Health professionals and consumers are well aware of the challenges facing the U.S. health care system. An estimated 98,000 Americans die every year due to medical errors, 66% of sentinel events in hospitals are caused by communication errors, and 99,000 deaths each year are attributed to infections acquired during hospitalization (Institute of Medicine [IOM], 2000; Klevens et al., 2007). These problems are increasingly complex in nature, and solutions are needed that start early in health professions training.
In Health Professions Education: A Bridge to Quality, the IOM called for a dramatic restructuring of health professions education to ensure all students gain competencies to deliver patient-centered care, use informatics to inform decision making, work in interprofessional teams, engage in evidence-based practice, and use quality improvement principles to improve practice (Greiner & Knebel, 2003). The Quality and Safety in Education for Nurses (QSEN) program added one additional competency, patient safety, and operationalized these competencies for nurse educators (Cronenwett et al., 2007).
Endorsing the importance of educational reform, accrediting agencies such as the Accreditation Council for Graduate Medical Education and the American Association of Colleges of Nursing integrated the IOM/QSEN competencies into program outcomes. Yet, despite the best intentions of educators, the education of health professionals has been slow to change due to various barriers such as different academic calendars between schools and few role models for change.
At one academic health sciences university, the University of Nebraska Medical Center (UNMC), three factors aligned simultaneously to propel UNMC into educational reform: the institution’s membership in the Health Professions Education Collaborative (HPEC), the institution’s strategic plan, and the receipt of a QSEN award by the institution’s college of nursing. This article describes the institution’s strategies, challenges, and successes in delivering interprofessional educational programs.
Health Professionals Education Collaborative
In December 2003, the Institute for Healthcare Improvement began the Teaching Improvement in Medical Schools Collaborative, aimed at improving the quality and safety of patient care by targeting medical school curricula with the hope that graduates would begin their career with these principles firmly in place. Restructuring clinical education to be consistent with the principles of the 21st century health system was a key recommendation of Crossing the Quality Chasm: A New Health System for the 21st Century published by the IOM (2001). Sixteen medical schools comprised the initial group, which evolved in a short time to an interprofessional collaborative called HPEC. Schools of nursing and health administration were added, and the collaborative expanded to 19 academic health professions universities. Membership was selective; schools were accepted on evidence of commitment from the deans to support their designees to attend the national meetings, host a national meeting, and participate in monthly conference calls.
Thus, HPEC evolved into a collaborative of health professions’ education programs committed to education and training that promote the ultimate improvement of patient care through interprofessional learning experiences. A variety of approaches and activities address these goals, both at the national meetings and during the conference calls.
For example, member universities share how their organizational infrastructure supports the interprofessional curriculum, how faculty development occurs at their institution, and how student-initiated quality improvement projects are managed. During monthly conference calls, members discuss updates on successes and challenges in their efforts to capture time and academic credit for interprofessional learning activities. The monthly calls keep members connected between meetings and help maintain the momentum needed to overcome the inevitable barriers inherent in the traditional silo-based educational systems.
At UNMC, the deans pledged support for curricular change and charged their respective associate deans with oversight. The enthusiasm from HPEC brought a sense of excitement to the annual chancellor’s strategic planning retreat, the result of which was a strong statement in the institution’s 2008–2011 strategic plan to “Build on the HPEC program to establish sustainable interprofessional education.”
Seven associate deans and department chairs from nursing, medicine, pharmacy, and allied health were charged with meeting the HPEC goals. This team met monthly and adopted the Plan-Do-Study-Act (PDSA) model to develop interprofessional learning activities (Nelson, Batalden, & Godfrey, 2007). As opposed to beginning with sweeping curricular change that would meet resistance, PDSA provided a framework to implement small projects, learn from problems, build on successes, generate enthusiasm, and eventually accelerate the change process. Four PDSA projects focused on interprofessional teamwork for quality care and patient safety:
- Interprofessional education day.
- Service learning project.
- Interprofessional simulation.
- Clinical teaching.
