Healthcare Systemsapproach to Continuing Education 19

HEALTHCARE SYSTEMSAPPROACH TO CONTINUING EDUCATION 1

Healthcare Systems Approach to Continuing Education: Education Requirements and on the Job

Training Applications for Public Health Professionals and Healthcare Professionals

John Quentin Harris

MPH 599 Public Health Field Practicum

Concordia University Nebraska

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Table of Contents

1. Title Page Page 1

2. Table of Contents Page 2

3. Abstract Page 3

4. Introduction Page 3-6

5. Discussion Page 6-13

6. Personal Assessment Page 13-17

7. Conclusions & Recommendations Page 17-18

8. Appendices & Evaluations Page 18-19

9. References Page 19-21

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Abstract

Advanced Professionals have over the course of their formal education and their ongoing careers have found that you’ll never stop learning. This is apparent or implied in the pursuit of

Continuing Education Units (CEUs) that are often a regulatory requirement for remaining in good standing for many professions. The enormous size of the healthcare industry and the many different occupational professions that are working in tangent to provide services from a minimum standard too an exceptional level of quality require various levels and types of both formal education and on the job training to successfully implement and succeed in delivering these services to the communities they serve. This paper is a reflection of the author’s practicum experience in providing services within the Veterans Hospital Administration (VHA) as one of the many professional roles that work in correspondence with the many other professional occupations in the healthcare system. The practicum experience was conducted in the

Prosthetics and Sensory Aids Service (PSAS) Department at the Salem VAMC. The professional role that was performed during the practicum experience was that of a Prosthetic

Representative.

Introduction

The deliverance of healthcare services to any population is a task that requires coordination among professionals in numerous fields of the spectrum of healthcare. Using a systems approach to identify the complexity of different professions communicating across the healthcare community and the software systems that are utilized to record and provide patient information to these professionals involved in either direct patient care or in patient care support roles and how it impacts the delivery of healthcare services. This includes Public Health and patient education as participants in their own health care planning for preventative care and continuing

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education of staff and clinical providers on the individual systems used to communicate and deliver healthcare services and communicate across the various professional specialties involved in the organization’s mission.

The designation or terms most commonly used for educational credentials and that are associated with becoming a professional that is qualified to practice the profession in any particular occupation is the result of obtaining either or both a formal education and/or on the job skills that allow for the credentials like a diploma, certificate and degree. The requirements for these various professional designations can be seen in the Credential Resource Guide from the

Department of Labor (DOL) that identifies a third party with relevant authority or jurisdiction is able to issue these credentials. These organizations such as educational institutions that are accredited by the department of education & recognized by industry associations, occupational associations or professional societies are often the primary source of these occupational specific credentials. (“EMPLOYMENT AND TRAINING ADMINISTRATION ADVISORY

SYSTEM,” 2010)

The number of variables that are involved in providing healthcare across a broad spectrum of services is an enormous task and undertaking and no individual can possibly retain the knowledge of providing each and every service in today’s technologically advance world of medicine which has given rise to the many different specialized areas of care that is provided by the healthcare industry. The field of healthcare is vast and it would be a considerable understatement to say that the field isn’t going to continue its expansion. The National Health

Expenditure Accounts (NHEA) are the official estimates of total healthcare spending for the

United States of America and measures the annual U.S. expenditures for all health goods and services for the health care industry including public health activities. Government

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administration and investments related to health care costs and the net cost of health insurance.

The field of healthcare and the costs are continuing to grow and it is estimated that the U.S.

Gross Domestic Product (GDP) for health spending accounted for 17.8% of the national GDP.

This is approximately $9,900 per person and grew 5.8% during 2015. (“National Health

Expenditure Data,” 2016)

Historical evidence from recent census data shows people are living longer lives and that the population is continuing to grow. (Mackun & Wilson, 2011) The expansion of both the population and the continuous longevity of lifespans increasing is altering the traditional demographics of what healthcare professionals will have to face in the future with an increase in the number of patients that they must service. (Werner, 2011) It is essential that the professions that provide these services to the population continue to improve and implement successful interprofessional education programs. Implementing such continuing education programs within the work place aids to bridge the communication gap from cross generational differences amongst professionals that are often overwhelmed by high workloads & demands of responsibilities.

