrediting agencies for them. Among these occupations are many different kinds of technologists, physicians' assistants, and therapists, as well as dietitians, medical librarians, phlebotomists, perfusionists, and many others. The American Medical Association catalog provides information on 6700 different educational programs devoted to these occupations that are hosted at 2500 institutions. These numbers dwarf the numbers of medical and nursing programs in the United States many times over and serve to illustrate the magnitude and diversity of the educational background of the total health professions workforce. The popularity of undergraduate programs in the "health sciences" that provide broad-based general preparation for allied health careers is increasing across the country (5).
Beyond the health professions, there are hundreds of thousands more people in the health care workforce for whom there are either very limited formal training options or no options at all that are directly relevant to their health care job. Bringing these workers into complex care-delivery environments represents an enormous challenge. The jobs they perform, among others, are scheduling, patient transportation, patient reception, secretarial work, medical transcription, housekeeping, food service, maintenance, coding, billing, and record keeping. Many of these workers are on the front line in terms of direct patient interaction, and many are directly involved in the exchange and communication of critical medical information between providers and to and from patients.
Data for the Massachusetts General Hospital (MGH) provide a measure of insight into the challenge posed by the need to assimilate workers with diverse educational backgrounds and job experiences into a cohesive delivery team. Together with its associated physicians' organization, MGH employs 18 859 people, in itself a staggering number. Of these, 2936 are staff physicians (n = 1811) or house staff (340 fellows, 785 residents), and 3487 are nurses. There are 3238 other allied health professionals, whose numbers are divided between those whose occupations require at least a bachelor's degree (n = 1885) and those whose occupations require some formal training after high school but less than that required for a bachelor's degree (n = 1353). There are 1007 officials and managers. Research scientists, fellows, and support staff account for another 2347 employees. This leaves 5834 employees, or 30% of the workforce, in office and/or clerical and service positions. Some of the people in these positions have had pieces of relevant training, such as training in medical transcription, but most have a high school education or less, no medically oriented training, and no exposure to the kinds of competencies put forth by the IOM or ACGME.
From the perspective of the employers, including hospitals, the distribution of educational backgrounds represented by the entire health care workforce is daunting and defies easy categorization. In some sense, hospitals can "buy" health professionals by hiring people who have graduated from the manifold training programs noted above. Typically, these members of the workforce have defined skill sets and have been indoctrinated, in variable measures, to the special values and challenges of medical practice as part of their training: patient confidentiality and right to privacy; respect for patients' dignity; respect for life and death; respect for the integrity of information and data; importance of timeliness in delivering care; adherence to standards of care; and the need for equability, efficacy, and efficiency in the stewardship of limited health care resources.
What of the thousands of other members of the health care workforce who have not had the benefit of direct experience or educational exposure to these concepts? To bring these workers into cultural alignment and to provide them with needed knowledge and skills, hospitals and other health care delivery organizations need to provide on-the-job training and exposure to their values. By analogy, just as hospitals can "buy" professionals, they must "make" everyone else.
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EDUCATION AND CULTURAL ASSIMILATION OF THE NONPROFESSIONAL HEALTH CARE WORKFORCE |
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If the health care system in the United States is going to achieve its ambitious quality and safety goals and improve its service standards and efficiency, as many oars as possible need to be in the water, with the entire health care team pulling together. This strongly suggests that hospitals and other health care organizations need to fundamentally rethink their outlook on education and training and develop explicit strategies that robustly encompass the nonprofessional members of their workforces.
Where to begin? The first introduction of workers to a new employer can be pivotal in how they regard their job—its importance to the organization and their own importance to the organization. The most important values of an organization should be put in front of all new employees as part of their orientation and should be reinforced on a regular basis. The higher the organizational level of the individuals involved in delivering that message, the more effective it will be. If it is left to a lower-organizational-level staff member in the human resources department to convey the mission, vision, values, and guiding principles of a hospital, the workers will equate the importance of those concepts to the organization to that person's rank. It would be instructive to know in how many health care organizations the chief executive officer meets with new employees to share his or her outlook on these important issues.
In the MGH Department of Radiology it has been our policy, for more than 15 years, for the chairman of the department, the administrative director, and other key leaders to meet individually with new employees in small groups. We share our departmental mission and values and explicitly state our expectations for everyone in the department. One of those expectations is that each person will have the opportunity to engage in career-long activities that support his or her own personal and professional growth. Providing support and encouragement for this is one of the most important aspects of the social contract between the department and the people who work in it.
What next in engaging new employees? Every new employee should receive competency-based training in his or her designated job. Even people with apparently obvious jobs such as housekeeping require such training because of the special needs of hospitals—for example, patient confidentiality and proper handling of hazardous waste. Other "entry level" jobs, such as reception or patient transportation, actually have extensive educational requirements, many of which are variable between organizations and require institution-specific curricula. The disciplined sequence of formal curriculum development, educational delivery, and competency assessment followed by periodic in-service refresher training and reassessment of competency is simply not followed in many institutions, especially for lower-level positions. Quite often, workers have some circumstantial level of orientation, some training (often from a recent previous hire), and cursory competency assessment (often informal and undocumented) and are then on their own unless a complaint is registered between the annual evaluations required by the Joint Commission on Accreditation of Healthcare Organizations.
