Publications

Teaching the Art of Collaborative Practice

September-October 2017

By: Fred Rottnek, MD, MAHCM and David Pole, Ph.D., MPH


BY: DAVID POLE, PhD, MPH, and FRED ROTTNEK, MD, MAHCM

Teaching the Art of Collaborative Practice
Andrea Eberbach

Safety is a core value of Catholic health care so deeply embedded that it seldom appears on lists of values or in mission statements. But safety in modern health care delivery is not a given. Health care is so complex, and so many people may be involved in a patient's care in so many ways — physical, virtual or financial, for example — that in acute and long-term care settings, dozens of people might "touch" a patient or a patient's case during a single day. These "touches" all can have an impact on care and outcomes.

Reports and strategic initiatives by the Institute of Medicine, the Joint Commission and the Agency for Healthcare Research and Quality to improve the quality and safety of patient care have established best practices and significantly raised expectations. However, one of the challenges in patient safety and quality-care initiatives is that safety is a non-event — safety is when nothing bad happens — but proactive behaviors and systems must be in place to minimize the potential for errors and adverse outcomes. Clinical and broader care teams must be high-functioning and effective. Health team members must understand and demonstrate the teamwork and team communication skills that support collaborative practice.

COLLABORATIVE PRACTICE
Collaborative practice means clinicians, nurses, social workers, aides — all the health professionals involved in a patient's care — work together as a team, with the patient at the center. Effective and highly functioning care teams need practitioners who have developed explicit skills in communication and collaboration, in addition to their clinical skills. The goal isn't civility, it is patient safety. Breakdowns in coordination, communication and collaboration across care teams, especially at transitions of care, are at the root of more than 75 percent of medical errors and adverse outcomes, according to the Joint Commission and other agencies.

Good communication skills and knowing how to coordinate with other health care practitioners take training and practice, because putting multiple professionals in the same space does not guarantee they will function effectively as a team, much less collaborate well across professional boundaries. To that end, many teaching programs in the health professions combine integrated interprofessional education, often called IPE, with patient-safety learning experiences so students will be trained and acculturated to provide collaborative, patient-centered, quality care.

At the Saint Louis University School of Medicine in Missouri, for example, interprofessional learning experiences and courses are embedded throughout health profession programs at both the undergraduate and graduate levels. A Jesuit Catholic institution, the medical school describes its mission as improving wellness, patient safety and quality care, and addressing social justice and inequities in health care and health outcomes.

In 2011, Saint Louis University established the Center for Interprofessional Education and Research to advance comprehensive programs across three tracks: freshman-entry, post-baccalaureate and clinical practice. In addition to educational programs, the center works to improve the documentation of outcomes, advance scholarship, support faculty development, teaching and learning, and to facilitate research in interprofessional education and collaborative care. The goal is to prepare students for graduation from their health profession programs as collaboration-ready practitioners who can contribute to improvements in individual patient care and outcomes as well as in population- and community-level health.

Education in interprofessional practice is an important mechanism for accomplishing the Institute for Healthcare Improvement's Triple Aim — improved individual patient care and outcomes, improved patient population and community health outcomes, and improved cost-effective care, which includes the concept of the right provider at the right time for the right patient. With increasing instances of provider burnout and turnover within the health care workforce, Saint Louis University, along with family medicine and other physician organizations, advocates adding a fourth category to the Triple Aim: provider wellness and well-being.

An individual provider's self-care is foundational to demonstrating a caring response towards a patient. A provider who is not taking care of himself or herself cannot continue to engage in care for others. Beginning early in students' education, Saint Louis University's interprofessional programs draw on the Jesuit tradition of "being men and women for and with others" to focus on self-care as part of professional formation.

When the IPE and family medicine programs at Saint Louis University discuss professional formation, their goal is to support and encourage the development of clinicians who have cultivated a sense of vocation and a strong, caring response towards self and others. They are clinicians who understand that quality and safety are goals of practice, and they engage in service to community because that is who they are, their authentic self. This concept is very different from a clinician who volunteers in his or her community because it is important to give back. Some may call such professional formation the skills of a mindful and present practitioner; others may call it creating the space for the healing presence of God or Creator.

MISSION AND IPE COMPETENCIES
Reflecting Saint Louis University's mission, the interprofessional education programs established five competency domains to guide the development and application of curricula to the care of individuals, communities and the health care system. The domains focus on:

1. Interprofessional Practice: a collaborative, interdependent use of shared expertise directed toward a unified delivery of optimal patient care. This includes understanding the roles, responsibilities and scope of practice of various health professions, as well as developing skills at collaborative decision-making and team-based communication.

2. Integrated, Patient-centered Care: the development of attitudes and skills that support patient empowerment and inclusion in care planning while demonstrating sensitivity to autonomy, culture, language, literacy, socioeconomic conditions and patient comfort. The domain also includes integration of evidence-based practice, informatics, self-management support and care coordination to provide the best patient care and health outcomes.

