Teams of health care professionals work together to solve quality and safety problems in primary care and other settings (Interprofessional Education Collaborative [IPEC], 2016). Interprofessional education and training should prepare students with the competencies needed for practice, yet barriers exist because of differing requirements for each program (Schrimmer et al., 2019). Quality and safety competencies are described by various interprofessional groups (American Association of Medical Colleges, 2019; Barnsteiner et al., 2013). Effective communication with members of a team and patients is a key competency across health care professional disciplines (National Association for Healthcare Quality, 2017; Sowko et al., 2019). Experiences that integrate these competencies while learning about the social determinants of health allow students to be immersed in physical and behavioral health and the social environment—particularly in underserved communities, where disparities most often exist (Murray, 2019).
Research linking patient outcomes to interprofessional education (Institute of Medicine, 2015) and collaboration is needed. Interprofessional teams demonstrated improved patient satisfaction in an ambulatory setting (Sanchez & Hermis, 2019) and clinical outcomes in patients who have diabetes (De La Rosa et al., 2019). A systematic review found low evidence that interprofessional collaboration improved professional practice and clinical outcomes and state the need for rigorous, mixed-methods studies (Reeves et al., 2017). IPEC is “inspired by the vision that interprofessional collaborative practice is key to the safe, high quality, accessible, patient-centered care desired by all” (IPEC, 2016, p. 4). This project presents a novel approach to interprofessional student collaboration in the primary care setting and may inform future studies on the design of interprofessional education quality improvement (QI) projects and their impact on patient, population, and health system outcomes.
Our university has an Institute for Healthcare Improvement (IHI) Open School chapter that meets regularly to learn about QI and patient safety, with students from the seven health science colleges on our campus. The mission of the IHI Open School is to advance health care improvement and patient safety competencies in the next generation of health professionals worldwide (IHI, 2019c). Students in our chapter are clear that they want to participate in volunteer QI projects to prepare them for their future practice roles. Student demand for QI projects is a novel element that prompted the chapter faculty advisor from the college of nursing to meet the learning need using innovative thinking.
The faculty advisor collaborates with the Federally Qualified Health Center (FQHC)—led by the college of nursing—which frequently hosts students for improvement projects. The nursing manager of the health center noted that patients experienced nonvalue-added time waiting for appointments and wanted an interprofessional student perspective on what patients wanted to learn about while waiting to see their provider. The aim of the QI project was to identify, provide, and evaluate culturally and language/literacy appropriate patient education materials to improve the value of wait time. Student introduction to quality improvement and interprofessional competencies was a natural offshoot of the project.
Structural elements need to be in place to facilitate an interprofessional student group. In addition to the student-friendly setting, the project was led by a student QI chair (baccalaureate nursing graduate enrolled in a Master's in Healthcare Administration program) possessing novice transformational leadership, project management, and communication skills.
The FQHC serves a population that primarily resides in a diverse urban community. The population is primarily Hispanic or Latino (56.1%) or Black non-Hispanic (35.2%), and less than half of the population speaks English as their primary language (Chicago Metropolitan Agency for Planning, 2020). The median household income in 2017 was $35,941, compared with $52,497 for the rest of the city (34% below the poverty level), and educational attainment was higher for high school graduation but lower for college than the entire city of Chicago (Chicago Metropolitan Agency for Planning, 2020). The nursing manager advised the students to prepare materials at a third-grade literacy level.
Twelve students joined the first project team from the chapter, representing a variety of health science programs at the undergraduate and graduate levels, including Physical Therapy, Healthcare Administration, Pharmacy, Medicine, and Biology/PreMed. Nursing and Occupational Therapy students joined later in the project cycle. Students in all health science programs are required to engage in a university-wide interprofessional immersion day, including prework content on the IPEC (2016) competencies. Under a single domain for interprofessional collaboration, the competencies include values and ethics for interprofessional practice, knowledge of one's role and those of others to assess and address health care needs of patients, communication with patients and professionals in other fields that supports a team approach to the promotion and maintenance of health, and to apply relationship building values to perform effectively in different team roles (IPEC, 2016). To understand the foundational principles of QI and beginning competencies, students completed the online IHI Basic Certificate in Quality and Safety (IHI, 2019b). They were also required to participate in a 2-hour training session at the health center led by the QI chair and faculty advisor. The purpose of the training session was for students to practice surveying skills with a script and to become familiar with the health center staff, facilities, and expected student behaviors.
