Keep Your Practice on Track with Cross-Training
A cross-trained staff fosters teamwork, boosts moral and improves patient flow. Here's how to get it done.
By Jane Shuman, C.O.T., M.S.M., Dedham, Mass.

Many ophthalmic practices still assign a defined job description to every employee. This was fine a few years ago, when qualified office personnel weren't so difficult to find. But in today's economy, with the unemployment rate hovering at a record low, a task-oriented environment often translates into frequent staffing shortages, especially during vacation periods and the cold-and-flu season. Inadequate staffing, in turn, results in frustrated technicians and patients kept waiting while you attempt to remain focused on the bottom line.

Now, more than ever, it's in your best interest to maintain your current staff, and keep employee morale high without sacrificing efficiency or quality patient care. One method of achieving these goals is to cross-train personnel. Philip Harris, M.D., introduced the concept of cross-training at Dedham Medical Associates in 1993. Since then, the absence of a secretary or a technician no longer wreaks havoc on office operations because others can substitute.

Cross-training has also had a positive impact on office morale and on our patient flow. For example, whenever our technicians are running behind, a secretary can leave the desk area long enough to work-up a few patients and eliminate any backlog.

Here, I'll give you a step-by-step approach for achieving similar results with cross-training in your practice.

Get everyone on board

Before you attempt to begin cross-training your staff members, it's imperative that all physicians in the practice agree that cross-training is an investment that will repay itself multiple times. Some of the rewards physicians will appreciate include:

• not having to reschedule patients when more than one technician calls in sick on any given day
• being able to see a higher volume of patients because clinical staff are qualified to answer questions, such as how to use a compress or how to follow post-op instructions, in their stead
• a decrease in improperly triaged calls because all staff understand what symptoms constitute an ocular emergency.

Once the physicians are enthusiastic about the challenge of cross-training, staff members must be convinced that they, too, will benefit from this change. You'll have greater success with getting staff to buy in to the concept of cross-training if you can arrange for the most skeptical technician and secretary to observe a fully cross-trained practice.

As ambassadors, they can see firsthand how well this system can work and answer many of their co-workers' questions. The enthusiasm they bring back to the office will spread to co-workers. (See "Cross-Training Kick-Off" on page 88 for more on communicating the advantages of cross-training to staff.)

Cross-Training Kick-Off
Before you begin cross-training, schedule a kick-off meeting for doctors and staff. Use this meeting as an opportunity to answer questions and allay fears and concerns among staff. Have the doctors address staff about the benefits of cross-training. Some of the advantages to communicate include: Equality. Cross-training reduces animosity between clerical and technical staffs. After everyone has been cross-trained, no position is more important than another. In fact, the impact of one position on another becomes apparent. For instance, when a secretary books a dilated exam at the end of the session, she is unaware of the burden she's placing on the technical staff until she is the person doing the patient work-up. Higher wages. Your pay scale can account for added responsibilities across the board. You can institute this once cross-training is completed. Keep in mind that the staff members with the most seniority should still receive the highest salaries. Flexibility. Cross-training gives employees the option of working in a different capacity instead of using up a sick day. For example, a technician who's afflicted with laryngitis can work as a scribe, and a scribe with a broken ankle can work as a secretary.

Assign trainers

Next, assign people in each area to teach their skills to others who will be new to those tasks. Ideally, trainers should be relieved of other duties until the initial cross-training is complete. If they're not required to perform their own duties, the training can be completed more quickly. This is crucial because completing cross-training will take considerable time. Depending on the size of your practice, it may take up to 2 years. Circumstances such as leaves of absence, vacations and varying patient loads will interrupt the process.

Assess everyone's abilities before beginning the cross-training. The fastest learners and those who can perform at least parts of various functions should be the first to become fully cross-trained. They, in turn, will help others learn. The most reluctant staff members will gain confidence from watching others in similar jobs successfully learn new tasks.

You should expect everyone to learn all aspects of the office, but if an employee doesn't have the physical, technical or communication skills necessary to perform a certain task satisfactorily, don't push it. Because patient care must come first, no practice should put equality of staff ahead of the patients.

Even if every staff member can't be fully cross-trained, a superficial level of equality can be achieved by having all staff members dress in clinical whites, lab coats or uniforms. This gives the appearance of a professional group that isn't differentiated by their clothing.

Start with scribing

The easiest transition to make is that of technician to scribe. People in these positions have the most familiarity with terminology and can usually comprehend your findings without much difficulty.

If you're unaccustomed to having a writer, you'll probably come to depend increasingly on the scribe to explain your findings and directions to patients. This allows you to move more quickly to the next patient without compromising face-to-face time with the patients. Ultimately, the increased volume of patients will increase revenue.

Before having a technician assume a scribe role, arm her with a standardized list of abbreviations and accepted terminology. This not only fulfills a compliance requirement, it also ensures that each abbreviation means the same thing to every person in the office. The ophthalmologists in the practice should be uniform in their descriptions (e.g. healthy vs. normal; quiet vs. clear) and when applicable, the same visit template should be used.

