Multiskilling: The Quiet Revolution in Healthcare Education and Training
Journal of Health Occupations Education
Multiskilling : The Quiet Revolution in Healthcare Education and Training
Jenny Auger Maw 0
HillCrest Health Care System 0
Catherine M. Sleezer Ph.D. 0
0 University of Central Florida Libraries , USA
Journal of Health Occupations Education Spring 1995, Volume 10, Number 1
Multiskilling: The Quiet Revolution
in Healthcare Education and Training
Jenny Auger Maw’
Catherine M. Sleezer
healthcare trends that drive the need for multiskilling, (b) perspectives from the
multiskflling literature, and (c) a case study describing the use of rnukiskilhng and
patient-focused care in one organization. Trends facing healthcare providers include cost
containment, mergers and alliances, and consumerism. Integrated, these trends cause a
fundamental reshaping of the field. One strategy that healthcare providers are using to
adapt to the changing business environment is multiskilling. This strategy can lower
costs, facilitate collaboration among those providing care and increase patient satisfaction.
‘Jenny Auger Maw is Corporate Vice President, Organizational Development, HillCrest
Health Care System, Tulsa, OK; Catherine M. SIeezer, Ph. D., is Assistant Professor,
Department of Occupational and Adult Education, Oklahoma State University, Stillwater, OK
Published by STARS, 1995 1
A Specialist is someone who knows more and more about less and less
knows less and less
about more and more
A growing number of healthcare executives say that the beleaguered industry can no
longer afford a workforce composed of too many types of specialized technicians, many of
whom are in short supply and protected by state legislative acts that regulate allied health
professions. Critics of the current system are quietly shaping a radical solution to the
problem: mukiskilling. The idea, which healthcare executives have modified from a
strategy created for high-tech manufacturing, is to train technicians to perform multiple tasks
so they can be deployed more efficiently (Peny, 1991). This paper examines the topic of
multiskilling in three areas: (a) healthcare trends that drive the need for multiskilliig, (b)
perspectives from the multiskilling literature, and (c) a case study describing the use of
multiskilling in one organization.
Healthcare Trends That Drive the Need for Multiskilling
The trends that provide the impetus for multiskilling include cost containment, mergers
and alliances, and consumerism. The first trend, cost containment, is currently receiving
press in relation to healthcare reform. Previously, advancements in medical technology and
patient care drove change. Today, the financing of healthcare to control costs drives change
(l+kalthcare Advisory Board, 1994). For example, the days of adequate reimbursement have
been replaced with meager reimbursement and shortfalls. Further, the cost shifting that once
provided a financial cushion has been limited by cavitation, and fee for service payment has
given rise to managed care, discounts, and cavitation. Such cost containment strategies have
changed the business environment for healthcare providers from one of stability,
predictability, and financial strength to one of turbulence, vulnerability, and concern about
As a response to this trend, healthcare providers are being pressured to do more with less
and to achieve better outcomes in the process
(Berwick, Godfrey & Roessner, 1991)
. To this
end, quality assurance has been replaced by quality improvement, continuous quality
improvement, total quality management and statistical measurement of patient clinical
(Marszalek-Gaucher & Coffey, 1991)
. Another result of this trend is that
healthcare providers, like other types of organizations, are controlling costs by moving from
full-time employment to outsourcing, contacting, and buying services on an as needed basis
(Health Advisory Board, 1989)
A second trend affecting healthcare is mergers and alliances. Hospitals are increasingly
recognizing the need to align and become part of a heahhcare system
(Health Care Advisory
. Similarly, physicians who used to practice independently, today practice
collaboratively. Physicians are increasingly becoming hospital employees, joint venturing
with hospitals in shared ownership/risk opportunities or forming networks to contract for
patients on a capitated basis. A result of this trend is that the field is moving from one
comprised mostly of individual, fragmented providers to one increasingly comprised of
fullyintegrated healthcare delivery systems.
The third trend is the changing view of consumers. In the past, healthcare providers
viewed individual patients both as primary customers and as uninformed individuals who
passively needed medical treatment--the more medical treatment, the better. Today providers
increasingly recognize heakhcare purchasers and their employees as major customers with
each individual patient viewed as an integral part of his or her healthcare team. Patients are
participating more in the decision-making and the care process and are being required to pay
more out-of-pocket expenses.
