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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

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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

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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

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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~. 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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 certificationwould 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 127

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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, 128

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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: 129

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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 130

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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 131

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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. 134

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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 135

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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. References ABIM Foundation. 2002. Medical professionalism in the new millennium: A physician charter. Annals of Internal Medicine 136 (3~:243-46. Accreditation Council for Graduate Medical Education. 2002. "ACGME Outcome Project." Online. Available at http://www.acgme.org/ outcome/about/faq.asp [accessed Aug. 27, 20023. Agency for Healthcare Research and Quality. 2002. "NHQR Preliminary Measure Set." Online. Available at http://www.ahrq.gov/qual/nhqrO2/ nhqrprelim.htm [accessed Fall, 20023. American Association of Colleges of Nursing. 1995. Interdisciplinary Education and Practice. California: AACN. American Board of Medical Specialties. 2000. "Recertification and Time-Limited Certification." Online. Available at http://www. abms. org/Downloads/General_Requirements/ Table6.PDF [accessed Nov., 20023. American Council on Pharmaceutical Education. 2002. "ACPE Web site." Online. Available at www.acpe.edu [accessed May 1, 20023. American Nurses AssociationdNursingWorld.Org. 2001. "On-line Health and Safety Survey: Key Findings." Online. Available at http:// nursingworld.org/surveys/keyfind.pdf [accessed 20023. Armstrong, E.G., and J.W. Barron. 2002. Issues and Strategies for Reforming Professional Culture: Lessons from the Health Professions and Beyond. IOM Commissioned Background Paper Bailit Health Purchasing. 2002. Provider Incentive Models for Improving Quality of Care. Washington, DC: National Health Care Purchasing Institute. Baker, R. 2002. ""Crossing the Quality Chasm: Next Steps for Health Professions Education"; Panel Discussion." Online. Available at http://www. kaisernetwork. org/health_cast/hcast_index. cam? display=detail&hc=601 [accessed Nov. 12, 20023. Bashook, P.G., S.H. Miller, J. Parboosingh, and S.D. Horowitz. 2000. "Credentialing Physician Specialists: A World Perspective." Online. Available at http://www.abms.org/Downloads/ Conferences/Credentialing/020Physician/O 20Specialists.pdf [accessed Sept. 15, 20023. Bashook, P.G., and J. Parboosingh. 1998. Continuing medical education: Recertification and the maintenance of competence. British Medical Journal 316 (7130) :545 -48. Batalden, P., D. Leach, S. Swing, H. Dreyfus, and S. Dreyfus. 2002. Generalcompetencies and accreditation in graduate medical education. Health Affairs 21 (54:103-11. 138

