Multiskilled Personnel

Purpose

The purpose of this technical report is to: (a) identify issues related to the concept of multiskilling, (b) provide definitions, (c) discuss implications for patient/client care, (d) explore the potential impact on speech-language pathologists and audiologists, and (e) serve as the basis for the development of a position statement about multiskilled personnel.

Return to Top

Background: Driving Forces in the Provision of Clinical Services

Clinical service delivery in the United States is undergoing an unprecedented level of scrutiny and change. Reform initiatives in federal, state, and private sector/marketplace arenas are resulting in:

• corporate mergers, leading to fewer but larger employers with increased bargaining power in the regulatory arena;

• funding and reimbursement reductions, with a demand for outcomes and a shift from fee-for-service to managed care, ^[1] with capitation ^[2] as the increasingly prevalent payment method; third party payors and consumers are no longer willing to pay for procedures or services that do not result in functional improvement;

• cost-saving measures, including organizational redesign, reengineering, and downsizing, with increased emphasis on productivity standards and efforts to reduce the nonclinical and/or nonbillable activities of clinical staff;

• implementation of patient/client focused care, with decentralization of clinical staff; and,

• required use of patient care maps and clinical protocols.

Increasingly, clinical services—including those in speech-language pathology and audiology—that traditionally have been provided on a Monday through Friday, 8:00 a.m. to 5:00 p.m., basis are expected to be provided around the clock, seven days a week. In health care, there is a steady shift away from hospitals as the primary sites of service delivery. Hospital-based employment opportunities are decreasing, and many practitioners are seeking employment opportunities in such settings as wellness programs, outpatient programs, home health agencies, health maintenance organizations, industrial rehabilitation programs, and long-term care. School-based practitioners as well are experiencing dramatic budget cuts, and changes to and potential elimination or reduction of services required under federal and state mandates (i.e., Individuals with Disabilities Education Act [IDEA] reauthorization). The political climate ushered in by the 104th Congress has shifted decision making and fiscal responsibility away from the federal government to the states. Entitlement programs such as Medicaid, under which service delivery flourished in the 1970s and 1980s, may be totally restructured. Many mandated services or qualified provider requirements may be eliminated as a result of the failure to reauthorize.

The emphasis on cost-effective service delivery has generated questions about the composition and delineation of responsibilities within the current clinical services workforce. Salary expenses represent the greatest cost of delivering services; therefore, cost-reduction efforts usually focus primarily on salaries. As a result, practitioners with skills or competencies in more than one area are likely to be regarded as more cost-effective and more employable than their traditional single-skilled counterparts. A 3-year study by the Booz, Allen and Hamilton consulting firm found that of every dollar a hospital spends on wages, 20 cents goes to idle time (Brider, 1992). The envisioned bottom line of multicompetency is the more efficient and effective use of human resources.

Return to Top

Overview: Multiskilling

Multiskilling is one redesign strategy being used or considered in some service delivery settings in an attempt to enhance cost-effectiveness, efficiency, quality, and coordination of services. The concept is not a new one. Multiskilling has been discussed for some time by the American Hospital Association, W. K. Kellogg Foundation, the Pew Health Professions Commission (supported by a grant from the Pew Charitable Trusts), and some health professions. A National Multiskilled Health Practitioner Clearinghouse was established in 1987 at the University of Alabama at Birmingham's School of Health Related Professions, under initial funding by the W. K. Kellogg Foundation. The clearinghouse defines multiskilled health practitioners as:

Persons cross-trained to provide more than one function, often in more than one discipline. These combined functions can be found in a broad spectrum of health-related jobs ranging in complexity from the nonprofessional to the professional level, including both clinical and management functions. The additional functions (skills) added to the original health care worker's job may be of a higher, lower, or parallel level (Bamberg et al., 1989).

A number of definitions of multiskilling and multiskilled personnel have been crafted. To date, no single definition has achieved official or universal acceptance. Despite many years of discussion, there is still little consensus on the responsibilities of multiskilled practitioners, the skills and abilities such practitioners should possess, or how to appropriately apply the concept of multiskilling to the clinical workforce.

The concept of multiskilling has been most closely associated with the health care arena. However, it also applies to school systems and the private sector, given funding reductions and personnel shortages in these settings. Current multiskilling proposals run the gamut from acquiring additional basic patient care skills (e.g., monitoring vitals), to taking lead responsibility for administrative functions (e.g., quality improvement), to developing such new professions as a “rehab specialist”—one who could practice across multiple scopes of practice, such as speech-language pathology, occupational therapy, and physical therapy.