A result of this trend is that healthcare providers are seeking ways to simultaneously meet
the needs of individual patients and the needs of healthcare purchasers and their employees.
So they are pursuing strategies that allow healthcare to be provided to more consumers at
lower expense. These strategies are designed to increase the patients’ ownership of their
problems and satisfaction with care and, at the same time, decrease costs, administrative
inefficiencies, and unnecessary services.
Each trend described above exerts a powerful force on healthcare providers, and when
integrated the trends cause a fundamental reshaping of the field. The Health Care Advisory
Board (1992, 1994) recently described the reshaping of one type of provider, hospitals.
They pointed out that the hospital of old is being totally and radically restructured to provide
more effective, efficient patient-centered care. The dynarhic business environment and the
restructuring of heahhcare entities by their very nature alter the roles of key stakeholders
including nurses, physicians, and allied health professionals.
One strategy that providers are using to adapt to the changing business environment is
multiskilling. The expectations are that this strategy can lower costs, facilitate collaboration
among those providkg care, and increase patient satisfaction.
Perspectives from the Multiskilling Literature
Multiskilling is a form of working that seeks to promote the exchange, sharing and
common ownership of tasks. Zander (1992) described multiskilling as an approach that is
designed to eliminate multiple caregivers, improve continuity and resource utilization, and
broaden jobs. The outputs of multiskilling include the re-arrangement of existing day-to-day
work and the creation of teams to undertake shofi-term and long-term improvement projects
(Bureau of Health Professions, 1994)
A clearer definition of this term is provided by the National Multiskilled Health
(Bamberg, Blayney, Vaughn & Wilson, 1989)
who delimit the
mukiskilled health care practitioner as follows:
A person who is cross-trained to provide more than one function, often in more than one
discipline. These combined functions can be found in a broad spectrum of health related
jobs ranking in complexity from non-professional to professional level including both
clinical and management functions. The additional function added to the original
healthcare worker’s job may be of higher, lower, or parallel level. (p. 14)
A concept related to mukiskilliig is patient-focused care. Patient-focused care appears
to have its origins in projects initiated by the healthcare consulting industry in the mid- 1980s.
The most prominent information published on consulting firm projects centers on the work of
Booz-Allen Health Care Inc. The Booz-Allen concept of patient-focused care evolved from a
three-year review of twelve institutions
(Lathrop, 1991, 1992)
. The study’s findings revealed
that the amount of compartmentalization in modem hospitals is the primary contributor to
poor service and high cost.
Journal of Health Occupations Education, Vol. 10 , No. 1, Art. 6
Patient-focused care was a specific model for institutional change started by staff and
consultants at Lakeland Regional Medical Center in Lakeland, Florida with consulting help
from Booz-Allen. Patient focused care involved grouping patients based on the resources
that were needed, and redeploying services and staff to patient care units where through
extensive cross-training and team assignments, 80% of all care needed by the patient could
be provided on the unit
, the objectives of patient focused care are:
1. reduction in time spent in scheduling, transportation, documentation, and structural
idle time and devotion of much of the time saved to direct patient care;
2. elimination of some staff time, reducing cost per patient day;
3. improvement in patient perceptions of quality and level of caring; and
4. improvement in staff members’ satisfaction with their roles, which would improve
retention and reduce turnover.
Commonalties between the concepts of mukiskilling and patient-focused care are the use
of generalists and teams and the expected approach that employees have toward working.
Employees have the freedom to progress tasks as far as they can, either as individuals or as
members of a team. They are expected to seek help and assistance from colleagues and to be
able to judge for themselves how far they can competently progress work. Multiskilling does
not mean that employees become jacks-of-all-trades and masters of none. What it does mean
is that employees are expected to take an adult, open-minded approach to their work both in
their primary skill area and in other areas. The development of multiskilling is usually based
on two principles
(Bureau of Health Professions, 1994)
: (a) competency within the
workplace where employees assess and rectify problems as they occur day to day, (b) the full
utilization of capabilities.
