InterprofessionalInterprofessional Education Education and Care: and Care:

The Time is NowThe Time is Now

Madeline H. Schmitt PhD, RN, FAANMadeline H. Schmitt PhD, RN, FAANProfessor Professor EmeritaEmerita

University of RochesterUniversity of RochesterJefferson IPE ConferenceJefferson IPE Conference

March 13, 2010March 13, 2010

Presentation OutlinePresentation Outline

Define IPP, IPE, CIPEDefine IPP, IPE, CIPEBrief historical context for Brief historical context for ““Why NowWhy Now””??Focus of IPE learning and basic elementsFocus of IPE learning and basic elementsIPE learning principlesIPE learning principlesIPE curricular strategiesIPE curricular strategiesIPE learning methodsIPE learning methodsIPE Basic curriculum elementsIPE Basic curriculum elementsIPE curricular examplesIPE curricular examplesPractice ModelsPractice ModelsKey challenges: Evaluating IPE Outcomes, Key challenges: Evaluating IPE Outcomes, Faculty Development, IPE researchFaculty Development, IPE research

DefinitionsDefinitions

IPPIPP ““twotwo or more professions working or more professions working together as a team with a common purpose, together as a team with a common purpose, commitment and mutual commitment and mutual respectrespect””((FreethFreeth et al. et al. 20052005))IPEIPE ""whenwhen two or more professions learn two or more professions learn with, from and about each other to improve with, from and about each other to improve collaboration and the quality of carecollaboration and the quality of care““ (CAIPE (CAIPE 2002)2002)CIPECIPE intentional IP learning for intentional IP learning for practitioners practitioners

IPEIPE-- Important Historical PointsImportant Historical Points

IPP has preceded IPE i.e., IPE is practiceIPP has preceded IPE i.e., IPE is practice--drivendrivenCIPE (informal) preceded other forms of IPECIPE (informal) preceded other forms of IPEUndergraduate IPE first introduced in US in midUndergraduate IPE first introduced in US in mid--late 1960late 1960’’ssFirst IOM report on First IOM report on ““Educating for Health TeamsEducating for Health Teams””--19721972IPE never IPE never ““mainstreamedmainstreamed””-- although IPE although IPE supported by various foundations, HRSA, supported by various foundations, HRSA, Veterans AdministrationVeterans AdministrationIn past, IPE almost always In past, IPE almost always ““electiveelective””, for small , for small numbersnumbers

IPEIPE-- Important Historical PointsImportant Historical Points

Cycles of interest in IPP emerged over time from Cycles of interest in IPP emerged over time from specific specialty sectorsspecific specialty sectors–– rehabilitation, mental rehabilitation, mental health, comprehensive care in chronic ills, primary health, comprehensive care in chronic ills, primary care, rural care, geriatrics [vulnerable population], care, rural care, geriatrics [vulnerable population], intensive care, hospice and palliative care. Blips in intensive care, hospice and palliative care. Blips in IPE might followIPE might follow……IPE in graduate medical education absentIPE in graduate medical education absentMost practice settings were not aligned to receive Most practice settings were not aligned to receive graduates ready to practice graduates ready to practice interprofessionallyinterprofessionallyPayment systems did not reward IPPPayment systems did not reward IPPHealth professions education remained in Health professions education remained in ““silossilos””

Why IPE now: Why IPE now: What has changedWhat has changed

Awareness of quality, but, especially SAFETY Awareness of quality, but, especially SAFETY issues in health issues in health carecare primarilyprimarily in hospital settings in hospital settings Incorporation of models from group dynamics, Incorporation of models from group dynamics, aviation, business, human factors, and aviation, business, human factors, and organizational changeorganizational changeAwareness that poor communication and teamwork Awareness that poor communication and teamwork contribute to safety and quality issuescontribute to safety and quality issuesIOM 2003 report on health professions educationIOM 2003 report on health professions educationSafety [as well as cost and quality] is a general Safety [as well as cost and quality] is a general concern that has brought everyone concern that has brought everyone ““to the tableto the table””raising the possibility for mainstreaming IPE raising the possibility for mainstreaming IPE

What else has changed What else has changed in the intervening decades?in the intervening decades?

