Training the eye care team: principles and practice.

One of the crucial factors to make high quality eye care services available, accessible and affordable to all is the availability of appropriately trained human resources. Providing health through a health care team is a better and cost effective alternative. The concept of the team approach is based on the principles of working together; task shifting; and ensuring continuity of care. Composition of a team varies based on the community needs, population characteristics and disease burden. But for it to be effective, a team must possess four attributes - availability, competency, productivity, and responsiveness. Therefore, training of all team members and training the team to work together as a unit are crucial components in the success of this concept. Some of the critical attributes include: Training across the health spectrum through quality and responsive curricula administered by motivated teachers; accreditation of programs or institutions by national or international bodies; certification and recertification of team members; and training in working together as a team through inter- and intra- disciplinary workshops both during training and as a part of the job activity.

INTRODUCTION

There are many different kinds of health teams, however, from the community health perspective; a team is defined as a “group of people sharing a common health goal and objectives, determined by community needs, to the achievement of which each member contributes in accordance to his or her competence and skills and in accordance with the functions of others”.1

In a true sense the health care team is comprised of technical staff (physician, nurses, medical assistants, etc.) and support staff (front desk staff, counsellors, biomedical technicians etc). In this article the health team refers to a group of health workers taking care of the visual needs of a population in a defined geographical area with the objective of reducing visual impairment and blindness.

The focus of this article is on the training of the comprehensive eye health team. It does not address the issues and challenges of training eye health professionals to work together effectively.

We will be discussing following aspects of health care team and team training:

The need and principles of the team approach in health care

Characteristics of an ideal team

Factors affecting the performance of a health care team

Principles and practice of training.

The article is primarily directed toward ophthalmologists, public health specialists, and heads of education and training institutions to familiarize them with the:

Challenges in making appropriate eye care available to larger sections of a community (universal coverage)

Concept of health care team as a strategy to overcome these challenges

Principles and strategies for training of health (eye) care teams and

factors determining a high performing team.

Need and principles of the team approach in health care

World Health Organization identified three major challenges for achieving “Universal Health Coverage”

Low per capita spending for health by governments

Low ratios of doctors and nurses to population; and

Inadequate health infrastructure at every level.

The situation is exacerbated by the unequal distribution of resources. For example, availability and accessibility to health care facilities between urban and rural areas differs significantly. Additionally, there are differences even in the health needs, perception and desire to access available health facilities, and overall health awareness among urban and rural populations.234 Eye care is no exception to these differences. With 39 million blind and 246 million with low vision, visual impairment is a major public health issue and efforts at controlling it are adversely affected by these challenges.5 The Andhra Pradesh Eye Disease Study (APEDS), a large population based epidemiological study to determine the prevalence and causes of visual impairment and blindness performed by the International Centre for Advancement of Rural Eye Care (ICARE) at the L V Prasad Eye Institute, Hyderabad India clearly showed trends that highlight these challenges in eye health.6

Realizing these challenges Vision 2020 – the Right to Sight set its goal as “to make high quality eye care services available, accessible and affordable to all, through a sustainable delivery system.”7

In order to achieve this goal of providing a comprehensive eye care and meeting the challenges one of the crucial factor is availability of appropriately trained human resource. Further, to meet this demand for human resource we cannot depend on physicians or nurses in view of the cost, duration of training, their attitude toward rural services, and mismatch between the skills of this group and the needs of the community.3

Providing health through a health care team is a better and cost effective alternative and must be implemented to achieve the goals set by Vision 2020 – the right to sight.89 Salas et al.,10 used qualitative and quantitative analysis to show that the team approach works. The authors also described principles of team training that are critical for the success of this approach in the health sector.10