At MGH, we have addressed the need to train the nonprofessional workforce in radiology by establishing a Quality Management and Education Program that works with operations managers in the department to develop curricula, deliver content, document training, and document achievement of required competencies. Work processes are delineated on flowcharts to determine each process step that a particular person is involved in and then to define the knowledge and skills necessary to accomplish that step. This process defines the curriculum for competency-based training. Achievement of each competency can then be documented with periodic reassessment. This approach is actually more rigorous conceptually than the usual approach to assessing professional education, which does not require that each competency be mastered but only that a certain overall score on a test be achieved.
Every new employee should also be evaluated with respect to his or her general educational background. Educational opportunities need to be developed that match these backgrounds, and pathways forward must then be provided. The pathway may be English as a second language, medical terminology, job-specific skills, computer skills, course work toward high school equivalency or a college degree, or remediation in any subject. It may not be possible, for a variety of reasons, to require employees to undertake broader training than absolutely required for their particular job, but a successful culture of supporting and encouraging people to undertake more education is a powerful factor that can differentiate organizations in the long run through differences in their respective levels of aggregate educational accomplishment.
Specific issues of importance to hospitals that hinge on higher overall education of all workers are the ability to communicate complex medical information more accurately, the ability to solve problems quickly and efficiently without having to engage managers, the ability to use sophisticated information technology systems, an improved ability to interact with patients, and a better ability to respond to medical emergencies where nonprofessional workers may be first responders. Tuition reimbursement programs, on-site classes, and direct encouragement from managers all serve to promote worker involvement in education.
Building on the foregoing programs for improving job skills and general education and life skills, institutions can then look at the competencies posited by the IOM and the ACGME and craft programs to engage their nonprofessional workers, along with their professional workers, in achieving them. A case in point is the core competency of the IOM for training in interdisciplinary teams. The "stretch concept" in the IOM's publications is to include key allied health professionals in the training envelope (1,6). However, the performance of nonprofessional workers can be the difference between success and failure, and even life or death, in many situations. In the response to a cardiac arrest on a nursing unit, the unit clerk can play a vital role in communicating the arrest and recording milestones in treatment while available professionals attend directly to the patient. Patient transporters can retrieve needed supplies and help move patients.
The emerging trend of using simulation for team training (7,8) presents an ideal opportunity to incorporate everyone in the training process. Simulation is especially valuable in teaching teams how to work together better. Why not include clerks and transporters and others as members of the team and include them in training exercises? Teach "nonprofessionals" to be professional in the simulation event. Set a goal that everyone coming into contact with patients should work to the same standards in what they do. Teach people that communication should be "classless," so that every worker is empowered to speak up in the care process if he or she has something to offer. The airline industry has pioneered this concept (9) to reduce intimidation across the hierarchy of people in an airplane crew. The "time-out" or universal protocol championed by the Joint Commission on Accreditation of Healthcare Organizations speaks to the same issue (10).
Other competencies of the IOM aimed at fostering a culture of patient-centered care, learning to use quality improvement methods, and learning to use informatics to improve communications and reduce errors would appear to apply beneficially to every health care worker, not just health professionals. Workers who perceive that they are included in achieving institutional goals and are valued as team members and supported in their careers will be more productive with better morale and are more likely to remain longer with their organizations than those with negative perceptions. This latter point is very important, because turnover of workers is extremely expensive in both direct costs incurred in the recruitment and hiring process and in even higher costs of reduced productivity of a short-handed and perpetually inexperienced workforce. High turnover of nonprofessional workers plagues many hospitals.
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DO YOU HAVE TO BE FRENCH TO MAKE AN IMPRESSION? |
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After developing a job-specific competency-based curriculum and associated general material on job-holding skills, we recruited 15 people to undergo several weeks of training. The ground rules were laid out for the class—only those who passed the competency examination, attended all of the classes on time, and demonstrated good interpersonal skills would be offered jobs at the end of training. All 15 passed and were offered jobs. To celebrate the event, we invited the chief executive officer of the hospital, the vice president of nursing, and the vice president with responsibility for radiology to join us for a graduation ceremony.
One of the graduates was selected to represent the group as valedictorian. When it was his turn to speak, he looked slowly across the audience and finally said, "Do you have to be French to make an impression?" He then paused and continued looking for some time while we grappled with his question. Where was this going? Sitting next to our chief executive officer, I was more than a bit nervous. The speaker then went on and said, "Yes, you must have seen the advertisements for the exhibition of French Impressionist paintings at the Museum of Fine Arts in Boston. The ads say ‘Do you have to be French to make an impression?’" He paused again briefly and continued, "When I saw that ad, I got to thinking about what we do here at the Massachusetts General Hospital. You know, it occurred to me that the great French Impressionists created their masterpieces by placing innumerable small brush strokes on the canvas, while we seek to create masterpieces in patient care by having many different people each contribute their part, however small. So, even though those of us graduating today are only patient transporters, we play a necessary role and we have the opportunity to add our small brush strokes to the canvas in helping the hospital create masterpieces in care delivery for our patients. We share that responsibility with you."
The room was very, very quiet after these remarks. We were all sitting in silence, humbled by this simple but powerful metaphor shared with us by a man living in a homeless shelter who had a grand total of 3 weeks of health care experience. He reminded us that everyone who touches the care process is important, even vital, no matter their station. I have reflected on the impressionist metaphor many times over the ensuing years and have come to the view that no health care institution can rest on its laurels until every last person in it feels the way our valedictorian did: That he or she is helping to create masterpieces in health care delivery and must do their part well because, no matter what that part might be, it is vital for the patient. That should be our goal in engaging the entire workforce—to share the same mission and values and to put all of our best efforts together.
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CONCLUSION |
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FOOTNOTES |
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References |
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