Health care fields other than medicine have Health care fields other than medicine have continued development as autonomous professions continued development as autonomous professions IPE pedagogies are much more developed; IPE pedagogies are much more developed; systematic reviews give glimpses into best systematic reviews give glimpses into best practices based on current evidencepractices based on current evidenceEvidence base for IPP and outcomes is growingEvidence base for IPP and outcomes is growingAwareness that IPE is not only a national, but Awareness that IPE is not only a national, but international concerninternational concern

Definition:Definition: IPEIPE ""occursoccurs when two or more professions when two or more professions learn learn

with, from and about each otherwith, from and about each other to improve to improve collaboration and the quality of carecollaboration and the quality of care““ (CAIPE 2002)(CAIPE 2002)

The safety issues have made clear that The safety issues have made clear that knowledge and skills in the knowledge and skills in the processes of care processes of care deliverydelivery are as important as clinical knowledge are as important as clinical knowledge

and skills. and skills.

What is the focus of the IP learning?

Differences in Differences in ““TeamsTeams”” vsvs ““TeamworkTeamwork”” languagelanguage

““TeamTeam”” language prevails, as in the IOM (2003) language prevails, as in the IOM (2003) competence:competence:““workwork in interdisciplinary teamsin interdisciplinary teams””; and ; and in the overall vision: in the overall vision: ““deliver patientdeliver patient--centered care centered care as members of an interdisciplinary teamas members of an interdisciplinary team””Teamwork language is embedded in the details Teamwork language is embedded in the details with words like: cooperate, collaborate, with words like: cooperate, collaborate, communicate and integrate [care in teams]; communicate and integrate [care in teams]; coordinate continuous carecoordinate continuous care

Differences in Differences in ““TeamsTeams”” vsvs ““TeamworkTeamwork”” languagelanguage

A A ““teamteam”” is a small group of people who share is a small group of people who share the care of a population of patients; it is one way the care of a population of patients; it is one way to organize care delivery, requires specific to organize care delivery, requires specific knowledge about small group dynamicsknowledge about small group dynamicsPatient safety, with its focus in large institutions, Patient safety, with its focus in large institutions, should challenge should challenge ““teamteam”” language as limited in language as limited in the context of complex institutional processesthe context of complex institutional processesTeamwork language Teamwork language namesnames the general the general processes of care that are the focus of learning processes of care that are the focus of learning togethertogether

Teamwork CompetenciesTeamwork Competencies----a Hierarchy: a Hierarchy: Three Three ““CC’’ss”” Plus OnePlus One

Cooperation

Coordination

Collaboration

Effective Communication processes underlie each “C”, as does the idea of professional and

patient relationships

Jody Gittell on Jody Gittell on ““Relational CoordinationRelational Coordination”” in in High Performance Health CareHigh Performance Health Care

(McGraw(McGraw--Hill, 2009)Hill, 2009)

Shared knowledgeShared knowledgeShared goalsShared goals

Mutual respectMutual respectAcross functional rolesAcross functional roles

““The quality of relationships may also determine the The quality of relationships may also determine the effectiveness of the communication. Even timely, effectiveness of the communication. Even timely,

accurate information may not accurate information may not be heard or acted on if the recipient does be heard or acted on if the recipient does

not respect the source.not respect the source.”” (p. 16)(p. 16)

““Learning as participation [is] not simply a way of acquiring Learning as participation [is] not simply a way of acquiring skills, but also of developing an identity and sense of skills, but also of developing an identity and sense of

belonging in a communitybelonging in a community””. (Barr, 2005). (Barr, 2005)

Professional selfgrown in silos

Inter-professionalself

Pedagogy of IPE: Educational and Pedagogy of IPE: Educational and Adult Educational PrinciplesAdult Educational Principles

Leveling, timing and sequencing of IPE Leveling, timing and sequencing of IPE trainingtrainingCombining didactic and experiential Combining didactic and experiential learninglearningBoth classroomBoth classroom--based and workbased and work--basedbased

Curricular StrategiesCurricular Strategies

Curricular Curricular vsvs extra or coextra or co-- curricularcurricularRequired Required vsvs electiveelectiveCourses Courses vsvs ““threadsthreads””

