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Interprofessionalism: The right answer to the right questions
at the right time
HealthForceOntario
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My Theory…
• Common view: We need Interprofessional Care and Education because there are not enough nurses and doctors
• My view: There are fundamental transformational changes at the system and individual level of health care which inexorably point to the need for IPC&E.
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Interprofessional Practice - Our Cornerstone
The provision of comprehensive health services to patients by multiple health caregivers who work collaboratively to
deliver quality of care within and across settings.
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Outline
• Forces of Change Leading to IPC • Health system challenges and evolution• HHR challenges and evolution
• Tools to Support an IPC Agenda• Conscious transformational change• Appreciative Inquiry• Focus on Value• Research• Leadership
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Caveats & Context
• One persons view:• ADM (Civil service not political)• FP • Strong rural and inner city practice background
• Not about:• OMA agreement• Minister’s Mental Health Agenda• E-HO, wait-times, OLG, Procurement
• Try to be evidence based
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Challenges for the Health Care System
• Increasingly more money but less productivity
• Aging population and a more expectant population
• Health is highly politicized and highly personal
• Health is global
• In the middle of a fundamental transformation
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• The system is designed to meet the needs of the provider
• System is fragmented and patients fend for themselves
• Sickness focused; episodic/individual
• Designed to facilitate freedom, independence and autonomy for individuals
• The system is designed to be customer-driven while incorporating the needs of all care-givers
• System is seamless and patients are supported as they move through it
• Health Status and outcomes focused; systemic & population based
• Designed to facilitate the best combination of independent and interdependent professionals
First Curve – Current System Second Curve - Emerging System
Adapted from M. Merry, M.D & Quantum learning systems
A System in Evolution/Revolution
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• Designed to encourage political behavior/power games
• Health is seen as a jurisdictional issue only and there is no co-ordination
• The system is designed to be complicated
• Despite increasingly massive investments productivity is declining and there are significant inefficiencies
• Designed to produce collaborative behavior and team work
• The national nature of the health care system and especially HHR is recognized and capitalized upon
• The system’s complexities and self-organizing potential is realized in a natural complex adaptive system
• Resources are freed for innovation and quality improvement. People and resources are leveraged and productivity improves
First Curve – Current System Second Curve - Emerging System
Adapted from M. Merry, M.D & Quantum learning systems
A System in Evolution/Revolution
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Challenges in Health Human Resources…
People will:
• be more numerous and older
• be more culturally diverse
• have more chronic than acute diseases
• be increasingly involved, informed consumers
• seek complementary and alternative care
• focus on wellness and disease prevention
Health service providers will:
•be older and seeking career transition and retirement
•continue to come from a range of other nations
•want more balance and flexibility in their careers
•work in a mobile, international and opportunity-laden market
•demand healthy and stimulating workplaces
•need new educational models to deal with a rapidly evolving base of knowledge and technology
Health services will:
• be increasingly based in the community setting
• be delivered by interprofessional teams
• focus on health promotion and disease prevention
• make greater use of new technology including tele-medicine and diagnostic imaging
…. New expectations, capacities and roles are demanded of our workforce
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Defensive Individual Behaviour
• Command & Control• Low Trust• High Blame• Alienation• Undertone of threats and fears• Anxiety• Guardedness• Hyperrivalry• Withholding• Denial• Hostile Arguments• Risk Avoidance• Cheating
• Highly participative• High Trust• Dialogue• Excitement• Honesty• Friendship• Laughter• Mutual Support• Sincerity• Optimism• Cooperation• Friendly Competition• Shared Vision• Flexibility
Collaborative Individual Behaviour
• Risk Taking• Tend to learn from
mistakes• Face difficult truths• Broad perspective• Open to feedback• Sense of contribution• Work experienced as
pleasurable• Internal motivation• Sense of purpose• Ethical behavior• Inspirational leadership• Authentic community
• Political Games• Greed• Attitude of entitlement• Deadness• Cynicism• Sarcasm• Tend to hide mistakes• Work experienced as
painful • Dependence on external
motivation• Self-serving leaders• Character Assassination
Adapted from R. Cooper & A. Sawaf – Executive EQ
HHR in Evolution/Revolution
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Five Tools To Support the Move to IPC
• Conscious Transformational Change
• Appreciative Inquiry
• Focus on Value
• Research
• Leadership
13Developmental Change
Improvement of what is: New state is aPrescribed enhancement of the old state
Transitional ChangeDesign and Implementation of a new state: Requires dismantling of the old state and Management of the transition (e.g hospital mergers)
Old New
Reactive Transformational ChangeOld state is forced to die: New state is unknown. Emerges via trial and error. New State Requires new organizing principles, behavior,culture, mindset
Death: forced change
Conscious Transformational Change
Planned/Natural death of old state
1998 Being First Inc (modified)And Ted Ball Managing Change
Wake up Calls
Wake up CallsInfo
Info
Info
Death of old state is required and supported.New state initially unknown. Principles driving changeare known and are the design criteria for the new stateand course correction. New State evolves as new information is generated and learning/course correction occurs
Learning/ course correction
Trial/Error emergence
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To Achieve IPE..