OCR for page 121
RECOMMENDATIONS FOR REFORM Belfield, C., H. Thomas, A. Bullock, R. Eynon, and D. Wall. 2001. Measuring effectiveness for best evidence medical education: A discussion. Medical Teacher 23 (24: 164-70. Berenson, B. 2002. ""Crossing the Quality Chasm: Next Steps for Health Professions Education"; Panel Discussion." Online. Available at http:// w w w . k a i s e r n e t w o r k . o r g / h e a 1 t h _ c a s t / hcast_index.ctm?display=detail&hc=601 [accessed Nov. 12, 20023. Bland, C.J., S. Starnaman, L. Wersal, L. Moorhead- Rosenberg, S. Zonia, and R. Henry. 2000. Curricular change in medical schools: How to succeed. Academic Medicine 75 (64:575-94. Branch, W.T., Jr. 2000. Supporting the moral development of medical students. Journal of General Internal Medicine 15 (74:503-8. Buckingham, C.D., and A. Adams. 2000. Classifying clinical decision making: A unifying approach. Journal of Advanced Nursing 32 (4~:981-89. Burack, J.H., D.M. Irby, J.D. Carline, R.K. Root, and E.B. Larson. 1999. Teaching compassion and respect: Attending physicians' responses to problematic behaviors. Journal of General Internal Medicine 1 4 ~ 1 ): 49-5 5. Busari, J., A. Scherpbier, C. Van der Vleuten, and G. Essed. 2000. Residents perception of their role in teaching undergraduate students in the clinical setting. Medical Teacher 22 (44:348. Byrd, G. 2002. Can the profession of pharmacy serve as a model for health informationist professionals? Journal of Medical Library Association 90 (1~:68-75. Callister, L.C., and D. Hobbins-Garbett. 2000. Enter to learn, go forth to serve: Service learning in nursing education. Journal of Professional Nursing 16 (3~: 177-83. Cantor, J.C., L.C. Baker, and R.G. Hughes. 1993. Preparedness for practice. Young physicians views of their professional education. JAMA 270 (94:1035-40. Carraccio, C., S.D. WolLsthal, R. Englander, K. Ferentz, end C. Martin. 2002. Shifting paradigms: From flexner to competencies. Academic Medicine 77~5~:361-67. Center for the Health Professions University of California San Francisco. 2002. "Leadership Initiative for Nursing Education (LINE). " Online. Available at http://www.futurehealth. ucsf.edu/line.html [accessed Nov., 20023. Centers for Medicaid and Medicare Services. 2002. "Program of All Inclusive Care For the Elderly (PACE)." Online. Available at http://www.cms. hhs.gov/pace/ [accessed 20023. Chen, S.P., N.E. Ervin, Y. Kim, and S.C. Vonderheid. 1999. Competency in community- oriented health care. Instrument development. Evaluation and Health Professions 22~34:358- 70. Closs, S.J. and F.M. Cheater. 1999. Evidence for nursing practice: A clarification for the issues. Journal of Advanced Nursing 3 0 ~ 1 ): 1 0- 1 7 . Collier, S. March 2002. Workforce Shortages. Personal communication to Ann Greiner. Commission on Collegiate Nursing Education. 2002. "CCNE Accreditation." Online. Available at h t t p : I I w w w . a a c n . n c h e . e d u / A c c r e d i t a t i 0 n / [accessed 20023. Cooksey, J.A., K.K. Knapp, S.M. Walton, and J.M. Cultice. 2002. Challenges to the pharmacist profession from escalating pharmaceutical demand. Health Aff(Millwood) 21 (5~:182-88. Davidson, R. 2002. Coummunity-based education and problem solving: The community health scholars program at University of Florida. Teaching &Learning in Medicine 14 (34:178. Davis, B.E., D.B. Nelson, O.J. Sahler, F.A. McCurdy, R. Goldberg, and L.W. Greenberg. 2001. Do clerkship experiences affect medical students attitudes toward chronically ill patients? Academic Medicine 76 (8~:815-20. Davis, D. 2000. Clinical practice guidelines and the translation of knowledge: The science of continuing medical education. Canadian Medical Association Journal: 163 (10~: 1278- 79. Davis, D., M.A. OBrien, N. Freemantle, F.M. Wolf, P. Mazmanian, and A. Taylor-Vaisey. 1999. Impact of formal continuing medical education: Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? Journal of American Medical Association 282 (9~:867-74. Dechairo-Marino, A.E., M. Jordan-Marsh, G. 139

OCR for page 121
HEALTH PROFESSIONS EDUCATION Traiger, and M. Saulo. 2001. Nurse/physician collaboration: Action research and the lessons learned. Journal Nursing Administration 31 (54:223-32. Duffy, D. 2002. ""Crossing the Quality Chasm: Next Steps for Health Professions Education"; Panel Discussion." Online. Available at http://www. kaisernetwork. org/health_cast/hcast_index. cam? display=detail&hc=601 [accessed Nov. 12, 2002]. Enarson, C., and F.D. Burg. 1992. An overview of reform initiatives in medical education. 1906 through 1992. [Review] [22 refs]. Journal of American Medical Association 268 (94: 1141 - 43. Epstein, R.M., and E.M. Hundert. 2002. Defining and assessing professional competence. Journal of the American Medical Association 287 (24:226-35. Evers, G. 2001. Naming Nursing: Evidence-based nursing. Nursing Diagnosis 12(4~:137-42. Federation of State Medical Boards. 1998. "Maintaining State-Based Medical Licensure and Discipline: A Blueprint for Uniform and Effective Regulation of the Medical Profession. " Online. Available at http://www.fsmb.org/ uniform.htm [accessed Jan. 12, 20013. Ferrill, M.J., L.L. Norton, and S.J. Blalock. 1999. Determining the statistical knowledge of pharmacy practitioners: A survey and review of the literature 1. American Journal of Pharmaceutical Education 63 (3) Galvin, B. April 2002. Health Professions Education. Personal communication to IOM Committee. Gelmon, S.B. 1996. Can educational accreditation drive interdisciplinary learning in the health professions? Joint Commission Journal on Quality Improvement 22 (3~:213-22. Gifford, A.L., D.D. Laurent, V.M. Gonzales, et al. 1998. Pilot randomized trial of education to improve self-management skills of men with symptomatic HIV/AIDS. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 18 (2~: 136-44. Glick, T.H., and G.T. Moore. 2001. Time to learn: The outlook for renewal of patient-centred education in the digital age. Medical Education 35 (54:505-9. 140 Griner, P.F.M., and D.M. Danoff. 2000. Sustaining change in medical education. Journal of American Medical Association 283 (18~:2429- 31. Griner,P.,andD.Blumenthal. 1998. New bottles for vintage wines: The changing management of the medical school faculty. Academic Medicine 73 (6~:720-724. Guyatt, G.H., R.B. Haynes, R.Z. Jaeschke, D.J. Cook, L. Green, C.D. Naylor, M. Wilson, and W.S. Richardson. 2000. Users guide to the medical literature: XXV. Evidence-based medicine: Principles for applying the users guides to patient care. Journal of American MedicalAssociation 284~10~:1290-1296. Hafferty, F.W., and R. Franks. 1994. The hidden curriculum, ethics teaching, and the structure of medical education. Academic Medicine 69 (114:861-71. Hales, A.P.R. 1997. Service-learning within the nursing curriculum. Nurse Educator 22 (2~: 15- 18. Hall, P., and L. Weaver. 2001. Interdisciplinary education and teamwork: A long and winding road. MedicalEducation 35~9~:867-75. Halpern,J. 1996. The measurement of quality of care in the veterans health administration. Medical Care 34 (3~:55-68. Halpern, R., M.Y. Lee, P.R. Boulter, and R.R. Phillips. 2001. A synthesis of nine major reports on physicians competencies for the emerging practice environment. Academic Medicine 76 (64:606-15. Harden, R.M. 2002. Developments inoutcome- based education. Medical Teacher 24 (24: 117- 20. Harmening, D.M. 1999. "Pioneering Allied Health Clinical Education Reform. A National Consensus Conference." Online. Available at ftp ://ftp.hrsa. gov/bhpr/publications/cerpdf.pdf [accessed Aug., 20023. Health Resources and Services Administration. 1999. Building the Future of Allied Health: Report of the Implementation Task Force of the National Commission on Allied Health. Rockville, MD: Health Resources and Services Administration. Higgs, J.P., A.M. Burn, and M.M. Jones. 2001.

