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A workforce in crisis: a case study to expand allied ophthalmic personnel
A workforce in crisis: a case study to expand allied ophthalmic personnel William Astle, MD, FRCS(C), Dipl. ABO,* Craig Simms, BSc, COMT, CDOS, ROUB,† Lynn Anderson, PhD‡ ABSTRACT ● RÉSUMÉ Objective: To examine how the development of allied ophthalmic personnel training programs affects human resource capacity. Design: Using a qualitative case study method conducted at a single Ontario institution, this article describes 6 years of establishing a 2-tiered allied ophthalmic personnel training program. Participants: The Kingston Ophthalmic Training Centre participated in the study with 8 leadership and program graduate interviews. Methods: To assess regional eye health workforce needs, a case study and iterative process used triangulations of the literature, case study, and qualitative interviews with stakeholders. This research was used to develop a model for establishing allied ophthalmic personnel training programs that would result in expanding human resource capacity. Results: Current human resource capacity development and deployment is inadequate to provide the needed eye care services in Canada. A competency-based curriculum and accreditation model as the platform to develop formal academic training programs is essential. Access to quality eye care and patient services can be met by task-shifting from ophthalmologists to appropriately trained allied ophthalmic personnel. Conclusion: Establishing formal training programs is one important strategy to supplying a well-skilled, trained, and qualified ophthalmic workforce. This initiative meets the criteria required for quality, relevance, equity, and cost-effectiveness to meet the future demands for ophthalmic patient care. Objet : Examiner l’impact de l’élaboration des programmes de formation de personnel médical en ophtalmologie sur la capacité en ressources humaines. Nature : Fondée sur une méthodologie qualitative appliquée dans un établissement unique en Ontario, cette étude décrit l’établissement, sur six ans, d’un programme de formation de personnel médical en ophtalmologie en deux volets. Participants : Huit responsables et des diplômés du Kingston Ophthalmic Training Centre ont participé à l’étude en se prêtant à un entretien. Méthode : Pour évaluer les besoins régionaux de personnel en soins oculaires, nous avons utilisé, dans le cadre d’une étude de cas et d’un processus itératif, des triangulations de la littérature, de l’étude de cas et d’entretiens qualitatifs avec des parties prenantes. Ces travaux ont servi à élaborer un modèle pour la création de programmes de formation de personnel médical qui renforceraient la capacité en ressources humaines dans le domaine de l’ophtalmologie. Résultats : La formation et le déploiement de ressources humaines sont actuellement inadéquats pour combler les besoins en services de soins oculaires au Canada. Un modèle de formation et d’accréditation fondé sur les compétences, pouvant servir de plateforme pour l’élaboration de programmes de formation formels, est essentiel. On peut assurer l’accès à des soins oculaires et à des services aux patients de qualité en confiant à du personnel médical dûment formé des tâches actuellement accomplies par les ophtalmologistes. Conclusions : L’instauration de programmes de formation formels représente une stratégie importante pour constituer un effectif ophtalmique hautement qualifié. Cette initiative satisfait aux critères de qualité, de pertinence, d’équité et d’efficience essentiels pour combler les besoins futurs en matière de soins ophtalmiques.
INTRODUCTION A large regional disparity in the number of Canadian ophthalmologists compared with a rapidly aging population implies an upcoming crisis in vision care delivery. In 2013, Bellan et al. reported a current ratio of 3.35 ophthalmologists per 100 000 people.1 The study’s evidence-based method indicated that a ratio of 3:100 000 is a reasonable target. However, the Canadian population is aging, with the Baby Boomer generation soon reaching 465 years. Projections show this outpacing the present ophthalmologist ratio by more than 4 times.
& 2016 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2016.04.008 ISSN 0008-4182/16
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More alarming, and acting as our call to action, is the projected 34% decrease in the ratio of ophthalmologists to population aged 465 years.1,2 A regional disparity is found, with Alberta, Manitoba, Newfoundland/Labrador, Saskatchewan, and the territories below Bellan’s accepted ratio.1 Calgary is a good example of the potential manpower crisis. With a 2015 population of approximately 1.3 million people (and a greater referral drawing area), Calgary is short of 10–15 ophthalmologists according to Bellan’s ratio.3,4 The Royal College of Physicians and Surgeons of Canada and other ophthalmologic stakeholders increased
Case study to expand allied ophthalmic personnel—Astle et al. Table 1——Current and identified need for training programs by level Training Program Level Ophthalmic assistant Ophthalmic technician Orthoptist
Ophthalmic medical technologist
Training Program
Percentage of Respondents Indicating Need
Centennial College, Toronto Southern Alberta Institute of Technology, Calgary Hotel Dieu Hospital, Kingston British Columbia Children’s Hospital, Vancouver Saskatoon Health Region, Saskatoon IWK Health Center/Dalhousie, Halifax IWK Health Center/Dalhousie, Halifax University of Ottawa, Ottawa Stanton Territorial Health Authority, Yellowknife Alberta Health Services/Rockyview Hospital, Calgary Hotel Dieu Hospital, Kingston
34
the number of positions available to train ophthalmologists.1,2 However, this is unlikely to address the future large patient numbers requiring visual care. Eye care is also provided by optometrists and nonophthalmologist physicians. Recent scope of optometric practice changes affect vision care delivery but cannot be accurately quantified at this time.1 Allied ophthalmic personnel (AOP—a cadre of midlevel eye health workers formally recognized by the World Health Organization) have not been adequately utilized in the Canadian ophthalmic scope of practice, although taskshifting to AOP is a long-standing practice.5–8 Strategies to increase patient access and improve care in response to the ophthalmologist shortage for urban and rural populations are to enhance present practice and efficiency by greater task-shifting (transferring responsibilities) to highly skilled AOP.6 In a 2011 study by Astle et al., over 80% of Canadian ophthalmologists surveyed responded that increasing the numbers and using certified AOP contributed to increased productivity and efficiency.6 Performing medical and diagnostic tasks under an ophthalmologist’s direct supervision, AOP have skills ranging from performing measurements, administering medications, assisting in patient care, and carrying out administrative duties. By delegating time-consuming patient tasks (i.e., gathering patient data) to AOP, the ophthalmologist can efficiently deal with patient diagnosis and treatment, thus significantly increasing productivity. Although Canadian ophthalmologists support taskshifting, a fundamental issue is the AOP shortage to successfully meet growing demands. In this article, the authors present the case of Hotel Dieu Hospital, Kingston, Ontario, establishing a 2-tiered AOP training program as a model to assist the Canadian Ophthalmological Society (COS) and its membership to increase the ophthalmologic workforce; identify skills, knowledge, training needs; and address future recruitment, training, and retention strategies. This model can be used for a national Canadian strategy to build eye care capacity.