Interprofessional Education Day
The first project included a half-day interprofessional learning exercise focused on teamwork, communication, and patient safety. Planning by 13 faculty from nursing, allied health, public health, pharmacy, medicine, and UNMC’s hospital partner, the UNMC, included coming to agreement on teaching-learning goals, learning activities and learner outcomes, recruiting of student and faculty participants, planning the logistics of faculty training and student experiences, and developing student and faculty materials.
Implementation included both faculty training and the student interprofessional experience. Student learning occurred in three phases. First, students were oriented to the concepts of quality, safety, and team-work through interactive online activities. Second, students attended a large group presentation where an organ transplant team role-modeled how interprofessional communication enhanced patient safety and quality of care delivery. Finally, students engaged in small group interactive exercises to solve a health care quality problem.
This event has been held successfully on two occasions that included 260 students and 50 faculty. Student and faculty comments have been extremely positive. Comments have included “incorporate interprofessional team meetings in curriculum. Team-work is essential to learn” and “This is the first step, but it will be a shame if it will be my only interaction with students from other colleges.” Evaluative data have been reported elsewhere (Margalit et al., 2009).
Service Learning Project
Seventy students and 12 faculty mentors from medicine, nursing, pharmacy, and public health participated in an interprofessional service learning project funded by the Association of Prevention Research and Teaching. Students engaged with community partners to identify community needs and subsequently to develop and implement interventions to address needs.
For example, for the project HELP (HIV/AIDS Education for Life Program), students developed a personalized program for HIV/AIDS patients and their families to enhance adherence to treatment protocols and self-management strategies. Subsequent years will allow students to continue the implementation and evaluation of existing project interventions as well as develop new ones.
A complex simulated patient scenario, developed by four faculty from pharmacy, medicine, and nursing, incorporated common problems confronting health professionals. In the scenario, simulated patient safety is jeopardized by ineffective communication during a rapid patient hand-off between an emergency department nurse and an admitting nurse. The patient, transferred as stable, declines after admission. Medication errors coupled with undetected patient allergies further complicate the patient situation. The admitting nurse assesses the patient and calls team members, physician, and pharmacist, to assist. Students must communicate with each other while managing distractions such as phone calls, pages, and family members. The scenario is followed by an in-depth debriefing during which students review their communication effectiveness and feelings, and assess strategies for improvement.
During a senior clinical experience for baccalaureate nursing students in the intensive care unit, students used the six QSEN competencies to develop their patient care plans, interventions, and evaluations. In addition, students evaluated near misses and sentinel events witnessed during their intensive care unit experience, and they used quality improvement processes such as flowcharts, cause-effect diagrams, and root cause analysis to study the events from a systems perspective.
Instructor evaluation of students was modified to reflect the development of these new skills. For example, evaluation criteria included the degree to which students elicited and demonstrated understanding of patient and family preferences for treatment and students’ ability to assert their own position in interprofessional teams. Students presented their event analysis to the intensive care unit staff with suggestions for improvement, if warranted, using the PDSA model.
Successes and Challenges
Graduating health professions students who actualize the IOM/QSEN core competencies and improve patient outcomes will require more than the few learning experiences reported in this article. However, in just 2 years our initiatives have fostered campus-wide enthusiasm and interest in long-range planning to sustain these programs and grow others.
Several factors converged to support UNMC’s success. The university’s membership in HPEC provided a venue to share ideas with colleagues from other academic medical centers and to discuss strategies for success. The commitments of the deans, associate deans, and university hospital included both strong administrative support for the HPEC goals and a willingness to share the associated costs. The enthusiasm created by the first HPEC meeting influenced UNMC’s strategic plan such that the HPEC goals were adopted by the university.
Within the university, the various colleges’ respective accreditation criteria are driving curriculum committees to revise content toward the IOM/QSEN competencies. UNMC’s careful planning and the implementation of several small projects that included development of faculty as well as students has increased awareness of health care system problems and generated a greater openness for changing curricula. Emphasizing system problems and the quality of patient care is decreasing professional silos and generating energy among students who are passionate about the care of their patients. Thus far, these pilot programs have used faculty volunteers, and the overwhelming positive student feedback has been a positive catalyst for faculty.