The concept of team approach is based on three principles

Working together: The categories of personnel providing health-care vary at different levels of the health-care system as well as from country to country. For example; health workers providing eye care include ophthalmologists, optometrists, ophthalmic nurses, orthoptists, ophthalmic and dispensing opticians and mid-level eye-care personnel. No one person can acquire all the necessary skills or have enough time to perform all the tasks to satisfy the health needs of even a small community. However, if the contribution of each individual (within the team) is optimized we will not only be able to reach more people but also enhance the effectiveness and efficiency of the delivery of eye care1011

Task shifting: This is a process of delegation or “rationale redistribution of tasks whereby specific tasks are moved where appropriate, to less specialized health workers with fewer qualifications and requiring less training. For example detection and correction of refractive error by mid-level ophthalmic personnel and public awareness and education against harmful practices by community health worker or vision guardian12

Links between different levels of health care delivery to ensure continuity of care: For the team approach to be successful as well as ensuring coverage of the entire spectrum of health from health education to the management of the most complicated cases it is essential to provide working linkages between different levels of health care/eye care.

Characteristics of an ideal team for health

Four major attributes of a well performing eye care team are:

Availability: in terms of space and time. It encompasses distribution of health workforce and attendance for work

Competence: It encompasses the combination of technical knowledge, skills and behaviours

Productivity: producing the maximum effective health services and health outcomes possible while reducing waste of staff time or skills

Responsiveness: taking the decision that is in the best interest of patients regardless of their socioeconomic status.

All these attributes must be considered while planning the health care workforce through the selection of appropriate candidates, training, placement, and providing the necessary infrastructure.13

Factors affecting the performance of health care teams

Performance of health care team is critical as it impacts health care delivery and ultimately the population health. Following factors have positive impact on the performance of health care teams:14

Clear job description

Well defined norms and code of conduct

Tasks matched with skills of health worker

Supportive supervision

Basic support systems including remuneration and infrastructure including equipments and supplies for performing the job efficiently

Timely transfer of information and open communication among team members as well as between members of team and the manager

Enabling work environment through incorporation of lifelong learning; effective team management and ensuring responsibility with accountability.

In this regard, it is important for organizations and team managers to:

Provide a clear sense of vision and mission

Provide clear career path

Make people feel recognized and valued whatever their job is

Listen to staff and increase their participation in decisions

Develop good interpersonal skills (encouraging teamwork) through mentoring and periodic coaching;

Create a culture of benchmarking and comparison;

Provide transparent appraisal and promotion system

Provide timely feedback and rewarding good performance while being fair and consistent while using sanctions for poor performance.

It is clear that the team training programs should not only be limited to technical or support staff but include training of managers.

Principles and practice of training of eye care team

The basic principle of training health care team is “giving the right training to the right people to create an effective workforce for the delivery of health care”.

Planning training of health care teams

The following factors are crucial in planning training of health care teams:

Numbers: How many people need to be trained?

Competencies: What tasks need to perform by each of the different levels of health workers and the required skills to accomplish those efficiently?

Eligibility: Attributes a candidate must possess for a particular role in the team including the degree to which they should reflect the socio-cultural and demographic characteristics of the population

Training institutions: Number, quality and appropriateness of organization where the training will take place

Eye health care needs of the community.

Information along these lines will guide to policies and possible actions related to training and recruitment.

Strategies to ensure that the training programs deliver the desired output

Below are some strategies that will ensure that the right people receive right training toward creation of an effective workforce:11

Strategy 1: Encourage training across the health care spectrum

To overcome the widespread shortage of human resource it is essential to encourage training across the health care spectrum. Unfortunately, the educational establishments training other health workers are heavily tipped towards physicians and nurses with very few schools training other health workers for community health. In addition, there are only limited number of schools dedicated for public health or community eye health. The world health report of 2006 related to global health professional training capacity observed that the WHO Eastern Mediterranean and South-East Asia regions have remarkably fewer schools of public health.15

It is therefore, essential to open new schools or programs or enhance the capacity of existing programs providing training to a health workforce across the health care spectrum.

