May 17, 2014
Team Training Takes Off As New Era in Health Reform Dawns
By Andis Robeznieks
At the University of Minnesota Malcolm Moos Health Sciences Tower, teams of students from around the country studying medicine, nursing, pharmacy, public health and healthcare administration come together each year to compete in a contest testing their ability to solve a systemic and individual patient problem through an interdisciplinary approach.
This year, the competition, which originated in 2002 with a University of Minnesota student group, focused on heart failure treatment and clinical problems of a fictional patient at a fictional hospital. Student teams had to assess the case and make a presentation explaining their approach to the patient and future patients in similar circumstances. This year's winner was a multidisciplinary team from University of Washington in Seattle.
Residents, senior clinical staff and “anyone who touches our patients” have to undergo regular team training at the North-Shore Long Island Jewish Medical Center.
A growing number of academic medical centers and health systems around the country are offering training to students and working professionals in how doctors, nurses, pharmacists, physician assistants and other clinicians should collaborate to provide coordinated care and work together on new models such as patient-centered medical homes and accountable care networks.
Experts say IPE faces issues of limited funding, lack of institutional leadership, skeptical faculty attitudes, and a shortage of qualified teachers and appropriate clinical sites.
Experts say such interprofessional education (IPE) is essential as the U.S. healthcare system moves toward integrated-care delivery and strives to improve quality and reduce costs. Traditionally, they say, physicians have tended to work independently, without optimal coordination with other healthcare professionals, resulting in fragmented care that too often leads to adverse patient outcomes.
But those leading IPE efforts face some resistance to the concept. Dr. Mark Earnest, director of interprofessional education at the University of Colorado Anschutz Medical Campus, said he recently was asked by a senior physician colleague, “What's with this hug-a-pharmacist class anyway?”
Despite such pushback, last July the Liaison Committee on Medical Education issued a new accreditation standard requiring all U.S. medical schools to “prepare students to function collaboratively on healthcare teams that include other health professionals.” A survey reported in the journal Academic Medicine this month found that progress is being made. Eighty-five percent of health-profession educators responding to the survey said elements of IPE existed in their courses, while 80% reported interprofessional collaboration takes place in clinical rotations or internships.
At the University of Colorado, students entering medicine, nursing and other healthcare professions learn side by side and prepare for future collaboration. Influenced by the 1999 report from the Institute of Medicine, “To Err is Human,” Earnest argues that better teamwork and communication reduce medical errors. “There was a strong sentiment that our students needed skill sets for the 21st century that we were not providing,” he said. “The evidence behind the importance of teamwork is just going to grow.”
In 2012, HHS' Health Resources and Services Administration, with funding from four healthcare philanthropies, chose the University of Minnesota Academic Health Center as the site of the new National Center for Interprofessional Practice and Education. Barbara Brandt, U.M.'s associate vice president for education who also serves as the center's director, said the challenge is training students for new practice models and designing education to get the outcomes the nation seeks.
“It's a different way of doing business,” said Dr. George Thibault, president of the Josiah Macy Jr. Foundation, one of the funders of the national IPE center. He said research has shown better teamwork results in better care.
IPE for students entering healthcare professions is a concept that goes back to the 1950s. But barriers remain, and Thibault said the training needs to be extended to practicing physicians and other working clinicians. The article in Academic Medicine cited funding limitations, lack of institutional leadership, variations in academic calendars and faculty attitudes as IPE hindrances. Other issues include a shortage of qualified faculty to teach IPE, a dearth of course materials and a lack of evidence about what training approaches work best.
Another issue is time. Students in the health professions have to master a lot of knowledge, and the time required to learn team building “competes with the need to learn kidney physiology that week,” Earnest said.
There's also a shortage of good training sites. “The single biggest obstacle is the paucity of practice sites that can serve as a good role model for team-based care and that are willing to have learners there,” said Dr. Carol Aschenbrener, chief medical education officer for the Association of American Medical Colleges.
Geisinger Health System in Danville, Pa., a leader in developing the patient-centered medical-home model and team-based care, provides IPE training to students and practicing professionals. “Medicine is truly a team sport, but we haven't treated it like a team sport,” said Dr. Douglas Kupas, Geisinger's associate chief academic officer for simulation and medical education.
Along with training its own staff, Geisinger offers IPE to students from Temple University School of Medicine in Philadelphia, the Philadelphia College of Osteopathic Medicine and Bloomsburg (Pa.) University's department of nursing.
Geisinger's program has medical, nursing and pharmacy students working on quality improvement projects, practicing in different scenarios and rounding together. The goal, Kupas said, is to build “situational awareness” so all members of the team know what they should be doing and how to complement each other's work.
Two-hospital health system Christiana Care in Wilmington, Del., has also received recognition for its IPE training program. It recently earned the 2014 Leape Ahead Award—recognizing excellence in patient safety among medical schools and teaching hospitals—from the American College of Physician Executives, for its team-based care and training program.
Dr. Virginia Collier, Christiana Care's chairwoman of medicine, said the system's teams of physicians and physician assistants in intensive care had been working so well together that there actually was tension when new resident physicians arrived for their ICU rotations and had to join the well-oiled teams. This issue was resolved by clarifying the roles and responsibilities assigned to the residents and PAs.
At Christiana Care, team-based care is emphasized for the department of medicine's training of its 65 residents. Simulation is used to build teamwork in scenarios involving attending physicians, nurses, case managers and others. Physician assistants are used extensively in intensive care, and nurse practitioners are heavily involved in the system's Acute Care for the Elderly unit. “We've heard our hospitalists call case managers the glue that holds everything together,” said Mike Eppehimer, vice president of Christiana Care's department of medicine.
Interprofessional teams also do rounds together, which leads to better communication between staff, patients and their families. “It's important that the entire team knows the care plan and speaks with one voice,” Collier said. “Studies show it gives patients and their families confidence and correlates to patient satisfaction.”
At North Shore-Long Island Jewish Health System in Great Neck, N.Y., the emergency department was the first hospital area to participate in team training. Now the system has 47,000 employees undergoing regular team-based simulation training, with as many as 20 simultaneous sessions, involving up to 300 people a day, said Kathleen Gallo, senior vice president and chief learning officer at the system. Simulations use high-tech mannequins with systems that mimic the human body as well actors with whom clinicians rehearse how to tell a patient or a family member bad news. It's mandatory “for anybody who touches our patients, whether it's the new residents or our chair of anesthesia,” Gallo said.
While team-based care is well established in operating rooms and EDs, the biggest new focus is primary care, given the growth of the patient-centered medical-home model. At Oregon Health & Science University, Dr. John Saultz, chairman of the department of family medicine, said team-based care is improving care quality. But the most lasting impact may be enhanced staff satisfaction.
Saultz is overseeing the participation of three OHSU clinics in the CMS Comprehensive Primary Care Initiative, in which insurers pay providers a per-member, per-month fee to support multidisciplinary care coordination. Saultz said the team-based nature of the medical home will attract new doctors to primary care. “I like going (to work) more than I have in my 30 years as a family physician,” Saultz said.