Urgently Needed, a Radical Transformation of Professional Collaboration and Teamwork

by Patricia Benner, copyright 2012

I am writing this month’s newsletter with vivid interprofessional educational innovations fresh in mind from the Josiah Macy Foundation Invitational Conference on Interprofessional Education led by George E. Thibault, MD.

This conference brought together a range of healthcare professionals committed to IHI’s three goals of improving the health of the population; improving our healthcare system’s quality and safety, while decreasing costs. Dr. George Thibault and his colleagues at the Josiah Macy Foundation have funded vibrant bold new experiments in interprofessional education, and this conference invited these innovative, committed healthcare professionals to come together and share what they have been learning from their experiments and what we need to do next to improve interprofessional education.

Dr.  Scott Reeves reviewed the state of the field of research on interprofessional education, and Dr. Dan Berwick summarized the difficulties of moving our current healthcare system forward in authentic efforts and voices. Berwick noted how difficult it is to have an authentic dialogue about improving our healthcare system in a political climate of polarization and lack of common ground for individually and collectively viewing healthcare as an essential right in a good society.  In addition to polarized political stances focused on fear of either government, or outrage over the lack of citizen protection, professionals have distracted themselves with over-focus on separate hierarchical visions of professional identities and a compartmentalized silo approach to professional education and practice.

The rest of the conference in many different voices and strategies, engaged in dialogues about how interprofessional education can and should advance healthcare education, delivery, and policy to achieve these goals.  Special interests, fear of change, and an anti-government ideology of fear of a government-run single payer healthcare system, distract from authentic concern for the well-being of the whole population.

The current confusing competing markets in healthcare, along with the polarized political positions, problem solving and dialogue, becomes debased and falls into the disarray of profession-centric educational systems disconnected from what is needed in the service sector. Interdisciplinary colleagueship and mutual respect in health professionals are needed to contribute a unified authentic voice about what changes need to be made within professional education and service to transform the current untenable healthcare system.  Most agree that the current increasing levels of spending cannot be stopped without a more rational and concerted focus on the three goals of increasing the health of the population, improving the quality and safety of the patient experience, and decreasing costs of healthcare.

Dan Berwick pointed out that our system, not surprisingly, delivers what is designed to deliver:  a market-driven, for-profit healthcare system focused on acute and tertiary care, competition for market share of pharmacy and technology; high, and unsustainably rising costs; lack of effective professional education for team work, and finally, poor levels of quality with wide ranges in the access to and variability in care and outcomes. Predictably, many personal and societal economic failures result from such a poorly-functioning healthcare system. Many interprofessional educators and healthcare service settings were struggling to find common language to stand together and co-own the responsibility for a new kind of professional education and a new kind of healthcare delivery focused on the patient and family (close others) as the center of the team.

Collectively, the group agreed that professional health education needs to share the moral vision of a civic professionalism where the focus is on citizen-participants in healthcare, with the patient/ client/ resident/ community and population  are at the center of the team. Interprofessional education is not a good “in itself”; it must impact the goals of a healthier population, decreased healthcare costs and improved patient experience with healthcare.

Civic professionalism puts the focus on the citizen role of professional to deliver effective health at reasonable costs, and in a trustworthy way and the centrality of the citizen’s need for effective care in order to fully participate in society. Technical professionalism that focuses on autonomy and control by professional groups focused on work benefits to healthcare professionals, and/or economic and intellectual achievements of professionals lacks the moral voice of a civic professionalism based upon improving society by responsible and effective healthcare.

Interprofessional teamwork requires that professional share the same notions of good central to healthcare, the well-being and health of citizen patients and families. IPE requires a shift away from profession-centrism and/or professional self- interests that clearly block the transformative impact of IPE on improving our healthcare institutions. Professionals have to work as partners in education and service sectors equally sharing the responsibility for solving the major practice-education gap and lack of fit, and for the three urgent three goals of improving our healthcare. Contrasts between Civic Professionalism, an older form of professionalism contrasts with the current dominant model of Technical Professionalism where the focus is on the sociological characteristics of professionals:

• Autonomy
• Control over Membership in the profession
• Possession and Control over a Body of Scientific Knowledge and Technological Procedures.