Development and Transition are not enough
We need Conscious Transformational Change
1998 Being First Inc (modified)And Ted Ball Managing Change
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Appreciative Inquiry
• Appreciative Inquiry rejects the more traditional ‘problem-focused’ approach and instead seeks to identify what is working well or opportunities for positive change. It is an engagement approach to encourage imagination, innovation and flexibility by building upon the positives that already exist
• AI focuses on what works rather than trying to fix what doesn’t. It means asking different questions and drawing from stories of concrete success. Asking questions that strengthen a system’s ability to apprehend, anticipate and heighten positive potential
• If you pay attention to problems you emphasize and amplify them – look for what works in the system/organization
• AI is core aspect of new MOH stewardship role
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Appreciative Inquiry Approach to HHR
• Paramedics
• Rural Settings
• Midnight - 8am
• Geriatric, Mental Health, Oncology and primary care teams have strong history and good evidence around IPC
• 85-90% of home care delivered by family care givers/volunteers
• Looked to other places for inspiration
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Increase Supply
• Today there are more:• Nurse Practitioners
• International Medical Graduates
• Family Medicine Residents
• Medical Residents
• Midwives
…In training than ever in the history of Ontario(But largely achieved in new ways…)
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New Roles and Responsibilities: Unlocking existing potential
Physician Assistant
Nurse Endoscopist
Surgical First Assist
Clinical Specialist Radiation Therapist
Scaling and Planning for Dental Hygienists without an order, limited rx authority
Enhanced role: radiation technologists, dieticians, podiatrists, physiotherapists, midwives
Anaesthesia Assistants
Pharmacy Assistants
Prescribing authority for Optometrists
RN-EC: New classes (3), prescribing authority and roles/powers
Remote pharmacy
Pharmacy renewal and rx powers
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Patient Value Care Delivery IPC is logical support
1. Goal is value for patients• Value= (All) health outcomes/total costs (in and outside of health care)• True health outcomes not process or indicators
2. Improved quality (i.e health outcomes) will contain costs3. Organize care around medical conditions, from the patient’s perspective,
over the full cycle of care4. Improve value by increasing provider experience, scale and learning at the
medical condition level5. Integrate Health care delivery across facilities and regions – don’t duplicate
– providers can cross geography6. Value must be measured and reported by every provider for each medical
condition7. Reimbursement must be aligned with value and reward innovation8. IT can help restructure care delivery and measure results but is not a
solution in isolationMichael E. Porter, Redefining Health Care2006
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Research
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Research to date:• Providers see improvements in patient morbidity and mortality.
• Help reduce errors, better coordination, enhanced working environments, better staff morale and increased patient satisfaction.
• Increased access to health care.
• Improved outcomes for people with chronic diseases.
• Less tension and conflict among caregivers.
• Better use of clinical resources.
• Easier recruitment of caregivers.
• Lower rates of staff turnover.
22IP Intervention
Stage
Participants
Intervention types
IP objectives
Intermediate outcomes
Patient outcomes
System outcomes
Reeves S, Goldman J, Zwarenstein M, Gilbert J, Tepper J, Beardall S, Silver I, Suter E (May 2009)
Interprofessional Education
Pre-licensure (37) Post-licensure (44)
Interprofessional Practice Interprofessional Organization
Post-licensure (9)Post-licensure (32)
Health care providers from
different organizations
(1)
Health care providers from
same site
(8)
Health care providers from
same site
(30)
Health care providers from
different organizations
(2)
Students from different health
and human programs (37)
Health care providers from
same site
(28)
Health care providers from
different organizations
(16)
Simulation (1)Seminar/workshop/
Course (24)Placement/fieldwork
(12)
Simulation (5)Seminar/workshop (34)
Degree/course (5)
“Teamwork”(45), “Communication”(28), “Role understanding” (24), “Collaboration”(18), “Leadership”(4), “Interdisciplinary
understanding/care/interaction”(5), “Cooperation”(4), “Interagency working”(3), “Interprofessional
working/practice/approach”(3), “Relationship skills”(1), “Coordination”(1)
Reactions (23)Attitudes (16)Awareness/
Knowledge (16)Skills (4)
Practice (1)
Reactions (21)Attitudes (5)
Stress/life satisfaction (2)Knowledge (14)
Skills (2)Behaviour (22)Satisfaction (1)
Patient outcomes (1)
IP checklists, Meetings, Rounds,
Communication tools, Briefings,
Forms, Pathways(30)
Referral process, Case
navigation binder, Weekly updates
(2)
StaffingPolicies
Work spaceCulture
(8)
Consultation arrangements
(1)
“Communication”(22), “Teamwork”(17), “Collaboration”(9), Coordination”(3), “Roles”(1), “Cooperation”(1)
Reactions (4)Attitudes (2)
Awareness and Knowledge (5)Behaviour (21)Satisfaction (3)
Quality of audit (1)Clinical processes (20)
Patient outcomes (16)
Economic (4)
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Leadership
• The critical success factor for Conscious Transformative Change, Value for Patients and AI
• Need transformational not transactional leadership• Conscious of structure, process, culture• Adaptive Leadership – Ask the ‘wicked questions’, don’t give answers, frame
the questions to spur innovation• Focus on Quality and CQI• Often ignored part of creating, sustaining tranformational change• Needs time and resources to nurture
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The New Leadership Qualities• Dialogue/Team Learning and effective dialogue• Emotional Intelligence and Political Intelligence• Integrated and systems thinking• Change Management/Adaptive leadership• Collaboration/Teamwork/Innovation• Facilitate/Coach/Reframe• Leveraged thinking• Lean Thinking, CQI• Risk Management and Conflict Resolution• Stewardship and Talent Management• Organizational Alignment and Strategic Budgeting
Ted Ball, Managing Change 2008
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Leadership
• Currently a significant paucity of investment in leadership
• Starting to change …very fashionable
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Conclusion
• The system is under tremendous pressure• A system under pressure is an opportunity• Interprofessional education and care is a key response to these
pressures• IPC can be supported by:
• Conscious transformative change - different approach to planning• Appreciative Inquiry - different way of addressing problems• Focus on value – Different motivation for change• Leadership – different people leading differently
• This conference is not about the past of mental health care but the future
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We are what we repeatedly do. Excellence then is not an act but a habit- Aristotle
Thank You