7

Moving Forward by Looking Back

Summary: This chapter captures the presentations of several speakers who reflected upon the ideas, presentations, and discussions offered at the two workshops. Workshop speakers Madeline Schmitt and Martha Gaines provided summaries that looked into recent and distant past experiences with interprofessional education (IPE) and considered present opportunities that could lead to future innovations in IPE and collaborative practice. In particular, Schmitt and others considered how examples from the 1960s and 1970s might inform today’s innovators. Barbara Brandt, the director of the new National Coordinating Center for Interprofessional Education and Collaborative Practice, is one such innovator who spoke about the center at the workshop. Her presentation is summarized here, followed by the final reflections of Martha Gaines. In her remarks, Gaines posed a series of provocative questions designed to stimulate thinking that might spark new ideas and create more innovations like those that resulted in the new National Coordinating Center.

REFLECTIONS

Workshop I

As a workshop planning committee member who was instrumental in helping plan the first workshop, Forum member Madeline Schmitt from the University of Rochester was well positioned to reflect upon that first meet-



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7 Moving Forward by Looking Back Summary: This chapter captures the presentations of several speak- ers who reflected upon the ideas, presentations, and discussions of- fered at the two workshops. Workshop speakers Madeline Schmitt and Martha Gaines provided summaries that looked into recent and distant past experiences with interprofessional education (IPE) and considered present opportunities that could lead to future in- novations in IPE and collaborative practice. In particular, Schmitt and others considered how examples from the 1960s and 1970s might inform today’s innovators. Barbara Brandt, the director of the new National Coordinating Center for Interprofessional Education and Collaborative Practice, is one such innovator who spoke about the center at the workshop. Her presentation is sum- marized here, followed by the final reflections of Martha Gaines. In her remarks, Gaines posed a series of provocative questions designed to stimulate thinking that might spark new ideas and cre- ate more innovations like those that resulted in the new National Coordinating Center. REFLECTIONS Workshop I As a workshop planning committee member who was instrumental in helping plan the first workshop, Forum member Madeline Schmitt from the University of Rochester was well positioned to reflect upon that first meet- 85

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86 INTERPROFESSIONAL EDUCATION FOR COLLABORATION ing. In her reflections Schmitt looked back at the workshop objectives to determine how well they had been addressed. Part of the first objective was “to engage in forward-looking dialogue.” Schmitt said that the workshop had effectively initiated those conversations. However, in thinking back, she said she sensed some tension as participants raised known challenges and as diverse opinions were offered about how educators and health professionals might address such challenges and take advantage of current opportuni- ties, particularly in the United States. Schmitt also said that she believed the participants embraced the second part of the first objective concerning the importance of aligning health professions education with the needs of clinical practice, consumers, and health care delivery systems. Schmitt then read the second objective, which was “to explore the opportunity for shared decision making, distributed leadership, and team- based care amongst other interprofessional education and practice inno- vations to fundamentally change health professions’ curricula, pedagogy, culture, human resources, and assessment and evaluation metrics.” In her opinion, she said, IPE per se was not as much a part of the general discus- sion as it might have been. However, she said, the breakout groups more adequately focused on IPE in the five areas noted in the objective. Then Schmitt read objective three, which was “to discuss how innovations in IPE will impact patient and population health as identified by the triple aim of better health, higher quality, and lower cost.” Again Schmitt said she thought that the workshop presentations and discussions did address this objective and that there were beginning conversations about how to think differently about measuring IPE and possibly reshaping the language. Schmitt shared two points that she said might help with future work- shop planning. First, would be the inclusion of a holistic, person-centered perspective. She noted that some of the workshop presenters had described useful tools that could help introduce or reintroduce this perspective into health professions education. The second would be to pay considerable attention to the many ways innovators address communities, population demands, and patient requirements within health care delivery systems when designing future workshop agendas. In this regard, Schmitt noted that one particular message—that service learning gets educators and health professionals into the community, and gets students into the community early—was touched on repeatedly throughout the workshop. But there was also the message that service learning is often disconnected from the clini- cal experiences that come after service learning. Judging from the Uganda experience with community-based IPE, she said, it seems to be within the third year that IPE drops off as students begin their clinical experiences. Judging from the Uganda experience with community-based IPE, she said, it seems to be within the third year that IPE drops off as students begin their clinical experiences.