3. Wellness: the integration of evidence-based prevention guidelines and development of patient education skills to enable a change of focus from sick care to wellness and prevention. Students across professions will demonstrate an understanding of an ecological model for determinants of health and program components that support community/population health.

4. Patient Safety and Quality Care: the ability to demonstrate skills at personal lifelong learning and contribute to systems of quality care. Students will demonstrate an understanding of the connection between effective teamwork, a culture of safety and patient care and outcomes. Additionally, they will demonstrate effective communication skills across professions that lead to reduced errors and adverse outcomes while learning about, from and with each other to enable more effective collaboration and improved outcomes.

5. Social Justice: the ability to recognize one's responsibility to act for the good of others and to apply knowledge and skills in helping the people who are most vulnerable. This includes both understanding and working to eliminate inequities in health and health care, eliminate health disparities and develop skills for advocacy, policy change and community development.

CHALLENGES AND OPPORTUNITIES
IPE and interprofessional collaborative practice face significant challenges at both the educational and health care system levels. At the educational level, these include:

  • Integration and time in the curriculum across the health professions to create meaningful interprofessional learning experiences
  • Recruitment and support of faculty members who demonstrate the value of interprofessional education and who can facilitate such learning experiences
  • Financial support for dedicated leadership, faculty development and staff support for interprofessional education, practice and research
  • Integration and support for collaborations on health outcomes research that demonstrate the value and positive impact on patient care and outcomes

At the health care system level, the challenges include:

  • Evaluating and supporting systems, policies, procedures and dedicated time and space for the clinical teams to engage in interprofessional collaborative practice
  • Focusing on interprofessional collaborative practice as a direct method and mechanism to improve patient care, to improve outcomes for quality and safety and to support professional development for team-based outcomes
  • Strengthening partnerships with academic health centers to identify key outcomes of health professions training programs that better prepare graduates for the collaborative practice environment
  • Using interprofessional collaborative practice as the framework for improving quality and safety of patient care. Demonstrating the equitable value and contribution of multiple health professions in the process of patient care
  • Being a collaborative partner in safety and quality initiatives based on interprofessional collaborative practice
  • Identifying clinical placements within the system where students can experience effective team-based care and interprofessional collaborative practice

DISCUSSION AND NEXT STEPS
Consistent quality outcomes are the product of effective systems and processes of care, individual professional skills and effective teamwork. Saint Louis University believes it is an obligation to integrate knowledge and skills in all three areas in order to appropriately prepare the future health professions workforce.

Interprofessional education programs broaden the application of clinical skills to develop clinicians as collaboration-ready members of health care teams. The health care system and post-graduate training programs must support and demonstrate accountability for interprofessional collaboration and teamwork as a standard of best practice.

Health professions education programs are required to discuss and teach patient-centered care and interprofessional collaboration. The ongoing challenge is to demonstrate the value of collaborating with other members of the care team and to actively engage patients and families in shared decision-making, recognizing them as additional members of that care team.

Training the future workforce of health care practitioners requires careful examination of teaching and learning methods, instruction and practice regarding behavior and language. The training starts with clear outcome behaviors in mind as the end goal of the education.

Health professions education is challenging because it requires the application of multiple styles of teaching, curriculum design, and evaluation methods. Health professions education must result in basic science and applied clinical knowledge, but also in the skills to demonstrate behavioral competencies that lead to safe, quality care.

Learners must be able to participate on and actively lead care teams, and they must be advocates for systems and policy change that improve equity in health care and health outcomes. To accomplish this task requires effective teamwork and collaboration by educators as they "walk the talk" of IPE — that is, learning about, from and with each other to improve effective collaboration and health outcomes. Otherwise, interprofessional education will be one more add-on to clinical practice with little perceived value.

CONCLUSION
The mission and values of Catholic health care position it to be a leader in interprofessional education and collaborative practice. The ministry can lead in cultivating practitioners and learning organizations that support a caring response and the "Quadruple Aim," that is, the Triple Aim plus a culture that supports a health care professional's mindfulness of his or her own professional formation, self-care and well-being.

In a time when health care is being challenged to do more with less, we have the opportunity to engage in collaborations that enable us to accomplish more by doing things differently while strengthening the workforce and improving outcomes.

DAVID POLE is an assistant professor in family and community medicine and directs the Center for Interprofessional Education and Research at Saint Louis University Medical Center.

FRED ROTTNEK is a professor in family and community medicine and director of community medicine programs at Saint Louis University Medical School.

