When Randi Nichols joined Fallon Clinic as chief human resources officer in 2004, she identified several opportunities to enhance functions within HR. One of these functions was in the area of training. Training as it existed at the clinic was expensive, ineffective, and lacking in strategic linkage to the business goals of the clinic.

One of Randi's first hires was Gary Segal as senior director of learning and organizational development (L&OD). In the past five years, Gary and his colleagues have worked to build programs that address the needs of the clinic and contribute to Fallon Clinic's earning recognition as one of the "Best Places to Work in Healthcare."

Founded in 1929, Fallon Clinic is a multilocation, multispecialty, group medical practice that employs more than 1,700 people. Approximately 350 of these are medical providers - doctors and advanced practitioners - and the rest work as nurses, therapists, lab technicians, and administrative and clerical support personnel. Collectively, clinic locations handle approximately 1.5 million patient visits per year.

One major change Nichols and Segal implemented was to move the computerized technical training department from under the IT umbrella and into the HR division. Nichols, who is now the executive vice president of human resources and operations support services, explains, "Our objective was to reinvent the training department. We were given full latitude to build a world-class learning organization."

While the L&OD team had the latitude to make the changes necessary to transform the training function at Fallon Clinic, it was critical that success could be demonstrated. Segal has built a training system that relies heavily on metrics, so that measurable improvements of all kinds could be clearly demonstrated to executive leadership.

Before measurement, however, comes needs assessment. On an ongoing basis, Fallon Clinic seeks to determine where in the organization additional or enhanced training would have the most value. The L&OD department conducts an annual enterprisewide needs assessment through employee surveys and face-to-face meetings with leadership and employees at all levels. Learning solutions are then designed, developed, and delivered by the department's staff, which is divided into two groups - technical training, and management and leadership training.

To this end, Segal's team has built an innovative learning program that is rooted in a few well-founded assumptions: There are certain staff and clinician behaviors that are key to patient satisfaction; and the best way to assess what a patient's experience is like at Fallon Clinic is to see that experience through the patient's eyes. Thus, the "Patient Shadowing Program" was created. As the name implies, members of Segal's team and others within the organization accompany consenting patients on their doctors' visits to observe the patient-staff experience firsthand.

The observation criterion used in the shadowing program is based on data from ongoing patient satisfaction surveys. To date, more than 15,000 patient surveys have been conducted. Patients are questioned about overall satisfaction with the provider (doctor or advanced practitioner), staff, office environment, and telephone interactions, and about whether they would recommend the provider to family and friends.

Rating templates list relevant behaviors associated with positive patient encounters. Volunteers from across the organization (selected for their strong interpersonal, communication, and feedback skills) are recruited and receive classroom training on the use of these templates.

Shadow coaches contact a provider's scheduled patients on a given day and request permission to observe their entire visit, from registration to check-out, recording their observations using the templates. The coaches prepare written reports for providers and staff, then hold a feedback session two weeks later that includes those employees as well as their supervisors. The L&OD staff follow-up 30 days later to ensure the sustainability of the behaviors.

Since the program began, volunteers have shadowed 113 physicians. Providers have achieved a 6 percent average increase in their patient satisfaction scores. Segal cites a 298 percent return-on-investment over what it would have cost to use an external consultant.

Employee satisfaction is also a key metric. A research effort using Rensis Likert's Systems Theory measured employees' perceptions of corporate and departmental culture in such areas as leadership, motivation, decision making, communication, goals setting, and control.

On receiving an assessment of their scores, departments were asked to create action plans to move toward a more participative group paradigm, and new learning initiatives, as well as a mentoring program, were rolled out. Fallon Clinic now offers 43 programs in leadership, diversity, supervision, and other skills; a personal growth workshop retreat; and a work-life balance program. Employee satisfaction scores in all areas studied have improved by 5 to 7 percent.

In 2008, Fallon Clinic completed a three-year, multiphase project to implement an electronic health record (EHR) software application for creating and maintaining patient records.

L&OD staff developed 16 instructor-led training modules for new staff hires, and two half-day, individualized on-site training sessions followed by on-site support for new providers. Technical trainers continue to add job aids, online courses, online assessments, webinars, and instructor-led refreshers to the available training resources for all staff.

Diana Kessler is manager of technical training. "The EHR is the way our industry is headed," she says. "We break training down into small, targeted chunks, and then train providers and staff to use the system efficiently within what they do clinically."

L&OD professionals meet with new providers before they begin seeing patients to train them in the EHR. They customize training to the way each physician works with patients, creating individualized shortcuts. A new voice-recognition feature eliminates the need for dictation and transcription, allowing patient records to be updated in minutes rather than days.

"This training is blended and highly customizable," says Kessler. "Almost everyone at the clinic will touch the EHR at some time, and we frequently modify materials to meet individual or department training needs."

Although L&OD at Fallon Clinic consists of just nine people, the clinic outsources very little of its learning function. "We try to do everything ourselves because we want our efforts to produce the best possible results; and more importantly, because we are here and can respond quickly to any request for assistance," says Segal.

All training is flexible and conducted during off hours when needed or through computer-based self instruction, and is usually delivered in two- and four-hour increments. As soon as a program is complete, L&OD staff applies to award continuing medical education or continuing education units for completion.

"This is no longer a hit-and-run training department," says Nichols. "Our offerings are now comprehensive and have grown exponentially. We are now a multidimensional university. L&OD's contributions are highly valued within this organization." t+d