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Ralph Gonzales MDCynthia Chiarappa, MBA, FACHEJosette Rivera MD
http://www.ucsfcme.com/MedEd21c/
From Interprofessional Education to Interprofessional Collaboration: Meaningful IPE in the Workplace
#UCSFMedEd21
Disclosures
We have nothing to disclose.
Overview
Interprofessional education (IPE) and interprofessional practice (IPP) must develop in tandem
A way forward: interprofessional communities of practice
Promising examples of IPE improving IPP
Strong clinical/educational leadership & faculty/staff development critical to workplace IPE
The State of Play
Parallel/Associative Play
Cooperative Play
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Ubiquitous challenges of workplace IPE
Al Ashkar M et al. BMC Med Ed 2018
High functioning collaborative care sites: too small, resource intensive to create
Sustainability tentative: funding, local IPE champions
Scaling up to reach all students
Lack of time for residents and teachers
The Status Quo
Interprofessional PracticeInterprofessional Education
Rethinking workplace learning for professionals
Healthcare professionals:
• Do not identify themselves either as learners or as teachers
• Unaware that they learn through collaboration
Most learning occurred informally via case discussions and role modelling
Mertens F et al. Med Teach 2017
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Ways Forward: Theoretical Roots
DOMAIN COMMUNITY
SHARED KNOWLEDGE
Communities of Practice
Ways Forward: IP Communities of Practice
Cultivates trust/support
Flattens hierarchy
Acknowledges other’s expertise
Vescio 2008, Risling 2013
Teaching/learning IPC skills in contexts that may not have stable, effective collaborative teams
Prepares learners to be the change we want
Initial domains:• Building social capital• Perspective taking• Negotiating priorities & resources• Managing conflict
Ways Forward: working with what we have
Bainbridge & Regehr 2015
Interprofessional Inpatient Patient-Aligned Care Team (iPACT)Re-engineered one IM inpatient ward team at SFVA:
Attending
Resident
Interns
Student
Pharmacist
Nurse CaseCoordinator
SocialWorker
Medicine team Core team
HALLWAY
DO
OR
BREAK ROOM
Intern
Intern
PharmD
MS3
RN
SW
Res
MS 3/4
Traditional Team
iPACT
8A-9A AM report AM Report
9A-12P MDRRounds
HuddleRounds
12P-1P Noon Conference
Noon Conference
1P-? Work separately
Work together in team room
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iPACT Charter
Purpose – why does this group exist?
Success – what will success for this group look like?
Roles & norms – feedback, team functioning, continual learning
Accountability – what are we responsible for? To whom should the group be accountable?
Decision making style – clinical and team process decisions
Resolving issues
iPACT Evaluation: Case Study
• 100% (n=34) residents agreed/strongly agreed iPACTimproved knowledge of core team members’ expertise and ability to work within an interprofessional team
• Observational study: all professions consistently seeking each other’s expertise
Lo D et al. JGME 2017
“iPACT gives residents…lessons of communication, teamwork, and understanding IP roles. iPACT is actually a team because of the co-localization… There’s so much to be gained from face-to-face interaction.”