Civic Professionalism focuses on the citizen responsibilities of the professional and on the citizen needs, vulnerabilities and strengths of the client, patient, resident, families, communities and population. A democracy cannot function without a robust and effective cadre of civic professionals to support the citizenry in their pursuit of happiness, well-being and participation in society.  Conferees by and large are in consensus that professional education should be interdisciplinary with the patient at the center of the team, and that each professional group needs to hold common professional goals around improving care, lowering costs and improving the health of the society.  Rather than status, power, autonomy and control, IPE shares these common goals with foremost in any situated clinical care: The well-being of the patient, client, community, population.

IPE seeks to solve the problems of disparate and hierarchical expectations of professional performance for the sake of patients and population health.  Just as hierarchies and status inequities create real safety hazards in the aviation industry, so do such social behaviors and systems create barriers to clear, effective communication among professionals, and ultimately safety and quality of healthcare. Professions have a tendency to foster adversarialism (May).  Scott Reeves, PhD, the new director for the Center for Innovation in Interprofessional Education at the University of California, San Francisco and current Editor-in-Chief of the Journal of Interprofessional Care  notes that the Rationale for IPE include the following:

• Improve interprofessional communication
• Enhance collaborative competencies
• Reduce interprofessional rivalry
• Restrict duplication
• Enhance practice
• Improve quality

All of these are both goals and a rationale for IPE, and they require a vision for civic professionalism, increased trust and mutual respect among healthcare professionals, as well as a better understanding of the knowledge and skills of each professional group. IPE requires interaction, knowledge and mutual respect among all members of the healthcare team, not just patients, nurses and physicians.

Pedagogical strategies include:

• Seminar and small group learning;
• Simulation with focused debriefing on interpersonal dynamics as well as clinical performance as a result of effective teamwork;
• Focus on interprofessional teamwork in clinical placements that also include debriefing opportunities
• E-learning, unfolding case studies with interprofessional communication and social media

Each of these strategies and yet-undiscovered approaches can contribute to improved IPE and healthcare quality.  Professionals are taught to think critically, stand alone, and often behave skeptically among their colleagues. This is what May (1985) means by adversarialism in the professions.  But in a Civic Professionalism, it is not considered sufficient. The goal must be focused on the well-being of the patient. A climate of competency, evidence-based practice, interprofessional mutual respect and trust, are all required for this.  Of course there are built-in role distinctions and educational preparation of the professionals.  Social workers, nurses, physicians, physical therapists function best when their competencies are used to the best advantage.  Interprofessional teamwork requires communication, collaboration and leadership…without any one professional having a fixed inflexible role.

There are functional built-in role distinctions among professionals that serve the patient well. For example, nurses being present in the healthcare setting most continuously and being responsible for titrating therapies, and providing effective early warnings about the patient’s condition to healthcare providers would prefer to provide an early alert, that may not turn out to be a problem (though they recognize the risks of false warnings), than err on the side of not alerting healthcare providers to ambiguous but potentially urgent problems.  On the other hand, healthcare providers, who must take responsibility for errors of un-needed or ineffective intervention, would prefer to err on the side of “waiting” to evaluate and confirm the need for intervention to premature and potentially a mistaken intervention. This is a built-in functional distinction between professional roles that can and usually does serve the patient well.  Strategies for improving communication between professional disciplines such as SBAR (Heinrich, Bauman & Dev, 2012; Thomas, Bertram & Johnson, 2009) can make this functional distinction even more effective through clearer communication about expectations, assessments and recommendations.  This functional distinction need not ever turn into a hierarchical power play, as long as the patient’s best interest is first and foremost for all professional team members.  Each professional team member, in the end, must want the patient’s best outcome more than they want to be in control, or remain “in charge.”

The Veterans Administration Hospitals have formed effective Centers for Excellence in Primary care, in which Yale University, Fairfield University and the VA Center of Excellence in Primary HealthCare IPE present exciting possibilities for the effectiveness of IPE Primary Care. They characterize workplace learning in IPE as follows:

Unscripted: Requires workers to go beyond approaches learned previously in order to resolve novel and poorly defined work challenges

Collaborative: Requires workers to enhance or replace their collective expertise as changes in technology and work processes necessitate the development of new skills

Distributive: Requires team leadership to be determined by expertise germane to the question at hand rather than artificial hierarchies VACHS, Yale University, & Fairfield University

Such innovative and effective innovations are encouraging and point the way forward. Yet, we have a long way to go in IPE.  We found IPE is “thought about”, and on paper and in wish-dreams in the schools we studied and in the faculty surveys done in the Carnegie National Study of Nursing Education. But in the schools we studied and the faculty and student surveys, few have developed sustainable innovative programs that reach all healthcare professionals. Dr. Dan Berwick states:

In order to maximize the services received we are going to need to quit being so insular and build upon already existing infrastructures related to subsidized housing programs, homeless programs, social services, schools, and the many other structures and systems that already exist that we essentially ignore.  Overall, if we are truly primarily a service industry touching a massively wide breadth of life issues and challenges, then we need to figure out how to leverage emerging technologies (smart phones with cameras, texting, Internet), emerging human platforms (i.e., texting, Twitter, Facebook, networking communities, etc.), and become maximally flexible, adaptive, and able to interweave our services into the lives of those who depend on us for knowledge, diagnosis, treatment, and support.  (Dan Berwick Josiah Macy Jr. Foundation, April 1, 2012)

At the Macy Conference, Dr. Dan Berwick illustrates the above principles for excellent primary care with the following successful dimensions of the Anchorage Native Primary Care Center (NUKA):

Dimension 1: Caring for a defined population or list – new goal

Defined list – patient panel, registered list – and responsibility for the list;

Ability to generate disease tracking data; ability to track requirements for effective intervention; longitudinal coordinating relationships as primary backbone of system.

Dimension 2: Barrier free team-based care – new structure

Care delivered by a team – not all doctors; all working at the top of their license;

Same day access – delays in access will divert to other care locations. Provision for ‘ad hoc’ contacts – e.g. after hours phone access, urgent-care/walk-in visits, and email.

Mind and Body back together – imbedded behaviorists

Dimension 3: Redefining relationship to specialists – new relating

Redefinition of role of specialists with primary care – consulting, procedures

Movement of care from just illness care to include secondary prevention (optimal management of already existing health issues).

Dimension 4: Shifting to deliver “health” not just “disease care”

Effective incorporation of primary prevention, including connectivity to other community resources – building on their existing infrastructures.

Becoming truly customer driven more completely, self-care, family-care.

Dr. Berwick concluded:

These four components or dimensions of healthcare were initially developed as the four requirements for an effective primary care system, but really they are the same requirements of the entire healthcare system, as well as an effective longitudinal primary care platform.  By the way, it is important to note, that in this context primary care is not capitalized and therefore may or may not include or be primarily centered on Primary Care physicians.  (Dan Berwick, Josiah Macy Jr. Foundation April 1, 2012.)

Berwick identified the following six “wasteful” expenditures in the current healthcare system that could trim 11 trillion dollars from our healthcare system over the next nine years:  over-treatment; failures to coordinate care; failures in healthcare delivery; excessive administrative costs; excessive healthcare prices; fraud and abuse.

An ethically-centered civic professionalism could go a long way in reducing all these wastes. One correction alone, will not solve the problem of wasteful overspending, with poor outcomes, but it is clear that must be involved in all these “waste problems”. This transformation has to be about the patient, client, community and population not focused on professional self-interest and compartmentalization. Transformed IPE will go a long way in transforming our healthcare system into one that we can be proud of.

References:

William F. May, “Adversarialism in America and the Professions” in Community in America, p185-201, Ed. C.H. Reynolds and R.V. Norman Univ. Calif Press, 1985).

Thomas, CM, BertramE., Johnson D. (2009) “The SBAR communication technique: teaching nursing students professional communication skills.”Nurse Educ.<http://www.ncbi.nlm.nih.gov/pubmed/19574858> Jul-Aug;34(4):176-80.

Heinrichs WM<http://www.ncbi.nlm.nih.gov/pubmed?term=%22Heinrichs%20WM%22%5BAuthor%5D>, Bauman E<http://www.ncbi.nlm.nih.gov/pubmed?term=%22Bauman%20E%22%5BAuthor%5D>, Dev P<http://www.ncbi.nlm.nih.gov/pubmed?term=%22Dev%20P%22%5BAuthor%5D>. (2012) SBAR ‘flattens the hierarchy’ among caregivers. Stud Health Technology Inform. 173  175-182.

Thomas, CM, Bertram E., Johnson D. (2009) “The SBAR communication technique: teaching nursing students professional communication skills.”Nurse Educ.<http://www.ncbi.nlm.nih.gov/pubmed/19574858> Jul-Aug;34(4):176-80.

William F. May, (1985) “Adversarialism in America and the Professions” in Community in America, p185-201, Ed. C.H. Reynolds and R.V. Norman Univ. Calif Press.