Strategy 2: Ensure quality and responsive curricula

One of the core principles of the health care team is task shifting. Therefore, the level of the knowledge and skills will differ among different classes of health workers. It is important to ensure a quality and responsive curriculum for each program. The curriculum must be aligned in regards to what is being taught to what is appropriate for the tasks they will be responsible for. For mid-level workers it is crucial that the curriculum must emphasize skills in addition to knowledge. One must also be careful to avoid overloaded curricula as it leads to dilution of focus on critical or core skills and knowledge.

For example vision guardians need to be trained in the assessment of vision and health education while ophthalmic assistants need to be trained in basic ocular examination, refraction and dispensing glasses. The curricula of each of these programs must be developed accordingly.

Strategy 3: Develop admission policies to reflect diversities and other attributes of the assigned role

There is a growing awareness of the importance of socio-cultural and linguistic issues in providing health care,16 especially in rural areas. It is therefore important to develop admission policies that will address this need for diversity. In addition to admission quotas, some other approaches include moving out in the community for selecting candidates especially from underrepresented areas.17

The other aspect of admission is to expand selection criteria to offer admission to students with personal attributes that make them well suited for their role in providing health care after the specific training.

Strategy 4: Encourage and support teaching excellence

Typically, faculty members of an academic training centre in the health sector are asked to participate in three broad categories of activities: teaching, research and service delivery. Ideally these three aspects should receive equal attention. However, the reality is that incentives are often heavily weighted in favour of research and service delivery, to the disadvantage of teaching. This overemphasis on service delivery or research leaves education and teaching neglected often with inadequate resources, poor infrastructure and low enthusiasm among faculty.18

Understanding what motivates teachers and supporting them in ways that help increase motivation is important. Some of the strategies that work well in this direction and enhance the overall quality of education are: acknowledgement by schools, allowing continuing education including promoting them to attend programs for educators; and attention to education/training resources and infrastructure.19

Strategy 5: Promoting innovative ways to access teaching expertise and materials

Access to textbooks and other quality teaching materials represents an important challenge in developing countries and can be tackled in a number of ways. In the current era of electronics, books and other teaching materials can be made available as soft copies in the library. Membership with professional organizations allows access to a variety of professionally developed educational resources. Providing opportunities to listen or interact with subject experts other than those in the program or school always motivate students. Webinars and videoconference facilities can be used to connect and expose students of multiple locations and make the best use of the limited pool of teaching faculty or subject experts.

All these strategies of accessing education resources in innovative ways will go a long way in enhancing the overall learning experience of students and thereby providing the right quality of the health workforce.

Strategy 6: Periodic evaluation of institutional performance, policy options and actions

To ensure standards of training programs it is essential to periodically conduct program evaluation. Program evaluation must use objective criteria in order to get true information. The information generated should be used to bring changes toward ensuring that programs meet desired objectives.

It is also important to periodically review training programs based on the changing community needs as determined through feedback on health parameters or health indicators.

Strategy 7: Accreditation of training programs or institutions

Accreditation is an essential mechanism not only for assessing institutional performance but, more fundamentally, for securing public trust. Accreditation of training programs or institutions is primarily conducted by ministries of education or delegated councils and can be program specific or institution specific covering all programs run by an organization.

Unfortunately, in most developing countries the practice of accreditation either does not exist or is not considered important. This is particularly true for programs training mid-level health care workforce. Therefore, it will be important and timely that while we expand the training capacity, systems necessary for accreditation are also put in place.

Strategy 8: Intra and Interdisciplinary workshops and continued medical education

For better coordination among team members performing different tasks and better understand each one's role in respect to others we must consider conducting intra- and inter- disciplinary workshops. Such workshops, involving the entire team, should become a component of training courses, and can be repeated at the time of job induction as well as on the job training. The objective of such workshops should be to give an overview of the health care teams, links between different levels of health care delivery, value of working together and the role played by each member.

Training health care teams should not end with completion of primary training. It is important to integrate reinforcement of skills through continued medical education, certification and re-certification. To ensure uniformity of standards it is important that the certification/recertification is earned from a professional organization or university.