The Pew Health Professions Commission has been an energetic and outspoken advocate of reshaping the health care workforce. It is sponsored by the Pew Charitable Trusts, a privately held foundation that supports several commissions that study issues of national importance. The Pew Health Professions Commission consists of leaders from government, business, and education; it supports a number of advisory panels, including the Pew Advisory Panel on Allied Health. That advisory panel has recommended major changes in the educational preparation of allied health practitioners (they include speech-language pathologists advocates eliminating specialized accreditation and creating new accreditation models based on “like task” clusters. Audiology, speech-language pathology, occupational and physical therapy are seen as a “liketask” cluster.

In September 1995 the Pew Commission's Task Force on Workforce Regulation released a summary of a report, “Reforming Health Care Workforce Regulation: Policy Considerations for the 21st Century” (Pew Health Professions Commission, 1995). The extent to which these policy considerations will be embraced by professional regulators and enacted by state legislators is yet to be determined. However, they will be widely disseminated and, quite possibly, seriously considered. (See Appendix for the policy considerations included in the report.)

Return to Top

Dimensions of Multiskilling

Multiskilling is not a unidimensional issue. In order to truly enhance the cost-effectiveness and efficiency of service delivery without compromising clinical outcomes or patient/client safety, several different multiskilling options—or dimensions—need to be considered. The suitability of any of these options varies with the clinical discipline, service delivery setting, patient/client population, and workforce resources:

• Cross-training of basic patient care skills —includes routine, frequently provided, easily trainable, low-risk procedures such as suctioning patients, monitoring vital signs, and transferring and positioning patients. Identifying a facility/agency/program-specific set of patient/client-care skills that can be performed by various practitioners in that particular setting may lead to less fragmented and less costly patient/client care (e.g., bedside treatment sessions do not have to be delayed waiting for another practitioner to suction the patient; home care patients' compliance with prescribed medications can be verified by clinicians already coming to the home on a regular basis; diabetic preschoolers' blood sugar levels can be monitored by on-site clinicians).

• Cross-training of professional, nonclinical skills —includes skills and services such as patient/client education, technical writing, team dynamics/communication/leadership, and such. Establishing competency standards for such skills across the workforce may enhance the overall quality, efficiency, and coordination of service delivery.

• Cross-training of administrative skills —includes programmatic activities such as quality improvement, case management, systems design, and the management of clinical services. As organizations down-size such responsibilities are increasingly moving from centralization in one or more “administrative positions” to distribution among clinical practitioners. Doing so may result in more efficient use of staff and better integration of these functions with clinical service delivery.

• Cross-training of clinical disciplines —involves training practitioners in one discipline to perform services traditionally regarded as within the purview or scope of practice of another discipline in an attempt to more efficiently deploy the clinical workforce to meet the needs of the patient/client caseload as it fluctuates at any particular point in time. Examples include training respiratory therapists to perform EEGs (electroencephalograms), or medical technologists to perform certain radiological procedures.

The appropriateness of cross-training of basic, clinical, professional (nonclinical), and administrative skills will vary with the setting, patient/client population, clinical discipline, and availability of human resources.

Some clinical practitioners already possess knowledge and skills that span a complex and essential domain of human function. They are already able to provide a variety of services to an array of patients/clients as a result of their scopes of practice. Speech-language pathologists and audiologists are among such practitioners, as evidenced by the range of services they provide across diverse patient/client populations and settings (i.e., audiologists diagnose hearing loss and related disorders, fit hearing aids, provide aural rehabilitation, perform and interpret site-of-lesion testing, etc.; speech-language pathologists evaluate and treat cognitive-communication, language, memory, swallowing, fluency, and/or voice disorders, etc.). Speech-language pathologists and audiologists have demonstrated their resilience in developing new services and acquiring new skills that are natural extensions of their scopes of practice (e.g., intra-operative monitoring in the case of audiology, dysphagia in the case of speech-language pathology) in order to better serve their patients/clients. Service delivery decision-makers need to be made better aware of the complex and varied services already provided by such professions.