OCR for page 121
RECOMMENDATIONS FOR REFORM Integrating clinical reasoning and evidence- based practice. Association of Critical-Care Nurses Clinical Issues: Advanced Practice in Acute & Critical Care 12 (44:482-90. Horder, J. 2000. Leadership in a multiprofessional context. Medical Education 34:203-5. Hundert, E.M., F. Hafferty, and D. Christakis. 1996. Characteristics of the informal curriculum and trainees ethical choices. Academic Medicine 71 (64:624-42. IDEATel. "Informatics for Diabetes Education and Telemedicine." Online. Available at http://www. ideal.org/info.html [accessed Sept. 12, 20023. Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, eds. Washington, DC: National Academy Press. . 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press. 2002. Leadership By Example. Washington, DC: National Academies Press. Johnson, J.A., and J.L. Bootman. 1997. Drug- related morbidity and mortality and the economic impact of pharmaceutical care. American Journal of Health-System Pharmacy 54 (5):554-58. Jordan, S. 2000. Educationalinput and patient outcomes: Exploring the gap. Journal of Advanced Nursing 31 (2~:461-71. Josiah Macy Jr. Foundation. 2002. "Leadership Training for Safety Net Hospitals." Online. Available at http://www.umassmed.edu/ externalwindow. ctm?URL=http :llwww. j o siahmacyfoundation. org/j macy 1. html&Link=http ://www.umassmed. edu/macy/ &DeptName=Macy/020Initiative/020in/O 20Health/020Communication [accessed Nov. 8, 20023. Juul-Dam, N.M., S.M. Brunner, R.M. Katzenellenbogen, M.M. Silverstein, and D.A. M.M. Christakis. 2001. Does problem-based learning improve residents self-directed learning? Archives of Pediatrics 155 (64:673- 75. Lang, N.M. 1999. Discipline-based approaches to evidence-based practice: A view from nursing. Joint Commission Journal on Quality Improvement 25 (10):539-44. Lavin, M.A., I. Ruebling, R. Banks, L. Block, M. Counte, G. Furman, P. Miller, C. Reese, V. Viehmann, and J. Holt. 2001. Interdisciplinary health professional education: A historical review. Advances in Health Sciences Education 6 (1~:25-47. Leach, D.C. 2002. Competence is a habit. Journal of the American Medical Association 287 (24:243-44. Lenburg, C. 1999. "Redesigning Expectations for Initial and Continuing Competence for Contemporary Nursing Practice. " Online. Available at http://www.nursingworld.org/ojin/ topic 10/tpclO_l.htm [accessed Aug. 19, 20023. Lenburg, C., R. Redman, and P. Hinton. 1999. "Competency Assessment: Methods for Development and Implementation in Nursing Education." Online. Available at in cabinet [accessed Mar. 19, 20023. Luttrell, M.F., C.B. Lenburg, J.C. Scherubel, S.R. Jacob, and R.W. Koch. 1999. Competency outcomes for learning and performance assessment. Redesigning a BSN curriculum. Nursing Health Care Perspectives 20 (34: 134- 41. Marwick,C. 2000. Willevidence-based practice help span gulf between medicine and law? Journal of American Medical Association 283 (21~:2775-76. Masys, D.R., P.F. Brennan, J.G. Ozbolt, M. Corn, end E.H. Shortliffe. 2000. Are medical informatics and nursing informatics distinct disciplines? The 1999 ACMI debate. Journal of American Medical Information Association 7 (3~:304-12. Maudsley, R.F. 2001. Role models and the learning environment: Essential elements in effective medical education. Academic Medicine 76:432-34 . Mazurek, B. 2002. Strategies for overcoming barriers in implementing evidence-based practice. Periatric Nursing 28 (2~: 159-61. MedCases. 2002. "Forces For Medical Education Curriculum Reform." Online. Available at http:// www.medcases.pdfs/pdf~agel.htm [accessed Oct. 27, 20023. 141