Multiskilling offers a new framework for considering who does what and how it gets
done, what specific skills are required to perform which tasks, and when and how employees
can acquire skills. The benefits of multiskilling for the provider can be expected in areas
such as increased productivity, reduced management hierarchies, better use of resources, and
improved customer service. As
pointed out, such benefits are very appealing to
a healthcare industry that is facing significant economic challenges.
Multiskilling also benefits health care professionals. Healthcare roles and responsibilities
are evolving and are impacting traditional health occupations significantly. Shomges of
hospital workers are being replaced by surpluses, and jobs in hospitals are decreasing
whereas out-patient jobs are on the rise
. With the healthcare world needing
fewer specialists and more generzdists, traditional, profession-centered roles are being
redesigned into patient-centered roles. In this environment, multiskilling provides a strategy
for individual employees who want to learn additional skills and remain employable.
The ramifications of mukiskilling for healthcare professions, their roles within the
healthcare systems of the fiture, and the educational reform required to produce the
healthcare worker of tomorrow are immense. Previously well-defined roles are now blurred.
For example, the nurse’s role in many organizations has changed to one of working on
patient care units, alongside a broad range of ancillary staff and supervising assistive,
nonnursing personnel. No longer does the head nurse alone run a hospital nursing unit,
delegating tasks to other nursing personnel. Instead, non-nurses frequently manage these
units. And, the days of ample staffing have given way to limited SUppOr’t staff ~d a ~
In this environment, professional scope of practice, which once regulated employers, is
now stretched to its legal limits and sometimes beyond. Increasingly, petitions to implement
waivers to current law are being made. Policy makers are resisting laws that restrict
professional practice; they are tending towards reducing regulations, and are revisiting
existing policy to identify and remove unnecessary barriers
. The power of
the professional association has been replaced by the power of the major purchasers of
healthcare. Whereas in the past professional associations were viewed as watch dogs for
quality, today they are viewed as turf-protectors (Pew Health Professions Commission,
In summary, mukiskilling serves as a useful strategy for healthcare providers who are
adapting to the trends that are reshaping the field. However, implementing thk strategy has
implications for healthcare providers, employees, and health care educators. The next
section of the paper details the implementation of multiskilling and patient-focused care by
one organization and describes the specific issues faced by each stakeholder group.
Multiskilling in One Organization: A Case Study
In 1990, Hillcrest Medical Center, a 607 bed facility in Tulsa, Oklahoma initiated a
project to implement patient-focused care that had multiskilling as its core. Hillcrest
management recognized the implications of the trends impacting the healthcare field and
proactively decided to initiate this project to improve stakeholder satisfaction and lower costs
Maw and Sleezer: Multiskilling: The Quiet Revolution in Healthcare Education
Prior to its implementation, Hillcrest’s President and Chief Executive Officer (CEO) wrote a
Message from the President that provided the following contextual frame for the project:
Over the years, hospitals have been places where doctors, nurses and other skilled
professionals come together to care for sick and injured patients. In more recent times,
however, the proliferation of modem technology, together with professional specialization
have combined to create a hospital environment where more and more care givers know
more and more about less and less. . . .We should not be surprised to learn that the
specialization, compartmentalization and fragmentation of everyday hospital tasks actually
get in the way of smooth running, cost effective operations. . .
(Skill, 1991, p. 1 )
Because the project represented significant change in organizational procedure and would
require carefully planned implementation, Hillcrest decision makers engaged external
consultants to guide the initial data gathering and project implementation. Each step in the
planning and implementation process is described in the following paragraphs.
Step one involved forming a team whose task was reviewing the way we do things today
and offering recommendations. Team members, who served voluntarily, were selected based
on their diverse clinical expertise. The team was comprised of nine members--Hillcrest
employees at all levels of the organization. In addition, the consulting group worked closely
with this team.
Step two involved assessing current performance.
To accomplish the task of reviewing
the way we do things today, the team divided into three subgroups, each focusing on one of
the following areas: examination of the professional and clinical staffs, analysis of the
administrative and business functions, and stud y of the support functions.