All first year medical students embedded in a clinical microsystem one half day/week, first 18 months
Quality improvement, direct patient care skills, interprofessional collaboration
Complete a system-based project -> value added
UCSF Clinical Microsystems Clerkship Value-added clinical systems learning roles
Gonzalo J et al. Acad Med 2017
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“These clinics wouldn't work if it was just doctors. And that becomes really, really clear when you do try to implement a QI project…the overall experience makes you really appreciate, that…they [doctors] would be nothing without their nurses. They'd be nothing without a good pharmacist, without medical assistants…” – MS1
“…it's healthy to understand the hard work that everybody in the healthcare team is doing. I think in order to do that, it's helpful to understand the different tasks that they're doing in detail. Actually going to the site and being able to see with your own eyes everything everyone is contributing is meaningful and helpful for first-year medical students.” – – MS1
Preparing the Workplace for IPE
Joint leadership from workplace & educational programs needed to:
• Align goals/priorities of clinical and educational missions
• Influence culture
• Leverage resources/address IPE barriers (time, effort)
Readiness tools
• IP-COMPASS: high level attributes conducive to an IP learning environment
• Assessment for Collaborative Environments (ACE 15): team centered
Faculty/staff training & positive modelling critical to successful workplace IPE
• Research strongly supports reflection and debriefing both positive and negative experiences –> core competence for teachers
• Multi-modal faculty development programs‒ Teach for UCSF Interprofessional Teaching Certificate‒ ‘Just in Time’ Teaching Observation Program
Preparing the Workplace for IPE Summary
Interprofessional education (IPE) and interprofessional practice (IPP) must develop in tandem
A way forward: interprofessional communities of practice
Promising examples of IPE improving IPP
Strong clinical/educational leadership & faculty/staff development critical to workplace IPE
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Aligning to Engage and ImproveClinical leadership and staff development to promote interprofessional collaboration in the workplace: why and how
11/20/17
Cynthia Chiarappa, MBA, FACHEVP Administration and Chief of Staff to CEO
Ralph Gonzales, MD, MSPHChief Innovation Officer, UCSF HealthAssociate Dean, UCSF School of Medicine
Burning Platform
Rising Costs
Lower Reimbursement
Stronger Competition
Pay for Performance
Recruitment and Retention More Challenging in Bay Area
Patient Safety
Rising Consumerism
Staff and Provider Burnout
Desire to Remain a Top Tier AMC
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Why Take a Fresh Approach?
“Lean healthcare is not an improvement program. It is an operating system within a management system that requires a complete cultural transformation.”
“Lean organizations…need leaders who respect the knowledge and experience of the people on the front line of care….This requires personal transformation…”
- John Toussaint, MD
(Management on the Mend)
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Why Take a Fresh Approach?
Lean – properly deployed – works because it activates all levels of the organization in solving problems. It is a very effective way to maximize engagement in an organization.
“This is the first time in 30 years that I have hope.”
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UCSF Health: Redefining Possible
Align: True North Definitions and Measures
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Enable: Visual Management and Leader Rounding
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Enable: Engage and Develop People
2/28/2018Credit: St. Vincent’s29
Executives/Directors
Managers
Team Leaders
Staff
New Staff
Level of process knowledge
Authority to change policies and process
Improve: System Design
2/28/2018Credit: St. Vincent’s Hospital30
Own practice
Unit-level change
System-level change
Front-line staff
Unit Manager
Senior management
Extent of Change
Reduce overburden and
unevenness
Remove steps
Improve the quality of each
step
Improve: Improve Process…
2/28/2018Credit: St. Vincent’s Hospital31
Own practice
Unit-level change
System-level change
Front-line staff
Unit Manager
Senior management
Extent of Change
Reduce overburden and
unevenness
Remove steps
Improve the quality of each
step
UBLT
The Power of Unit-based Leadership
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The Power of Unit-Based Leadership
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Key Unit /Practice Partners
MedicalDirector
Nurse /Practice Manager
ImprovementSpecialist
Relationship-Based Culture
Value of UBLT in Clinical Microsystems
• Forms a foundation for multidisciplinary collaboration
• Aligns initiatives between nursing and medicine
• Boosts physician/nursing leadership engagement in tactical and strategic initiatives
• Ensures that frontline voice informs local and strategic decision making
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Communication Coordination Teamwork Relationship
Case Study: UPenn Unit Based Clinical Leadership
Goal: Enhance interdisciplinary collaboration, Improve coordination of care and improve quality by reducing bloodstream infections (BSI).
Approach: Physician and Nurse Leaders are paired at the unit level with an Improvement Specialist who brings data and project management skills.
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2007 2008 2009
The job:• Weekly Operating meeting
• Interdisciplinary Rounding
• Orienting house staff
• Two Improvement Projects
• 5 teams BSI
13 Pilot Teams
34 Official Teams, + 12 “Operating As”
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Results
13 patient units with UBCL avg. 100 fewer BSIs in FY 08 vs. FY 07 Unit Clinical Leadership Model: A Successful Partnership between Front-Line Penn Systems: Taking Quality to the Next Level Our Winning Strategies Assessing the Financial Impact of a Unit Based Clinical Leadership Model at a
University Hospital:
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A great patient experience startswith a great provider and staff experience.