OCR for page 121
HEALTH PROFESSIONS EDUCATION Mennin, S., and S.P. Kalishman. 1998. Issues and strategies for reform in medical education: Lessons from eight medical schools. Academic Medicine (Supplement) 73 (9) Meyer, S. 19 December 2002. Health Professions Scholar. Personal communication to Ann Greiner. Mitchell, G. 1999. Evidence-based practice: Critique and alternative view. Nursing Science Quarterly Vol. 12,No. 1:30-35. Murray, E., L. Gruppen, P. Cation, R. Hays, and J.O. Woolliscroft. 2000. The accountability of clinical education: Its definition and assessment. Medical Education 34 (104:871-79. National Association of Boards of Pharmacy. 2002. "Examinations -- NAPLEX." Online. Available at http://www.nabp.net/ [accessed Aug. 10, 2002]. National Center for Healthcare Leadership. 2002. "Strategic Plan." Online. Available at in cabinet [accessed Aug. 30, 20023. National Committee for Quality Assurance. 2002. "What Does NCQA Review When It Accredits an HMO?" Online. Available at http://www. ncqa. org/Programs/Accreditation/MCO/ mcostdsoverview.htm [accessed 20023. National Council of State Boards of Nursing. 2000. "Nurse Licensure Compact." Online. Available at http: //www. no sb n . o rg/p ub l i c/ nurselicensurecompact/mutual_recognition.htm [accessed Aug., 20023. . 2001. "NCLEX - RN(~ Examination: Test Plan for the National Council Licensure Examination for Registered Nurses." Online. Available at http://www.ncsbn.org/public/ testing/res/NCSBNRNTestPlanBooklet.pdf [accessed Aug., 20023. National Institutes of Health. 2002. "National Institute of Health Web site." Online. Available at www.nih.gov [accessed May 13, 20023. National League for Nursing Accrediting Commission. 1999. " 1999 Standards and Criteria and Interpretative Guidelines." Online. Available at http://www.nlnac.org/Manual/O 20&%20IG/01_accreditation_manual.htm [accessed Aug. 14, 20023. OBrien, T., N. Freemantle, A.D. Oxman, F. Wolf, D. A. Davis, and J. Herrin. 2001. Continuing education meetings and workshops: Effects on professional practice and health care outcomes. Cochrane Database System Review (2~: CD003030. OConnor, G.T., S.K. Plume, E.M. Olmstead, J.R. Morton, C.T. Maloney, W.C. Nugent, F. Hernandez, Jr., R. Clough, B.J. Leavitt, L.H. Coffin, C.A. Marrin, D. Wennberg, J.D. Birkrneyer, D.C. Charlesworth, D.J. Malenka, H.B. Quinton, and J.F. Kasper. 1996. A regional intervention to improve the hospital mortality associated with coronary artery bypass graft surgery. The Northern New England Cardiovascular Disease Study Group. Journal of the American Medical Association 275 (114:841-46. ONeil, E. H. and the Pew Health Professions Commission. 1998. Recreating health professionalpractice for a new century - The fourth report of the PEW health professions Commission. San Francisco, CA: Pew Health Professions Commission. Parboosingh, J. 2000. Credentialing physicians: Challenges for continuing medical education. Journal of Continuing Education in the Health Professions 20pl88~34:3p. Partnership for Quality. 2002. "About PQE. " Online. Available at www.pqe.com [accessed 20023. Pomeroy, W.M., and I. Philp. 1994. Healthcare teams: An interdisciplinary workshop for undergraduates. Medical Teacher:6p. Prentice, T., and T. Bentley. 1999 . Counting on clinical terms: The Healthcare Intervention Aggregation project. British Journal of Healthcare Computing & Information Management 16~14:38-40. President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. 1998. "Quality First: Better Health Care for All Americans." Online. Available at http://www.hcqualitycommission.gov/final/ [accessed Sept. 9, 20023. Rideout, E., V. England-Oxford, B. Brown, F. Fothergill-Bourbonnais, C. Ingram, G. Benson, M. Ross, end A. Coates. 2002. A comparison of problem-based and conventional curricula in nursing education. Advances in Health Sciences Education 7:3-17. Saba, G.W. 2000. Preparing healthcare 142

