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OCR for page 121
Chapter 6
Recommendations for Reform
This chapter sets forth the committee's recommendations for achieving the following
overarching vision for the reform of health professions education to enhance the quality and safety of
patient care. This vision for all programs and institutions engaged in the clinical education of
health professionals encompasses the five competencies that health professionals need in order to
practice in the redesigned system described in the Quality Chasm report (Institute of Medicine,
20014.
All health professionals shouldt be educated to deliver patient-centered care as
members of an interdisciplinary team, emphasizing evidence-base~practice, quality
improvement approaches, and informatics.
A number of the following 10 recommendations focus on oversight organizations. This is
because the committee believes that integrating a core set of competencies one that is shared across
the professions into health professions oversight processes would provide a good deal of leverage
in terms of reform, and is an important first step in aligning incentives and providing a catalyst for
both educational institutions and professional associations to make necessary changes. This effort
would build upon existing efforts and create synergies across the disciplines. A recent article
synthesizing nine major reports on physician competencies appears to support this approach,
concluding that "without data about medical-education quality, accreditation is the most potent lever
for curricula reform in our decentralized medical education system." (Halpern, 2001)
The committee also recommends pursing other leverage points to reform health professions
education such as the use of report cards that incorporate education-related measures and
innovations in financial incentives. However, the preponderance of its recommendations are directed
at oversight organizations. This is the case in part because of the lack of education measures and the
121
OCR for page 122
HEALTH PROFESSIONS EDUCATION
charge to this committee, which was focused on
clinical education. Also, health professions
oversight processes, such as accreditation and
certification, function at the national level,
thereby affording a mechanism for systemwide
change. Oversight bodies are diverse, including
representation on their boards from professional
associations, educational institutions, and
consumer representatives, and include both
public and private organizations.
The committee believes that a competency-
based approach to education could result in
better quality because educators would begin to
have information on outcomes, which could
ultimately lead to better patient care. Defining a
core set of competencies across educational
oversight processes holds the potential for
reducing costs as a result of better
communication and coordination across
oversight bodies, with processes being
streamlined and redundancies reduced.
Integrating core competencies into oversight
processes would likely provide the impetus for
faculty development, curricular reform, and
leadership activities. Specifically, academic
institutions would add or modify coursework,
boards would revise licensing exams, and
certifying organizations would seek to respond
to the new criteria in their requirements for
maintaining competency. The importance of
this area was apparent at the Institute of
Medicine (IOM) summit, where the oversight
working group attracted the largest number of
participants and generated the largest number of
proposed actions, even though members of
oversight bodies represented only about 20
percent of the summit participants (see
Appendix B). Moreover, participants identified
oversight processes as a primary driver in an
exercise aimed at identifying key strategies.
Common Language and Adoption of
Core Competencies
Any collective movement by the health
professions to reform education must begin with
defining a shared language that will enable the
professions to communicate and collaborate
with one another (Bashook and Parboosingh,
1998; Carraccio et al., 2002; Halpern et al.,
2001; Harden, 20024. A synthesis of nine major
reports related to curriculum reform and
competencies underscores the need for such a
shared vocabulary (Halpern et al., 2001), noting
that common terms can facilitate the
development of new curricula, with departments
and programs having a greater ability to
coordinate related courses and training
activities. A lack of consensus around language
and terms related to the five competencies may
be hampering their implementation. It may also
be undermining attempts to define a core set of
competencies across the professions and to
integrate these competencies into oversight
processes (Lavin et al., 2001; Pomeroy and
Philp, 1994~.
In the case of evidence-based practice, for
example, there is no standardized definition of
evidence. The existing definitions include
evidence that can be quantified, such as
randomized controlled trials; evidence based on
qualitative research; evidence that exists in
institutional databases; and evidence derived
from the knowledge and experience of experts
and peers, including inductive reasoning
(Guyatt et al., 2000; Higgs et al., 2001; Welch
and Lurie, 20004. In recent years, leaders in the
field have worked to expand the definition of
evidence to include qualitative research and to
dispel the myth that evidence-based practice
ignores clinical experience and expertise
(Guyatt et al., 20004. However, a review of the
literature suggests that misunderstanding and
misconceptions regarding the definition of
evidence persist (Marwick, 2000; Mazurek,
2002; Mitchell, 1999; Satya-Murti, 2000;
Woolf, 20004. Some also argue that clinicians
must think in terms of hierarchies of evidence
and always seek the highest level of available
quantifiable evidence to inform their practices
(Sackett, 19984. This view concerns some
leaders, who argue that such an approach could
introduce bias in methodologies and
conclusions (Ching, 2002) and further
~ A current Institute of Medicine study addressing academic health centers is considering financing questions.