Return to Top

Issues in Multiskilling

Return to Top

Perspectives From Other Disciplines

Multiskilling is in various stages of consideration and implementation. If the clinical professions/disciplines do not influence the development and use of multiskilling practices, the roles and responsibilities of clinical providers could be determined by administrators, committees, and organizations with little knowledge of or concern for the knowledge, skills, and abilities required for competent service delivery. Below is a sampling of the consideration of this issue to date by various professional organizations:

• Dieticians—In 1995 the American Dietetic Association's Council on Education developed a paper identifying a number of benefits or opportunities related to multiskilling (American Dietetic Association, 1995). These include greater collaboration among practitioners, better understanding of nutrition practice, and additional employment opportunities. Ten new areas of clinical practice in which registered dieticians could engage with additional training are listed. These include providing home health services such as catheter site care and evaluation of tube feeding tolerance; instructing patients with diabetes on insulin injections or modifying medication schedules; drawing blood for cardiovascular disease and diabetes management; conducting physical exams; conducting psychological assessments along with social services; providing prevention counseling services related to nutrition and oral health, smoking cessation, and stress management; assuming case management roles; and becoming clinical managers for specialty services such as wellness, health promotion programs, and diabetes education centers. The paper encourages educators in that field to teach flexibility, open-mindedness, respect for other disciplines, problem-solving, creative thinking, appreciation for cultural diversity, and leadership/management skills and refers to a curriculum model developed for cross-training in nutrition and oral health in dietetics and dental professional education programs.

• Nursing—The American Nurses Association (ANA) reports that it has no statement or policy addressing multiskilled personnel at this time. However, it does have a number of documents addressing related workforce redesign issues. One such document, titled “Unlicensed Assistive Personnel in Community Settings,” (a) reaffirms ANA's support of individual licensure (versus institutional licensure) as a means of assuring the public that registered nurses possess the basic knowledge and skills to provide safe care to the consumer; and (b) supports state boards of nursing as the appropriate body to license and regulate the practice of nursing (American Nurses Association, 1994).

• Occupational Therapy—The American Occupational Therapy Association (AOTA) defines cross-training as the preparation of an individual in one profession to perform skills typically associated with another profession; a multiskilled practitioner is defined as an individual from one profession who has established competence in specific skills usually associated with another profession. AOTA's position is that all individuals who practice occupational therapy need to have successfully completed an accredited occupational therapy education program and acquired the knowledge and skills that underlie competent entry-level occupational therapy practice. AOTA recommends that its members become knowledgeable about the laws, regulations, reimbursement issues, practice guidelines, and standards of their profession (American Occupational Therapy Association, 1995).

• Optometry—The American Optometric Association (AOA) reports that it has no statement or policy addressing multiskilled personnel at this time. Traditionally, the majority of optometrists work in independent solo practices, although the number in multidisciplinary practices is reportedly increasing.

• Physical Therapy—The American Physical Therapy Association (APTA) opposes the concept of the multiskilled professional practitioner (defined as “a health care practitioner who is cross-trained in area[s] of practice in which the individual is neither educated nor licensed”). APTA opposes cross-training of physical therapists and physical therapist assistants in areas outside the scope of physical therapy practice, as well as the cross-training of other health care practitioners in physical therapy practice. APTA supports the use of multiskilled support personnel who perform delegated components of physical therapy intervention under the direct supervision of physical therapists and physical therapist assistants in accordance with state laws and regulations. These “cross-trained support personnel” would be trained on-the-job and work under the direct supervision of the appropriate licensed individual. A “rehabilitation aide,” for example, would function as a physical therapy aide when working under the direction of a physical therapist, an occupational therapy aide when working under an occupational therapist, and so forth. APTA guidelines urge that “physical therapists must become contributors, negotiators, and collaborators in change efforts; the profession must be proactive, must be at the table, and be an equal partner in planning for future changes in the provision of health care services” (APTA, 1995).

• Psychology—The American Psychological Association (APA) reports that it has no statement or policy addressing multiskilled personnel at this time.

• Recreational Therapy—The American Therapeutic Recreational Association (ATRA) reports that it has no statement or policy addressing multiskilled personnel at this time. However, members who call ATRA's national office seeking guidance on this issue are advised to be “flexible.”

• Respiratory Therapy—The American Association for Respiratory Care (AARC) advocates the use of multiskilled or cross-trained respiratory care practitioners, provided that the practitioner is qualified through formal education and adequate skills assessment. AARC encourages the assimilation of new competencies and skills by its members, who are described as already having assimilated such diverse additional skills as electroencephalography, electrocardiography, phlebotomy, extracorporeal membrane oxygenation, endotracheal intubation, sleep laboratory studies, and drug administration via routes other than aerosol.

Return to Top

Conclusions and Recommendations

This report identifies issues related to the concept of multiskilled personnel and includes definitions, discussion of the implications for patient/client care, and exploration of its potential impact on speech-language pathologists and audiologists. Multiskilling has already begun to affect clinical practitioners in many states, and this trend is likely to continue across settings. As previously stated, multiskilling is not necessarily an all-or-none phenomenon. As is true for most changes, both benefits and risks are associated with multiskilling. Potential benefits include enhanced opportunities for professional growth and development, expanded scopes of practice, employability and job security, focus on clinically challenging services (for professional-level practitioners), greater flexibility in justifying staff increases given the ability to combine staff needs across related services, and improved efficiency and coordination of clinical services. Risks include potential decreases in the quality and outcome of clinical services, loss of specialized clinical services, loss of autonomy, erosion of scopes of practice, loss of revenue, and reduced number of positions for some clinical service providers.