Learning MethodsLearning Methods

Active learningActive learningProblemProblem--based learningbased learning

Reflective learningReflective learningSituated learningSituated learning

SelfSelf--directed learningdirected learning

Basic elements of IPEBasic elements of IPE

Ethical frameworkEthical frameworkKnowledge, attitudes, and skillsKnowledge, attitudes, and skillsTeamwork trainingTeamwork training-- WHOWHO’’ss ““collaboration collaboration readinessreadiness””SystemsSystems’’ contextcontext

Interprofessional Ethical FrameworkInterprofessional Ethical Framework

Basic values uniting all who work in [a Basic values uniting all who work in [a particular sphere of] health care particular sphere of] health care Mutual obligationsMutual obligationsThe common goodThe common goodExpression in societal values, professional Expression in societal values, professional codes of ethics, organizational and codes of ethics, organizational and educational mission statements, and educational mission statements, and personal valuespersonal values

IP KnowledgeIP Knowledge-- Process Oriented and Process Oriented and Relationship FocusedRelationship Focused

Own roleOwn roleOther health team membersOther health team members’’ role, training role, training and capabilitiesand capabilitiesPrinciples of communication and Principles of communication and teamworkteamworkConflict resolution approachesConflict resolution approachesIP process improvement approachesIP process improvement approaches

KnowledgeKnowledge

Own roleOwn roleOther health team membersOther health team members’’ role, training and role, training and capabilitiescapabilitiesLarger context of collaborative careLarger context of collaborative care

Learning strategiesLearning strategies Learner outcomesLearner outcomes--KnowledgeKnowledge

DidacticDidactic-- e.g., e.g., Studying codes of Studying codes of

ethics, standards of ethics, standards of practice, examining practice, examining personal stereotypes personal stereotypes (reflection), (reflection),

Looking at socioLooking at socio-- political, professional political, professional and organizational and organizational contextcontext

Experiential e.g.,Experiential e.g.,Talking to young people Talking to young people

as a group of health as a group of health professionsprofessions’’ students students about different rolesabout different roles

Interviewing persons Interviewing persons from other from other ““professionsprofessions’’

Shadowing/ engaging in Shadowing/ engaging in the work of the work of ““otherother”” professionalprofessional

Knowledge and SkillsKnowledge and Skills

Principles of communication Principles of communication and teamworkand teamwork

Conflict resolution approachesConflict resolution approachesIP Process improvement approachesIP Process improvement approaches

Learning strategiesLearning strategies Learner outcomesLearner outcomes--Knowledge Knowledge andand SkillsSkills

Didactic e.g., Didactic e.g., Reading about basic Reading about basic

theories/principles of theories/principles of teamwork; observing teamwork; observing role models in role models in practice;practice;

Use of Team STEPPS Use of Team STEPPS and other electronic and other electronic educational resourceseducational resources

Process improvement in Process improvement in teamworkteamwork

Experiential e.g., Experiential e.g., Teamwork Teamwork

exercises/games*exercises/games*ProblemProblem--based team based team

competitions, e.g., competitions, e.g., ClarionClarion

Second Life familySecond Life familySimulation exercisesSimulation exercises

*communication distortion, *communication distortion, cooperation, handcooperation, hand-- offs/coordination, timeoffs/coordination, time-- limited exerciseslimited exercises

Knowledge, skills, Knowledge, skills, and and context of carecontext of care

Incorporating knowledge and skills Incorporating knowledge and skills into systems of careinto systems of care

Learning strategiesLearning strategies Learner Outcomes: Knowledge and Skills Learner Outcomes: Knowledge and Skills andand Patient & Community Improvement OutcomesPatient & Community Improvement Outcomes

Training wards and studentTraining wards and student--run clinicsrun clinicsOrganizational and community needs Organizational and community needs

assessment and health improvement assessment and health improvement projectsprojects

Service learning projectsService learning projectsInternational clinical experiencesInternational clinical experiences

Applying Process of Care Applying Process of Care CompetenciesCompetencies

Knowledge of SystemsKnowledge of Systems--small and large small and large [diverse health delivery models][diverse health delivery models]

e.g. e.g. -- prevention and primary care like the prevention and primary care like the Alaska rural team model or health care Alaska rural team model or health care home modelhome model-- hospitalhospital--based based microsystemmicrosystem like ICU like ICU -- specialtyspecialty--based model, small team in based model, small team in

a a large hospital, like a palliative care large hospital, like a palliative care consultation teamconsultation team

Key Question?Key Question?

