UCSF and Others Strive to Create True Health Care Teams
On a sunny afternoon last October, around 600 future master’s-prepared nurses, physicians, dentists, pharmacists and physical therapists gathered at UC San Francisco’s Parnassus campus to hear about an astounding medical error. In 2003, a 16-year-old patient at UCSF Benioff Children’s Hospital received a 38-fold overdose of the antibiotic Septra, leading to a grand mal seizure and respiratory arrest. (The patient ultimately recovered fully.)
A pair of keynote speakers, Assistant Professor of Clinical Pharmacy Sheri VanOsdol and UCSF hospitalist and patient safety expert Robert Wachter, professor and interim chair of the Department of Medicine, took the students through the case step-by-step, slowly revealing a picture in which each element – from physicians, pharmacists and nurses to multimillion-dollar computer systems – failed to communicate well enough to prevent a massive, life-threatening error. The startling story was part of the kickoff to a series of interprofessional education (IPE) sessions designed to teach future health care professionals to work together effectively in interprofessional teams, in part to prevent errors like this from occurring.
Interprofessional Education: Not a New Idea
Educating for the Health Team, noted that “Few subjects are more appropriate for consideration by the Institute of Medicine than the one of interprofessional education.” Barbara Brandt, director of the National Center for Interprofessional Practice and Education, says, “The vision back then was that the health system was going to be all team-based, but for a variety of reasons, it didn’t happen.”The idea of training health care professionals to work together is not new. Back in 1972, an Institute of Medicine (IOM) report,
The reasons included logistics, organizational politics, money and a general reluctance to make the kinds of sweeping changes that would be required to refashion health care in the way the IOM report imagined it: “redeploy[ing] the functions of health professions in new ways, extending the roles of some, perhaps eliminating others, but more closely meshing the functions of each than ever before.”
Focus on Quality Brings Increasing Urgency
Over the past decade and a half, a confluence of events has brought IPE into the spotlight again, this time with the enthusiastic backing of the federal government and national organizations: a trilogy of IOM reports released between 1999 and 2003; an influential 2010 commentary in The Lancet, which issued a worldwide call to reinvent health profession education around interdependency and collaboration; the formation of the IOM’s Global Forum on Innovation in Health Professional Education, which brought together 60 experts from across 18 disciplines and nine countries to focus on interprofessional issues in education worldwide; and the development of a set of competencies for interprofessional collaborative practice by the Interprofessional Education Collaborative (IPEC), a national organization that comprises six national health care profession education associations.
Health care reform in the US – including payment changes that emphasize value-based care – has also been a significant driver. To achieve the reform’s “triple aim” – increasing care quality, improving population health and reducing costs – most agree that professionals across disciplines will have to work more collaboratively and efficiently than ever before.
Finally, changes in the patient population are bringing an increased urgency about interprofessional practice and education. Older, sicker patients with more chronic illness make effective teamwork essential, says internist Maria Wamsley, professor of medicine and co-chair of UCSF’s Curriculum Development Working Group (CDWG). “As a primary care provider, I take care of a lot of patients with chronic illness, and I’ve seen firsthand the need for more interprofessional collaboration to manage them,” she says.
For example, because caring for an elderly woman with diabetes and dementia requires specialized knowledge from different if overlapping fields, and thoughtful care coordination, a single clinician or a group working in silos may be less effective than coordinated teams in the emerging health care environment. And her providers will be expected to do everything more cost-effectively than ever before.
“Clearly, the end point [of IPE] is improving patient outcomes,” says Angel Chen, associate clinical professor and vice chair of the UC San Francisco School of Nursing’s Department of Family Health Care Nursing, co-chair of the CDWG and a 2015 interprofessional inductee of the Haile T. Debas Academy of Medical Educators. “But you have to start…with education, of students, faculty and clinical preceptors.”
Implementing IPE at UCSF
UCSF began in earnest in 2011, with the inception of the Center for Innovation in Interprofessional Education. The original goals were ambitious: to combine curriculum development, research and outcomes measurement for IPE. But the difficulty in achieving these goals simultaneously quickly became apparent. Chen says, “We had limited resources, and we didn’t have the building blocks to sustain all of it. [Each school] has its own missions, culture and infrastructure, and we weren’t yet operating in an interprofessional way in our schools and clinical environments.”
The executive committee of the center (now the Program for Interprofessional Education) focused first on what every learner should know before leaving school in order to work collaboratively and effectively. They wound up adapting a simplified version of a set of IPEC’s competencies as the basis for a new set of IPE graduation milestones, encompassing areas such as knowledge of one’s own and other health professionals’ roles; communicating with other health professionals in a responsive manner; and working with other health professionals to maintain a climate of mutual respect, dignity, diversity, ethical integrity and trust.
The CDWG developed a core curriculum composed of both online modules and small-group sessions. The online modules cover topics such as introduction to interprofessional concepts, understanding interprofessional team roles and responsibilities, communication and accountability, task distribution and conflict management. Students complete the online modules, then come together each quarter in groups of 10 to 12 students from mixed professions, with small-group facilitators, to apply skills they’ve learned, often in role-playing sessions. Facilitators also receive faculty development time to prepare them to better support students during the small-group sessions.