LITERATURE REVIEW Are properly trained and certified AOP crucial to solving our home-grown Canadian ophthalmologic care crisis? The
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answer is 2-fold. First, the question can be answered by examining 2 landmark evidence-based studies published by Woodworth et al. (U.S.) in 2008 and a similar study by Astle et al. (Canadian) in 2011.6,9 Both studies compared practice productivity and performance attributes of noncertified versus certified AOP. The research demonstrated remarkably similar results, with certified and institutionally trained AOP greatly enhancing the quality and productivity of ophthalmic academic and private practices. Jointly conducted by the COS, Joint Commission on Allied Health Personnel in Ophthalmology (JCAHPO), Canadian Society of Ophthalmic Medical Personnel (CSOMP), and Canadian Medical Association (CMA), the Canadian quantitative study surveyed the COS membership (15% response rate) and engaged focus groups. Results were presented to the Association of Canadian University Professors in Ophthalmology (2010) and published in the Canadian Journal of Ophthalmology (2011). Findings showed that well-trained, certified AOP significantly improved patient follow-up, increased the number of patients seen per hour, reduced patient complaints, and improved effective patient flow.6 AOP improved patient triage screening and were able to effectively trouble shoot patient care problems while improving rapport. Increased doctor productivity leads to overall improvement in patient satisfaction with medical and surgical outcomes. Of responding ophthalmologists, 26% planned to increase staff in their practices, with 61% indicating difficulty in recruiting new AOP.6 The COS membership had high awareness of the 11 Canadian AOP training programs, yet identified the need for additional programs with 51% indicating that additional programs should be established and 11% responding that more programs are not needed.6 Table 1 presents data on the current training programs and need for new training programs. Of responding AOP, a correlation was found between certification and retention: 97% were certified—49% averaged over 16 years; 40% averaged 6–15 years in the profession. In the Association of Technical Personnel in Ophthalmology’s 2015 Salary and Compensation Report, over 3600 AOP (5% Canadian AOP) averaged 17 years in ophthalmology and 10 years with the same employer, averaging 35% greater career longevity than noncertified AOP.10 CAN J OPHTHALMOL — VOL. 51, NO. 4, AUGUST 2016
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Case study to expand allied ophthalmic personnel—Astle et al.
Problem
Inputs
Increasing aging population needing services Lack of training programs in some population areas Unskilled workforce in some areas
Acvies
Outputs
Funding
Didactic training
Trained graduates
Institutional support
Clinical training with affiliates
Ophthalmologist expertise
Certification
Canadian Society of Ophthalmic Medical Personnel membership
Continuing education
Curriculum Leadership support
Outcomes Short and long term increased eye care workforce Intermediate increased efficiency & productivity Increased training options
Workforce shortage
Increased job opportunities
Fig. 1 — Strategy to build eye care team capacity.
Second, the question relates to expanding AOP human resource capacity in underserved areas where Bellan’s ratio is much lower than 3:100 000. Studies indicate that the average ophthalmologist-to-technician ratio ranges from 1:2 to 1:3 (Canada and the United States).6,9 JCAHPO’s annual certification report shows 424 Canadian-certified AOP and a total estimate ranging from 850 to 1200.11 With approximately 1100 Canadian ophthalmologists at a 1:2 or 1:3 ratio, there is a current need of 2200 to 3300 AOP—approximately a 60% shortfall. Research globally shows that AOP make valuable vision care contributions where there are unmet needs.12,13 AOP improve health-care worker distribution in underserved areas and enhance access to health services in a region, with the northwest territories as a good example.14
Support and integration of adequately trained and certified AOP into the health-care system has a strong correlation with sustainable health.
METHODS This qualitative case study, conducted at Hotel Dieu Hospital in Kingston, Ontario, over a 6-year period, examined the establishment of its 2-tiered AOP training program. This ophthalmic technician and medical technologist training program can serve as a national model for building human resource capacity. The 2015 study’s iterative process used triangulations of literature, case study, and qualitative interviews with 8 local and hospital ophthalmologists, employers, training program medical
Workforce Opportunities Community-Based Clinics, Hospitals, Private Practice Ophthalmic Technician Program
• Knowledge and skills taught accurately and consistently • Mid-length intensive training of 10 months by educators
Ophthalmic Medical Technologist Program
• Knowledge and skills taught accurately and consistently • Extensive training of 20 months by educators
Allied Ophthalmic Professionals On-the-Job Trained
• Longer training period • Inconsistent training by co-workers
Training Time to Job Start 10 months
20 months
36+ months Length of time on the job after training
Fig. 2 — Program training length equivalency to on-the-job-training and access to work.