Accomplishing this step was not easy. It required the cooperation of team members from
different hospital areas, different cultures, and different problem solving skills and life
experiences. As members of the subgroups scrutinized their own and other areas in the
hospital, they often engaged in self-examination and rigorous debate among themselves. As
reported in the hospital’s magazine, accomplishing the task also involved
shedding of professional skins that are acquired with great cost over time. It also asked of
all of us that we leave departmental boundaries and turfs that we had enormous stake in
building. . We stopped seeing the world with pharmacy glasses, accounting spectacles,
or nursing bifocals. We started seeing ourselves as our patients see us—a kaleidoscope
of faces often asking the same question they answered an hour ago, systems that cannot
produce snacks without notice, and a bewildering barrage of titles who appear too busy to
ask a question. (p. 3)
In analyzing the data, the team discovered that only small percentages of staff time were
given to direct patient care activities, such as giving medications, changing dressings, taking
temperatures or assisting with surgery or procedures. In contrast, the majority of staff time
was dedicated to scheduling, transportation of patients or goods and documentation of care.
In addition, approximately one-fifth of staff time was structuml idle time--time that staff
members with narrowly assigned tasks spent waiting for the opportunity or need to carry out
Step three involved developing recommendations. The consultants favored implementing a
patient-focused model that they had used in other locations. Members of the project team
felt that this model was inappropriate in its entirety for the organization’s culture, system,
and politics. Instead, the project team favored developing prototypes. Developing
prototypes would limit the amount of change that had to be absorbed in one time. It would
also allow the opportunity to have support systems in place to modify and refine the designs
as Hillcrest stakeholders realized how the project worked.
Using an external facilitator, the team members met, processed the situation, and
developed recommendations for management. The team recommended implementing two
pilot prototypes, one on a general medical surgical unit and the second on a cardiac unit.
They further recommended that the majority of patient care on the prototypes be provided on
the unit. Strategies for accomplishing this goal included grouping patients based on
resources needed, redeploying services, and providing staff with multiskilling. With
multiskilling, the expectation was that a patient’s care could be provided consistently by a
small number of workers who would became familiar to the patient. The team also
recommended using solely internal resources to implement the project. The CEO and the
members of the executive staff accepted the recommendation.
Step four involved implementing the pilot projects. Employees volunteered to participate
in the multiskilling and to work in decentralized, patient-units. The expectation was that unit
based staff would work together to accomplish the following tasks for the unit: admit
patients, code medical records, change linen, distribute meal trays, perform phlebotomies and
provide basic care, routine lab tests and routine respiratory care. The team conducted a
needs assessment to determine the specific skill sets of the caregivers and the clinical
demands of their patient populations. The team used Hillcrest training and development staff
expertise in designing and delivering customized training that matched the needs.
Step five involved evaluating the project results. The success of the project was assessed
using measures of patient satisfaction, physician satisfaction, employee job satisfaction, and
sound fimancial performance. Surveys were used to gather the satisfaction data. The results
of the surveys indicated that each stakeholder group’s satisfaction was higher with
patientfocused care and multiskilling. Multiskilled staff capably demonstrated their new abilities,
and both patients and physicians appreciated the personalized nature of patient care. Patient
and physician surveys showed perceptions regarding quality of care to be higher. Staff
reported higher levels of job satisfaction attributed to an increased sense of competence,
increased skill sets and closer interaction with the patients.
In evaluating financial performance, it was discovered that the two pilot projects did not
generate the cost savings expected if implementation had been considered on a broader scale.
The difficulty in measuring the financial benefits was that after the project was implemented
the hospital operated with two systems: the prototype units operated using a patient-focused
system and multiskilling and the other units operated using a functional system. The use of
two systems meant that even when employees on the prototype units provided services, the
hospital still needed to maintain central services to meet the needs of units operating under
the functional system.
Analysis over time revealed that implementing multiskilling had low costs and high
benefits. Implementing patient-focused care, on the other hand, required extensive capital
start-up costs. Today, the prototype units are still in operation at Hillcrest HealthCare
System, mukiskilling training is still being used, and under the I=dership of the president
and CEO the organization continues to explore ways to maximize human performance and
leaning in healthcare.