Project Leadership and Team Engagement
Leadership presence was abundant throughout the 1-year-long first phase of the ongoing project. The QI chair held bimonthly meetings with the team to track progress, celebrate successes, discuss challenges, and delegate next steps. Meetings were held in person with video conferencing capabilities, and documents were stored on a shared drive. Action items were emailed to everyone following each meeting to ensure accountability and follow-through. Regular communication on project progress was shared with the faculty advisor, nursing manager, and clinical staff at the monthly meetings.
Prior to kickoff, the QI chair met with the nursing manager to solidify the project aim and scope, create milestones and deliverables, and decide on an appropriate time line. The Plan-Do-Study-Act (PDSA) improvement method with small tests of change was used (IHI, 2019a; Langley et al., 2009). The team developed a Voice of the Customer survey for students to interview patients at the health center to help them better understand the patients' educational needs (Lloyd, 2019). Questions were driven by health center leaders and staff to ensure literacy and language appropriateness for the patient population served. No protected health information was collected at any time. Because this was not a research project, no institutional review board approval was needed according to university policy.
Students met patients in the waiting room and used a dyad format to allow the interviewer to actively engage with the patient and for the scribe to record the answers as stated in order to fully capture the voice of the customer. Clarifications between members of the dyad were accomplished with an informal debrief before documentation of responses. The target populations included pediatric-primary care, adult-primary care, and adult-psychiatric. One student was bilingual and able to conduct interviews fluently in Spanish, and health center staff was also available for translation. A total of 47 patient interviews were conducted during this time frame (goal = 60). Limitations included:
- difficulty capturing the psychiatric and pediatric patient subset because of student dyad and clinic schedule mismatch,
- shortened/interrupted interviews if the providers were ready to see patients,
- difficulty capturing data for internet proficiency because patients did not seem to fully understand the question,
- and a lengthened interview period because of schedule conflicts and patient no-shows.
Nine students, the QI chair, and faculty advisor met in a series of structured meetings to discuss, categorize, and identify common themes, and a Pareto chart was used to prioritize the top patient-reported health educational needs (Figure 1). Healthy Lifestyle/Nutrition was the topic chosen most frequently, defined as leading a healthier lifestyle, including topics related to diet, weight management, and proper nutrition. This topic became the priority for the next steps.
Top three health topics/concerns: Respondents (N = 126) could give up to three responses to the question, “What are three health topics that you want to learn more about?” Note. y axis = the total number of patient responses; cumulative line = the sum of all the percentage values up to each category.
Using this analysis in the next PDSA cycle, student dyads conducted a search for existing reputable educational offerings and evidence-based tools including the American Heart Association, American Diabetes Association, World Health Organization, and the National Institutes of Health. Because no specific themes could be identified in the pediatric population (due to a small number of patients interviewed), Healthy Lifestyle/Nutrition was explored in both the adult and pediatric population, given that this was the highest frequency topic. Multimodal educational resources/tools were sourced, given that patients' preferred method of learning was evenly distributed. Finally, best efforts were made to identify tools and resources that were available in both English and Spanish and at a third-grade literacy level.
After review, the team met to discuss their findings and preview the resources. The test of change included trialing different tools and modalities and determining patient reported helpfulness. The chosen modalities were a student designed 2-hour YouTube channel of Healthy Lifestyle videos in English and Spanish played on the television in the main waiting room and a nutritious Recipe of the Month and Healthy Lifestyle pamphlets available in English and Spanish posted on the bulletin board and available for patients to take home.
Following implementation, student dyads spent 3 weeks surveying patients in the waiting room. To gain feedback on the interventions and not burden or confuse patients with a long survey, patients were asked four questions on what grabbed their attention and the helpfulness of the materials.