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Case study to expand allied ophthalmic personnel—Astle et al. Table 2——KOTC student outcomes: 5 years Population COT: 11
Not Completing Program 2 students left KOTC after graduating to find work: 1—Kingston 1—Trinidad
Completing Program 9 graduates and 2 students currently enrolled in COT program
100% pass rate in COT Examination
Graduate Employment 100%
72.2% pass rate in COT Skills Examination
Reasons: Not having required postsecondary education Cost of additional 10 months’ training Desire to enter workforce faster COMT: 9
JCAHPO Certification
8 graduates and 1 student are currently 100% pass rate in COMT Examination enrolled. 100% pass rate in COMT Performance Examination
100%
JCAHPO, Joint Commission on Allied Health Personnel in Ophthalmology; KOTC, Kingston Ophthalmic Training Centre; COT, Certified Ophthalmic Technician; COMT, Certified Ophthalmic Medical Technologist.
director and program director, faculty, and graduates. Interview questions focused on challenges, program design, and outcomes. The interviews were transcribed and narratives were coded and analyzed.
CASE STUDY The Kingston area has an urban population of 159 500 (referral drawing area up to 250 000), which significantly exceeds Bellan’s ratio with a 1:13 000 ratio (1:21 000 areawide). Hotel Dieu Hospital leadership and local ophthalmologists assessed trends, needs, and availability of the workforce, health care, and resources. The driving force to establish a training program was the lack of available skilled, qualified AOP. The hospital leadership conducted an informal needs assessment at departmental meetings with 85% of the ophthalmologists citing the inability to recruit skilled, qualified AOP. Factors identified in these interviews included developing a training strategy with preferred outcomes and results (Fig. 1). Training equivalency options for expanding the eye care team were (i) on-the-job training, or (ii) academic training at 1 of 3 skill levels: basic (assistant), intermediate (technician), or advanced (medical technologist). Figure 2 compares equivalency of length of training to outcomes. Leadership and systems
A development model requires a “foundation” of leadership support, structures, systems, and roles. This foundation requires a hospital or university institution (Hotel Dieu Hospital) with interest and capacity to add a training program. A nurse/faculty quote represented stakeholder input, “the biggest challenge to setting up the program was convincing senior leadership of the benefits of running a training program in the hospital. The support from the hospital administrators is essential to run a proper program.” The hospital leadership initially proposed developing an ophthalmic medical technologist (COMT) training
program, the Kingston Ophthalmic Training Centre (KOTC). With local ophthalmologists’ input, the leadership identified the lack of qualified applicants and the need for more graduates to fill job openings than the number of graduates produced from 1 program. A 2-tiered ophthalmic technician (COT; 10-month) and COMT (10month) training program was established, offering students training options and diverse work opportunities. Employers had the benefit of hiring graduates at a lower skill and pay level at a faster pace or more advanced graduates. Leadership interviews identified cost, space, and sufficient infrastructures as key challenges. One ophthalmology employer stated, “Cost and space—both are extremely scarce resources in the current health care environment. We were lucky that the KOTC program was supported by both the hospital and the Department of Ophthalmology.” Securing proper staffing, an ophthalmologist as medical director and a certified ophthalmic medical technologist/technician as program director is essential. The hospital leadership discussed staffing considerations: “Programs such as KOTC require a full-time program director to manage schedules, provide teaching in both clinical and didactic setting, and evaluate students. Funding for a full-time program director is very hard to secure.” In transcribing the stakeholders’ interviews, major themes emerged on staffing expectations and characteristics. Three key roles emerged: advisory committee— technical program guidance; medical director—leadership and secure properly credentialed faculty; and program director—knowledgeable, skilled, credentialed, and ability to teach and motivate students and for daily administration. Faculty characteristic themes identified are expertise, empathy, enthusiasm, clarity, and cultural responsiveness. Required resources include an adequate number of instructors and ophthalmology practices as clinical affiliations for student hands-on clinical experience. CAN J OPHTHALMOL — VOL. 51, NO. 4, AUGUST 2016
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Case study to expand allied ophthalmic personnel—Astle et al. Curriculum and resources
Capacity building is at the very core of Hotel Dieu’s program, with the competencies and curriculum based on national competencies and job analysis conducted by the JCAHPO, CMA, and CSOMP. The KOTC program design adheres to the CMA accreditation model that requires that the 10 plus 10-month intermediate and advanced program levels demonstrate student competency and assessment spanning both profiles. “Performance capacity” (availability of necessary resources) is crucial. The hospital leadership stated that securing “resources such as an office and study area for students poses a challenge.” Adequate facilities, equipment, classrooms, equipment, and clinical space are necessary for quality didactic and clinical training.
Value-added benefits
KOTC has 9 COT program graduates and 8 COMT graduates. Outcomes have met the hospital leadership’s goals and expectations with 100% of KOTC graduates employed at their respective training levels (Table 2). All graduates take the JCAHPO certification examinations. In addition to raising the AOP skill level, a value-added benefit was an increase in the number of available AOP. All stakeholders indicated that the benefits of academically trained graduates were significant compared with onthe-job trained AOP. Employers stated that graduates being JCAHPO certified upon program completion contributed to higher productivity over noncertified AOP. All stakeholders indicated that highly trained and skilled graduates out-pace on-the-job-trained AOP, a direct result of graduates having a training path that is consistent, efficient and faster and which assesses knowledge and skills. Stakeholders indicated that students working under the direct supervision of an ophthalmologist can practice their skills by carrying a small patient load and increasing clinic productivity with fewer risk management issues than a nontrained new hire. Formally trained AOP accelerate their contribution to the ophthalmologist’s productivity, efficiency, effectiveness, and clinic revenues by being able to see more patients in less time.6 Other related benefits of program-trained and certified AOP contributing to
Essential foundations are key leadership support, infrastructure and resources. A model program with curriculum and resources is useful in assisting academic institutions to start ophthalmic training programs. A six-month or one year-long training program for clinicians could build human resource capacity in population areas that are underserved.
