Global transformation is occurring at an unprecedented pace. Soaring population rates, climate change, rapid urbanization, technological innovation, and globalization all are intersecting in ways that would have been unthinkable just a few decades ago. Such convergences have dictated the critical need for improved communication and collaboration at both the global and local levels.
Within health and health care, new and different types of collaboration are emerging among and between the providers of health, welfare, and social care (Frenk et al., 2010). Interprofessional teamwork and collaborative practice are becoming key elements of efficient and productive efforts to promote health and treat patients. This work involves health and/or social professions that share a team or network identity and work closely together in an integrated and interdependent manner to solve problems, deliver services, and enhance health. Patients, families, consumers, and communities have traditionally been excluded as integral members of such collaborations despite repeated calls for their inclusion (Cox and Naylor, 2013; Hibbard, 2003; Hibbard et al., 2005; Hovey et al., 2011; IOM, 2003, 2006; WestRasmus et al., 2012; WHO, 2010). Yet, they are all part of the broader health system that according to Murray and Frenk (1999) is driven by three intrinsic goals: health, responsiveness, and fairness in financing—more specifically, improving the health of the population and enhancing the responsiveness of health systems to such important nonhealth dimensions as respect for patients and families, consumer satisfaction, and affordability of all households’ contributions to the health system.
Effective interprofessional collaboration requires the alignment of values, skills, and resources toward attaining these goals (Cox and Naylor, 2013; Zwarenstein et al., 2009). In health care, this alignment not only results from a moral imperative to work together to combat a specific disease (e.g., cancer diagnosis and treatment) or public health crisis (e.g., the recent Ebola epidemic) but also increasingly, in western countries, is driven by concerns about the overall health of the population, the quality and safety of health care, and health care costs (IOM, 2000; Leonard et al., 2004; Nielsen et al., 2014; Reaves et al., 2014; Sands et al., 2008). Health care institutions around the world may have much to learn from sectors such as the airline industry that demonstrate effective implementation of teamwork for the purposes of minimizing errors and improving safety (Baker et al., 2006; de Korne et al., 2010; Helmreich et al., 1999; Manser, 2009; Shaw and Calder, 2008; WHO, 2009).
Inadequate preparation of health professionals for working together, especially in interprofessional teams, has been implicated in a range of adverse outcomes, including lower provider and patient satisfaction, greater numbers of medical errors and other patient safety issues, low workforce retention, system inefficiencies resulting in higher costs, and suboptimal community engagement (Epstein, 2014; IOM, 2003; WHO, 2010; Zwarenstein et al., 2009). But unlike other sectors—such as aviation, the military, and many for-profit corporations—that have been quick to integrate teamwork into their training, the health, welfare, and social care sectors often have been slower to implement team-based care and other models of collaboration, as well as the interprofessional education (IPE) that is necessary to support and improve collaboration (Baker et al., 2006; Miller et al., 2008; Salas and Rosen, 2013; Schmitt et al., 2011). This difference may be a reflection of differences in alignment. While the aviation industry closely aligns training, flying, and federal safety regulations, systems of education and health care delivery display little to no alignment. Other reasons also are believed to promote a reluctance to fully accept IPE, including a lack of systematic evidence for its effectiveness in improving health and system outcomes (e.g., Braithwaite and Travaglia, 2005; Reeves et al., 2013).
In 2013, the Institute of Medicine’s (IOM’s) Global Forum on Innovation in Health Professional Education held two workshops on IPE. At these workshops, a number of questions were raised, the most important of which was, “What data and metrics are needed to evaluate the impact of IPE on individual, population, and system outcomes?” To answer this question, the Forum’s individual sponsors (listed in Appendix D) requested that an IOM consensus committee be convened to examine the existing evidence on this complex issue and consider the potential design of future
studies that could expand this evidence base. The committee’s statement of task is presented in Box 1-1.
To fulfill the Forum’s request, the committee employed a study process that included
- a balanced committee of experts vetted for biases and conflicts of interest;
- a commissioned paper (1) examining the best methods currently used for measuring the impact of IPE on collaborative practice, patient outcomes, or both, and (2) describing the challenges to conducting high-quality research linking IPE with measurable changes in patient and clinical practice outcomes (see Appendix A);
- an examination of recent review articles, conducted by three committee members using a format similar to that of the commissioned paper (see Appendix B);
- one day of open testimony from outside experts, which supplemented the knowledge of the committee members (see Appendix C for the agenda for this session);
- three days of closed-door deliberations during which the committee agreed upon its conclusions and recommendations; and
- virtual meetings during which the conclusions and recommendations presented in this report were finalized.