Twenty-five patients were interviewed to gather initial feedback on whether the chosen tools and modalities were helpful. Of those interviewed, seven patients noticed the videos playing in the waiting room and 11 noticed the Healthy Lifestyle bulletin board. Of those who noticed the interventions, 13 patients answered the question on level of helpfulness. Three found the video to be helpful, eight found the recipe and handout to be helpful, and two said the materials were not helpful. Although the sample size for feedback was small (total n = 25, 13 of whom gave input on the helpfulness of the tools), additional qualitative data were collected that provided improvements for the future. For instance, one patient described that she would like to see a “variety of recipes and a video to watch at home on how to cook them.”
Six students who participated in the project completed a simple survey that addressed the overall experience, attainment of IPEC competencies, and project alignment with the mission of the IHI open school. All students agreed that the overall experience of the project was good and remained dedicated until they graduated. Students described achievement of basic IPEC competency level in their responses.
Values/Ethics for Interprofessional Practice
Teams working on the project were described as educationally diverse, and each brought ideas influenced by their varying professional education. Students said they shared the value of keeping the patient-centered perspective as the priority, regardless of program. One student said that an ethical climate was maintained when working with students from different programs, such as nursing and health care administration.
Students stated that everyone's thoughts were treated seriously for planning next cycles or general improvement for the project. Awareness of others' roles is the first step to understanding how others' roles contribute to the project.
Student comments affirmed that the project gave each participant the opportunity to practice interprofessional communication.
Teams and Teamwork
Enthusiastic comments included that the project gave them an opportunity to further strengthen teams and teamwork and the ability to engage effectively with students from different health professional backgrounds. Although working together to provide quality educational materials to patients led to several challenges, the students said they have grown and improved efficiency due to their ability to work together as a unit. Students described the overlapping IPEC/QI competency, patient-centered care, as the ability to partner with patients. They said the project allowed patients to take charge of what they want to learn about and noted it a very important—yet often overlooked—topic in the health care world.
Students commented on how the work aligns with the IHI open school mission to advance health care improvement and patient safety competencies. They highlighted that they are developing skill in listening to the voice of the customer and prioritizing responses using QI tools. Using PDSA cycles was beneficial, and one student described being proud to have been involved with the project since its earlier stages and excited to see how much more improvement can be made in order to make the most impact in the community. One student felt they contributed to improving the overall care the patients received. Another student described the relevance of the project to their future as the next generation of health professionals in their respective fields.
Working in student dyads was a useful approach for interprofessional communication, collaboration, and early learner confidence through different phases of the project. With input from the student team, the QI chair prepared an executive summary including graphical displays and presented it to all health center staff during a monthly meeting. Staff shared their feedback and support for expansion of the project by (a) incorporating more students to capture specific patient subsets and students who are bilingual in English/Spanish, (b) identifying ways to sustain the chosen modalities and expand education materials, (c) identifying innovative ways in which patients can access education from their own and health center devices, and (d) providing a hands-on, group learning experience, such as a visiting chef.
The graduating QI chair handed off the project to the incoming QI chair during two meetings. Momentum for the project was lost over the summer but was reignited on the students' return. Project sustainability is a high priority in the next phase because the nursing manager shared that patients were disappointed that new recipes were not provided, but video use was maintained by nursing students over the summer using health center electronic devices. Incorporating aspects of the project in health center workflow and roles (starting the video as part of health center morning opening duties) may normalize and sustain the improvement.
Innovative Next Steps
Something as simple as a recipe board generated great interest with potential to improve patient outcomes. The chapter is beginning a collaboration with our university Institute for Healthcare Delivery Design Director and their students to focus on human-centered design for this project. As a first step, our chapter students added a Did You Know campaign by providing program specific content by embedding a QR code with the recipe, such as, Did you know that quinoa has fewer calories and carbohydrates than white rice? Other students are visiting the local food markets to facilitate access to healthy ingredients in their community.
Students developed quality competencies including learning an improvement method (PDSA), using QI tools, communicating priorities using narrative and visual tools and project management responsibility, accountability and sustainability (American Association of Medical Colleges, 2019; Barnsteiner et al., 2013; National Association for Healthcare Quality, 2017), and interprofessional education competencies (IPEC, 2016). The opportunity to engage in an interprofessional project in a FQHC provides lessons on social determinants of health superior to traditional learning opportunities. Support from a valued partner helps develop competencies in the next generation of health professionals. This project is a small test of change on how students can develop competencies together. Additional university structural supports are under consideration to increase interprofessional education opportunities.
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