Make sure each new writer understands: If it's not documented, it wasn't done! It's important that your findings, as well as recommendations, assessment and related conversations, are documented. In other words, the plan must contain any element of decision-making that is spoken aloud (e.g., to consider laser therapy if the newest glaucoma medication doesn't decrease intraocular pressure to the desired level).

You and your administrator must decide who will code the visits. Many doctors refuse to relinquish billing elements to staff persons. If, however, you want staff members to assume this responsibility, you must make certain that a qualified person teaches this complex subject on a level the learner can understand. Offer periodic refresher courses and audit charts to ensure accuracy.

Once a technician has learned to scribe, she should do it daily for 3 or 4 weeks or until she's fluent enough to sustain the skill. After the next person has it down, the original scribe should take it on for another week, and so on until all technicians can scribe.

Move on to the front desk

The next step is for technicians/scribes to be trained as secretaries. It's important that they be trained individually, preferably by the strongest front-desk person in the practice. They'll follow the manners and customer service practices they observe. The front-desk person doing the training should be the last to learn the technical side of the business.

Sometimes technicians are reluctant to take on front-desk duties. One technician in our practice accepted a position with the understanding that he would be cross-trained. Although eager to scribe, he was reluctant to learn secretarial skills and was frustrated with the errors he made initially. He became comfortable with front-desk responsibilities once he'd performed the tasks repeatedly and observed how others processed the work flow.

End with technicians

While technical staff are learning to work at the desk, it's time to begin the slow process of teaching everyone else to become technicians. As tempting as it may seem, this isn't an area to rush through. Begin with the easiest tasks, including automated refractometry and lensometry, and the principles behind checking vision.

From the start, teach staff that history-taking is the cornerstone of every visit. Make sure they use a minimum of four qualitative factors to describe every chief complaint.

Encourage learners to shadow your "star" technician to observe proper patient work-ups. This will foster consistency among newer technicians. If, of course, you're fortunate to have one technician training everyone, this consistency will be intrinsic. One by one, as the learners become more confident in their tasks, they'll begin to progress through the steps. According to Dr. Harris, a system of mutual teaching will eventually emerge that will bring the staff closer together.

Ultimately, trainees will need to learn to perform refractometry and applanation tension. The thought of this may paralyze them. If a formalized class in these skills isn't available, initiate one. If you have a staff optometrist, enlist his help. Give students ample time to practice on one another before proceeding to patients. Then, hand pick which patients should be among the first a new assistant should work-up. The 30-something myope is usually a good place to begin because refractive change is usually minimal at this age.

Measuring intraocular pressure may be the most frightening element for the trainees to learn because of the danger of causing a corneal abrasion. Proceed by having students applanate a model eye, and then other staff members'. Lastly, they should do applanation on actual patients. It's a good idea to have them begin with the glaucoma population because these patients are the least likely to flinch during the procedure.

One person must be fully trained before beginning with the next. Maintaining the proper balance between newer technicians and more skilled staff members is crucial to running on time. Although it's tempting to put only the strongest staff on the busiest days, you should use almost equal numbers of strong technicians and newer assistants. Senior technicians should expect to initially work-up almost 50% more patients than those new to the job. This way, the physician won't be kept waiting for patients while newer technicians complete their work-ups. Ironically, patients will periodically remark that the work-up from the novice is the most thorough they've ever had, equating time spent with quality.

Once cross-training is complete, the person responsible for scheduling will have the additional task of maintaining the proper balance of staff at the desk and in the back. For continuity's sake, each staff person should be expected to remain in the same position for a full week. This will be easier to accomplish with a staff comprised of primarily full-timers as opposed to those working less than 40 hours per week.

A winning approach

When cross-training is done correctly, you'll notice a gradual improvement in staff morale and team spirit. As the challenges of learning increase, everyone becomes less defensive. People realize that various talents and abilities are needed to make a practice run efficiently. With time, staff members will begin to play to one another's strengths and weaknesses. Staff turnover may diminish as a result of improved morale.

The only pitfalls we've observed are the occasional loss of staff after the training period and some lack of evenness in talent and inclination. Not everyone likes clinical science and its responsibilities, and not everyone likes the pressure of being the administrative target for the public.

It will take time for patients to catch on to the new office policy. In fact, they may mistakenly perceive the "new" faces as new employees. However, patients who visit regularly will come to appreciate that the staff is knowledgeable at every point of their encounter. They will ask questions about cross-training and get involved as participatory observers. Ultimately, they will be the recipients of exceptional service.

Cross-training isn't an easy process -- not for the staff who must leave the comfort zone of their familiar tasks, or the ophthalmologists who have grown accustomed to the same people performing their usual tasks, or for the patients who are on a first-name basis with one secretary.

Yet, I'm confident that you'll find, as we have, that it's well worth the effort you put into it. It's helped us attain new heights. Our employee morale has never been higher, and our patient care has never been better. OM

Jane Shuman, C.O.T., M.S.M., is manager of the Ophthalmology Department at Dedham Medical Associates in Dedham Mass. She's also Director of the Ophthalmic Assistant Program for the Massachusetts Society of Eye Physicians and Surgeons.