Hillcrest Healthcare System has profited from the many lessons learned during the
implementation of this project. One lesson was that multiskilling and patient-focused care
did result in better patient care. Another lesson was the importance of needs assessment. In
implementing human resource performance improvement,
organizational needs, work-behavior needs and individual capabilities. In implementing the
project at Hillcrest, each of these levels of anaIysis was critical to the project’s success. Yet,
another lesson learned was the importance of adapting this process of organizational change
to fit the organization’s culture, system, and politics. Hillcrest leaders continue to view
multiskilling as a key strategy for addressing healthcare challenges. An important
contribution to this view was the involvement of Hillcrest staff in designing and
implementing the project.
A4ultisktiing can provide benefits to healthcare providers, healthcare professionals and
patients. But, implementing this strategy means breaking new ground for both employers
and educators. It requires rethinking boundaries, gaining broader perspectives, and valuing
generalist skills. Multiskilled education and training is similar to other programs in that it
poses its own challenges and controversies. One challenge is that there are no universaI
essentials or guidelines available to guide practitioners and educators.
Another challenge is identifying who will train multiskilled workers, To be effective,
mukiskilling education or training must be relevant to the employees’ jobs and organizational
business goals. Colleges, universities and schools of allied health educated health
professionals very capably in the 1980s. In the 1990s, health providers are increasingly
willing to education and train staff when schools are unable or unwilling to do so--but such
training comes with a high price tag.
As recently as ten years ago, health professional associations and schools that responded
promptly to health sector changes could be seen as being in control, if not in command of
their environments. Today the strategy of merely reacting to change in one’s environment is
a sure sign of professional rigor mortis. As
Selker and Broski (1991)
point out, the future
increasingly belongs to those who are anticipating, shaping and influencing change even as
they are immersed in it. Multiskilling provides a way to harness the future.
Health Care Advisory Board. (1992).
patient care. Washington, DC: Author.
Health Care Advisory Board. (1994). Network advantage: Scale economics and cost
e. Washington> DC: Author.
Zander, A. (1992, September). The muddied waters of patient-focused care. Birmingham,
AL: NationaI Mtdtiskilled Health Practitioner Clearinghouse Newsletter.
Bamberg , R. , Blayney , K. D. , Vaughn , D. G. & Wilson, B.R. ( 1989 ). Multis~led he~th practitioner education: A national Dersmxtive . Birmingham, AL: University of Alabama at Birmingham, School of Health Related Professions, National Multiskilled Health Practitioner Clearinghouse.
Benvick , D. M. , Godfrey , A. B. , & Roessner , J. ( 1991 ). Curim health we: New strategies for Quality improvement . San Francisco, CA: Jossey-Bass.
Bureau of Health Professions . ( 1994 ). Multiskilling and the allied health workforce . Washington, DC: Department of Health and Human Services.
Cross , M. ( 1991 ). Monitoring multiskilling: The way to guarantee long term change . Personnel Management, Q (3) , 4449 .
Health Care Advisory Board. ( 1989 ). M reducing hosuital labor costs . Washington, DC: Author.
Lathrop , J. P. ( 1991 , July -Aug). The patient-focused hospital . Health Forum, y (i) 17 - 21 .
Makely , S. ( 1994 , December). Overview: Multiskillinz and the allied health workforce. Paper presented at the meeting of the Multiskilling and the Allied Health Workforce National Conference , Washington, D. C.
Marszalek-Gaucher , E. & Coffey , R. J. ( 1991 ). Transforming healthcare organizations: How to achieve and sustain organizational excellence . San Francisco, CA: Jossey-Bass.
Perry , L. ( 1991 ). Staff cross-training caught in cross fire . Modem Healthcare , 26 - 29 .
Pew Health Professions Commission. ( 1994 ). Healthv America: Practitioners for 2005 An axenda for action for US health professional schools and health professions education for the future: Schools in service to the nation . San Francisco, CA: Author.
Selker , L. G. , & Broski , D. C. ( 1991 ). Forces and trends shaping allied health care practice and education . Journal of Allied Health, ~ (1) , 5 - 14 .
Sleezer , C. M. ( 1991 ). Developing and validating a performance analysis for training model . Human Resource Development ouarterlv, ~ (4) , 355 - 372 .
Still , M. ( 1991 ). Perspective from the Front Line . ~, 1- 3 .