Organizational changes and early impressions of continuing inter-professional development and education programs in the work place impact teamwork downstream and affect the moral and culture of the workplace. Positive reception of practices for continuing education affects the organization’s retention & recruitment of talented and skilled occupations and should be a priority for healthcare organizations. (Veerapen & Purkis, 2014)

To fulfill President Abraham Lincoln’s promise. “To care for him who shall have borne the battle, and for his widow and his orphan.” This is the mission of the Department of Veterans

Affairs. An organization that is dedicated to serving and honoring the men and women that are

America’s Veterans. The Department of Veterans Affairs was established and made part of the

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President’s Cabinet in the Executive branch of the United States government. (“History - VA history,” 2015) There are approximately over 20.1 million Veterans in the United States.

(Office of Policy & Planning, 2017) and the VHA is the largest integrated health care system in the United States providing the essential functions of health care services to those Veterans and their family members eligible for care. These facilities are dispersed across the United States and its territories with 168 VA Medical Centers and 1,053 outpatient clinic sites that provide care at various levels of complexity and services more 8.9 million Veterans annually for their healthcare needs in addition to other benefits and services that the Veterans are eligible to receive. (“Veterans Health Administration,” 2017)

Discussion

The role that I performed in the practicum experience was the performance of my normal assigned duties as a Prosthetic Representative, the additional duties of Automated Data

Processing Application Coordinator (ADPAC) and Records Liaison (RLO) in addition to the goals of the practicum experience which involved the tracking and monitoring of a training program for the Prosthetic and Sensory Aids Service (PSAS) Department and participating in training regiments either through discussion or through leading the education or period of instruction. The duties that a Prosthetic Representative for the Department of Veteran’s Affairs are to perform the administration and work concerned with rendering prosthetic and sensory aids services to disabled patients. This work is not exclusive to the PSAS Prosthetic Representative alone but may include participation with a team of other professionals to accomplish the goals of the organization. These duties may include the following roles or actions depending on the need and level of involvement and the responsibility of the Prosthetic Representative’s Pay Grade:

The following are the duties and qualifications of knowledge, skills & abilities or experience for

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a Prosthetic Representative performing at the GS-9 series pay grade. This is the position that I have been performing in and the occupational listings will vary slightly from location but the general functions and performance descriptions are parallel toward a career tract. ("USAJOBS -

The Federal Government’s Official Jobs Site")

Duties Include but are not limited to the following:

The action of developing a “Statement of Work” section for service contracts. Responds in a timely fashion to a variety of correspondence. I.e. contractors, Home Oxygen program issues.

Responds to a variety of correspondence from other agencies. I.e. congressional inquiries.

Participates in or as Chairperson in local family committees, workgroups, teams etc. Assess & provide technical guidance concerning equipment & benefits to beneficiaries & other health care staff. Implements new local & national guidelines. Develops tools that allow monitoring of a quality assurance program. Analyzes reviews & evaluates the results of various monitors & databases. Confers with contractors & other health care staff. Informs veterans and family members on different appliances and services available. Resolves conflicts impacting program supported issues.

Knowledge, Skills & Abilities (KSAs):

The Prosthetic Representative has the ability to understand and apply procedures, regulations and laws. They have knowledge of procurement practices. Possess knowledge of appropriations

& obligations relating to accounts. They have knowledge of general anatomy and medical terminology. The Prosthetic Representative has experience in the principles and practices of budget formulation and execution. They have the ability to maintain & control an inventory system. The Prosthetic Representative is proficient in the knowledge of methods to identify

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trends and causation factors sufficient to analyze prepared data and gather information to inform and advise management.

Qualifications:

Meet the basic requirements of being a U.S. Citizen; be fluent in the English language and possess either the experience, education or a combination of experience and education for the grade by having at least 1 year of experience at the grade level below the position applied for education equivalent to a bachelor’s degree or higher from an accredited university or combination of education & experience equivalent to the position. ("USAJOBS - The Federal

Government’s Official Jobs Site")

Records Liaison Officer (RLO):

The role that I perform for the PSAS department as RLO is to prepare and transfer the hard copy of our annual records from the department to the facility’s long term record storage area.

Using the Record Control Schedule (RCS 10-1) and the VA Form 7468 for the Disposition of the

Temporary Files, these records are primarily a backup document of the transactions of daily business conducted in the patient’s individual Electronic Health Record (EHR) which is displayed for the PSAS department on form 2319. These transactions display purchases and correspondence between VHA employees and vendors or contractors on behalf of the patient.