122
OCR for page 123
RECOMMENDATIONS FOR REFORM
reinforces a biomedical model that could
prevent greater adoption of more holistic views
of human health (Shaver, 20024.
A related issue is the implementation of
evidence-based practice skills across the
professions particularly as part of a
computerized decision support system that
supports all clinicians. The problem is that
terms and therefore standards for indexing are
lacking, making linkages between profession-
specif~c databases difficult. Therefore, each
profession's evidence base exists in its own silo
(Closs and Cheater, 1999), without the linkages
required in an interdisciplinary academic or
practice environment (Evers, 2001; Lang, 1999;
Prentice and Bentley, 1999~. Finally, the lack
of common terms may make assessing the
evidence base on any given topic difficult
(Jordan, 2000~.
The lack of consistent language impedes the
development of interdisciplinary team skills.
Even the term interdiscip1/tinary may confuse
and confound; in medicine, it can mean working
across the medical specialties. A review of the
literature related to teaching interdisciplinary
team skills reveals differing terminologies as an
obstacle: faculty struggle to understand other
professions' core concepts and content, and the
result may be conflict when developing and
teaching interdisciplinary courses (Lavin et al.,
2001; Pomeroy and Philp, 19944.
Some argue that to have effective
interdisciplinary settings, clinicians must
develop a unifying framework for interpreting
all types of decisions. For example,
Buckingham and Adams (2000) stress the need
for the professions to go beyond a framework
that describes nurses' clinical decisions as
evaluative and physicians' as diagnostic,
viewing such distinctions as a barrier to
interdisciplinary teams, overlapping roles, and
fluidity in role boundaries.
In the area of informatics, there is
disagreement about whether the subject needs to
be viewed and taught in discipline-specific ways
or approached more generically. Some argue
that each discipline should require its own core
informatics curricula and training programs to
best serve the needs of that particular health
professions group. Others disagree, asserting
that informatics is built upon a reusable and
widely applicable set of methods that is
common to all health professionals (Masys et
al., 2000; Raymond H. Curry et al., 2000~.
Dan Duffy, American Board of Internal
Medicine, acknowledged the lack of consistent
language at the summit:
Although I thought I had a pretty
broad view of collaboration and
interdisciplinary work, it's mind
boggling how our languages and
our cultures and our ways of doing
things actually impede [our] goals
(Duffy, 20024.
Ross Baker, University of Toronto, echoed this
point and also noted the divide across
competencies:
One of the difficulties we face is
that there are silos around the
content...the informatics people
talk to each other and the quality
improvement/patient safety people
talk to each other and the team
people talk to each other and the
evidence-based health care people
talk to each other. And we need to
be drawing the links more
strongly...to think about ways to
make linkages between those
communities, the scholars, and the
practitioners in order to try and
identify ways in which they can
learn from each other (Baker,
20024.
Creating a common language is no small
task. Developing and adhering to distinct
profession-specific terms may be a
manifestation of professionals' desire to
preserve identity, status, or control. This
observation may explain, in part, why the
competency movement in education, which has
been gaining steam, has been contained within
each profession, although spanning the
continuum of a given profession also has proven
difficult.
123
OCR for page 124
HEALTH PROFESSIONS EDUCATION
Some analysts characterize this movement
toward competencies as a major paradigm shift
and revolution for the 21 St century (Carraccio et
al., 2002; Lenburg, 19994. The competency
movement actually began to gain some steam in
the 1970s as a "back to basics" response to the
more open-ended curricula of the 1960s that
Reemphasized basic skills. Innovative health
professions schools of that era sought to
integrate competencies into their curricula, but
despite predictions that this was an idea whose
time had come, competency-based education
did not catch on. This may be because
education leaders did not agree on a common
set of competencies and ways to measure those
competencies, nor did accreditors require such
an approach (Carraccio et al., 2002; Luttrell et
al., 19994.
A review of the literature suggests the close
connection between common language and
common competencies. For example, a group
of 200 oversight and education professionals
from 25 countries brought together to discuss
systems for ensuring the competency of
physicians noted the pressing need for common
terminology to fulfill its charge (Bashook and
Parboosingh, 19984. A recent review of
attempts to incorporate competency-based
training and evaluation in health professions
education likewise stresses the importance of a
common language (Carraccio et al., 2002;
Parboosingh, 20004~ Although the Europeans
have been successful in defining a set of core
competencies for physicians (Harden, 2002), a
review of such efforts on the international front
reveals a lack of standardized terminology and
"wide variation...in the extent to which true
competency-based learning objectives were
instituted" (Carraccio et al., 2002:3654. Box 6-1
describes one example of a successful
interdisciplinary effort to define core
competencies.