Fig. 3 — Summary of key strategies and lessons learned.
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practice productivity is employee retention, low turnover, and greater longevity by staying longer with an employer and in the same position.6,10 A training program also raises staff and preceptors’ knowledge levels by challenging them to keep current.
DISCUSSION Although Hotel Dieu Hospital’s goal was to increase new hires’ quality and skill, the KOTC case presents a 2tiered program as a successful model in expanding capacity and quality. Curriculum, accreditation, and certification systems do not have to be re-invented; the models exist to speed the process and ensure continuity with lessons learned (Fig. 3). A limitation of this study is the limited evidence-based data available directly related to AOP. Other AOP studies have relied on expert opinion, consensus statements, and position papers to evaluate human capacity building.6,9,12–14 However, the subject expert matrix in this study provided strong insights into what is needed across Canada. The KOTC and other Canadian training programs are accredited according to national standards, including competencies in the national competency profile. Therefore, training of AOP in any program is transferable to any jurisdiction. Employment and mobility possibilities are enhanced. To date, KOTC graduates are employed in Toronto and Calgary, in addition to the graduates remaining in Kingston. With an average of 2 technician graduates and 10 medical technologist graduates per year from all Canadian programs, there are not enough students graduating to fill the Canadian AOP shortage over the next decade. Based on issues outlined in this article and the upcoming manpower crisis in vision care delivery, we suggest the following implementation strategy: 1. Formal recognition of the lack of Canadian AOP with vital statistics collected to plan for future vision care needs and promote a national AOP job database. 2. Support for implementation of thoughtful and planned AOP programs across Canada. 3. Form a standing COS committee, represented by AOP stakeholders in education, certification, and hiring to launch a coordinated effort that will identify leadership support, start new programs in targeted institutions, especially in the underserved areas, and work with current AOP training programs to expand enrolment. 4. Strengthen partnerships between the COS, CMA, CSOMP, and JCAHPO to achieve these goals. 5. Require all Canadian AOP to be certified and maintain continuing educational requirements, mirroring the importance placed on ophthalmologist certification and CPD requirements.
Case study to expand allied ophthalmic personnel—Astle et al. CONCLUSION Innovative solutions are needed to solve the upcoming crisis in vision care delivery. Efforts to increase the number of ophthalmologists graduating still fall short in addressing vision care needs as our population ages. We can effect system change by implementing an appropriate human resources strategy and recognizing this as a vision care delivery team. Ophthalmology’s commitment to resident training programs can be duplicated and extended to AOP programs and must not wait for a natural shift, which may take too long to effect change. Studies demonstrate many benefits from AOP utilization. These range from comparable quality and affordable patient care to other medical specialists at one-tenth of the cost; cost-effectiveness of AOPs’ shorter training duration and lower salaries than those of ophthalmologists; and improved patient access to care with shorter travelling distances.6,9,10,12–14 Finally, a clear need has been identified for establishing systems and procedures to integrate core management functions, such as accreditation, regulation, professional development, and AOP career progression in the Canadian health system. The KOTC is an excellent model with great success in achieving its goals. A vision care manpower crisis is in Canadian’s near future. Our ophthalmologic organizations should be leaders in initiatives to create a more effective and productive AOP workforce. We can choose to ignore this looming crisis and continue to “rearrange deck chairs on the Titanic,” or we can choose to be leaders in delivering more effective vision care for all Canadians. Employing well-trained and certified AOP is no longer a luxury, but a crucial and imperative necessity of modern up-to-date ophthalmic practice. REFERENCES 1. Bellan L, Buske L, Wang S, Buys Y. The landscape of ophthalmologists in Canada: present and future. Can J Ophthalmol. 2013;48:160-6. 2. Bellan L, Buske L. Ophthalmology human resource projections: are we heading for a crisis in the next 15 years? Can J Ophthalmol. 2007;42:34-8.
3. 2014 Civic Census Results Book. City of Calgary. www.Calgary.ca/ census. Accessed August 31, 2015. 4. Canadian Medical Association Statistic Report, 2013. https://www. cma.ca/En/Pages/specialty-profiles.aspx. Accessed August 31, 2015. 5. World Health Organization. Universal eye health: a global action plan 2014–2019. Geneva: WHO; 2013. 6. Astle W, El-Defrawy S, LaRoche G, et al. Survey on allied health personnel in Canadian ophthalmology: the scalpel for change. Can J Ophthalmol. 2011;46:24-8. 7. Stein HA. Ophthalmic assistants. Arch Ophthalmol. 1967;78:419. 8. Trobe JD, Kraft RE, Crandall LA, Marks RG, Krischer JP, Demaris A. Proficiency and patient acceptance of ophthalmic medical assistants. Ophthalmology. 1990;89:53A-60A. 9. Woodworth K, Donshik P, Ehlers W, Pucel D, Anderson L, Thompson N. A comparative study of the impact of certified and noncertified ophthalmic medical personnel on practice quality and productivity. Eye Contact Lens. 2008;34:24-8. 10. Association of Technical Personnel in Ophthalmology. Salary and Compensation 2015 National Report. St. Paul, MN: ATPO; 2015. 11. Joint Commission on Allied Health Personnel in Ophthalmology. 2015 Annual Certification Report. St. Paul, MN: JCAHPO. Accessed August 1, 2015. 12. du Toit R, Palagyi A, Brian G. The development of competencybased education for mid-level eye care professionals: a process to foster an appropriate, widely accepted and socially accountable initiative. Educ Health. 2010;23:1-4. 13. du Toit R, Brian G. Mid-level cadre providing eye care in the context of Vision 2020. N Z Med J. 2009;122:77-88. 14. Brown A, Cometto G, Cumbi A, et al. Mid-level health providers: a promising resource. Rev Peru Med Exp Salud Publica. 2011;28: 308-15.
