Establishing Transdisciplinary Professionalism for Improving Health Outcomes: Workshop Summary (2014)

6

Making It Real

To better understand how individual members of the forum viewed the notion of an open dialogue between health professionals and the public—which includes patients and care givers—forum members and other workshop participants were separated into four small groups. Each group looked at the issue of transdisciplinary professionalism from a different perspective. The perspectives were as follows:

• Group 1: Patient and Community Roles
• Group 2: Accountability and Leadership
• Group 3: Health and Well-Being
• Group 4: Economic and Physical Infrastructure

The groups were assigned leaders who facilitated discussions on the basis of case studies that enabled an exchange of ideas and experiences from a multidisciplinary perspective. In these groups, opinions were shared about the feasibility of bringing health professionals and the public together and what the mechanisms and requirements might be for accomplishing that goal. Four small-group participants were asked to report back to the larger

forum membership their views that were informed by their group’s discussions. The speakers included

• Meg Gaines, Group 1
• Catherine Grus, Group 2
• Mary Jo Kreitzer, Group 3
• Susan Chimonas, Group 4

Table 6-1 provides a summary of their views. The views are then described in greater detail in the sections below.

HOLDING HEALTH PROFESSIONALS ACCOUNTABLE BY PATIENTS AND SOCIETY

Patient and Community Roles in Transdisciplinary Professionalism

Meg Gaines from the Center for Patient Partnerships at the University of Wisconsin Law School provided comments on her group’s discussions on the patient and community roles in transdisciplinary professionalism. In her remarks, she discussed the power imbalances between health professionals and individuals and between health professionals and communities. This discussion influenced the way the individual participants in her group thought about whether diverse health professionals could be held accountable for their collective actions by patients and society. The first obstacle, she said, was defining who would be included within patients and society. But assuming a group could be assembled, Gaines added, the group identified three ways in which patients and society could hold health professionals accountable.

The first way was to use community group assessments. She provided an example from India, where patient groups assess all aspects of health care delivery institutions and report on how well organizations are delivering care. For this effort to be successful, however, there would have to be transparency that allows for mutual understanding of the challenges that providers and users of the health care system face. Gaines reported that by involving patients in assessment programs, individuals begin to understand the difficulties involved with delivering health care effectively. Conversely, patient involvement in assessments helps health professionals begin to understand the challenges faced by communities and individuals as members of that community. As a result, providers become more compassionate, and patients become active participants in their own care. The second way in which society could hold the health professionals accountable was through the acquisition of knowledge. Specifically, patients could learn about harmful and wasteful procedures and actions and begin speaking the truth to

TABLE 6-1 Four Individual Perspectives on Elements of Shared Social Contract^a

^a None of the answers to the questions should be construed as representing a group consensus but rather the individual viewpoints of the speakers.

decision makers. The third point was to start the conversation locally or regionally, build momentum, and ultimately develop a national dialogue.

Accountability and Leadership in Transdisciplinary Professionalism

Catherine Grus of the American Psychological Association presented on the constructs of accountability and leadership. A major theme that came up during her group’s discussions was whether a team could be held accountable versus an individual. She noted that although current structures such as insurance systems and the courts are unlikely to be considered team-based responsibilities, she thought there were models at the systems level, possibly through root-cause analysis that could address team functioning and could analyze how the team had contributed to a particular outcome. Another point brought up by Grus under the theme of accountability was the need for upfront structures that are transparent so the procedures are clear and everyone understands what is expected of them.

With that background, Grus then went on to describe the reactions of the individual participants in her group as to whether diverse health care professionals can be held accountable for the collective actions by patients and society. Basically, she expressed the view that in this culture, uncertainty exists about whether society had accepted the need for team-based care and whether the general public understood the concept well enough to act on it. Grus believed that this step would get society closer to being able to hold health professionals accountable. For this to work, reimbursement would also need to be redesigned from the individual focus of the past to reflect a new paradigm for team accountability. Many changes would need to be considered, including moving away from a culture of individual blame, enhancing communication, and helping individuals understand how the complexities of the health care system work.