The committee believes that an
interdisciplinary group, created under the
auspices of the Department of Health and
Human Services, should be charged with
developing a common language across the
health disciplines with the purpose of defining a
core set of competencies and achieving
threshold consensus around this core set. A
similar notion was embraced by a participants in
a summit working group focused on common
language (see Appendix B).
Recommendation 1: DHHS and leading
foundations should support an
interdisciplinary effort focused on
developing a common language, with the
ultimate aim of achieving consensus
across the health professions on a core set
of competencies that includes patient-
centered care, interdisciplinary teams,
evidence-based practice, quality
improvement, and informatics.
124
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RECOMMENDATIONS FOR REFORM
Integrating Competencies into
Oversight Processes
The current call for oversight organizations
to integrate competencies into their processes is
in response to growing concerns about patient
safety (Institute of Medicine, 2000; National
Institutes of Health, 2002) the astounding
geographic variation that exists in patient care
that is not related to patient characteristics
(O'Connor et al., 1996), and the associated
desire on the part of public payers and
consumers for increased accountability (Leach,
2002; Lenburg et al., 19994. In Europe, there
also appears to be a sense that increased
globalization will afford greater interaction
among clinicians of different countries,
generating the need for a set of core
competencies that define clinicians regardless of
where they are trained, and a related need for
enhanced accountability (Harden, 20024. Box
6-2 describes one example of an effort to shift
to a competency-based curriculum, in this case
for pharmacy education.
During the last decade, competencies have
begun to redefine the way some oversight
organizations and professionals approach
accreditation, as discussed in Chapter 5. In
1997, the American Council on Pharmaceutical
Education (ACPE) adopted accreditation
standards focused on 1 ~ professional
competencies (American Council on
Pharmaceutical Education, 2002~. In 1999, the
Accreditation Council for Graduate Medical
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125
OCR for page 126
HEALTH PROFESSIONS EDUCATION
Education (ACGME) and the American Board
of Medical Specialties (ABMS) endorsed six
general competencies as the foundation for all
graduate medical education; these competencies
are currently being phased in (Accreditation
Council for Graduate Medical Education, 2002~.
Until they have been fully implemented and
evaluated, it remains to be seen what effect they
will have on pharmacy and medical education,
but they do overlap with the core competencies
defined by the committee. In nursing, the two
accrediting organizations also have defined
competencies which do not fully overlap with
the core competencies defined here but they
differ in whether they require demonstration of
such competencies (Commission on Collegiate
Nursing Education, 2002; National League for
Nursing Accrediting Commission, 19994.
Finally, the curricula for the selected allied
health professions examined in this report vary
in the extent to which they incorporate the five
competencies outlined herein (Collier, 20024.
The competency movement, however, does
not have as much of a foothold in processes
related to initial licensure or certification. As
discussed in Chapter 5, requirements for
maintaining license to practice vary
considerably across the professions, as do
requirements for those who pursue recognition
or certification of clinical excellence. Further,
research has raised serious questions about the
efficacy of continuing education courses, the
most common requirement for demonstrating
ongoing competency (Davis et al., 1999;
O'Brien et al., 2001; O'Brien et al., 20014.
Some organizations, including the ABMS, the
American Nurses Association, and the National
Council of State Boards of Nursing, among
others, have responded to these issues by taking
steps to provide a better assessment of
competency (Bashook et al., 2000; Whittaker et
al.. 20001.
Despite this increased momentum, one
review found scarce evidence to support the
efficacy of competency-based education
(Carraccio et al., 2002~. Yet the evidence that
does exist demonstrates that competency- or
outcome-based educational approaches lead to
improvements, such as better performance in
licensing exams. Also, ways to assess
competency are under development, and there
does not yet appear to be a consensus on an
appropriate approach. For example, some
instruments are directly linked to particular
definitions of competency (Chen et al., 1999),
while others are more open-ended and attempt
to assess aspects of competency that are
difficult to define, such as management of
ambiguity, professionalism, and teamwork
(Epstein and Hundert, 20024.
Efforts to incorporate a core set of
competencies across the professions into the full
oversight framework accreditation, licensing,
and certification—would need to occur on the
national, state, and local levels; coordinate both
public- and private-sector oversight groups; and
solicit input from professional associations and
educational institutions. In developing a
proposed strategy focused on oversight
organizations, summit participants suggested a
"big tent" approach (see Appendix C).
The committee believes that the
involvement and support of DHHS, and
specifically the Health Resources and Services
Administration, would be important in getting
this effort off the ground, in helping to establish
a process for soliciting input from professional
associations and the education community, and
in identifying linkages and synergies from
various oversight groups within and across
professions. It is imperative to have such
linkages among accreditation, licensure, and
certification; it would mean very little, for
example, if accreditation organizations required
certain competencies, but these competencies
were not reflected in licensing exams or
requirements for continued practice. All
processes must be linked so they are focused on
the same outcome: enhancing the quality of
patient care.
