2
Alignment of Education and Health Care Delivery Systems
A critical factor in examining the effectiveness of interprofessional education (IPE) is the context in which the education intervention is implemented. National, institutional, and point-of-care differences impact study design and analysis and complicate comparisons across studies (as discussed in more detail in Chapter 4). What may be less well appreciated is that context also is a critical factor in determining whether education initiatives in general and IPE interventions in particular are effective and worthy of investment.
THE NEED FOR GREATER ALIGNMENT
Coordinated planning among educators, health system leaders, and policy makers is a prerequisite for creating an optimal learning environment and an effective health workforce (Cox and Naylor, 2013). Coordinated planning requires that educators be cognizant of health systems’ ongoing redesign efforts, and that health system leaders recognize the realities of educating and training a competent health workforce. Further, education and health systems are impacted separately or together by a wide variety of policies, necessitating joint planning among educators, policy makers, and workforce leaders. This is especially important when health systems are undergoing rapid changes, as they are across much of the world today (Coker et al., 2008). The One Health movement may offer strategies for bridging potential policy, education, and workforce divides in a complex environment given that emerging zoonotic and environmental threats to human health require a multisector, coordinated response that
aligns activities, strategies, policies, and funding (One Health Initiative, n.d.; WHO, n.d.).
Despite calls for greater alignment, however, education reform is rarely well integrated with health system redesign (Cox and Naylor, 2013; Earnest and Brandt, 2014; Frenk et al., 2010; Ricketts and Fraher, 2013; WHO, 2010, 2011). Accountability for workforce and health outcomes often is dispersed between academic health centers and health care networks (Ovseiko et al., 2014). Possible exceptions include the rare cases in which ministries of education and health work together on individual initiatives (Booth, 2014; Frenk et al., 2010; MOH, 2014). Even when the education and practice communities work together, however, collaboration tends to be restricted to a single health profession.
“Education reform is rarely well integrated with health system redesign.”
In the United States, several federal and state team-based health system redesign initiatives are currently under way, such as Vermont Blueprint for Health, the Center for Medicare & Medicaid Innovation (CMMI), and the Veterans Health Administration’s (VHA’s) patient-centered medical homes (CMMI, n.d.; Department of Vermont Health Access, 2014; Klein, 2011). Yet as with many other IPE developments around the globe, such as those in Australia, Germany, Japan, and the United Kingdom, these initiatives display no systematic linkages between the education and practice communities in their design and implementation and demonstrate very few explicit efforts to support and learn about IPE. One exception in the United States is the VHA health system, where Centers of Excellence in Primary Care Education have been established as an integral part of an enterprise-wide effort to redesign the VHA’s primary care delivery system by integrating purposeful IPE with team-based care (Gilman et al., 2014; Rugen et al., 2014; VA, 2015).
Despite isolated efforts to the contrary, the separation of governance and accountability for education and patient care is the rule for many countries around the world. In the United States, for example, although some deans of schools of medicine are involved in health system oversight, this generally is not the case for the academic leaders of other health professional schools within and across institutions of higher education. This makes joint planning for linking IPE to practice more difficult, particularly for the vast majority of health professional schools that are not housed in academic health centers.
Bringing together academic leaders alone also has significant limitations, as evidenced by the work of Batalden and Davidoff (2007) on quality improvement. Batalden and Davidoff define quality improvement as “the combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to
make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning)” (p. 2). In keeping with this definition, alignment is needed between the entities responsible and accountable for educating the health workforce and delivering care if IPE is to have beneficial effects on health and health care systems.
Community-based health initiatives have the potential to enable better alignment of IPE and health care delivery. In British Columbia, for example, Jarvis-Selinger and colleagues (2008) examined university–community collaborations for interprofessional development through work with Aboriginal communities. The authors note that “interprofessional approaches to education and community practice have the potential to contribute to improvements in access to care, as well as health professional recruitment in underserved communities” (p. 61).
Student-run clinics, interprofessional training wards, and other service-learning initiatives are other venues in which interprofessional teamwork can flourish in tandem with community-based practice (e.g., Haggarty and Dalcin, 2014; Holmqvist et al., 2012). However, these initiatives generally are voluntary, do not purposefully pursue IPE or faculty development for interprofessional collaborative practice, and lack sufficient human and financial resources for conducting robust evaluations (Holmqvist et al., 2012; Khorasani et al., 2010; Meah et al., 2009; Society of Student-Run Free Clinics, 2011).
Aligning the organizations responsible for IPE and collaborative practice will allow for more robust evaluations of IPE interventions and will facilitate the creation of feedback loops between practice and education.
Conclusion 1. Without a purposeful and more comprehensive system of engagement between the education and health care delivery systems, evaluating the impact of IPE interventions on health and system outcomes will be difficult.
Such alignment will necessarily involve the active participation of education leadership (in public and private universities and their health professional schools), health care delivery system leadership (in teaching health systems, centers, and clinics), health professions societies, and public health authorities. It also will require the assumption of joint accountability for both patient and community health, and shared adoption of competency-driven approaches to instructional design and evaluation of health and system outcomes.
Better alignment will necessitate that regulators, accreditors, and other professional bodies strengthen collaborative partnerships between health professions education programs and health systems in support of interprofessional learning by requiring the adoption of competency-based expectations for accreditation. At the same time, those who provide resources for system redesign, innovative practice models, and maintenance of the overall health system can facilitate progress by offering economic incentives for better alignment.
Achieving greater alignment entails significant challenges resulting from the complexity of the relationships among the various stakeholders and their sometimes overlapping responsibilities. Examples of this complexity include the joint responsibility for IPE of universities, affiliated clinical training sites, and health system employers across the continuum of education and practice; the divided responsibility of professional and governmental health professions regulatory bodies; and the overlapping roles of local, regional, national, and international policy makers. Given this complexity, the concept of alignment may best be regarded as having both vertical and horizontal dimensions, each composed of continuously interacting systems designed to achieve (but not always achieving) improved efficiency and effectiveness.
The overall result of this complexity is that although the logic of alignment between education and practice is widely accepted, it has been slow to take hold (Chen et al., 2015; Cox and Naylor, 2013; Earnest and Brandt, 2014; Frenk et al., 2010; Ricketts and Fraher, 2013; WHO, 2010, 2011). Engagement around the importance of alignment would be greatly accelerated by evidence from demonstration projects convincingly linking IPE (and other education interventions) to positive outcomes. Creating a more conducive environment for such engagement will require strong advocacy and leadership, well-targeted policy changes, and innovative incentives.
Such a strategy could be guided by the many examples around the world of effective relationships among universities, government, and industry (Martin, 2000; Ovseiko et al., 2014). Strategies specific to IPE were the subject of a recent conference (Cox and Naylor, 2013). Among the many recommendations made by participants in that conference were including patients and communities in advocacy initiatives, changing professional and hospital accreditation standards to explicitly promote team-based care, creating new models of resource sharing between education and health care institutions, and demonstrating a positive value proposition for linking IPE and collaborative practice. Giving the public a direct voice in health professions governance (for example, by including patients and representatives of consumer organizations on boards of directors), creating joint accreditation standards and joint accreditation boards (Joint Accreditation, 2013), and
using financial incentives to promote change in health professions education and health care delivery may be especially powerful.1
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