Footnotes and Disclosure: The authors have no proprietary or commercial interest in any materials discussed in this article. The authors thank Sherif El-Defrawy, MD, University of Toronto, for input on the history of KOTC and the study. From the *Alberta Children’s Hospital, Calgary, Alta; †Hotel Dieu Hospital, Kingston, Ont; ‡Joint Commission on Allied Health Personnel in Ophthalmology, St. Paul, Minn. Originally received Nov. 2, 2015. Final revision Apr. 5, 2016. Accepted Apr. 10, 2016. Correspondence to Lynn Anderson, PhD, Joint Commission on Allied Health Personnel in Ophthalmology, 2025 Woodlane Drive, St. Paul, MN 55125; [email protected]
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INTRODUCTION A large regional disparity in the number of Canadian ophthalmologists compared with a rapidly aging population implies an upcoming crisis in vision care delivery. In 2013, Bellan et al. reported a current ratio of 3.35 ophthalmologists per 100 000 people.1 The study’s evidence-based method indicated that a ratio of 3:100 000 is a reasonable target. However, the Canadian population is aging, with the Baby Boomer generation soon reaching 465 years. Projections show this outpacing the present ophthalmologist ratio by more than 4 times.
& 2016 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2016.04.008 ISSN 0008-4182/16
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More alarming, and acting as our call to action, is the projected 34% decrease in the ratio of ophthalmologists to population aged 465 years.1,2 A regional disparity is found, with Alberta, Manitoba, Newfoundland/Labrador, Saskatchewan, and the territories below Bellan’s accepted ratio.1 Calgary is a good example of the potential manpower crisis. With a 2015 population of approximately 1.3 million people (and a greater referral drawing area), Calgary is short of 10–15 ophthalmologists according to Bellan’s ratio.3,4 The Royal College of Physicians and Surgeons of Canada and other ophthalmologic stakeholders increased
Case study to expand allied ophthalmic personnel—Astle et al. Table 1——Current and identified need for training programs by level Training Program Level Ophthalmic assistant Ophthalmic technician Orthoptist
Ophthalmic medical technologist
Training Program
Percentage of Respondents Indicating Need
Centennial College, Toronto Southern Alberta Institute of Technology, Calgary Hotel Dieu Hospital, Kingston British Columbia Children’s Hospital, Vancouver Saskatoon Health Region, Saskatoon IWK Health Center/Dalhousie, Halifax IWK Health Center/Dalhousie, Halifax University of Ottawa, Ottawa Stanton Territorial Health Authority, Yellowknife Alberta Health Services/Rockyview Hospital, Calgary Hotel Dieu Hospital, Kingston
34
the number of positions available to train ophthalmologists.1,2 However, this is unlikely to address the future large patient numbers requiring visual care. Eye care is also provided by optometrists and nonophthalmologist physicians. Recent scope of optometric practice changes affect vision care delivery but cannot be accurately quantified at this time.1 Allied ophthalmic personnel (AOP—a cadre of midlevel eye health workers formally recognized by the World Health Organization) have not been adequately utilized in the Canadian ophthalmic scope of practice, although taskshifting to AOP is a long-standing practice.5–8 Strategies to increase patient access and improve care in response to the ophthalmologist shortage for urban and rural populations are to enhance present practice and efficiency by greater task-shifting (transferring responsibilities) to highly skilled AOP.6 In a 2011 study by Astle et al., over 80% of Canadian ophthalmologists surveyed responded that increasing the numbers and using certified AOP contributed to increased productivity and efficiency.6 Performing medical and diagnostic tasks under an ophthalmologist’s direct supervision, AOP have skills ranging from performing measurements, administering medications, assisting in patient care, and carrying out administrative duties. By delegating time-consuming patient tasks (i.e., gathering patient data) to AOP, the ophthalmologist can efficiently deal with patient diagnosis and treatment, thus significantly increasing productivity. Although Canadian ophthalmologists support taskshifting, a fundamental issue is the AOP shortage to successfully meet growing demands. In this article, the authors present the case of Hotel Dieu Hospital, Kingston, Ontario, establishing a 2-tiered AOP training program as a model to assist the Canadian Ophthalmological Society (COS) and its membership to increase the ophthalmologic workforce; identify skills, knowledge, training needs; and address future recruitment, training, and retention strategies. This model can be used for a national Canadian strategy to build eye care capacity.
