Cross-training your employees: Boosting flexibility, fostering teamwork

There are no office positions called "receptionist," "billing clerk" or "scheduler" in medical practice heaven. Instead there is only one nonclinical job: "office worker," the perfect interchangeable staffer.

Busy day today? No problem: Move a generic worker to reception.

Falling behind in billings? Move a few workers into that department.

Sound impossible? Not if you do a little cross-training.

In athletics, cross-training is designed to develop different parts of the body, rather than work exclusively on one group of muscles. The same principle applies with cross-training in your practice. Instead of having just one person do one thing, you train your staff to handle multiple tasks.

Cross-training in your practice does not guarantee all workers can be brought to equal competency in all jobs, just as a cross-training athlete might never develop an elite skill. However, a cross-training athlete can shift workouts when, say, a part of the body is sore or injured. A cross-training practice can shift workers among various nonclinical work when, say, one is sick or otherwise out of the office.

Practices have to carefully consider the pros and cons of cross-training. They must be able to determine when and where it can be used to advantage and when and where it may result in unacceptably reduced productivity, unhappy patients, or even serious mistakes.

"I'm a strong believer in cross-training. But it has to be part of an overall, well-planned strategy," says David Zahaluk, MD, a family physician with two-doctor Trinity West Urgent Care in Lewisville, Texas. Dr. Zahaluk, also a practice management consultant, says among the factors that will affect the success or failure of cross-training are the size of the practice, the level of technology, the office's culture, the nature of the training, and the specificity and complexity of the jobs for which workers may be cross-trained.

While there are pitfalls to avoid, many doctors said cross-training is worthwhile.

The first advantage is staff flexibility. If multiple office workers can handle multiple tasks, then you can shift people in and out of jobs as needed. And, you might not have to hire temporary workers to fill in.

"The more we can train our staff to handle different jobs, the more flexibility we have," says solo gastroenterologist Patricia L. Raymond, MD, in Chesapeake, Va. Dr. Raymond attributes cross-training and an electronic medical records system to keeping the number of her office staff to an efficient four, thus keeping a lid on costs.

Dr. Raymond admits that when some people, including her, take on jobs for which they are not primarily trained, the task might take a little longer. And because a nurse's salary is higher than a clerk's, that job-shifting means overpaying. However, by reducing reliance on temporary staff during vacations, and eliminating outsourcing of jobs like coding, she said the practice is enjoying an overall cost benefit.

Other benefits

Doctors note that cross-training:

• Breaks up the monotony of the week, giving workers more challenges and variety.
• Gives workers a sense of how the practice works together as a team.
• Helps the doctor or administrator discover that certain workers are well-suited for a different position.
• Helps patients get answers to billing or insurance questions on the first call, because more people will know how to find the answers.

And, it can be easier to discover problems when a position is not solely handled by a single person. For example, an attempt at embezzlement might be averted if more than one employee is handling the money.

None of these benefits require regular volleyball-like rotation of workers. Few practices try to develop completely interchangeable staffers.

In fact, one of the biggest disadvantages of cross-training is that you can end up with staff who know a little of everything, but not much of anything.

Health care consultant Nan Andrews Amish, principal of Big Picture Healthcare in El Granada, Calif., says she worked with a number of groups who experimented with large-scale cross-training. But push-back on the part of staff, as well as problems with productivity, have caused many of them to roll back their cross-training strategy. She says she has found that cross-training staff "is about as effective as sport cross-training. You get lots of people who know a little about a lot."

Amish is in favor of cross-training as a way of filling in for lunch breaks, or for emergencies and vacations. But doctors should be aware that often the person filling in will not be as productive and effective as the primary worker.

"In general, health care organizations who have done small amounts of cross-training to support scheduling issues, for example, have done well, but organizations who allegedly teach everyone to do everything have not done so well," she said.

Experts say success of cross-training efforts is often in inverse proportion to practice size.

In general, small or solo practices are more successful at cross-training then are medium-sized or large practices. For one thing, smaller practices with lean staff require a lot of filling-in, so workers move around often and maintain their cross-trained skills. There might also be more of a team spirit when the staff is small, with only one or two doctors. But doctors have to work to maintain that spirit.

Solo family physician Catharine Tabb, MD, in Louisville, Ohio, believes that doctors who foster the sense of teamwork have a better chance of getting workers willing to fill in alternative jobs. She'll pitch in to handle some clerical tasks.

And while she's clearly the boss, she tries to create a feeling of collegiality. "I'm very careful to treat my staff with utmost respect."

Technology may help

An EMR or practice-management application usually requires more training than traditional paper-based office procedures. But once trained on the applications, users might be more efficient, even at alternative jobs.

Here again, size of the practice is an important factor. Smaller groups, where people have an opportunity not only to be trained on different aspects of the technology but also use various aspects regularly, might do better than larger groups where workers may only work at alternative jobs occasionally, experts say.

Nick Fabrizio is now a consultant with MGMA Healthcare Consulting Group, but for 15 years, he was the administrator of a 13-doctor group in Syracuse, N.Y.

Fabrizio says when his practice installed practice-management software -- two years before he left -- problems arose because people who were not regular users of some screens of the software had difficulty using them when asked to fill in. "In order to use practice-management software efficiently, you have to use it regularly. When a group is medium-sized or large, there is just not enough opportunity for people to practice on all the screens," he says.

His suggestion for medium-sized groups is to assign workers to subgroups comprised of similar jobs -- for example, intake, outtake and reception -- and cross-train them within their groups.

Whether using technology or paper-based systems, Dr. Zahaluk points out that cross-training means more than just filling in for other workers. "If you're going to cross-train workers, you actually have to train them." For example, he says, "From a marketing perspective, the receptionists are extremely important: They are the public face of your practice." If you place someone there without training them how to respond to patients, you're doing your practice a disservice.

Accordingly, all positions at his practice are assigned very specific business processes. For example, receptionists must answer all calls within a specific number of rings. The practice has listed three categories of patient calls: scheduling an appointment; speaking to a doctor; or attending to back-office functions such as checking lab tests or refilling a prescription. Dr. Zahaluk and his partner have developed scripts for handling each of these calls. These printed scripts greatly assist in cross-training.

Cross-training can be an important aspect of a well-run practice. Or it can result in a chaotic situation where frustrated workers vainly try to figure out how to handle jobs for which they are not qualified or trained.

The difference between the two scenarios, experts say, is a direct result of the amount of time and attention paid to the training process.