Recommendation 2: DHHS should
provide a forum and support for a series
of meetings involving the spectrum of
oversight organizations across and within
126
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RECOMMENDATIONS FOR REFORM
the disciplines. Participants in these
meetings would be charged with
developing strategies for incorporating a
core set of competencies into oversight
activities, based on definitions shared
across the professions. These meetings
would actively solicit the input of health
professions associations and the
education community.
Strategies for incorporating the
competencies into oversight processes would
naturally differ across the oversight framework
based on history, oversight approach, and
structure, with consideration given to what steps
particular groups have already taken. In all
cases, the oversight bodies should proceed with
deliberation. Efforts should be made to solicit
comments on draft language related to new
requirements, and to test new requirements
wherever possible before implementation, such
as through the use of provisional standards.
Processes should also be established to monitor
and evaluate new requirements to ensure that
they are useful and not overly burdensome.
The experiences of ACPE and ACGME
provide some guidance on how accrediting
bodies, which operate at the national level,
could incorporate competencies into their
processes. Both ACPE and ACGME undertook
an intensive, decade-Ion" process of rethinking
how they were preparing professionals for
practice. They concluded, as did many reports
that preceded their efforts, that fundamental
change was necessary, and that they needed to
move away from approaches that had become
increasingly precise, prescriptive, and
burdensome (Byrd, 2002~.
What has not yet occurred is coordination
across accrediting bodies of the various
professions in defining a core set of
competencies and designing related standards
and measures. Such coordination could obviate
the need for each accrediting body to reinvent
the wheel, and synergies would likely result,
enabling better communication and working
relationships, as well as more consistent
integration of the core competencies across
schools. This sort of coordinated effort would
also help to ensure that educational innovators
would not be stifled by outdated accreditation
requirements. Organizational accreditors such
as the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) and the
National Committee for Quality Assurance
(NCQA) should likewise consider more fully
how clinicians maintain competency in the core
set of competencies outlined in this report.
Recommendation 3: Building upon
previous efforts, accreditation bodies
should move forward expeditiously to
revise their standards so that programs
are required to demonstrate through
process and outcome measures that
they educate students in both academic
and continuing education programs in
how to deliver patient care using a core
set of competencies. In so doing, these
bodies should coordinate their efforts.
As noted in Chapter 5, with the exception of
patient-centered care, which is consistently
included in examinations across the professions,
licensing exams for health professionals vary
considerably in whether they test for
competency in the five core areas highlighted in
this report (National Association of Boards of
Pharmacy, 2002; National Council of State
Boards of Nursing, 2001; United States Medical
Licensing Exam, 2002~. This situation also
needs to be addressed and could be the focus of
a subset of the oversight organizations described
in recommendation 2.
In addition, separate, exclusive, and
sometimes conflicting scope-of-practice acts
and geographic restrictions on licensure need to
be examined to determine whether they are a
serious barrier to the full integration of
competencies into practice. If so, consideration
should be given to how they might be modified
so that all clinicians can practice to the fullest
extent of their technical training and ability, as
well as take full advantage of new technologies,
such as telemedicine (Safiiet, 2002~. While
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HEALTH PROFESSIONS EDUCATION
such an examination is beyond the scope of this
report, the committee views it as important
because ofthe influence scope of practice has
on how clinicians are deployed and, in turn,
how they are prepared for practice.
Finally, the committee believes that there
should be an effort to integrate a core set of
competencies into oversight processes focused
on the continued competency of practicing
clinicians. Such an effort would require
coordination among an array of public- and
private-sector licensing and certification
organizations, within which there is currently
little uniformity in approach across the
professions or within a given profession across
the states.
TO herein with state le~islat:~res wn~1~1 need
Recommendation 4: All health
professions boards should move toward
requiring licensed health professionals to
demonstrate periodically their ability to
deliver patient care as defined by the
five competencies identified by the
committee through direct measures of
technical competence, patient assessment,
evaluation of patient outcomes, and other
evidence-based assessment methods.
These boards should simultaneously
evaluate the different assessment
methods.
There is more uniformity among certifying
organizations as compared with professional
~ , ~ ~ ~ , . . . .
Boards, In tnat nearly all require some means of
to require state licensing boards to Insist that
demonstrating con nun competence. The vast
their licensees demonstrate competence to . . ~ ~ ~
majority allow for two or more approaches, and
maintain their authority to practice. To date,
many also consider competency at various
state legislators have not Insisted upon such a
requirement, in part because there is
disagreement about what constitutes evidence of
competency and how often it should be
demonstrated, not to mention who should judge
such ability. Absent such a requirement, there
will continue to be many boards that require
only a fee for license renewal (Swankin, 2002)
and many others that view continuing education
as evidence of competence, even though such a
linkage has not been demonstrated (O'Brien et
al., 20014. Licensing boards also would need to
consider clinician competency at varying career
stages. For example, a veteran intensive care
nurse or physician subspecialist should be
expected to have a higher level of competence
than a new graduate in either profession.
