ADDRESSING PROFITABILITY ISSUES
Challenged with the dilemma of maintaining profitability in the face of decreasing reimbursements, our clinic incorporated hearing instrument specialists (HIS) into the practice in 2005. Our state does not have specific licensure requirements for hiring an audiology assistant or HIS, so we developed our own criteria and selection process. The state licensure educational requirement for hearing aid fitting and dispensing is a high school diploma. Our clinic expanded the criteria to require an undergraduate degree in speech pathology and audiology, completion of the Council for Accreditation in Occupation Hearing Conservation (CAOHC) certification and in-house training, and a state license in hearing aid dispensing. The process took 12 to 18 months to complete, and even after training and credentialing, all tests were supervised and co-signed. However, productivity turned out to be significantly below that of audiologists and externs, which made the next path clear: Phase out HIS to expand and develop an appropriately structured fourth-year extern program.
CONSIDERATIONS FOR EXTERN PROGRAMS
Optimum educational and financial outcomes will not be achieved without proper planning and structuring of an extern program. Preceptors must feel they have been trained and well supported, while externs need to know where to go and what to do. Too many of us have heard horror stories of externs being thrown into a situation where they become “audio-dogs” or free labor. A poorly executed extern program is damaging to the extern, the preceptors, and the practice.
Before 2012, our clinic was a classic offender, lacking structure and often resulting in disorganized and negative extern experiences. In 2011, our department was re-structured, which included doing a complete overhaul of the extern program and designing a new one based on several published mentoring programs.1-3
STEPS TO DEVELOP AN EXTERN PROGRAM
1. Organizational Support. Mentorship programs usually fail due to any of these reasons: (1) lack of alignment with the organization's top talent needs, (2) lack of sponsor or stakeholder involvement and championship, and (3) lack of planning for program scalability and sustainability.³
Identify the primary goals, benefits, and stakeholders of your extern program. Stakeholders are those who need to know about the externship and likely to be affected by the program. Stakeholders may have different priorities, so prepare to discuss the purpose and benefits of the externship by identifying which stakeholder goals support the program and catering your goals to the stakeholder's desires.¹
2. Program Administration. Extern programs need a clinical coordinator associated with the central program functions, which is often required in university affiliation agreements (see online sample here http://bit.ly/2HnheTL). The clinical coordinator takes care of:
- Defining the application process, timelines, and deadlines,
- Familiarizing self and team with university requirements and governmental regulations,
- Supporting preceptors and externs,
- Recruiting and marketing,
- Participant matching/preceptor preparation,
- Gathering and reporting all evaluation info,
- Emergent issues,
- Measuring effectiveness by gathering and analyzing data,
- Final evaluations, meetings, and communications,
- Facilitating improvement of the program design and materials.¹
3. Extern Recruitment and Selection. Career fairs, direct communications with universities, recommendations from previous externs, and recently, Facebook groups are some of your allies in promoting your program and finding candidates. The selection process can be difficult, so develop a set of criteria to help you objectively evaluate the candidate pool. Letters of recommendation and input from professors are invaluable. Many candidates may look wonderful on paper, so prepare a comprehensive interview process.
4. Preceptor Selection, Recruitment, and Retention. Preceptor selection criteria must include competency, credentials (some universities require ASHA-Cs), years of experience, motivation, and readiness. Use formal readiness and motivation questionnaires to evaluate these aspects.
Good preceptors can be hard to recruit. Ideal candidates are often externally busy with competing demands. Research shows that those with previous experience either as a preceptor or as an extern are usually the ones willing to mentor.1 Preceptors who volunteer are typically no more successful than those assigned if they are well trained and involved in the process. Preceptors are more likely to return annually when they believe they are prepared. Provide opportunities for communication, training, preparation, support, and preceptor mentoring.¹
5. Matching. Several options are available to match a preceptor with an extern. Research shows no difference in overall success regardless of matching option utilized.1 We use a collaborative precepting approach to take full advantage of the depth of experience provided by our preceptor team. This approach also decreases any chance of adverse results from a personality conflict.¹
6. Training and Support. Preceptors require training and support to feel ready and confident. Sources include literature on mentoring and precepting, articles, and online training such as the CAPCSD Foundations of Clinical Education, the CH-AP™ABA certificate from the Audiology Preceptor Training Program, and the Western Ontario University's Preceptor Education Program (OWL).
Our clinic finds periodic meetings throughout the year to be beneficial. We include various topics such as extern progress, discussion of issues and resolutions, planning, general support, and storytelling.
7. Familiarization and Implementation. Externs need official orientation and training from human resources to include OSHA and HIPAA compliance, benefits, and customer service expectations. In addition, they need departmental training in practice protocols, learning objectives, expectations and responsibilities, clinic flow, supervision, feedback and evaluation timelines, boundaries, and conflict resolution.
8. Monitoring. Develop a structure that incorporates internal assessment and monitoring to make sure that goals and objectives are being met. Daily and weekly feedback must be incorporated into the clinical schedule.1-4
9. Outcomes. Outcomes provide guidance for how your program should grow or develop. It is optimal to complete simple but targeted clinic evaluations at mid-quarter, during the first quarter, then at the end of subsequent quarters. We find simple online survey formats to be effective and most likely to be completed in a timely manner.
10. Evaluation and Design Review. At the end of the year, we complete and compile our year-end evaluations of externs, preceptors, and the program. Our externs have a formal exit interview with our human resources department, and evaluations are reviewed and discussed with the department director and clinical coordinator. Years ago, we had concerns that students were hesitant to honestly evaluate the extern programs, but our recent graduates are more than ready to provide constructive criticism. My recommendation for surviving the exit interview summaries is to find the nuggets of gold in any negative feedback. Search the literature on mentoring, coaching, and managing millennials. Take what you learn, and apply it going forward.
EVALUATING THE PROGRAM
Evaluate year-end numbers to confirm the program's sustainability and project next year's budget, including the number of externs and extern locations. At our clinic, we do a quarterly evaluation of the numbers from our analytics programs, electronic medical records (EMR), and practice management reporting systems. You can also run the numbers from manual spreadsheet tracking systems.
Our data show that a carefully run extern program benefitted our clinical practice, with average units billed that increased from 542 in 2013 to 880 in 2017. The revenue generated from the extern program divided by the total compensation grew from 2.7 in 2013 to 3.8 in 2017, confirming the program's sustainability. By July 2019, 50 percent of our audiologists will be from our own extern pool, supporting the program's effectiveness in succession planning.
Our externs have made our practice better. Their questions have challenged us to take a fresh look at everything we do, and their different perspectives and passionate approaches to hearing care have made our team more engaged. The future is definitely bright for practices with robust extern programs.Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.