LITERATURE REVIEW Are properly trained and certified AOP crucial to solving our home-grown Canadian ophthalmologic care crisis? The
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20
answer is 2-fold. First, the question can be answered by examining 2 landmark evidence-based studies published by Woodworth et al. (U.S.) in 2008 and a similar study by Astle et al. (Canadian) in 2011.6,9 Both studies compared practice productivity and performance attributes of noncertified versus certified AOP. The research demonstrated remarkably similar results, with certified and institutionally trained AOP greatly enhancing the quality and productivity of ophthalmic academic and private practices. Jointly conducted by the COS, Joint Commission on Allied Health Personnel in Ophthalmology (JCAHPO), Canadian Society of Ophthalmic Medical Personnel (CSOMP), and Canadian Medical Association (CMA), the Canadian quantitative study surveyed the COS membership (15% response rate) and engaged focus groups. Results were presented to the Association of Canadian University Professors in Ophthalmology (2010) and published in the Canadian Journal of Ophthalmology (2011). Findings showed that well-trained, certified AOP significantly improved patient follow-up, increased the number of patients seen per hour, reduced patient complaints, and improved effective patient flow.6 AOP improved patient triage screening and were able to effectively trouble shoot patient care problems while improving rapport. Increased doctor productivity leads to overall improvement in patient satisfaction with medical and surgical outcomes. Of responding ophthalmologists, 26% planned to increase staff in their practices, with 61% indicating difficulty in recruiting new AOP.6 The COS membership had high awareness of the 11 Canadian AOP training programs, yet identified the need for additional programs with 51% indicating that additional programs should be established and 11% responding that more programs are not needed.6 Table 1 presents data on the current training programs and need for new training programs. Of responding AOP, a correlation was found between certification and retention: 97% were certified—49% averaged over 16 years; 40% averaged 6–15 years in the profession. In the Association of Technical Personnel in Ophthalmology’s 2015 Salary and Compensation Report, over 3600 AOP (5% Canadian AOP) averaged 17 years in ophthalmology and 10 years with the same employer, averaging 35% greater career longevity than noncertified AOP.10 CAN J OPHTHALMOL — VOL. 51, NO. 4, AUGUST 2016
289
Case study to expand allied ophthalmic personnel—Astle et al.
Problem
Inputs
Increasing aging population needing services Lack of training programs in some population areas Unskilled workforce in some areas
Acvies
Outputs
Funding
Didactic training
Trained graduates
Institutional support
Clinical training with affiliates
Ophthalmologist expertise
Certification
Canadian Society of Ophthalmic Medical Personnel membership
Continuing education
Curriculum Leadership support
Outcomes Short and long term increased eye care workforce Intermediate increased efficiency & productivity Increased training options
Workforce shortage
Increased job opportunities
Fig. 1 — Strategy to build eye care team capacity.
Second, the question relates to expanding AOP human resource capacity in underserved areas where Bellan’s ratio is much lower than 3:100 000. Studies indicate that the average ophthalmologist-to-technician ratio ranges from 1:2 to 1:3 (Canada and the United States).6,9 JCAHPO’s annual certification report shows 424 Canadian-certified AOP and a total estimate ranging from 850 to 1200.11 With approximately 1100 Canadian ophthalmologists at a 1:2 or 1:3 ratio, there is a current need of 2200 to 3300 AOP—approximately a 60% shortfall. Research globally shows that AOP make valuable vision care contributions where there are unmet needs.12,13 AOP improve health-care worker distribution in underserved areas and enhance access to health services in a region, with the northwest territories as a good example.14
Support and integration of adequately trained and certified AOP into the health-care system has a strong correlation with sustainable health.
METHODS This qualitative case study, conducted at Hotel Dieu Hospital in Kingston, Ontario, over a 6-year period, examined the establishment of its 2-tiered AOP training program. This ophthalmic technician and medical technologist training program can serve as a national model for building human resource capacity. The 2015 study’s iterative process used triangulations of literature, case study, and qualitative interviews with 8 local and hospital ophthalmologists, employers, training program medical
Workforce Opportunities Community-Based Clinics, Hospitals, Private Practice Ophthalmic Technician Program
• Knowledge and skills taught accurately and consistently • Mid-length intensive training of 10 months by educators
Ophthalmic Medical Technologist Program
• Knowledge and skills taught accurately and consistently • Extensive training of 20 months by educators
Allied Ophthalmic Professionals On-the-Job Trained
• Longer training period • Inconsistent training by co-workers
Training Time to Job Start 10 months
20 months
36+ months Length of time on the job after training
Fig. 2 — Program training length equivalency to on-the-job-training and access to work.
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Case study to expand allied ophthalmic personnel—Astle et al. Table 2——KOTC student outcomes: 5 years Population COT: 11
Not Completing Program 2 students left KOTC after graduating to find work: 1—Kingston 1—Trinidad
Completing Program 9 graduates and 2 students currently enrolled in COT program
100% pass rate in COT Examination
Graduate Employment 100%
72.2% pass rate in COT Skills Examination
Reasons: Not having required postsecondary education Cost of additional 10 months’ training Desire to enter workforce faster COMT: 9
JCAHPO Certification
8 graduates and 1 student are currently 100% pass rate in COMT Examination enrolled. 100% pass rate in COMT Performance Examination
100%
JCAHPO, Joint Commission on Allied Health Personnel in Ophthalmology; KOTC, Kingston Ophthalmic Training Centre; COT, Certified Ophthalmic Technician; COMT, Certified Ophthalmic Medical Technologist.
director and program director, faculty, and graduates. Interview questions focused on challenges, program design, and outcomes. The interviews were transcribed and narratives were coded and analyzed.