The committee believes that all health
professions boards need to require
demonstration of continued competency, and
that they should move toward requiring rigorous
tests for this purpose. Beyond licensing
examinations, there is evidence to suggest that
structured direct observations using
standardized patients, peer assessments, and
case- and essay-based questions are reliable
ways to assess competency (Epstein and
Hundert, 2002; Murray et al., 20004.
career stages. Moreover, in response to the
paucity of evidence that taking continuing
education courses improves practice outcomes,
some certifying organizations are beginning to
emphasize alternative measures that are more
evidence based (American Board of Medical
Specialties, 2000; American Nurses
Association/NursingWorId.Org, 2001; Bashook
et al., 2000; Board of Pharmaceutical
Specialties, 2002; Federation of State Medical
Boards, 2002; Finocchio et al., 1998; National
Council of State Boards of Nursing, 1997-2000;
Swankin, 2002a). Although such efforts are
challenging to implement and often costly,
certification bodies should only recognize
continuing education courses as a valid method
of maintaining competence if there is an
evidence-based assessment of such courses; if
clinicians select courses based on an assessment
of their individual skills and knowledge; and if
clinicians then demonstrate, through testing or
other methods, that they have learned the course
content.
The committee recognizes that there is a
monetary and human resource cost to moving to
evidence-based assessment, whether it is related
to licensure or credentialing. Consequently,
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RECOMMENDATIONS FOR REFORM
such assessments may need to be phased in,
competency by competency, or less costly
assessment methods identified. The committee
also recognizes that increased investment in
computer-based clinical records would provide
the kind of rich clinical data necessary to fully
realize competency-based licensure and
certification.
Recommendation 5: Certification bodies
should require their certificate holders to
maintain their competence throughout
the course of their careers by periodically
demonstrating their ability to deliver
patient care that reflects the five
competencies, among other requirements.
Training Environments
Education does not occur in a vacuum;
indeed, much of what is taught during the
educational experience and much of what is
learned lies outside formal academic
coursework. This "hidden curriculum" of
observed faculty or clinician behavior, informal
interactions and conversations with fellow
students and with faculty and practicing
professionals, and the overall norms and culture
of the training or practice environment is
extremely powerful in shaping the values and
attitudes of future health professionals (Ferrill et
al., 1999; Hafferty and Franks, 1994; Maudsley,
2001).
What is learned through this hidden
curriculum often can contradict the goals and
content of the coursework that is formally
offered. Courses may emphasize the
importance of information technology in
clinical care, but that message is not reinforced
if students continue their education in health
care organizations that are not equipped with
information technology or whose faculty are not
prepared to utilize informatics themselves.
Students educated in a culture where the
dominant belief is that physicians are all-
knowing will likely not value shared decision
making with patients regardless of whether they
are taught to do so. Students educated in a
discontinuous system in which patients are
quickly handed off to personnel in new venues
of care will likely develop a narrow, task-
specific view of illness, rather than a
perspective of the whole patient or a systems
orientation (Glick and Moore, 2001~.
Environments that punish those who make
medical errors, with health providers blaming
themselves, each other, or the patient, do not
encourage students to explore alternative
solutions, take risks, or apply quality
improvement strategies to reduce future errors.
In many training settings, the institutional
norms are such that authoritarianism,
boundaries of practice, and silos among
professional disciplines are strictly enforced,
and further reinforced by payment systems. In
such settings, the value of interdisciplinary
teams will likely not be grasped by students.
Role models, whether they be faculty,
residents, clinician teachers, or other practicing
health professionals, have a large part to play in
this cultural influence. Branch (2000)
documents the extent of the problem in medical
education, with one survey of medical students
showing that the majority believe their moral
values were eroded during their clinical
training. Another study showed widespread
abuse of medical students by those in positions
of power, and in one survey, 74 percent of
residents reported directly observing
mistreatment of patients. Equally alarming are
studies demonstrating medical students' and
residents' ambivalence and even antipathy
toward management of the chronically ill as
their education progresses (Davis et al., 20014.
There is a need for health professions faculty to
consider how they influence students' and
residents' moral, ethical, and professional
development as they become health
practitioners, but little reform has been
attempted in the area of faculty development
and role modeling (Branch, 2000; Burack et al.,
1999; Dechairo-Marino et al.,2001; Hundert et
al., 1996; Maudsley, 20014. Summit panelist
Bob Berenson, AcademyHealth, noted:
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HEALTH PROFESSIONS EDUCATION
I guess I'd go back to my days as a
medical student and house officer...
a lot of what I did back then was
seeing role models, emulating what
senior people were doing, what the
faculty were doing ... And if the
system gives incentives to not
participate in multidisciplinary
teams, that's what I'm going to
learn even if somebody comes to a
classroom and shows me a video of
the potential benefits (Berenson,
20024.