In addition to the core curriculum, students also participate in a series of Interprofessional Standardized Patient Exercises at the UCSF Kanbar Center for Simulation, Clinical Skills and Telemedicine Education to work through real-world clinical challenges in a controlled environment. Group discussions allow students and facilitators to debrief and assess how they did.
While feedback from students has been positive, says Chen, refining the curriculum is an ongoing process. “We constantly have to reassess and tweak it to meet the needs of learners from all professions,” she says.
Many Hurdles to Overcome
Even getting this far hasn’t been easy. There are a host of barriers to realigning curricula for diverse professions. Competition for funding, complicated logistics and differing priorities among both learners and administration create difficult challenges despite the commitment of IPE’s champions.
American Association of Colleges of Nursing, who serves as IPEC’s treasurer/secretary, says, “In some institutions, the difficulty with implementing IPE relates more to logistics than to an unwillingness to engage in this type of learning. Academic calendars vary greatly by discipline, so scheduling IPE opportunities can be a challenge.” This is a problem even at UCSF, which has the advantage of being a multidisciplinary health professions campus. For smaller schools, especially those not affiliated with an academic health center, it can be particularly difficult to find IPE opportunities.Deborah Trautman, president and CEO of the
For administrators, IPE represents a new set of requirements to develop, implement, measure and, hopefully, meet. Chen says, “Each professional training program is already governed by multiple rules and regulations, accreditations and competencies. It becomes a big ask to say to a program, ‘OK, you need to pause, talk to each other and realign your curriculum to meet this common goal.’”
For learners, this means adding another required competency to an already-steep learning curve – one they may not always prioritize, given the amount of clinical knowledge they have to master.
Wamsley notes that interprofessional communication and collaboration make up a skill set that students may not realize they need to deliberately develop and practice. “There’s a sense that they are skills [students] have already mastered, that it’s about being nice and being respectful,” she says. “They may not see that they may be all those things and still not be an effective communicator.” She notes that the overdose story at this year’s IPE kickoff session was intended to shake learners out of any complacency about communication: “Part of our impetus was to show them that really smart people working together in a system that isn’t perfect can be more prone to errors. We want them to ask, ‘How can we work together to mitigate that?’”
It has also been difficult to figure out how to ensure each component of the curriculum is relevant to all learners, says Chen. UCSF students have widely differing levels of experience and expectations, from first-year medical and dental students with little to no direct clinical experience, to master’s-level nursing students, many of whom have had full nursing careers before deciding to go into advanced practice.
“The challenge is to create an environment in which all of the students can learn with, from and about each other to improve collaboration and the delivery of care,” Chen says.
Training the Trainers: What Do Preceptors Need?
Among the biggest hurdles facing health profession educators is finding clinical opportunities where learners can actually practice collaboratively. At UCSF, as at many other schools, there is no centralized list of interprofessional clinical placements. There are pockets, such as the transplant service and the diabetes clinic, says Wamsley, “but we don’t often see learners from different professions working in teams in a way that fosters interprofessional collaboration. Often, they may be on a team, but they’re not doing a lot of interacting.”
Part of the problem is that preceptors often don’t know what they need to do to create a truly interprofessional experience for learners. As UCSF, as Chancellor Sam Hawgood put it at the IPE kickoff event, “Health care hasn’t been recognized as a team sport for very long.” He added that most faculty came up in a system that was, if anything, subliminally hostile to the idea, and trained under an ethos that emphasized personal autonomy and independence.
In 2013, Chen and UCSF geriatrician Josette Rivera conducted a study in which they observed preceptors interacting with learners at three clinical training sites and asked them about the difficulties in dealing with interprofessional learners. Chen says, “While the support for interprofessional training was strong, the number-one thing we heard was, ‘We don’t know what their objectives are. We don’t know what they’re here to learn.’” Such confusion makes it difficult not only to teach interprofessional learners, but also to provide meaningful feedback, says Wamsley.
A related problem is how to select experiences that are most important for specific types of learners. There are no set guidelines, so a case may be of interest to both an emergency medicine resident and an acute care pediatric nurse practitioner student, for example, but a preceptor with limited space and time may struggle to determine which learner should manage the patient or be on the team.
Then there are potential regulatory and institutional barriers. Who can sign off on which learners to certify that they have successfully completed a clinical experience? How are encounters billed? How does that affect clinical precepting of interprofessional learners?
Perhaps the biggest barriers in clinical settings are limited time and resources. Wamsley says, “It’s challenging to figure out places where [learners] can work together to actually foster some skills practice.”
Preceptors are under the same pressures as every other health care provider to provide better care to sicker patients at lower cost. Teaching takes time, as does providing feedback, and many preceptors can take only one or two learners per quarter. Adding an interprofessional component may seem like an extra burden.
The most hopeful note Chen and Rivera found was that sites that had an IPE champion had the most collaborative environment. Chen says, “It really takes someone to orchestrate the mix of learners in the clinical environment and insert meaningful IPE teaching huddles that focus on learners’ goals and objectives for the rotation [or] session.”