However, as academic medical centers transform education to incorporate the IOM/QSEN competencies, several factors demand attention, including faculty development, the coordination and costs of programs, and measurement of learning outcomes. Although faculty generally endorse these competencies, most have not been educated in these competencies. Faculty development must be built into curricular change and include basic knowledge as well as new learner-centered strategies that role-model interprofessional communication and engage students.
At UNMC, faculty volunteers have committed time above and beyond their normal workload. Sustainability will demand a different model, one that recognizes faculty workload and encourages involvement and innovation. In addition, creating campus-wide learning experiences requires extensive coordination and staff support; UNMC’s projects have relied on cobbled-together staff support, but our experience suggests a dedicated staff position will be necessary.
Although students and faculty have been enthusiastic, assessing real learning outcomes is problematic. Few psychometric measures exist. Current survey tools that measure attitudes and perceptions have been used in different student populations with different educational levels and have been shown to be minimally valid and reliable (e.g., Luecht, Madsen, Taugher, & Petterson, 1990; Reid, Bruce, Allstaff, & McLernon, 2006). In addition, changes in knowledge, attitudes, and perceptions do not necessarily result in behavioral change, and assessment of longitudinal outcomes is especially problematic.
Developing robust measures of behavior change will be necessary to evaluate the outcomes of educational interventions. Other challenges to consider include determining how to level the content and learning activities to student cohorts, deciding how much time to devote in the curriculum, and juggling college calendars when scheduling activities.
Urgent Agenda for Quality and Safety Education
The education of health professions students is rooted historically in time-honored and silo-bound traditions of pedagogy, with content not easily influenced by outside forces. However the quality chasm work of the IOM, Institute of Healthcare Improvement, QSEN, and other groups has led to a remarkable willingness to change, evidenced at UNMC by these four projects over 2 years. Sustaining momentum and growing programs now requires several specific actions.
At UNMC, the associate deans are planning an interprofessional curriculum committee (Figure) that will report to both the HPEC steering group and to each college’s respective curriculum committee; this will coordinate and plan programs and evaluate outcomes. The college deans have agreed 2 hours per month will be dedicated to interprofessional activities; costs will be shared among deans until such time as a university-level structure exists. There is general support for a plan that every student will be required to obtain a specified number of interprofessional course credits.
Figure. Flowchart Depicting Interprofessional Education Coordination.
Finally, a campus-wide assessment and evaluation committee will develop a core set of competencies for all UNMC graduates. The committee is dedicated to two competencies aligned with IOM/QSEN competencies—teamwork and quality—and to their measurement. In such ways, one academic health sciences university is embracing quality and safety education for the 21st century.
- Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J. & Mitchell, P. et al. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122–131. doi:10.1016/j.outlook.2007.02.006 [CrossRef]
- Greiner, A.C. & Knebel, E. (Eds.). (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press.
- Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press.
- Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.
- Klevens, R.M., Edwards, J.R., Richards, C.L. Jr.. , Horan, T.C., Gaynes, R.P. & Pollock, D.A. et al. (2007). Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Reports, 122, 160–166.
- Luecht, R.M., Madsen, M.K., Taugher, M.P. & Petterson, B.J. (1990). Assessing professional perceptions: Design and validation of an interdisciplinary education perception scale. Journal of Allied Health, 19, 181–191.
- Margalit, R.S., Thompson, S., Visovsky, C., Geske, J., Collier, D. & Birk, T. et al. (2009). From professional silos to interprofessional education: Campuswide focus on quality of care. Quality Management in Health Care, 18, 165–173.
- Nelson, E.C., Batalden, P.B. & Godfrey, M.M. (2007). Quality by design: A clinical microsystems approach. San Francisco: Jossey Bass.
- Reid, R., Bruce, D., Allstaff, K. & McLernon, D. (2006). Validating the Readiness for Interprofessional Learning Scale (RIPLS) in the postgraduate context: Are health care professionals ready for IPL?Medical Education, 40, 415–422. doi:10.1111/j.1365-2929.2006.02442.x [CrossRef]