Given the rapidly developing initiatives to define and implement multiskilling throughout the country, the Ad Hoc Committee on Multiskilling recommends the development of an Association policy to address whether or not our professions support the concept of multiskilling as it relates to the practice of speech-language pathology and audiology. If so, at what levels of practice and in which settings? The Ad Hoc Committee on Multiskilling suggests that cross-training of clinical skills is not appropriate at the professional level of practice, but may be appropriate for tasks delegated to support personnel.

An Association policy should consider the speech-language pathology and/or audiology tasks that could be shared with other disciplines, tasks performed by other disciplines that could be performed by speech-language pathology and/or audiology personnel, and the potential for multiskilling within each level of clinical practice (i.e., professional, assistant, and aide levels). Consideration of shareable tasks should include clinical and nonclinical patient/client care tasks and administrative tasks.

Other important areas requiring specification are basic qualifications, educational materials, training, and competency assessments. Each of these areas should be addressed separately for the professions of audiology and speech-language pathology. Important resources in the development of multiskilling guidelines include the “Guidelines for the Training, Credentialing, Use, and Supervision of Speech-Language Pathology Assistants” (LC 1-95) and materials that may be available through the TriAlliance of Health and Rehabilitation Professionals. ^[4]

The Legislative Council recently approved a Specialty Recognition Program for the professions of speech-language pathology and audiology (LC 22-94) and Guidelines for the Training, Credentialing, Use, and Supervision of Speech-Language Pathology Assistants (LC 1-95) as well as revised (and for the first time separate) scopes of practice for speech-language pathology (LC 5-95) and audiology (LC 8-95). Collectively, these initiatives address the scope of services provided by a continuum of providers within the professions of speech-language pathology and audiology. What, if any, place multiskilling has within that scope and continuum must be considered.

Speech-language pathologists and audiologists, must (a) consider the complex questions regarding multiskilling, (b) identify when the use of multiskilled personnel is or is not in their patients'/clients' best interests, and (c) determine how it may or may not apply to the professions of speech-language pathology and audiology. The need for and appropriateness of multiskilling options is likely to vary with the discipline, level of practitioner, setting, population served, other professional resources available, and the mission of the service delivery organization. In this era of cost reductions and redesign, the potential benefits and risks to our patients/clients and to our professions associated with multiskilling must be carefully and thoroughly explored.

Appendix

Policy recommendations from the “Reforming Health Care Workforce Regulation: Policy Considerations for the 21st Century,” report of the Pew Health Profession Commission's Task Force on Health Care Workforce Regulation, September 1995.

• Recommendation # 1: States should use standardized and understandable language for health professions regulation and its functions to clearly describe them for consumers, provider organizations, businesses, and the professions.

• Recommendation # 2: States should standardize entry-to-practice requirements and limit them to competence assessments for health professions in order to facilitate the physical and professional mobility of the health professions.

• Recommendation # 3: States should base practice acts on demonstrated initial and continuing competence. This process must allow and expect different professions to share overlapping scopes of practice. States should explore pathways to allow all professionals to provide services to the fullest extent of their current training, experience, and skills.

• Recommendation # 4: States should redesign health professional boards and their functions to reflect the interdisciplinary and public accountability demands of the changing health care delivery system.

• Recommendation # 5: Boards should educate consumers to assist them in obtaining the information necessary to make decisions about practitioners and to improve the board's public accountability.

• Recommendation # 6: Boards should cooperate with other public and private organizations in collecting data on regulated health professions to support effective workforce planning.

• Recommendation # 7: States should require each board to develop, implement, and evaluate continuing competency requirements to assure the continuing competence of regulated health care professionals.

• Recommendation # 8: States should maintain a fair, cost-effective, and uniform disciplinary process to exclude incompetent practitioners to protect and promote the public's health.

• Recommendation # 9: States should develop evaluation tools that assess the objectives, successes, and shortcomings of their regulatory systems and bodies in order to best protect and promote the public's health.

• Recommendation # 10: States should understand the links, overlaps, and conflicts between their health care workforce regulatory system and other systems that affect the education, regulation, and practice of health care practitioners and work to develop partnerships to streamline regulatory structures and processes.

Notes