This is done according to VA Directive 6300 which adheres to the policy and mandates of the

National Archives and Records Administration (NARA) under Authority: Title 36, Code of

Federal Regulations (CFR), Chapter XII, Subchapter B. (EWAS, 2017)

Automated Date Processing Application Coordinator (ADPAC):

The role of ADPAC is to function as a liaison and requestor for the service line in requesting and obtaining access menus to software systems for staff to perform their assigned roles within

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the department. This is an additional assigned duty that facilitates access to sensitive systems that allow users to enter and record data into the individual patient records of veterans.

Performing in this role has opened up an abundance of knowledge and resources to me in performing this particular role for the PSAS department. It has taught me that the many different software systems utilized by the various different service lines are unique to that specific service and that the other staff throughout the facility may not be able to see the same information. This access is about privileged information that not all users may be authorized to view. They have these restrictions in place to preserve privacy rights about the access to unique systems that identify sensitive information. Some elements of information are presented in different formats or through different attributes.

Having conducted further research into the software systems utilized by the VHA, I have found that the systems were first conceived and placed into use in the 1970s. Early in the 1970s, the National Center for Health Services Research and Development, a component of the U.S.

Public Health Service, began planning for development of what would become Electronic Health

Records (EHR). (Office of Information and Technology) In the early 1980s, the VA began to make the software available to the public and the EHR has evolved to wat we know today after going through many transformations from becoming an open source software system. The most notable changes that I would like to highlight here is the transformation into the VISTA operating system that happened to be the standard-bearer of the HER being implemented around the world. One of the primary operating systems that I perform my role in as a Prosthetic

Representative is still the DOS based prompt system of VistA.

Other points of notoriety are the initial implementation of the Decentralized Hospital

Computer Program (DHCP) and how it was nationally implemented. This allowed for emerging

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technologies to be promoted in all VA locations. VistA imaging became operational in the

1990s allowing for physicians to have immediate access to medical images regardless of their location. In the early 1990s the development of Computerized Patient Record System (CPRS) began and the DHCP was renamed Veterans Health Information Systems and Technology

Architecture (VistA). In the late 1990s, CPRS was completely implemented nationally. I have utilized some other software systems in performing the role of a Prosthetic Representative such as VBMS and also performing as the sponsor for our department’s PIV badge renewals. The

Evolution of VistA moving forward and other new software systems which communicates between services, facilities agencies and even other secured systems operated by professionals in the private sector. Technology has brought about change during the short time period that I have performed this role and there are things on the horizon that will possibly change or alter how business is currently conducted to provide healthcare services.

The VHA and all federal agencies utilize the Talent Management System (TMS) to conduct mandatory training and track this information through a standardized national network platform.

I’ve accumulated over 60 hrs. of mandatory or occupational type training in the past year through the TMS portal. I’ve also obtained an additional 60 plus hours of specialized training for

Contracting Officer Representative (COR) which I must maintain every two years now. The two combined are an average of 90 hrs. a year annually that I must have logged for mandatory training to perform occupational positions. This mandatory training is without having to acquire any training to maintain good standing for professional licensing requirements. Discussion with other medical professionals and past occupational professions I have had would require various amounts of Continuing Education Units (CEUs) to maintain good standing for the specific occupation.

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The use of various training methods is a routine within any occupation. The healthcare industry is a shining example of having students conduct on the job training through residency & fellowship programs where they complete clinical hours of training in performing the tasks that they will be doing as professionals in that vocation. This task is a daunting one for students that must learn multiple system applications and go through continuous rotations in different departments within the facility. To place it in a comparison of scale, the VHA has 5 primary sections for Applications in the Library of VA Software Documents. These are the Clinical

Section, Infrastructure Section, Financial-Administrative Section, HealtheVet Section & Benefits

Section.

The Benefits Section currently has no applications at this time and must be under development for future applications. The Clinical Setting has 94 different applications and each of these applications will have additional subsections that identify the specifics of the operating systems unique to the professions utilizing these applications. i.e.: manuals on use, updates and various other training resources or guides. The Infrastructure Section has 38 different applications. The Financial-Administrative has 38 different applications. The HealtheVet

Section has 17 different applications. (Danis, 2016a) Please see the appendix for the specifics in the Excel file “System Applications by Section” for a complete listing of the major applications.

Each Application will take you to the subsections for the specific application in the links for the application. This enormous amount of data and knowledge is unlikely if not impossible for any individual to know proficiently how to operate and utilize all functions of the applications in conjunction with the regulatory requirements of maintaining good professional standing with their respective licensing authority.

Barriers:

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The barriers most frequently encountered during the practicum experience and over the course of my professional career within the VHA are adjusting to the many different elements involved in the Organizational development and changes that are a continuous ongoing process.