Team approach and team training at the L V Prasad eye institute

In this section, we will share the team approach and team training at the L V Prasad Eye Institute, Hyderabad, India.

The existing model of eye care delivery adopted by us is the result of the “Andhra Pradesh Eye Disease Study”.6 Following were some of the important findings of APEDS:

The prevalence of blindness and visual impairment in the state of Andhra Pradesh was estimated to be 1.84 and 8.1% respectively

The odds of having moderate visual impairment increase with increasing age, decreasing socioeconomic status, female gender and in those living in rural areas compared to those in urban areas

Cataract and refractive error were the two most important causes of visual impairment

The prevalence of visual impairment due to refractive error and cataract was higher in rural areas than in the urban areas

Awareness of various eye diseases was variable however; the awareness was significantly lower in lower socioeconomic strata

Health care resources to provide eye care were unavailable and poor in rural areas compared to urban areas.

These findings suggested that if we need to make eye care available and accessible in a cost effective manner we will have to provide the following services and appropriately trained human resources:

Health education including promoting the use of health care services

Community screening for visual impairment

Services to take care of uncorrected refractive error including dispensing of glasses even in rural areas

Services to take care of cataract blindness.

This formed the basis of village vision complex and, an eye care delivery model that will ensure availability of high quality and cost effective eye care even in remote rural areas and will be able to cater to the needs of 50% of the visually impaired population.

Based on these findings, the L V Prasad Eye Institute proposed and adopted within its network:

A pyramidal model of eye care delivery

Team approach for community eye health

Training programs for all levels of human resources required for primary, secondary and tertiary eye care

Integration of some of the services into primary health care systems in various communities.

The pyramidal model of eye care delivery is presented in the Figure 1 and different training programs run by the institute are described in the Table 1.

Figure 1

Pyramidal model of eye care delivery

Table 1

Programs for training of eye care teams

Features of our training programs that exemplify the strategies for team training described in this article are:

Training programs cover the entire spectrum of the human workforce required for community eye care

All programs have well defined curricula based primarily on the skills required to perform tasks they will be responsible for. Significant focus is given on hands on training while ensuring the candidates are provided basic knowledge

Well defined and clearly laid out admission policy: In order to ensure community participation and representation in health care delivery we select candidates from the communities they will be serving after the training. Number of trainees for various programs is determined by the capacity of the program (to ensure quality of training is not compromised) as well as needs of the community

We make a conscious effort at providing necessary infrastructure including study materials. In the school of optometry training optometrists and allied health personnel different wet/training laboratories were established to acquire skills in visual acuity assessment, refraction, optical dispensing, slit lamp examination, and in handling various ophthalmic instruments. All these laboratories are properly equipped [Figure 2]

Figure 2

Refraction laboratory

Contribution in teaching/training programs is considered one of the essential roles of each faculty member and is considered during their annual appraisals. To enhance teaching skills we periodically conduct mentoring workshops

LVPEI believe in the value of accreditation. The residency program of our organization is accredited by the National Board of Examination. In June 2013 we received accreditation of the International Joint Commission of Allied Health Personnel in Ophthalmology (IJCAHPO) for our vision technician and ophthalmic assistant training programs

We use a videoconference facility to connect trainees on different campuses. The morning session starting at 7 a.m. sharp every single day is a unique feature of our organisation. All faculty members and trainees are required to attend these sessions

Global leaders lecture series: This is a unique education program wherein leaders in Ophthalmology, Optometry, Basic Science and Education address the faculty, fellows and all trainees of the L V Prasad Eye Institute through the videoconference network without the need to travel.

CONCLUSIONS

The health care team is a well accepted approach toward ensuring quality health care that is available, accessible and affordable. The concept needs to be extended and made popular even for providing eye care. In this manuscript we have described the principles of team approach and strategies that will ensure success of this approach. We have also shared the experience at the L V Prasad Eye Institute where the team approach is used as an eye care delivery model.