THE INTERPROFESSIONAL TEAM SEMINAR APPROACH

At Saint Louis University, interprofessional team seminars are series of six 90-minute seminars that include more than 700 students from nine health care professions:

  • Medicine
  • Nursing (ABSN and AMSN)
  • Physician Assistant
  • Physical Therapy
  • Occupational Therapy
  • Social Work (MSW)
  • Pharmacy
  • Nutrition and Dietetics
  • Athletic Training

The seminar cases emphasize a range of clinical and collaborative situations such as multiple transitions of care, addressing a trauma history, understanding roles and responsibilities of different professions specific to the case, shared decision-making with the patient and collaborative decision-making with the care team. Students are able to practice effective team communication that includes how to demonstrate appreciation of other professions' experience and perspective. The curriculum team embedded 14 competencies into the seminar activities so that students practice and demonstrate proficiency according to three learning objectives:

  1. Communicate your professional role and responsibilities clearly to other care professionals. Explain the roles and responsibilities of other care providers and how you will work together as a team to meet patient care needs.
  2. Understand the relationship between effective team communication and improved patient safety and health outcomes. Choose effective communication techniques to facilitate discussion and interactions that enhance team function.
  3. Demonstrate skill at effective interprofessional teamwork and patient-centered communications. Integrate the knowledge and experience of other health professionals and patients in order to provide appropriate care of the patient.

Students are assigned to small groups composed of students representing at least six professions. Faculty facilitators work with assigned teams during the seminars. Each seminar centers on case-based learning that blends clinical care with a particular focus on the practice and demonstration of interprofessional collaboration and effective team-based care.

For example, one seminar that includes the athletic training students involves care of an individual who suffered a traumatic neck injury on the athletic field. Students must work through multiple transitions of care, engage appropriate professions at each stage of care, and determine issues of shared responsibility to get the patient back to best possible engagement in activities of daily living.

Another seminar introduces the nutrition/dietetic graduate interns to the care team addressing a complex patient with diabetes and multiple social-behavioral factors that affect her self-care and her engagement with the care team. The team must address care needs across inpatient care and outpatient follow-up after the patient has experienced a fall and injuries while cooking dinner. The team must also address the fact that the patient is at high-risk of hospital readmission at the time of the primary care visit.

For additional information, visit http://ipe.slu.edu.

 

CATHOLIC HEALTH CARE IS NOT IMMUNE TO THE TYRANNY OF THE URGENT

We have lots of urgencies. But our concern here is not about urgencies in front of us, or putting out fires. Rather, it's about getting in front of the fires — looking to the horizon with planning, training and instilling professional training and a sense of mission upstream. It's about creating a stronger workforce in Catholic health care that starts in the classroom and labs, and then building a pipeline of providers ready for practice.

Catholic health care and Catholic higher education in the United States have faced similar challenges in recent decades — increasing costs, changing financial models, competitive markets, evolving sponsorship and challenges to sustainability in a rapidly changing world. But too often these ministries have evolved in isolation. When I began attending Catholic Health Association leadership meetings a few years ago, serving on Health Progress' Editorial Advisory Committee, I was surprised how often people asked me why I was attending the meeting. I wasn't working in Mission, I wasn't practicing in a Catholic system, I wasn't in the C-suite, but I was a physician with a degree in theology.

Usually I answer something like, "I'm on the editorial committee of the journal, and I teach medical students in longitudinal community service and students from a dozen health professional programs through our Center for Interprofessional Education."

"Oh, that's so important. As a ministry, we should do more with Catholic higher education. I wonder why we don't think of that more often?"

We exchange cards, promise to get in touch. And that's usually the end of it. Because urgencies get in the way of follow-up discussions, planning and implementation.

In the best tradition of Health Progress, we hope this issue catalyzes conversations —sustained conversations that lead to action — about the intersections and opportunities of Catholic higher education and Catholic health care. We have almost limitless opportunities for linking mission-focused training programs with mission-driven delivery systems. And we are not limited to one direction, that is, from the classroom to the clinic; health care systems have an opportunity to inform training programs what they need in terms of professional skill sets and mission-driven approaches to safety and outcomes. Systems can provide the incubators for pilot programs of patient-care delivery and the real-world training experiences to attract the "right kind" of health care providers to their practices.

To get in front of the urgencies, we need to invest our resources, including perhaps the most precious one, our time, in connecting our training programs that produce the providers and leaders our systems need. I pray this issue inspires such commitment.

Next time, let's do more than exchange business cards.

— FRED ROTTNEK, MD

Guest co-editor for September-October 2017 Health Progress

 

QUESTIONS FOR DISCUSSION

  • How can Catholic health care support interprofessional education and collaborative practice as a means to the end of clinical outcomes and patient safety?
  • In what way does your ministry use intentional integration of critical reflection to help caregivers contribute to effective team-based care and patient-centered care?
  • Can you give examples of how your ministry imparts personal meaning and vocation around effective team-based care, improved patient care, and patient outcomes?
  • How do members of care teams learn and refresh skills for engaging in critical reflection, effective collaboration with and for others, and improving patient care and patient outcomes?

 

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