Health and Well-Being in Transdisciplinary Professionalism

In setting the stage for her breakout group on health and well-being, Mary Jo Kreitzer from the Center for Spirituality and Healing at the University of Minnesota reported reviewing case studies that framed two issues. The first issue addresses work–life balance and a culture that supports the setting of boundaries, and the second involves the need for cultures that support the well-being of individuals as well as communities. According to Kreitzer, well-being includes not only health in all of its dimensions—physical, emotional, social, and spiritual—but also purpose. Purpose influences behaviors and decision making and directly impacts well-being. Relationships are also central to health and well-being, so a goal of health professional education is to foster an understanding of healthy relationships and the community that

nurtures and sustains its members. Safety and security are also fundamental to well-being because it cannot exist when individuals live in fear; whether it is organizational or found in some other form, fear immobilizes.

With this orientation to her group’s perspective, Kreitzer addressed whether diverse health professionals could be held accountable for their collective actions by patients and society. She responded with a qualified “yes,” adding that it all depends on the context and the circumstances. Her group discussed the balance of roles and responsibilities, both individually and collectively, and how these roles overlap with understanding the scope of practice, incentives and rewards, and accountability in the legal sense. Kreitzer also brought up financial reimbursement systems that are shifting to value-based contracts, which reward quality outcomes rather than providers for the volume of services performed. She emphasized that these new models are heavily nuanced and require agreed-on definitions of quality and quality metrics. In contrast, Kreitzer reported that one of her small-group participants from India said that in his country, a mistake is attributed to an individual, and he could never see an instance when such an error might be attributed to a team.

Economic, Physical, and Social Infrastructure for Transdisciplinary Professionalism

Susan Chimonas from Columbia University reported on the economic, physical, and social environment in which community members reside. She emphasized the importance of avoiding assumptions and engaging communities in decision making at all levels, particularly around infrastructure needs. This framing of the issues led to reluctance by her and her group members to consider a system of team accountability. Rather, she reported a preferred method that relies more on the acceptability of health care professionals and society to work together willingly.

HOLDING HEALTH PROFESSIONALS ACCOUNTABLE TO EACH OTHER

Patient and Community Roles in Transdisciplinary Professionalism

In considering whether diverse health professionals could hold each other accountable for decisions made collaboratively, Gaines emphasized the need to shift from a culture of blame to a culture of safety and mutuality. She cautioned, however, that organizational, legal, and financial barriers could impede such a shift. Financial issues driving a system that produces health care at a profit may be in conflict with a culture of maintaining safety and avoiding wasteful practices and procedures.

Gaines also identified mutual respect among professions as important. Respect involves how health professionals are treated and how they treat others within an organization, a delivery system, an academic medical center, or a university or other school. In thinking about reform, Gaines suggested that it could start by educating students across disciplines together from the beginning. In this way, different health professions gain a fundamental understanding of the added value of each team member. Gaines also pointed out that working by one’s self seems very lonely. Bringing even just two people together to work through a difficult situation is a powerful connection. This connection among team members, according to Gaines, could lead to a shared identity and mutual responsibility for outcomes. Students could be assessed by their team’s performance as well as by their individual knowledge, skills, and ability.

Accountability and Leadership in Transdisciplinary Professionalism

Grus, the leader of the Accountability and Leadership Group, expressed a sense that health professions should hold each other accountable. To get to that point, Grus suggested many of the elements that had been previously stated. There is a need for a culture shift away from blaming; power dynamics need to be addressed; the value system of each profession needs to be articulated; and a system of transparency needs to be set up from the start. She also identified a need to operationalize what efficient and effective health care teams would look like and how they would perform.

Health and Well-Being in Transdisciplinary Professionalism

In addressing the second question, that is, whether diverse health professionals could hold each other accountable for decisions made collaboratively, Kreitzer reflected on her group’s discussion. She raised the issue of reframing the question to ask whether the collective, which includes individuals, can be held accountable for decisions that are made collaboratively. Regardless of how the question is phrased, however, certain themes became apparent. First was the importance of “just culture” for improving safety and transparency. Just culture could move health professionals from a culture of blame to a culture of learning. But Kreitzer also acknowledged the issue of moral distress. In this instance, if a particular health professional feels ethically challenged or dissatisfied with his or her work environment, how might the other team members handle the situation, particularly if the norm is built around consensus decision making? In her group, Kreitzer speculated that there might be a circumstance where decisions were made that were not in the best interest of the patients or where perhaps patients and families had not been involved in conversations as they should have

been. Other key elements Kreitzer brought up involved information integrity and consensus decision making, both of which she believed would be important factors for this type of accountability to work.