CASE STUDY The Kingston area has an urban population of 159 500 (referral drawing area up to 250 000), which significantly exceeds Bellan’s ratio with a 1:13 000 ratio (1:21 000 areawide). Hotel Dieu Hospital leadership and local ophthalmologists assessed trends, needs, and availability of the workforce, health care, and resources. The driving force to establish a training program was the lack of available skilled, qualified AOP. The hospital leadership conducted an informal needs assessment at departmental meetings with 85% of the ophthalmologists citing the inability to recruit skilled, qualified AOP. Factors identified in these interviews included developing a training strategy with preferred outcomes and results (Fig. 1). Training equivalency options for expanding the eye care team were (i) on-the-job training, or (ii) academic training at 1 of 3 skill levels: basic (assistant), intermediate (technician), or advanced (medical technologist). Figure 2 compares equivalency of length of training to outcomes. Leadership and systems
A development model requires a “foundation” of leadership support, structures, systems, and roles. This foundation requires a hospital or university institution (Hotel Dieu Hospital) with interest and capacity to add a training program. A nurse/faculty quote represented stakeholder input, “the biggest challenge to setting up the program was convincing senior leadership of the benefits of running a training program in the hospital. The support from the hospital administrators is essential to run a proper program.” The hospital leadership initially proposed developing an ophthalmic medical technologist (COMT) training
program, the Kingston Ophthalmic Training Centre (KOTC). With local ophthalmologists’ input, the leadership identified the lack of qualified applicants and the need for more graduates to fill job openings than the number of graduates produced from 1 program. A 2-tiered ophthalmic technician (COT; 10-month) and COMT (10month) training program was established, offering students training options and diverse work opportunities. Employers had the benefit of hiring graduates at a lower skill and pay level at a faster pace or more advanced graduates. Leadership interviews identified cost, space, and sufficient infrastructures as key challenges. One ophthalmology employer stated, “Cost and space—both are extremely scarce resources in the current health care environment. We were lucky that the KOTC program was supported by both the hospital and the Department of Ophthalmology.” Securing proper staffing, an ophthalmologist as medical director and a certified ophthalmic medical technologist/technician as program director is essential. The hospital leadership discussed staffing considerations: “Programs such as KOTC require a full-time program director to manage schedules, provide teaching in both clinical and didactic setting, and evaluate students. Funding for a full-time program director is very hard to secure.” In transcribing the stakeholders’ interviews, major themes emerged on staffing expectations and characteristics. Three key roles emerged: advisory committee— technical program guidance; medical director—leadership and secure properly credentialed faculty; and program director—knowledgeable, skilled, credentialed, and ability to teach and motivate students and for daily administration. Faculty characteristic themes identified are expertise, empathy, enthusiasm, clarity, and cultural responsiveness. Required resources include an adequate number of instructors and ophthalmology practices as clinical affiliations for student hands-on clinical experience. CAN J OPHTHALMOL — VOL. 51, NO. 4, AUGUST 2016
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Case study to expand allied ophthalmic personnel—Astle et al. Curriculum and resources
Capacity building is at the very core of Hotel Dieu’s program, with the competencies and curriculum based on national competencies and job analysis conducted by the JCAHPO, CMA, and CSOMP. The KOTC program design adheres to the CMA accreditation model that requires that the 10 plus 10-month intermediate and advanced program levels demonstrate student competency and assessment spanning both profiles. “Performance capacity” (availability of necessary resources) is crucial. The hospital leadership stated that securing “resources such as an office and study area for students poses a challenge.” Adequate facilities, equipment, classrooms, equipment, and clinical space are necessary for quality didactic and clinical training.
Value-added benefits
KOTC has 9 COT program graduates and 8 COMT graduates. Outcomes have met the hospital leadership’s goals and expectations with 100% of KOTC graduates employed at their respective training levels (Table 2). All graduates take the JCAHPO certification examinations. In addition to raising the AOP skill level, a value-added benefit was an increase in the number of available AOP. All stakeholders indicated that the benefits of academically trained graduates were significant compared with onthe-job trained AOP. Employers stated that graduates being JCAHPO certified upon program completion contributed to higher productivity over noncertified AOP. All stakeholders indicated that highly trained and skilled graduates out-pace on-the-job-trained AOP, a direct result of graduates having a training path that is consistent, efficient and faster and which assesses knowledge and skills. Stakeholders indicated that students working under the direct supervision of an ophthalmologist can practice their skills by carrying a small patient load and increasing clinic productivity with fewer risk management issues than a nontrained new hire. Formally trained AOP accelerate their contribution to the ophthalmologist’s productivity, efficiency, effectiveness, and clinic revenues by being able to see more patients in less time.6 Other related benefits of program-trained and certified AOP contributing to
Essential foundations are key leadership support, infrastructure and resources. A model program with curriculum and resources is useful in assisting academic institutions to start ophthalmic training programs. A six-month or one year-long training program for clinicians could build human resource capacity in population areas that are underserved.
Fig. 3 — Summary of key strategies and lessons learned.
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practice productivity is employee retention, low turnover, and greater longevity by staying longer with an employer and in the same position.6,10 A training program also raises staff and preceptors’ knowledge levels by challenging them to keep current.