To help address these concerns, Chen, Rivera, Wamsley and their colleagues offer a certificate program in interprofessional teaching, as well as coaching for faculty members engaging in IPE.
Developing Collaborative Learning Environments
Based on their findings, Chen and her colleagues were able to secure grant funding from UCSF Innovations Funding for Education to place nurse practitioners (NPs) who were specifically trained in interprofessional precepting across two sites at San Francisco General Hospital (SFGH): the pediatric urgent care clinic in the Children’s Health Center and the Family Health Center.
“The NP students and [medical] residents got to see an NP serve as an attending who was also facilitating interprofessional collaboration within the clinical environment,” says Chen. Part of the idea, she says, was to build the trust and understanding between professions that is key to making collaboration work.
Developing interprofessional clinical experiences is an ongoing priority for the CDWG. “We’re trying to catalog where it’s happening,” says Wamsley. They’ve enlisted curriculum ambassador students to identify interprofessional clinical placements and experiences across UCSF schools. A pilot project, known as the “IPE Passport,” set to begin this year, will provide faculty with a rubric that helps them make existing experiences more interprofessional, and will allow students to document and track the number of IPE experiences they have completed within their training program.
The Passport system is also intended to help with the challenging matter of assessment. Interprofessional skills haven’t been tested in the past, and it’s difficult to know how much practice a learner has actually had – there are no procedure counts or specific types of patient encounters to quantify. The Passport system’s rubric provides a way to score each experience, based partly on how many professions, learners and objectives were involved.
Eventually, says Chen, “We want to be able to say to every learner that before they graduate, they need to have completed the didactic, and they need to have completed a number of experiences that fall within a range of IPE scores.” The CDWG has created a subcommittee tasked with developing tools to assess learner competence and develop remediation strategies where necessary.
Putting It Together
Despite the difficulties, there are clinical sites where interprofessional education seems to be coming together. The San Francisco VA Medical Center’s Education in Patient Aligned Care Teams (EdPACT) program has been named a Center of Excellence in Primary Care Education by the Department of Veterans Affairs. Through the program, second-year NP students and medical residents train together, along with other disciplines, in a medical home model that allows each team to have a yearlong experience working together to care for a panel of patients.
A pair of Health Resources and Services Administration (HRSA) Advanced Nursing Education grants is funding two more projects to expand IPE. The first, a partnership with UCSF Benioff Children’s Hospital Oakland’s Department of Psychiatry, trains pediatric and psychiatric nurse practitioner students with psychiatry residents and social work students from San Francisco State University at school-based clinics. Learners work together to provide direct access to mental health professionals at school clinics, where providers have generally been solo practitioners.
The second grant is geared toward training preceptors to work with learners from different professions in a model to provide coordinated care in a traditionally underserved area, California’s Central Valley. There are three elements: improving the clinical environment to support interprofessional precepting, faculty development and outcomes measurement.
“We’re asking what needs to happen in the clinical environment to make it easier to train students in an interprofessional manner,” says Chen. To address such issues, the IPE team (through consultation with the UCSF Office of Medical Education) is developing a formal interprofessional preceptor development program for larger community organizations within the Central Valley Health Network.
The third element of the project, outcomes measurement, is a bit trickier, says Chen. While implementing interprofessional education is the first step, the ultimate target of IPE is, of course, improved patient outcomes. That’s an achievement that short-term projects like this will have a challenge in demonstrating. As Chen says, “We can’t say that this patient had five less hospitalizations because of this IPE curriculum. So how do you prove that what you do will have an impact on patients?”
A National Challenge
As noted above, the difficulties with implementing IPE at UCSF are not unique. Institutions across the country have been struggling with trying to make sweeping changes in a complex, evolving system with multiple stakeholders. “For 40 years, the challenges have outweighed the advantages,” says Brandt. “But it’s a moot point because leaders and universities have to get with the program. The national drivers are there.”
In addition to the incentives provided by the Affordable Care Act, state governments and individual institutions are pushing educators to move ahead quickly with implementing IPE. The National Governors Association has taken it on as a key element in its health care platform, says Brandt, and the Texas legislature has directed (and provided funding to) academic health centers to create a common IPE curriculum.
Like UCSF, many other institutions have come up with innovative programs to manage the herculean task of overhauling health professions education and practice. The University of Washington has created a curriculum to train interprofessional groups in accountability and error disclosure, using simulations. Philadelphia’s Thomas Jefferson University’s Health Mentors Program brings together learner teams from across several disciplines; these teams then work with a person living with chronic illness to foster understanding of different roles and prepare students to work in teams to provide patient- and family-centered care. The Medical University of South Carolina has perhaps gone the farthest, by tying its regional accreditation to a requirement to demonstrate interprofessional practice.
At the national and institutional level, implementing IPE is a massive undertaking that must occur in classrooms, clinics and boardrooms simultaneously. The success or failure of these efforts will have a significant effect on whether the country’s fragmented health care system will thrive or flounder in the 21st century.
As Brandt says, “Ethically and morally, we have to make certain that our graduates have these skills, because that’s the world they’re headed into.”