Economic, Physical, and Social Infrastructure for Transdisciplinary Professionalism

Chimonas reported for her group that when holding other health professionals accountable, hierarchy or power would be a major factor. Another key element would be the ability to reach consensus. With such a diverse group of individuals that includes patients, she questioned whether consensus was possible. Moreover, if the team could reach a consensus, how well would it work for patients? Chimonas also brought up the notion of accountability and whether it implies trust and team support or whether it is about placing blame. This question invoked discussions in her breakout group about relational autonomy and whether the roles within an organization or a team are fixed or whether they are shaped by relationships with one another.

MEASURABLE ATTRIBUTES FOR TRANSDISCIPLINARY PROFESSIONALISM

Patient and Community Roles in Transdisciplinary Professionalism

In looking at what specific, measurable attributes organizations and training programs should exhibit to create and support the preparation of health care providers, patients, and communities for transdisciplinary professionalism, Gaines put a “changing culture” first. By changing culture, she said, patients are at the center of care and systems and should be encouraged to lead and guide the process. For education and training, learning should take place with other professions while doing real work that engages patients as teachers.

Gaines drew on her experience as a lawyer in describing a central attribute of a contract known as “consideration.” With this, both people entering into the contract have to offer something of equal value in order to have a valid contract. Gaines encouraged the forum members to consider what value patients bring to the contract. In her opinion, the patient’s or society’s role in a social contract would need to be more than just a promise of respect and financial rewards. It might involve restructuring the current “expert” model of care that assumes one party has all the knowledge. The redesign could start by accepting that patients have expertise that is critical to the mission or the goal of the team. That may be a starting place for what patients have to bring to their side of the social contract.

A final measurable attribute suggested by Gaines involved collaborative leadership. The collaboration would fully engage patients and community members in the leadership of academic institutions, academic medical centers, and other organizational care delivery centers. Academic center chief executive officers (CEOs) would be held accountable for making contact with community CEOs at the highest level, and, for success, there must be accountability for linking communities with health delivery organizations.

Accountability and Leadership in Transdisciplinary Professionalism

On the basis of the discussions in her group, Grus reported that transparency was at the top of the list for organizations and training programs addressing transdisciplinary professionalism. Also important were getting patients’ views as a result of providing them with data and establishing a common terminology. She expressed a desire to target interventions at the systems level mainly to deal with such issues as the hidden curriculum to prevent students from internalizing negative attributes from poor role models. And she underscored the importance of involving the community and patients. A main challenge to implementing transdisciplinary professionalism in the workplace is the reimbursement system that focuses on individual diseases and procedures while transdisciplinary professionalism embraces a holistic approach to the individual.

Health and Well-Being in Transdisciplinary Professionalism

In looking at the third question of measurable attributes, Kreitzer brought up a discussion from her breakout group that stressed the importance of education and training. Education and training are core to health and well-being, she said, adding that addressing content areas is similarly critical. In her view, the content could include self-awareness, self-care, health and well-being, leadership, courageous conversations, communication, health policy, the role of other health care professionals, just culture, and the whole notion of the importance of letting go of ego. Another important point she emphasized was respectful and courageous leadership.

Economic, Physical, and Social Infrastructure for Transdisciplinary Professionalism

On the basis of her group’s discussion, Chimonas commented for her group that embedding teamwork into the daily operations of an organization would create opportunities for people to come together and share their values. For this to work, a common language would have to be agreed on that allowed the team to communicate about important issues. Chimonas

reiterated that team responsibility is not about placing blame; rather, it is characterized by everybody coming together to understand what went right and what went wrong, or “just culture.” The shared goal is trust to gain understanding and reduce future errors.

LEADING THE CHARGE

Forum members were asked to reflect on who or what organization might create a forum for health professionals, patients, and other key stakeholders to begin creating an explicit and shared social contract for the health professions. There was a suggestion that the Institute of Medicine (IOM) could fill this role, although the suggestion was met with some resistance. One participant admitted to being in strong opposition to the idea. In her view, the work of the IOM is primarily at the policy level, and she could not envision the IOM constructing a meaningful dialogue at the level of the community or the individual patient or provider. Although Sally Okun from PatientsLikeMe agreed, she also thought that the conversation needs to begin and that the IOM is a place where a conversation can begin. She added that the IOM has a lot of convening power but was concerned about the potential uneven distribution of representatives from the patient community. She also expressed concern about the funding. She said that a funder was needed for this because there cannot be an expectation that people who are giving care will volunteer their time.