DISCUSSION Although Hotel Dieu Hospital’s goal was to increase new hires’ quality and skill, the KOTC case presents a 2tiered program as a successful model in expanding capacity and quality. Curriculum, accreditation, and certification systems do not have to be re-invented; the models exist to speed the process and ensure continuity with lessons learned (Fig. 3). A limitation of this study is the limited evidence-based data available directly related to AOP. Other AOP studies have relied on expert opinion, consensus statements, and position papers to evaluate human capacity building.6,9,12–14 However, the subject expert matrix in this study provided strong insights into what is needed across Canada. The KOTC and other Canadian training programs are accredited according to national standards, including competencies in the national competency profile. Therefore, training of AOP in any program is transferable to any jurisdiction. Employment and mobility possibilities are enhanced. To date, KOTC graduates are employed in Toronto and Calgary, in addition to the graduates remaining in Kingston. With an average of 2 technician graduates and 10 medical technologist graduates per year from all Canadian programs, there are not enough students graduating to fill the Canadian AOP shortage over the next decade. Based on issues outlined in this article and the upcoming manpower crisis in vision care delivery, we suggest the following implementation strategy: 1. Formal recognition of the lack of Canadian AOP with vital statistics collected to plan for future vision care needs and promote a national AOP job database. 2. Support for implementation of thoughtful and planned AOP programs across Canada. 3. Form a standing COS committee, represented by AOP stakeholders in education, certification, and hiring to launch a coordinated effort that will identify leadership support, start new programs in targeted institutions, especially in the underserved areas, and work with current AOP training programs to expand enrolment. 4. Strengthen partnerships between the COS, CMA, CSOMP, and JCAHPO to achieve these goals. 5. Require all Canadian AOP to be certified and maintain continuing educational requirements, mirroring the importance placed on ophthalmologist certification and CPD requirements.
Case study to expand allied ophthalmic personnel—Astle et al. CONCLUSION Innovative solutions are needed to solve the upcoming crisis in vision care delivery. Efforts to increase the number of ophthalmologists graduating still fall short in addressing vision care needs as our population ages. We can effect system change by implementing an appropriate human resources strategy and recognizing this as a vision care delivery team. Ophthalmology’s commitment to resident training programs can be duplicated and extended to AOP programs and must not wait for a natural shift, which may take too long to effect change. Studies demonstrate many benefits from AOP utilization. These range from comparable quality and affordable patient care to other medical specialists at one-tenth of the cost; cost-effectiveness of AOPs’ shorter training duration and lower salaries than those of ophthalmologists; and improved patient access to care with shorter travelling distances.6,9,10,12–14 Finally, a clear need has been identified for establishing systems and procedures to integrate core management functions, such as accreditation, regulation, professional development, and AOP career progression in the Canadian health system. The KOTC is an excellent model with great success in achieving its goals. A vision care manpower crisis is in Canadian’s near future. Our ophthalmologic organizations should be leaders in initiatives to create a more effective and productive AOP workforce. We can choose to ignore this looming crisis and continue to “rearrange deck chairs on the Titanic,” or we can choose to be leaders in delivering more effective vision care for all Canadians. Employing well-trained and certified AOP is no longer a luxury, but a crucial and imperative necessity of modern up-to-date ophthalmic practice. REFERENCES 1. Bellan L, Buske L, Wang S, Buys Y. The landscape of ophthalmologists in Canada: present and future. Can J Ophthalmol. 2013;48:160-6. 2. Bellan L, Buske L. Ophthalmology human resource projections: are we heading for a crisis in the next 15 years? Can J Ophthalmol. 2007;42:34-8.
3. 2014 Civic Census Results Book. City of Calgary. www.Calgary.ca/ census. Accessed August 31, 2015. 4. Canadian Medical Association Statistic Report, 2013. https://www. cma.ca/En/Pages/specialty-profiles.aspx. Accessed August 31, 2015. 5. World Health Organization. Universal eye health: a global action plan 2014–2019. Geneva: WHO; 2013. 6. Astle W, El-Defrawy S, LaRoche G, et al. Survey on allied health personnel in Canadian ophthalmology: the scalpel for change. Can J Ophthalmol. 2011;46:24-8. 7. Stein HA. Ophthalmic assistants. Arch Ophthalmol. 1967;78:419. 8. Trobe JD, Kraft RE, Crandall LA, Marks RG, Krischer JP, Demaris A. Proficiency and patient acceptance of ophthalmic medical assistants. Ophthalmology. 1990;89:53A-60A. 9. Woodworth K, Donshik P, Ehlers W, Pucel D, Anderson L, Thompson N. A comparative study of the impact of certified and noncertified ophthalmic medical personnel on practice quality and productivity. Eye Contact Lens. 2008;34:24-8. 10. Association of Technical Personnel in Ophthalmology. Salary and Compensation 2015 National Report. St. Paul, MN: ATPO; 2015. 11. Joint Commission on Allied Health Personnel in Ophthalmology. 2015 Annual Certification Report. St. Paul, MN: JCAHPO. Accessed August 1, 2015. 12. du Toit R, Palagyi A, Brian G. The development of competencybased education for mid-level eye care professionals: a process to foster an appropriate, widely accepted and socially accountable initiative. Educ Health. 2010;23:1-4. 13. du Toit R, Brian G. Mid-level cadre providing eye care in the context of Vision 2020. N Z Med J. 2009;122:77-88. 14. Brown A, Cometto G, Cumbi A, et al. Mid-level health providers: a promising resource. Rev Peru Med Exp Salud Publica. 2011;28: 308-15.
Footnotes and Disclosure: The authors have no proprietary or commercial interest in any materials discussed in this article. The authors thank Sherif El-Defrawy, MD, University of Toronto, for input on the history of KOTC and the study. From the *Alberta Children’s Hospital, Calgary, Alta; †Hotel Dieu Hospital, Kingston, Ont; ‡Joint Commission on Allied Health Personnel in Ophthalmology, St. Paul, Minn. Originally received Nov. 2, 2015. Final revision Apr. 5, 2016. Accepted Apr. 10, 2016. Correspondence to Lynn Anderson, PhD, Joint Commission on Allied Health Personnel in Ophthalmology, 2025 Woodlane Drive, St. Paul, MN 55125; [email protected]
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