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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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Questions?Josette.Rivera@ucsf.edu

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

2/28/201823

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

2/28/2018Title here46 2/28/2018Title here4646

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

2/28/2018Title here48

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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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