Jordan Cohen, a co-chair of the Global Forum, suggested that possibly Consumer Reports could be a place to begin the conversation. The organization is increasingly interested in health, and it is the voice of the public. Matthew Wynia, co-chair of the workshop planning committee, agreed and added that what he likes about using Consumer Reports is that its leadership understands innovation. Holding focus groups to gather information is not the same as convening leaders who can turn conversation into action.

Forum member Lucinda Maine, who represents the American Association of Colleges of Pharmacy, encouraged the other members to consider engaging specific groups that are already motivated to work together around a particular disease or concern like Alzheimer’s. In her view, groups of caregivers and clinicians who are motivated to rally around a specific disease are already in conversation. It would not be unrealistic to bring the providers into a conversation with caregivers and patients about forming a common language that could lay the foundation for a shared social contract. But it would be a social contract in the context of their care and social service delivery system. Their output could possibly form the basis for a national or international debate around a social contract. The initial conversation, said Maine, would have to begin locally.

Although forum member Madeline Schmitt, representing the American Academy of Nursing, saw value in such an activity, she reminded the members that this forum is focused on health professional education. She expressed a desire to link efforts on establishing a social contract to innovations in education. In her opinion, organizational competencies could be developed to assess whether organizations are creating practice climates that support the hypothesized shared social contract. This would be separate from teaching competencies for students. The organizations would look at their own environments and determine whether they support the notion of a shared contract of trustworthiness across all the professions.

Richard Murray, the dean of the School of Medicine and Dentistry at James Cook University in Australia, agreed with this key point, saying that many discussions take place about addressing ethical behavior and teamwork, but unless the talk gets turned into action through reform and structural redesign, then such dialogue will have the same fate as the Travistock meeting. The Travistock meeting, which Maine had mentioned, was a remarkable gathering of high-level people from many organizations who established a set of shared ethical principles that were never able to be operationalized. To avoid this same fate, Murray believed that one needed to address the question of how to set up structures within organizations that institutionalize engagement and reflection and provide opportunities for authentic partnerships. This would open opportunities for people to think differently about how they are allowed and encouraged to build authentic partnerships with community stakeholders.

LOOKING FORWARD

A tremendous gap cited throughout the workshop is the paucity of effective role models that demonstrate the positive attributes of a healer that was cited by Sylvia Cruess; the effective team communication that was noted by Susan McDaniel; and the balanced living that was brought up by Juanita Bezuidenhout. According to Bezuidenhout, some leadership strategies have emerged that are crucial for health teams and for strong health professions education. Part of this strategy needs to include role models and mentoring to become a leader while also being aware that as a role model and a mentor there is a responsibility to develop the next generation of leaders and that negative role models can suffocate learners and those around them. This is why Bezuidenhout emphasized the need for role models and structured mentorship program.

George Alleyne also emphasized the value of good role models, saying that education would benefit from the formal incorporation of mentoring and role model exposure rather than relying on the often random opportunities that make up the current system. In his belief, the mentoring and

following of the role models does the most to engender the formal relationship with the patients, with other health workers, and with the society that has to be the bedrock of good health care.

As Dave Chokshi from the next-generation session commented, a shared social contract is about being held accountable both to the patients and to the communities that health professionals serve. This, he believes, means integrating the patient’s values into the clinical processes. From the patient and caretaker perspective, Judith Miller Jones thought a social contract is not necessarily about making the medical decisions herself but about being part of the team that makes the decisions together. And as Maria Tassone, who corepresents the Canadian Interprofessional Health Leadership Collaborative (CIHLC) of the forum, said, their community engagement strategies are grounded in the recognition that local, social, and physical environments fully influence what works and how solutions must be tailored to be effective in particular contexts. The CIHLC program is all about collaborative leadership, but, she added, social accountability and community engagement principles are the anchors of their work. CIHLC members are convinced that these principles, which are reflected in the social contract, will help individuals go beyond self-interest and assist them in reaching a sense of collective intelligence and shared accountability.

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