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MOVING FORWARD BY LOOKING BACK 87 Schmitt then discussed what she had heard about institutional lead- ership; in particular, she noted that collaborative leadership is critically important in moving the IPE agenda forward. One of the most significant insights the workshop provided to her involved the larger political, eco- nomic, and cultural context within which educators and health profes- sionals are trying to work. For example, there were robust discussions at the workshop about moving toward social accountability as a broad framework for action. It was then that Schmitt realized the patient per- spective may not be getting adequate attention, particularly in the U.S. health care system. The U.S. health care system is benefitting financially from business models—including the business models of publicly traded health care corporations—that often are unfamiliar to many health educa- tors, researchers, and IPE innovators. The United States is now seeing the ultimate consequences of the economic and corporate imperative which ne- glects social accountability, Schmitt said, noting that the United States does have sufficient levels of primary care. After acknowledging comments from non-U.S. workshop participants who called primary care an “imperative,” Schmitt said that addressing this issue is not a simple process. She reflected on the United States in the 1960s and 1970s, when there also was a huge need for primary care, but, despite the need, neither a robust primary care system nor interprofessional education became a priority. Before Schmitt’s presentation, another workshop speaker had reminded the audience about the Declaration of Alma Ata (WHO, 1978). This was an attempt in 1978 to bring together health leadership from around the world to promote expansion of primary care and to propose what was called “health for all.” This document emphasized that health is more than simply the absence of disease; it also includes the most positive aspects of mental, physical, and environmental health (WHO, 1981). Although the expansion of primary health was certainly a laudable goal, as the participant pointed out, those who tried to move “health for all” concepts forward came to realize just how many challenges such an undertaking posed. In a similar vein, Forum member Maryjoan Ladden from the Robert Wood Johnson Foundation acknowledged the long history of IPE, of which Ladden has been an active proponent since the 1970s. Educators have been trying for a long time to institute IPE and although momentum is grow- ing, the many challenges have made it difficult. However, she said that she believes that the United States has a unique current opportunity to address neglected issues with the Affordable Care Act, the HRSA coordinated effort to develop a national clearinghouse, and the National Coordinating Center for Interprofessional Education and Collaborative Practice, which a group of funders has committed to supporting. It is also a good time, she said, to learn from the global conversations and the global partners in the Institute of Medicine Forum and to learn from the early adopters of IPE and collab-

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88 INTERPROFESSIONAL EDUCATION FOR COLLABORATION orative care models. In the end, Ladden said she would like to learn what additional evidence chief executive officers of health systems and other key stakeholders need to be convinced of the value of collaborative care and of IPE and also what evidence early adopters of IPE need to provide to others to convince them to move forward? Some of that evidence will likely come from the National Center for Interprofessional Practice and Education, initiated under Barbara Brandt. Although it was very early in the center’s development, Brandt presented a description of the center at the workshop. She spoke about the plans for the center and how the idea for it grew out of the concern over a growing gap between the changing U.S. health system and health professions edu- cation. The center will focus on training in team-based care that improves health and community outcomes, she said. The particular outcomes they are interested in are grounded in the Institute for Healthcare Improvement’s triple aim of improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care. The center will also be focusing on research and evidence to confirm the value added by its interventions. Box 7-1 offers a more detailed description of the center as described in Brandt’s presentation. Workshop II As the final speaker of the second workshop, Martha Gaines said she would like to provide new ways of looking at old problems. Gaines is not a health professional. Rather, she is a lawyer by training, a former public defender, and a law professor for the past 25 years on the faculty at the University of Wisconsin Law School. Half of the years at the law school were spent with a prison program training students to work with prison in- mates, and the other half were spent providing interprofessional education. Nineteen years ago, she had a harrowing experience when she was diagnosed with metastatic ovarian cancer and told to go home and think about the quality, not the quantity, of her remaining days. At the time, her two children were ages 3 years and 6 months. After surviving the cancer, Gaines got together with a nurse, a physician, and two other colleagues and founded the Center for Patient Partnerships, an interdisciplinary center of the schools of law, medicine, nursing, and pharmacy at the University of Wisconsin. Gaines has been its director since its founding. The center advocates for people with life-threatening and serious chronic illnesses and educates graduates and health professionals about health advocacy. This was the context within which Gaines provided her reflective comments. She started by saying, “If the 20th century was about thinking the world apart because we have such amazing machines with which to make everything smaller and more microscopic, then I think the 21st century must be about