What are the appropriate outcomes of IPE What are the appropriate outcomes of IPE across the continuum of undergraduate to across the continuum of undergraduate to CE? CE? Knowledge?Knowledge?Attitudes?Attitudes?Skills?Skills?Behaviors?Behaviors?Patient and family outcomes?Patient and family outcomes?

Alternative Assessment FrameworksAlternative Assessment Frameworks

SkillSkill--basedbasedCapabilityCapability-- basedbased

CompetencyCompetency--basedbasedIntegrative approachIntegrative approach

Good resource: A National Interprofessional Good resource: A National Interprofessional Competency Framework, CIHC,2010 (built Competency Framework, CIHC,2010 (built on the integrative approach) Appendix 1, on the integrative approach) Appendix 1, and Appendix 2: one page summaryand Appendix 2: one page summary

Key challenges: Competency Key challenges: Competency assessmentassessment

Defining interprofessional competencies Defining interprofessional competencies Linking IPE learning principles, methods, Linking IPE learning principles, methods, and strategies to competenciesand strategies to competenciesMeasuring levels of competence Measuring levels of competence [[““collaborationcollaboration--readinessreadiness””] along the ] along the learning continuumlearning continuumLinking competent performance to Linking competent performance to appropriate health care outcomesappropriate health care outcomes

Institutional tailoringInstitutional tailoring

One size will not fit all One size will not fit all Overall competencies, learning principles Overall competencies, learning principles and methods may be similarand methods may be similarBasic principles of organizational change Basic principles of organizational change will apply BUTwill apply BUTIPE learning strategies will need to be IPE learning strategies will need to be tailored to the specific institutional tailored to the specific institutional educational and clinical learning contexts, educational and clinical learning contexts, opportunities and needsopportunities and needs

http://www.cabhalifax2009.dal.ca/Abstract_Directory.php

CAB II, May, 2009: Dr Carol Aschenbrener’s

presentation on organizational change principles

The Need for Faculty DevelopmentThe Need for Faculty Development

Learning to teach together across the Learning to teach together across the professionsprofessionsTheoretical frameworks for content being Theoretical frameworks for content being taught (relationships and processes) taught (relationships and processes) e.g. e.g. SargeantSargeant, J (2009), J (2009)-- Theories to aid understanding Theories to aid understanding and implementation of IPE. J Cont Ed and implementation of IPE. J Cont Ed HealtHealt Prof, 29, 178Prof, 29, 178-- 184. 184.

Applying learning principles, methods, and Applying learning principles, methods, and strategies to IPEstrategies to IPEEvaluation of IP learningEvaluation of IP learning

The Importance of Evidence: The Importance of Evidence: Educational ResearchEducational Research

The rationale for IPE is The rationale for IPE is ““to improve to improve collaboration and the quality of carecollaboration and the quality of care””If we prepare health professions students If we prepare health professions students to be competent collaboratorsto be competent collaborators

IPEIPE collaborative competencecollaborative competenceCollaborative competenceCollaborative competenceimproved outcomesimproved outcomes

Evidence for Positive Outcomes of IPEEvidence for Positive Outcomes of IPE

UK Joint Evaluation Team (JET) teamUK Joint Evaluation Team (JET) team 88--year effort; worldwide reviews of the year effort; worldwide reviews of the outcomes of IPE outcomes of IPE 20052005: : Hugh Barr et al. Hugh Barr et al. Effective Effective Interprofessional Education: Argument, Interprofessional Education: Argument, Assumption and EvidenceAssumption and Evidence. Blackwell. . Blackwell. 2007: M. Hammick et al. A best evidence 2007: M. Hammick et al. A best evidence systematic review of interprofessional systematic review of interprofessional education. BEME Guide no. 9. education. BEME Guide no. 9. Medical Medical TeacherTeacher, , 2929(8), 735(8), 735--51. 51. Cochrane systematic reviewsCochrane systematic reviews