There is staff across the various professions that are resistant to change and this makes implementing any processes that are new and unfamiliar to staff that have a routine which works well for them as an individual a task. Additional barriers’ that create an environment that is resistant to change is the education level of some career professionals that are not embracive of new technology and unwilling to learn new processes. This makes retention of qualified staff to perform the necessary roles a difficult ongoing process as there is a constant turnover of professionals that retire, transfer to new departments, advance professionally, or initiation of new employees and the time involved on training an individual to meet the minimal occupational standards to be a productive employee in performing the workload to address the needs of the patients and other customers within the VHA. The role of task shifting will also place additional stress on some professionals in performing roles that are not a normal function of their career scope of practice. Collaboration of education through communication both from students and senior staff facilitates learning in a two way directional method for obtaining knowledge in the various technology that is available as new processes are perhaps more familiar to younger professionals and facilitation of information both ways allows for multidisciplinary proficiencies in the use of applications and continuing education from student led teaching. (Lynn, 2014)

Part of the functions that I have participated in the past to address these barriers is the interview panel process conducting structured interviews and making recommendations to management on candidates that would be the best fit for the position versus the most qualified.

The most qualified or over qualified applicants are not usually a good selection for positions in

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available occupational roles as these candidates usually leave within a short period of their initial hiring process creating a vacuum of wasted time and delaying the services that are provided to our customers through having to begin new recruitment processes and initial training again with new staff once selected. The abundance of knowledge that is learned through on the job training through use of the many different software applications is one of the significant barriers that prevent career advancement in some occupational roles and the types of advancement opportunities for support staff due to limited education background or the high demand of learning so many various applications that are unique and independent of other applications affects the moral of staff and the functionality of professionals being able to perform quality customer service. This is where emphasis on proper selection for the interview process for candidates that are committed to the organizational goals rather than financial motivations is a key element. (“I CARE core values,” 2017)

Personal Assessment

The practicum experience provides valuable insight in understanding how the system of healthcare works and the role as a public health professional, fulfilling the functions of communication and administration of healthcare needs to the community and decision makers is of vital importance. We as professionals may not be directly involved with direct patient care and making clinical decisions based off of physiology and clinical assessments but we do impact the ability of direct patient care providers to perform their occupational roles through the performance of our professional competencies and skills knowledge

Public Health Domains & Competencies:

Each of the eight domains for Public Health Professionals has a role that is reflected in the practicum experience for my occupational role as a Prosthetic Representative for the PSAS at the

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VHA. These domains and the competencies related to the domains are as follows: (“Core

Competencies for public health professionals,” 2015)

1) Analytical & Assessment Skills: This is a daily occurrence used to review the workload

and determine in what areas of immediate need or departmental assistance that additional

staff should be designated to address the present workload. It is also done for daily

reporting and short or long term planning of fiscal budgeting or staffing needs.

2) Policy Development & Program Planning Skills: This is a continuous ongoing process as

we must react to new directives and decisions from higher echelons of management to

perform current workload and also improve departmental processes for addressing the

need of our customers. The smallest changes can have a significant impact on the

deliverance of services and the adaptability to change or incorporation of new processes

to address the needs of the customers is always in flux based on the environment and

state of the department’s needs and the needs of the customers.

3) Communication Skills: The communication skills of Prosthetic Representative are an

absolute necessary skill to develop and promote both literacy of VHA staff and the

patients on the use of devices for outpatient services that are provided by the PSAS

department. Communicating to the medical practitioners or the patients the scope of

competencies needed for certain devices. This includes explaining to the patients their

role in communicating with their providers on where they need to request being referred

or communicating with the practitioners about providing guidance or training on the use

of specific prosthetic devices which may exceed the scope of their practice and clinical

expertise and require them to arrange for their patients to be seen in one of the specialty

clinics that possess the competencies for these devices. Knowledge of the various

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computer software applications used to conduct these tasks are an important function in

this communication process as many professionals are not familiar with how some of the

other departments’ applications are utilized or structured.

4) Cultural Competency Skills: Cultural competency is an important aspect of delivering

quality services to the different communities of customers that you interact with

regularly. Everyone you communicate with is a customer, and understanding the needs

of that customer culture are part of good communication skills and customer service.

