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February 5, 2007
To combat the dearth of medical coders, a college professor proposes that hospitals invest the time and money to tutor new coders—before it’s too late. In 1998, the leaders of the Metropolitan Police Service at London’s New Scotland Yard knew they were in trouble. For centuries, they had been successful at policing one of the largest cities in the world. However, they knew they needed to improve the force’s corporate image and its service quality. So, under much scrutiny and a large investment of time and money, it launched the Plus Program. This action went against the core beliefs and values that had existed for centuries and significantly altered attitudes within the police service. Today, the Metropolitan Police Service employs more than 45,000 people and has managed to progress into the 21st century, dealing with numerous challenges while maintaining the public’s trust and building on its historic roots. This situation is analogous to the one faced in the coding profession, where we constantly hear and read about a shortage of medical coders—yet it appears the chasm between those who have been in the industry for many years and those doing their utmost to break into it continues to widen. How do we begin to effect the change we need to move forward? In ancient times, teaching and learning were accomplished through apprenticeship: We taught our children how to speak, grow crops, craft cabinets, or tailor clothes by showing them how and by helping them do it. Apprenticeship was the vehicle for transmitting the knowledge required for expert practice in fields from painting and sculpting to medicine and law. It was the natural way to learn. In modern times, apprenticeship has largely been replaced by formal schooling. It has become apparent that schooling by itself is not enough and additional hands-on training is required. “We just don’t have the time to train any new coders,” I hear you say. You are so busy doing more and more with less and less that you simply don’t have the time. Eventually, this can be fatal to any organization. In today’s competitive marketplace, what happens to a hospital that doesn’t continually invest in upgrading its employees’ skills? It’s the same thing that would happen to a championship football or baseball team that doesn’t practice every day. Soon, they are no longer winners. Many managers are confronted by employees and students who want a chance. These people want to develop their skills and help the hospital succeed. Many coding and health information managers just don’t know how to respond. So, like many people, when they don’t know how to do something, they avoid it. Perhaps we should examine our past and consider the apprenticeship system to solve this problem. The Apprenticeship System There are four important aspects of traditional apprenticeships: modeling, scaffolding, fading, and coaching. In modeling, the student observes the trainer demonstrating how to do different parts of the task. The trainer makes the target processes visible, often by explicitly showing the student what to do, and much of the learning occurs as students watch others at work. Scaffolding is the support the trainer gives students in carrying out a task. This can range from doing almost the entire task for them to giving occasional hints as to what to do next. Fading is the notion of slowly removing the support, giving the student more and more responsibility. Coaching is the thread running through the entire apprenticeship experience. The trainer coaches the apprentice through a wide range of activities, including choosing tasks, providing hints and scaffolding, evaluating student activities, diagnosing problems, issuing challenges, offering encouragement, giving feedback, structuring the way to complete tasks, and working on particular weaknesses. In short, coaching is the process of overseeing the student’s learning. The interplay involved in observation, scaffolding, and increasingly independent practice aids students both in developing self-monitoring and correction skills and integrating the skills and conceptual knowledge needed to advance toward expertise. Giving students a conceptual model—a picture of the whole—is an important factor in apprenticeship’s success in teaching complex skills without resorting to lengthy practice of isolated subskills for three reasons. First, it provides learners with an advanced organizer for their initial attempts to execute a complex skill, thus allowing them to concentrate more attention on execution than would otherwise be possible. Second, a conceptual model provides an interpretive structure for making sense of the feedback, hints, and corrections from the master during interactive coaching sessions. Third, it provides an internalized guide when the apprentice is engaged in relatively independent practice. Cognitive Apprenticeship Cognitive apprenticeship is a useful instructional paradigm when a teacher needs to teach a fairly complex task to students, such as coding. It does not require that the teacher permanently assume the role of the “expert”—in fact, we would imagine that the opposite should happen. Trainers need to encourage students to explore questions trainers cannot answer, challenge solutions the “experts” have found—in short, to allow the role of “expert” and “student” to be transformed. Cognitive apprenticeship encourages the student to become the expert, a key element in coding. How might a manager apply the ideas of cognitive apprenticeship to his or her department? There is not a formula for implementing the activities of modeling, scaffolding, fading, and coaching. Ultimately, the trainer must identify ways in which cognitive apprenticeship can work in his or her own facility. Apprenticeship is the way we learn most naturally. It characterized learning before there were schools, from learning one’s language to learning how to run an empire. There are successful models of how apprenticeship methods, in all their dimensions, can be applied to teaching the school curriculum of reading, writing, and mathematics. Trainers can create their own models and develop the framework, which will help point the way toward the redesign of developing the new wave of medical coders so students may better acquire expertise and problem solving skills, as well as an improved ability to learn throughout life. How Can We Apply This
Idea? In today’s global market, all business practices can ultimately be communicated and copied by others. New machines and IT applications can be bought off the shelf immediately. Replicating healthcare processes is more difficult; replicating an organization’s culture and knowledge is the most difficult of all. Although it may sound trite, a hospital’s people are its most valuable asset—but only if that knowledge and those skills are fully utilized. Creating a culture that empowers employees and encourages and rewards innovation and risk-taking is critical. Supporting this with effective training processes to help the collection, codification, and communication of an organization’s knowledge will deliver the highest return on its people assets. What kind of ongoing coding training do you have where you work? At first glance, it may seem that the notion of building mentor/apprentice relationships places a burden on us, but this does not have to be the case. The highest calling of exemplary leaders is to build leadership in others, and effective managers recognize this. Managers who engage with their employees as mentors will find themselves reflecting on their own practice and grow as a result. Finally, managers who invest in building the capacity of their subordinates increase their own effectiveness as they build the strength of their teams. There is a risk, based on previous experience, that once you have spent the time and resources training employees, they will leave for the facility down the street for 50 cents more per hour or go to work for a contract agency. Developing an agreement for all employees, based on mutual understanding and trust, is one way to prevent this type of constant turnover. Some elements of this agreement to consider might be: • You and your facility commit to shared training outcomes. • The development of students/employees through structured training in the form an apprenticeship. • Develop future employees who have the skills, attitudes, behaviors, and courage to lead and train in a manner that will maximize the learning of all students. • Design the role of an employee in a manner that supports the work of the trainer as a leader within your organization. • Design the apprenticeship program and trainers in a manner where the new coders who qualify for these positions not only survive but thrive. One of the most important and difficult jobs of a leader is to gauge the need for organizational change, relate it to the business environment, then convince the “troops” and your boss that organizational change is not only necessary but desirable. “Growing our own” can demonstrate that one way to cope with the coding shortage is establishing explicit mentor/apprentice relationships within existing organizational structures. Everyone benefits when we build leadership within our own ranks. When the external environment is in sync with the organizational strategy and behaviors, then change comes in the form of fine-tuning rather than massive transition. As a leader, now is the time to initiate change. Often, natural forces clash with the process of change, making it difficult to implement. This is normal and a common aspect of human behavior. But leaders can deal with this resistance if they understand its origins. In summary, you need to be cognizant that humans resist change at every turn. That is probably an overstatement, but it is not far from the truth. As you determine the change required to adjust your department to the external environment, back up and assess the likelihood of change being successful. Pick ways in which you can achieve early success so all in the organization will embrace your change. Seeking help at every juncture of this process in addition to networking at a local level will help as you progress. Remember what Alvin Toffler once said: “The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn.” Now ask yourself, am I a leader? — Martin Smith, MEd, RHIT, CCA, is a faculty
member in St. Petersburg (Fla.) College’s HIM program.
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