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MOVING FORWARD BY LOOKING BACK 89 thinking it back together again.” Gaines said that it seems to her that this is the essence of IPE. It is “thinking the world back together again” so that the people who are meant to be served, namely patients and communities, can be something other than “the medication problem” that speaker Dennis Helling described. Gaines listed some questions that came to her during the workshop. These included • How does one approach working together when there is a lack of understanding about how the others work, what skills and knowl- edge they have, and what language they speak? • What is IPE? • How might it be known if IPE is delivering higher-quality and bet- ter care? • Are there other models than IPE that could accomplish the same goals as well or better? • Is there an ideal number of professions for IPE? • Are there any irreplaceable professions within IPE? • What is the minimum number of courses or programs needed to launch IPE? • What are the roles for academics and practitioners in design and implementation? • How is success defined? • What is the value added from work in IPE? • How has time for reflection been preserved? • How has progress with other professionals been made? • Who else needs to be part of the dialogue? • What do university leaders think of health sciences education? • Where are broader sources of support and resources? In reflecting upon the last question, Gaines wondered how educators could connect with other similar movements to IPE to initiate new inno- vations. Thinking in this way could open a range of new possibilities for funding and collaborations. Gaines also listed a number of important points that had particular resonance for her, as follows. Take the Time to Be Intentional When initiating IPE, take the time to form a mission and a vision, then share that mission and vision across interdisciplinary collaborations.

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90 INTERPROFESSIONAL EDUCATION FOR COLLABORATION BOX 7-1 Barbara Brandt, Ph.D. University of Minnesota Barbara Brandt of the National Center for Interprofessional Practice and Education started her talk by acknowledging Hugh Barr, who she said was instru- mental in transforming her thinking about IPE. In June 2008, Barr gave a presenta- tion about IPE in Stockholm at the All Together Better Health conference in which he spoke about IPE in a way that differed from the usual thinking at the time. It was this transformed thinking, Brandt said, that serves as the underpinning for the National Center. Brandt explained that most people who worked in IPE were focused on teamwork and the patient safety agenda. It was Barr, she said, who pushed people to consider how interprofessional education could have a major impact on workforce development. And by combining health systems transforma- tion with health professions transformation, interprofessional education could have an impact on both health and learning outcomes. Another thing that happened in 2008 was that the state of Minnesota passed health care reform and was very aggressively implementing it. This was particu- larly significant to Brandt at the University of Minnesota. She noted that Minnesota has 197 certified health care or patient-centered medical homes, accountable care organizations, and other similar institutions. What that is demonstrating is that a gap is developing between health systems, which are undergoing a transforma- tion, and health professions education in its current state. This was a message from Paul Grundy (the Global Director of IBM Healthcare Transformation) to the workshop participants that Brandt said she used as a focus of the National Center—the need for a more functional “nexus” between health systems and health professions education. The new nexus coming to team-based care, she said, focuses ultimately on improved health and community outcomes. The funded Health Resources and Services Administration (HRSA) proposal concentrated on the Institute for Healthcare Improvement’s “triple aim,” which consists of improving