BOX 1-1
Statement of Task
An Institute of Medicine committee will examine the methods needed to measure the impact of interprofessional education (IPE) on collaborative practice, patient outcomes or both, as determined by the available evidence. Considerable research on IPE has focused on assessing student learning, but only recently have researchers begun looking beyond the classroom for impacts of IPE on such issues as patient safety, provider and patient satisfaction, quality of care, community health outcomes, and cost savings.
The committee will analyze the available data and information to determine the best methods for measuring the impact of IPE on specific aspects of health care delivery and health care systems functioning, such as IPE impacts on collaborative practice and patient outcomes (including safety and quality of care). Following review of the available evidence, the committee will recommend a range of different approaches based on the best available methodologies that measure the impact of IPE on collaborative practice, patient outcomes or both. The committee will also identify gaps where further research is needed. These recommendations will be targeted primarily at health professional educational leaders.
SCOPE AND ORGANIZATION OF THE REPORT
The committee identified a number of factors that complicate evaluation of the impact of IPE on patient, population, and system outcomes, but three factors dominated its deliberations and therefore receive particular attention in this report.
First, the context within which education interventions are implemented matters greatly (Barr et al., 2005; Thistlethwaite, 2012; see Appendix A). In the global context, most IPE studies are published in the English literature, with Canada, the United Kingdom, and the United States having the greatest presence, while developing countries have very few publications on the subject (Abu-Rish et al., 2012; Paradis and Reeves, 2013; Rodger and Hoffman, 2010; Sunguya et al., 2014). Drawing overarching conclusions is therefore difficult. Context likewise is important in examining the impact of education interventions from a national, community, or institutional perspective or even in comparing results from different points of care (clinical microsystems) within a single institution. The importance of context is especially salient given the rapid change that characterizes the health care system today.
Second, during the committee’s open data gathering session (IOM, 2014), it was noted that although changes in interprofessional curricula are increasingly common and collaborative competencies are being written into accreditation standards, the outcomes of adopting these standards in a meaningful way remain unclear. It also was noted that the critical step in documenting the effectiveness of IPE across the education-to-practice continuum is better coordinating education interventions with ongoing health system redesign. The importance of context and the consequences of the lack of alignment between education reform and practice redesign in evaluating the outcomes of IPE are addressed in Chapter 2.
Third, it quickly became apparent that a common language and conceptual model are needed as a template for the design of education interventions and the analysis of IPE outcomes. During the committee’s open session, the multiple and sometimes conflicting definitions with which the committee would have to grapple were highlighted, along with the wide variety of perspectives on how to define IPE and its outcomes and the lack of linearity and alignment of IPE; collaborative practice; and patient, population, and system outcomes (Cooper et al., 2004; Weaver et al., 2011). In short, there was support for a conceptual framework that could guide a common understanding of the impact of IPE (Clark, 2006; Reeves et al., 2011). Existing models for describing IPE and learning that the committee reviewed did not meet this need. Therefore, the committee created a comprehensive model that would allow for a description of IPE across the continuum of health professions education. The concepts and language
developed for this model proved to be especially valuable in distinguishing between intermediate and more distal outcomes (i.e., between the acquisition of collaborative skills and the ultimate effects of IPE on individual, population, and system outcomes). This model is described in Chapter 3 and is referred to throughout Chapters 4 and 5.
The central goal of IPE is to produce a health workforce prepared to collaborate in new and different ways to yield positive impacts on the health of individuals, the communities in which they live, and the health systems that care for them (WHO, 2010). The need to strengthen the evidence base for linkages between IPE and these outcomes is described in Chapter 4. As a central focus of the report, Chapter 4 lays the foundation for the report’s two recommendations provided in Chapter 4 and in Chapter 5, which call for the development of measures of collaborative performance that are effective across a broad range of learning environments and a mixed-methods approach to measuring the impact of IPE on individual, population, and system outcomes.
Chapter 4 relies heavily on the background paper commissioned by the committee to inform its deliberations (see Appendix A), as well as the committee-initiated synthesis of review articles on IPE published between 2010 and 2014 (see Appendix B). The conclusions and recommendations in Chapters 4 and 5 draw on the findings presented in these papers.
While the sponsors of this study are the primary audience for the report’s conclusions and recommendations, other individuals and organizations that are responsible for funding education and health care delivery systems are intended audiences as well. This list would likely include accreditors of health professions education and those who provide resources for education reform and health system redesign, as well as government agencies that fund health professions education and university leadership associated with academic health centers. Individuals in these positions who are accountable for funding education and health systems would have particular responsibilities in this regard.
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