Every patient has unique needs and may come from different backgrounds and ethnicities

that require a different approach. The same can be observed with other customers such as

VHA staff or contractors and vendors. Each of these customers has a different

professional culture which needs to be addressed in a different manner. The effects of

policies, programs and the interaction from staff addressing these different cultural needs

each has a distinct impact on the customer service and how this can be seen by other

providers and participants in the continuation of care for the patients later in the day or at

their next appointments.

5) Community Dimensions of Practice Skills: This skill is utilized in addressing the

customer service needs of the various cultures that you interact with. Everyone that you

communicate with is a customer and the cultural dimensions of the community you are

communicating with and nurturing a relationship through networking or addressing the

needs of a customer reflect on you as a professional, your department and the

organization.

6) Public Health Sciences Skills: Understanding the events in the community that is

affecting the health of individuals and how to address these within the scopes and

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limitations of our resources and meet the continuous needs of all of our customers is a

process of constant collection of data and being familiar with the new technologies and

developments in the field. The culmination of all the other domains and competencies

are congregated in the need to pull all of these skills together to address the organizations

goals using public health sciences.

7) Financial Planning and Management Skills: Communicating the needs of budgeting our

resources as a department and the resources of the facility or other departments and the

utilization of these resources to address the needs of our customers is a constant process

of adapting to new information and adjusting accordingly. We must have a proactive

plan to address future needs and still remain reactive to current needs and unknown

arising factors that will change the needs of the proactive planning. This is seen in

having to make do with what resources you have in times where additional assistance is

absent and communicating effectively with other agencies that share similar goals or have

similar needs and services that can be provided to the customer in lieu of our organization

being able to address the direct need because of limitations in the scope of our

professional practice.

8) Leadership and Systems Thinking Skills: Leadership skills have been utilized in

motivating the organization to continue to improve and identifying solutions to problems

that require addressing through critical thinking skills, instituting ethical standards,

inspiring others to go the extra mile and creating opportunity for others to develop and

advance their skills in the same fashion through training, mentoring or additional

voluntary assignments to benefit the organization and continue with progression toward

organizational change while advocating for every customer that is encountered.

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Leadership must continuously be proactive and reactive to the environment of the

organization and being on the management staff for the PSAS department has

enlightened me to remain flexible always and committed to our goals, mission and the

vision we have to provide service to our customers.

Conclusions & Recommendations

The PSAS department is continuously undergoing change at the local, regional and national levels. My personal recommendation is to continue implementation of training regiments and attempt to expand on these developing talent from within the organization as it has been my experience that talent that is obtained from outside the organization doesn’t benefit the organization’s goals as it interrupts the consistency of providing the needed services in a timely fashion due to high turnover of talent from outside the organization. In my opinion, the same is true for the Department of Veterans Affairs three primary agencies which are The Veterans

Benefits Administration (VBA), Veterans Hospital Administration (VHA) and the National

Cemetery Administration. The immense size of these offices and the scope of various professions which these agencies perform and are responsible for in servicing our nation’s veterans is no small task. The many different resources and tools utilized in conducting daily business to provide for these services requires many different occupational specialists across the technical & medical fields of Medicine/Health care & Information Technology. I.e. software design, hardware maintenance, specialty clinic providers, medical support staff etc. These industries are constantly evolving and the need for ongoing communication and continuing education between the various services is an absolute necessity for the services to be rendered to the veteran community all in various states of need. This requires the staff within the top three agencies of the Department of Veterans Affairs being able to communicate effectively up and

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down the organizational pyramid to disperse information appropriately and plan in conjunction to implement organizational change by embracing it and the ideologies of the organization while delivering services to those that are its customers. This process of communication and continuing education based off of research and data collection from the processes of addressing the current needs of the veteran community allows for Senior Executive Management to address these needs before our Legislative and Executive Branches of the United States government.

There are other Lobbying groups that represent the veteran community as well and influence the politics of our country by lobbying for increases in funding for programs like Public Health measures or increases in funding for hiring additional VA staff to address the medical needs for the veteran population. The figure below demonstrates the organization flow chart of the major departments and agencies that make up the Department of Veterans Affairs. These are the top level organizational departments and executives and each has a separate organization flow chart that reports to departments or agencies. All have to communicate data and information effectively up and down their respective organizational flow charts and across multi-disciplinary roles of professionals each with unique system applications and roles to perform the service of providing health care or benefits administration.

Appendices

Appendix A:

Practicum Log Books, Work Summaries & Supervisor’s Final Evaluation

Appendix B:

Department of Labor Credentialing Resource Guide

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Appendix C:

Excel Spreadsheet of VHA System Applications by Section and Hyper-Links

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