The committee believes educational reform
cannot happen without overall cultural reform.
Panelist William Stead, Vanderbilt University,
said at the summit:
I think what we have to do is to
require that our academic health-
science centers become models of
the type of clinical services that we
want. I don't think we can expect
people to learn to practice
differently in a place that's run the
old way (Stead, 2002~.
The committee believes that initial support
should be given to existing exemplary practice
organizations including innovative academic
health centers, that are already providing the
interdisciplinary education and training
necessary for staff to consistently deliver care
that incorporates the core competencies.
Further, the committee believes that these
leading organizations should be identified as
training models for other organizations, and
should be given the resources necessary to test
alternative approaches to providing curricula
that integrate the core competencies. Such
organizations should be encouraged to expand
their efforts by opening their doors to other
students, faculty, and clinicians. Emphasis
should be given to all three populations,
although approaches will differ depending upon
which is targeted at any given time. In light of
the evidence that faculty shortages and lack of
preparedness are barriers to integrating the core
competencies (Griper and Danoff, 2000;
Halpern et al., 2001; Weed and Weed, 1999),
faculty development should be a key focus of
such centers. Summit participants also echoed
the importance of faculty development (see
Appendix C).
These exemplary organizations should serve
as models for other practice and educational
institutions as they seek to incorporate the core
competencies into their curricula. They can
help answer key operational questions, such as
whether problem-based learning is the best
approach to teaching these competencies, or
other approaches would be preferable; which of
these competencies might be taught by
interdisciplinary teams in mixed settings and
which discipline-by-discipline; and in terms of
staging, when these competencies should be
taught to students. These learning centers
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RECOMMENDATIONS FOR REFORM
should also consider how to develop a
sustainable business model, so that after an
initial investment they could become self-
sustaining in 3-5 years. Such a model might
include provision of health care services or
require training of outside clinicians and
faculty.
There is precedence for focusing on
learning centers that span occupations. For
example, in health care there are examples of
area health education centers that train a broad
range of professionals with support from
HRSA, while in other sectors, such as the airline
industry, there are more comprehensive training
efforts (O'Neil and the Pew Health Professions
Commission, 1998~. These learning
organizations could provide centralized
locations for information technology
infrastructure, which would be an efficient way
of aggregating costs across many organizations.
Examples of the kinds of information
technology that could be housed by these
organizations include patient simulators and
decision support tools incorporating electronic
patient records and access to clinical databases.
Recommendation 6: Foundations, with
support from education and practice
organizations, should take the lead in
developing and funding regional
demonstration learning centers,
representing partnerships between
practice and education. These centers
should leverage existing innovative
organizations and be state-of-the art
training settings focused on teaching and
assessing the five core competencies.
There are many barriers to incorporating the
five competencies into the practice
environment, where medical residents and new
graduates in nursing, pharmacy, and allied
health obtain initial real-life training that leaves
an important imprint on their future practice.
Further, studies have shown that if there is too
much of a disconnect between what is learned in
school and the initial practice norms
encountered, new graduates and residents
become disheartened and cynical (Davis et al.,
2001~. In addition tothebarriersoftime
constraints, oversight restrictions, resistance
from the professions, and absence of political
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HEALTH PROFESSIONS EDUCATION
In addition to developing a better evidence
base related to the competencies, it is important
to assess how such competencies are taught.
Evidence suggests that the traditional methods
and approaches for teaching students and
practicing clinicians may not be effective. As
van der VIeuten et al. (2000) note, teaching is
dominated by intuition and tradition, which do
not always hold up when submitted to empirical
verification. Within many academic settings,
patient care and research are held to more
rigorous standards, with teaching being guided
more by personal beliefs and opinions and less
by scholarly inquiry, evidence, and professional
standards (Mennin, 1998~.
For example, studies have shown that
lecture-based teaching of isolated components,
the most common way of imparting information
in the academic setting, fails in that it does not
provide a way for students to integrate or apply
knowledge (Wass et al., 20014. Other
approaches, such as problem-based learning,
appear to engender more self-directed learning
and do a better job of providing students with a
way to integrate what they have already learned,
(Rideout et al., 2002; Juul-Dam et al.,2001;
Mennin, 1998) although some critics question
the rigor of such an approach. With problem-
based learning, embraced by approximately 100
medical schools (MedCases, 2002), students
work on problem-solving exercises in small
groups, actively applying their knowledge in a
meaningful context (The Commonwealth Fund,
2002~. Another educational approach that
allows students to apply academic knowledge to
practice is service learning, in which academic
coursework is integrated with relevant
community service. This approach also exposes
students to cultural diversity, helps develop
values, and fosters inductive reasoning (Hales,
1997; Callister and Hobbins-Garbett, 2000;
Davidson, 2002; Schamess et al., 2000~.