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Employee Experience Mirrors Patient Experience
38Source: Ascension Health
50%
55%
60%
65%
70%
75%
80%
85%
90%
-40.0% -30.0% -20.0% -10.0% 0.0% 10.0% 20.0% 30.0% 40.0%
Correlation: .539
Pat
ient
NP
S
Associate NPS
Source: Ascension Health
Experience Impacts Financial Performance
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5%+ in customer loyalty results in a 25-85%+ in profits
Employee & Provider
Experience
Patient & Family
ExperienceProfitability
and Outcomes
+ =
Source: Adapted from The Service Profit Chain – How Leading Companies Link Profit and Growth To Loyalty, Satisfaction and Value, James L. Heskett, Thomas Jones, Gary Loveman, W. Earl Sasser, and Leonard Schlesinge Copyright 1997
Engagement and Outcomes
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Building Capacity to Lead Improvementat UCSF Health– The Lean UBLT
UBLTs and WIP Groups
Mission Bay UBLTs (4/2016)-combined WIP: PICU, P-CICU, ICN, Peds ED, MB ICU; Multiple Sclerosis; Cardiology; Head/Neck CA
Parnassus/MZ UBLTs (4/2016)-Inpatient WIP: 9/13 ICU, 8/11 ICU, 14 M/L, 8 L/S, Adult ED/CDU-Outpatient WIP: Lakeshore, Peds PC, Pain Management, Otolaryngology, Hepatology, Heme-Onc, SACC
Attributes of Successful UBLTs
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1Mutual respect and recognition of each other's valuable knowledge and skills
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Joint strategic agenda and accountability for performance goals, whereby disagreements occur privately, but in public the UBLT speaks with one voice
3A clearly defined operating rhythm and communication process
4Clear ownership and championing of key initiatives based on individual capabilities and strengths
Align
2/28/2018Title here44
-True North and Leader Rounding
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Enable
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We agree to the terms of the Unit-Based Leadership Team charter and operating agreement established above:
Signed:___________________
Name:____________________
Date:_____________________
Signed:___________________
Name:____________________
Date:_____________________
Signed:___________________
Name:____________________
Date:_____________________
Signed:___________________
Name:____________________
Date:_____________________
• Lean Bootcamp• A3 Thinking
Coaching/Development
• Leader Rounding• Active Daily Engagement• Collaborative WIPs 5S
Value Stream
Mapping
Facilitation
Training Workshops
ImproveDaily Improvement A3-Guided Improvement
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ProblemProblem
TargetsTargets
AnalysisAnalysisDesignDesign
PDSAPDSA
Week 1
Weeks 2-3
Weeks 4-5Weeks 7-8
Weeks 9-16
Things to Consider - Common Pitfalls
1. Failure to truly build relationship and work collaboratively
2. Breakdown of communication, either in terms of amount or quality
3. Undermining the unit-based leader by communicating disagreement or blame
4. Failure to align the UBLT goals and projects with existing strategic priorities + projects
5. Inability to energize front line teams to own and accelerate improvement
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Impact
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UBLTs Designed and Implemented 78 A3-guided Improvement Projects.
IMPROVE: A3-Guided Improvement CyclesProvider and Staff Engagement
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Peds Primary Care +39Cardiology +33H/N Cancer +31
PICU +35
2016Hepatology +70
Otolaryngology +78SACC +100
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Quality Cycle
Quality Metrics: Access to Care and C. difficile Rates
2/28/2018SOURCE: Service Line Dashboard, accessed 2/24/1752
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
$16,000
Jul
Aug Sep
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Jun Jul
Aug Sep
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Jun Jul
Aug Sep
Oct
Nov
Dec Jan
Feb
Mar
Apr
May Jun Jul
Aug Sep
Oct
Nov
Dec
UBLT
ALL
2013 2014 2015 2016
CMI-Adjusted Direct Cost per Case
MissionBay
Mar-Dec 2015 vs. Mar-Dec 2016 % ChangeUBLT $12,949 $12,508 -3.41ALL $11,556 $11,432 -1.07
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Hospital Cost per Adjusted Discharge1
March towards the 75th Percentile…
Questions?
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