OCR for page 121
RECOMMENDATIONS FOR REFORM professionals for the 21 st century: Lessons from chirons cave. Families, Systems & Health: The Journal of Collaborative Family Health Care 18 (34:353-64. Sackett, D. 1998. Finding and applying evidence during clinical rounds. Journal of American MedicalAssociation 280~154:1336-38. Safriet, B. 2002. Closing the gap between can and may in health-care providers scopes of practices. Yale Journal on Regulation 19 (24:301-34. Satya-Murti, S. 2000. Evidence-based clinical practice: Concepts and approaches. The Journal of American Medical Association 282 (174:2306-7. Schamess, A., R. Wallis, R.D. David, and Fiche. 2000. Academic medicine, service learning, and the health of the poor. American Behavioral Scientist 43 (5~:793-08. Shaver, J. 24 September 2002. Personal Conversation . Personal communication to Ann Greiner. Smits, P., J. Verbeek, and C. de Buisonje. 2002. Problem based learning in continuing medical education: A review of controlled evaluation studies. British Medical Journal 324 (7330) Stead, W. 2002. "Crossing the Quality Chasm: Next Steps for Health Professions Education; Panel Discussion." Online. Available at http://www. kaisernetwork. org/health_cast/hcast_index. cam? display=detail&hc=601 [accessed Nov. 12, 2002]. Superio-Cabuslay, E., M.M. Ward, and K.R. Lorig. 1996. Patient education interventions in osteoarthritis and rheumatoid arthritis: A meta- analytic comparison with nonsteroidal anti- inflammatory drug treatment. Arthritis Care Research 9 (4~:292-301. Swankin, D.S. 2002. Results of a Survey of Selected State Health Licensing Boards and Health Voluntary Certification Agencies Concerning their Continuing Competence Programs and Requirements. Washington, DC: Citizen Advocacy Center. The Commonwealth Fund. 2002. Training Tomorrows Doctors. Boston, MA: U.S. News and World Report. "Latest Hospital Rankings." Online. Available at www.usnews. com/usnews/nycu/health/hosptl/tophosp.htm [accessed Summer, 20023. United States Medical Licensing Exam. 2002. "United States Medical Licensing Examination - Steps 1, 2, 3." Online. Available at http://www. usmle.org/stepl/intro.htm [accessed Aug. 10, 20023. Von Korff, M., J.E. Moore, K.R. Lorig, et al. 1998. A randomized trial of a lay person-led self- management group intervention for back pain patients in primary care. Spine 23 (234:2608- 51. Wagner, E.H., R.E. Glasgow, C. Davis, A.E. Bonomi, L. Provost, D. McCulloch, P. Carver, and C. Sixta. 2001. Quality improvement in chronic illness care: A collaborative approach. Joint Commission Journal on Quality Improvement 27 (24:63-80. Wass, V., C. Van der Vleuten, J. Shatzer, and R. Jones. 2001. Assessment ofclinical competence. Lancet 357 (92604:945-49. Weed, L.L. and L. Weed. 1999. Opening the black box of clinical judgment. Part II: consumer protection and the patients role. British Medical Journal. November 13 Welch, H.G., and J.D. Lurie. 2000. Teaching evidence-based medicine: Caveats and challenges. Academic Medicine 75 (3~:235-40. Whittaker, S., W. Carson, and M.C. Smolenski. 2000. Assuring continued competence -- policy questions and approaches: How should the profession respond? Online Journal of Issues in Nursing: 18. Woolf, S.H. 2000. Taking critical appraisal to extremes: The need for balance ~n the eva~uat~on of evidence. Journal of Family Practice 49 (124:1081-85. 143

OCR for page 121