In the continuing education arena, the
education is mainly course-based, an approach
that has not been found effective in imparting
new knowledge to existing practitioners. There
also is no consistent evidence that problem-
based learning in continuing education is
superior to other educational strategies (Smite et
al., 2002~.
The leaders of U.S. health professions
education may learn from recent European
initiatives to develop the evidence base for
education. One outcome of these initiatives is
best-evidence medical education, which
operates on two levels:
· What is taught: Development of an evidence
base related to key competencies required in
the practice environment, focusing on their
relationship to quality.
· How it is taught: Reform of educational
methods and practices based on available
evidence about what works, and further
development of the evidence base on the
effectiveness of educational interventions.
The committee believes the time has come
to focus energy and resources on developing a
more robust and compelling evidence base
about what educational content matters for
patient care and what works in teaching
clinicians so that educators, payers, and
regulators can assess objectively what needs to
be emphasized in the health professions
curricula and what should be eliminated.
Specific research areas should include a focus
on particular dimensions of patient-centered
care and interdisciplinary teams and their link to
patient health, as well as on comparison of
traditional approaches to evidence-based
education. The research should also span
disciplines.
Recommendation X: The Agency for
Healthcare Research and Quality
(AHRQ) and private foundations should
support ongoing research projects
addressing the five core competencies and
their association with individual and
population health, as well as research
related to the link between the
competencies and evidence-based
education. Such projects should involve
researchers across two or more
disciplines.
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RECOMMENDATIONS FOR REFORM
The committee further believes that if the
vision of health professions education
articulated in this report is to become a reality,
ongoing monitoring of the effort will be
required, and education-related measures will
eventually need to be incorporated into national
and regional quality-reporting efforts. The
committee views this approach, which may be
characterized as relatively market oriented, as
complementary to the oversight approach, but
less well developed at present.
The lack of standardized information about
the quality of clinical education makes the job
of leaders seeking to reform education that
much more difficult. This lack of standardized
measures also sets clinical education apart from
the broader health care quality movement, in
which such measures have affected where
health care organizations channel their
resources. A ranking for example,byNCQA
regarding health plan quality or by U.S. News
and WoricI Report regarding hospitals forces
leaders to focus their attention on improving
performance on a given set of comparable
metrics (National Committee for Quality
Assurance, 2002; U.S. News and World Report,
20024. The National Healthcare Quality Report
Card, anticipated for release by the Agency for
Healthcare Research and Quality in 2003 and
annually thereafter, will likely serve to further
standardize quality measurement across all
health sectors and focus attention on the
strengths and weaknesses of the current system.
Yet no education-related measures are
anticipated for inclusion in this first annual
report (Agency for Health Care Research
Quality, 2002~. Such information might drive
clinicians to improve and patients to demand
improvement (Calvin, 2002; Institute of
Medicine, 20024. While the committee
acknowledges that there is still limited evidence
about the link between health professionals'
competencies and quality, a focused effort to
develop education-related measures must begin
now, given the amount of time required to
develop and test prospective measures before
they can be incorporated into report cards. The
committee recognizes that initially there will be
a small number of measures ready for public
reporting.
Recommendation 9: AHRQ should work
with a representative group of health
care leaders to develop measures
reflecting the core set of competencies, set
national goals for improvement, and issue
a report to the public evaluating progress
toward these goals. AHRQ should issue
the first report, focused on clinical
educational institutions, in 2005 and
produce annual reports thereafter.
Providing Leadership
Significant reform in health professions
education is a challenge to say the least. The
oversight framework is a morass of different
organizations with differing requirements and
philosophies, now under considerable pressure
to demonstrate greater accountability (Batalden
et al., 2002; O'Neil and the Pew Health
Professions Commission, 1998~. In academia,
deans, department chairs, residency directors,
and other leaders face a stream of requests for
adding new elements to a curriculum that is
already overcrowded. Shortages of key
professionals, such as nurses and pharmacists,
are another significant challenge. Moreover,
funding for some academic health centers has
been under pressure, and states are facing
budget shortfalls that are causing them to trim
education budgets, including funding for
universities and community colleges (Griper
and Blumenthal, 19984. In most academic
health centers, education has become secondary
to the operational needs of the institution's
research and clinical missions (Enarson and
Burg, 1992), with little reward provided for
teaching (Cantor et al., 19934.
When change happens in health professions
education, it does not happen overnight.