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MOVING FORWARD BY LOOKING BACK 91 the patient experience of care, improving the health of populations, and reducing the per capita cost of health care. Brandt then clarified that HRSA set the baseline rules for the National Center. These rules included having focuses on leadership, scholarship, evidence, coordi- nation, and national visibility in order to advance interprofessional education and practice as a viable and efficient health care delivery model. It is a cooperative agreement, so she and her colleagues at the university are planning the center jointly with HRSA. HRSA is assisting Brandt by connecting the National Center with federal agencies that are working on health care reform, particularly the Cen- ter for Medicare and Medicaid Innovations, which has 104 projects being carried out throughout the United States. Another part of the work of the center involved HRSA’s mandate: to transform a siloed U.S. health care system and to create new health care organizations; to facilitate the preparation of a workforce that is fully prepared through structured training and exposure; and to operate as a neutral and unbiased convener among stakeholders in education, practice, and public policy. Because the primary funder for the center is HRSA, the center will focus on rural and underserved populations. As Minnesota’s director of the statewide network of area health education centers, Brandt has a consortium of practice partners that she characterized as being an important underpinning of the pro- posal. Another group that had a prominent part in her proposal was Minnesota’s Interprofessional Education and Collaborative Practice network, in which IPE is being implemented through the use of practice sites and the process of evaluating outcomes has begun. Evaluation was another key element in the proposal submit- ted to HRSA. The University of Minnesota has a fairly long history of evaluation through its Minnesota Evaluation Studies Institute. Brandt said that roughly 15 years ago the institute’s evaluators developed essential competencies for program evaluators that have been translated worldwide. These evaluation experts are now looking at the center’s vision to determine how their evaluation methods can be applied to interprofessional education and collaborative practice. Having reliable evaluation methods will be important as the center hopes to be a national innova- tion incubator for conducting research. This is extremely important to Brandt, who expressed her desire to get the metrics right. Brandt then described the methodology framework used in the proposal. There are significant, uncoordinated activities going on in interprofessional educa- tion and collaborative practice. In an attempt to improve coordination, the center will be a central repository for relevant information that can be used in part to develop standards, definitions, measures, and protocols. Brandt also hopes to use informatics to connect patient electronic records with education and practice modalities to possibly evaluate the impact of IPE and interprofessional practice (IPP) on patient outcomes. In her closing, Brandt described where she would like the center to be in 5 years. She envisions the center being connected with the world’s best thinkers about IPE and IPP, who are fully engaged in the National Center’s priority projects and who receive recognition for their work publicly across and within the professions. She wants public and private funders and partners to receive the highest return on investment possible. This includes making use of the latest technology and drawing conclusions from data that were collected and evaluated using rigorous evaluative processes. And finally, Brandt wants to see that the center makes significant contri- butions to improving health outcomes and to advancing the “triple aim.”

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92 INTERPROFESSIONAL EDUCATION FOR COLLABORATION Few Substitutes for Trusted Committed Leadership There is little substitute for passion and commitment by a person or people with vision. And when inspiration does not come from leadership, the people who have the passion and commitment will have to “manage up” to explain and demonstrate the value of IPE to their leadership. This can be done by sharing stories, gathering evidence, and building a network with other champions. Adverse Conditions Create Opportunities for Change Gaines pointed to the example from Ghent University’s medical school described earlier, when a bad evaluation was the needed spark for move- ment from a fragmented, discipline-based curriculum to what is now an integrated patient- and problem-based curriculum. Learn More About Culture Change Much has been written about disciplinary and cross-disciplinary culture (Dee Fink, 2003; Zajonc, 2008; Palmer, 2010), Gaines said. Learning more about culture change through the literature and from personal experiences will help students, educators, and professionals become more astute agents for positive cultural changes. Lack of IPE Measurements There is a lack of evidence, data, and proof of the value of IPE. Gaines emphasized that the value proposition—or the assessment of value—can be strengthened by including that which is not traditionally considered in the evaluation of the bottom-line cost–benefit equation. Such things might include workforce morale, patient satisfaction, a life well-lived, inspiration, or excitement about doing a job. Those are all things that could be inserted into the evaluation equation to get a better sense of the value of IPE and collaborative work. It Is Hard to Learn Publicly Gaines gave one description of teaching as “to learn publicly.” This is difficult to do and horribly embarrassing. Fear of others knowing that the expert is not the expert in all things can be a source of apprehension for those who are engaging in new processes, such as IPE. By establishing learning communities that bring together different professions across the continuum of education to practice to better understand IPE, could be an

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MOVING FORWARD BY LOOKING BACK 93 important leveler of hierarchies and a way of breaking free from conven- tional stereotypes. Create Value for the Learning Sites Gaines commented that speaker Mark Earnest had talked about “value- added learners.” If learning sites viewed students as adding value to their work, this would likely lead to more sustainable relationships between education and practice. It would also be better for students who gain from the experiential learning. Plagiarize with Pride Although educators do not like using the word “plagiarize” in aca- demia, Gaines said, it is generally accepted that in IPE educators should imitate the work of others rather than reinvent that which has already been tested. As an example, Gaines pointed to speaker Dawn Forman and others who talked about drawing on previous IPE efforts to come up with formulas that work at their own universities. Listen to Nontraditional Sources of Ideas and Innovation Gaines noted the creative interprofessional ideas that had been pre- sented at the workshop but had not come from faculty. In particular, she cited speaker Lloyd Michener, who commented that solutions are often driven by students. She also described the potentially underutilized value of others, such as front office staff and janitorial hospital workers. These nonprofessionals may be in a better position to connect with people and patients in a unique way, and this could be a tremendous resource for col- laborative work. Create and Protect Space to Reflect Gaines noted that some of the student presenters had commented that social interactions for establishing personal relationships are just as impor- tant for learning about other professions and cultures as the physical space and time to interact with the other health professions. IPE Is Best When It Is Memorable Gaines noted students’ comments about the value of memorable IPE that is interactive both professionally and personally and in which educa- tion and practice are linked.