Multiyear processes are required to develop,
review, and achieve consensus on new
requirements or methods before they can be
implemented (Batalden et al., 2002~. For
example, to implement new accreditation
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HEALTH PROFESSIONS EDUCATION
standards, accreditors need to go through a
lengthy process of development that may take 2
years or longer and requires substantive input
and discussion. The standards must be tested to
see whether they achieve the stated objective
(Gelmon, 19964. Once the standards have been
finalized, they must be phased in over a 3-year
period or longer. Within institutions, changing
course requirements in response to new
accreditation requirements may take many
years, and often involves a highly charged
political conflict within and across departments
and disciplines.
Given this environment, the committee
believes that reform of health professions
education will be possible only through the skill
and dedication of a broad set of health care
leaders from the professions, educational
institutions, and oversight bodies, among others.
A review of the literature underscores the
importance of leadership. One analysis and
synthesis of 44 curriculum reform efforts
revealed that leadership is the factor most often
cited as affecting the success of such efforts
(Bland et al., 20004. The authors also note the
importance of five other factors critical to
curriculum change a cooperative climate,
participation by organization members, human
resource development, a manageable political
environment, and ongoing evaluation of the
effort and conclude that leadership is the
pivotal element in success, as leaders control or
substantially influence all the other factors
(Bland et al., 20004. Other studies also confirm
the centrality of leadership (Mennin, 1998~.
Box 6-6 describes some noteworthy examples
of interdisciplinary leadership.
Consequently, the committee believes that
to maintain momentum for reform in clinical
education, there will need to be biennial
summits at which leaders who have
demonstrated a real commitment to
implementing the committee's overarching
vision can gather. These summits should serve
as a forum for taking stock including
reviewing education-related performance
measures and, over time, related trends against
goals and defining future plans. There should
be a written report issued from the summit that
captures such information and communicates it
more broadly to the field.
Recommendation 10: Beginning in 2004,
a biennial interdisciplinary summit
should be held involving health care
leaders in education, oversight processes,
practice, and other areas. This summit
should focus on both reviewing progress
against explicit targets and setting goals
for the next phase with regard to the five
competencies and other areas necessary
to prepare professionals for the 21St-
century health system.
136
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RECOMMENDATIONS FOR REFORM
Conclusion
The committee has set forth 10 major
recommendations for reforming health
professions education to enhance quality and
meet the evolving needs of patients. Each of
these recommendations focuses on ways of
integrating a core set of competencies into
health professions education. Taken together,
they represent a mix of approaches related to
oversight processes, the practice environment,
research, public reporting, and leadership.
The staging ofthese recommendations is
important. The first step is to articulate
common terms so that shared definitions can
inform interdisciplinary discussions about core
competencies. Once the disciplines have agreed
on a core set of competencies, public and
private oversight bodies can consider how to
incorporate such competencies into their
processes providing a catalyst for many
educational institutions and professional
associations, as well as support for those who
have already moved toward adopting a
competency-based approach. The committee
believes that the development of common
language and definition of core competencies
should happen as rapidly as possible and by no
later than 2004, given that the integration of
core competencies into oversight processes will
take considerable time, perhaps a decade or
more if the efforts of ACGME and ACPE are
any guide.
As the work of integrating core
competencies into oversight processes proceeds,
the efforts of leading practice and education
organizations to provide a training environment
that integrates the core competencies into care
delivery should be fostered through regional
demonstration learning centers and Medicare
demonstration projects. Simultaneously with
these efforts, AHRQ and private foundations
137
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HEALTH PROFESSIONS EDUCATION
should provide support for research focused on
the efficacy of the competencies and
competency education and, most important,
develop a set of measures reflecting the core set
of competencies, along with national goals for
improvement. Given that the committee calls
upon AHRQ to issue a first report on health
professions educational institutions by 2005,
albeit with a limited number of initial measures.
efforts related to reporting must begin
immediately. Finally, the committee believes
that biennial summits of health care leaders who
control and shape education starting in
2004 will be an important mechanism for
integrating and fi~rther~ng the efforts of those
developing measures, practice and education
innovators, researchers, and leaders Tom
oversight organizations.
The committee is confident that its
recommendations are both sound and feasible to
implement because they are supported by a
literature review, and informed by a broad range
of leaders who shape education both directly
and indirectly. Building a bridge to cross the
quality chasm in health care cannot be done in
isolation. The committee hopes that this report
will jump start other efforts to reform clinical
education, both individually and collectively, so
that it focuses on continually reducing the
burden of illness, injury, and disability, with the
ultimate aim of improving the health status,
functioning, and satisfaction of the American
people (President's Advisory Commission on
Consumer Protection and Quality in the Health
Care Industry, 19984. The public deserves
nothing less.
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Representative terms from entire chapter:
professions education