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94 INTERPROFESSIONAL EDUCATION FOR COLLABORATION Harmonize Academic Calendars Harmonizing academic calendars could be one way to better ensure representations of more professions in IPE. At least one student, Gaines noted, had identified the absence of other health professional learners as an impediment to her IPE. IPE Is a High-Touch Learning Environment Several participants spoke of the need to engage educators beyond the faculty because IPE a high-touch learning environment. For example, Gaines said, speaker Rose Nabirye talked about how problems arise when the number of students is too high and not everyone gets access in a way that he or she believes is meaningful. Gaines closed her remarks by posing four questions to the workshop participants. The first involved engaging patients in designing, planning, evaluating, and promoting IPE. If patients think it is important to be in- volved with educating the next generation of health professionals—and assuming professionals do as well—then why is it still so rare for patients to be engaged across the continuum not just in IPE, but across education and across service delivery as well? Her second question was, “How should educators handle students who are not so enthusiastic about IPE?” Gaines suggested that maybe educators will have to make IPE a mandatory require- ment for graduation. But that assumes the interprofessional experience is intentionally grounded in the context of students’ lives, because it is when the experience is based in real-life practice that value is added to students’ education. The third question Gaines posed was “What holds educators and health professionals back from letting go of traditional models of care?” This may, she suggested, be tied to feelings of identity and a fear of losing the history and stories linked to professional heroes and heroines that make each pro- fession unique. Her fourth and final question was “Should a social mission be a mandatory part of health professions education?” Gaines thought that addressing social determinants of health would bring in additional disci- plines such as social work and law, which would lead to a wider impact on various health outcomes but would increase the complexity of the team possibly presenting new challenges in management for both the student and the IPE coordinator.

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MOVING FORWARD BY LOOKING BACK 95 Transformative Health Professional Education and IPE In his reflective comments on the workshop, Forum and planning committee member Jan De Maesaneer from Ghent University in Belgium commented that social accountability will lead to transformative health professional education and changes resulting in greater equity. At one point during the workshop, De Maesaneer was asked to define “transformative health professional education.” Although it is not easy, De Maesaneer said, he did attempt to come up a definition, and the result was as follows: Transformative health professional education is a process. It occurs when institutions for health professional education respond to the needs of the population through a series of socially accountable change actions aimed at three levels—the micro, the meso, and the macro. The micro level focuses on educational transformations to help prepare health care providers to practice more person- and people-centered care, combining appropriate knowledge and skills training in a process of self-directed caring, to what is reflective practice. The meso level involves interactions with health services, providers, and citizens in the community, including the establishment of community-based training complexes that emphasize those areas most in need—like deprived rural and urban environments. At the macro level, there would be active participation in processes of health policy development with special attention to human resources spending and contributions that make health systems worldwide increasingly based on relevance, equity, quality, cost effectiveness, system ability, person- and people-centeredness, and innovation. De Maeseneer’s definition of transformative health professional educa- tion had clear links to Paul Worley’s closing comments. In those comments Worley said he thought that the workshop had provided an excellent reflection on interprofessional education and that participants had discov- ered not only that cultures can change and practical bottlenecks should be overcome, but that interprofessional education is needed and that it is possible to make it happen now. He said that he had also learned that for this to be accomplished, there will need to be a transformative process that involves patients and populations, the educational system, and the health system; excellent examples exist that were described in this workshop for all to learn from. To find out more about the workshops discussed in this report, please visit the Global Forum on Innovation in Health Professional Education website at www.iom.edu/IHPEGlobalForum.

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96 INTERPROFESSIONAL EDUCATION FOR COLLABORATION REFERENCES Dee Fink, L. 2003. Creating significant learning experiences. Hoboken, NJ: Jossey-Bass. Palmer, P. 2010. The violence of our knowledge: Toward a spirituality of higher education. http://www.21learn.org (accessed March 12, 2013). WHO (World Health Organization). 1978. Declaration of Alma-Ata. Geneva: WHO. WHO. 1981. Global strategy for health for all by the year 2000. Geneva: WHO. Zajonc, A. 2008. Meditation as contemplative inquiry: When knowing becomes love. Aurora, CO: Lindisfarne Press.