Interdisciplinary Training

Interdisciplinary Medical, Nursing, andAdministrator Education in Practice: TheJohns Hopkins ExperienceJo M. Walrath, RN, PhD, Nailya Muganlinskaya, MS, ACNP, Megan Shepherd, MHS,Michael Awad, MD, PhD, Charles Reuland, ScD, Martin A. Makary, MD, MP, andSteven Kravet, MD

Abstract

Reforming graduate medical, nursingand health administrators’ education toinclude the core competencies ofinterdisciplinary teamwork and qualityimprovement (QI) techniques is a keystrategy to improve quality in hospitalsettings. Practicing clinicians are bestpositioned in these settings tounderstand systems issues and craftpotential solutions. The authors describehow, in ten months during 2004 and2005 the school of medicine, the schoolof nursing, and an administrativeresidency program, all at Johns HopkinsUniversity, implemented and evaluated

the Achieving Competency Today IIProgram (ACT II), a structured andinterdisciplinary approach to learning QIthat was piloted at various sites aroundthe United States. Six teams of learnersparticipated, each consisting of amedical, nursing, and administrativeresident.

The importance of interdisciplinaryparticipation in planning QI projects, thevalue of the patient’s perspective onsystems issues, and the value of asystem’s perspective in crafting solutionsto issues all proved to be valuablelessons. Challenges were encountered

throughout the program, such as (1)participants’ difficulties in balancingcompeting academic, personal andclinical responsibilities, (2) difficulties inachieving the intended goals of a broadcurriculum, (3) barriers to openlydiscussing interdisciplinary team processand dynamics, and (4) the need todevelop faculty expertise in systemsthinking and QI. In spite of thesechallenges steps have been identified tofurther enhance and developinterdisciplinary education within thisacademic setting.

Acad Med. 2006; 81:744–748.

A series of seminal reports from theInstitute of Medicine (IOM)1–3 havefocused health care providers on the needto improve health care delivery systemsin the United States. The IOM findingssuggest that the chasm between whatactually exists in practice and whatproviders know to be good quality carecan be bridged only through a radical

redesign of the health care deliverysystem.2 A redesign is itself dependent inpart on reform of the education systemfor health care providers. Greiner andKnebel4 envision that “all healthprofessionals should be educated todeliver patient-centered care as membersof an interdisciplinary team, emphasizingevidence-based practice, qualityimprovement approaches, andinformatics.” Two of the corecompetencies defined by theAccreditation Council for GraduateMedical Education (ACGME), systems-based practice and practice-basedlearning and improvement, specificallyaddress interdisciplinary qualityimprovement,5 and residency programsare beginning change their curricula tofoster this approach.6

While systems-focused educationalinitiatives and groundwork have alreadybeen established in many academicsettings, significant reform has beenslow.7 Nevertheless, several institutionshave created initiatives to keepeducational reform of this type at theforefront, including The PEW HealthProfessions Commission,8 the Institutefor Healthcare Improvement through the

Interdisciplinary Professional EducationCollaborative,9 and more recently, theIMPACT network of academic medicalcenters.10 In spite of this progress,physician and nursing education isusually delivered as separate and parallelprocesses with each discipline teaching itsown content while its students areacquiring clinical skills. Althoughcollaboration is desired and expected, theintense clinical environment hastraditionally left little time forinterdisciplinary dialogue regardinghealth delivery systems and potentialprocess improvement. Althoughacademic medical centers are typicallyknown for discovery, innovation, and acommitment to excellence, their complexorganizational structures present uniquechallenges to teamwork, communication,interdisciplinary collaboration anddissemination of new knowledge, all ofwhich underpin successful qualityimprovement (QI) initiatives. Perhapsdesigning curricula focused on systemsthinking and improvement, wheremultidisciplinary learning and practiceare core components, can help toeffectively address these challenges. In therest of this article, we describe how aschool of medicine, a school of nursing,

Dr. Walrath is assistant professor of nursing, JohnsHopkins University, School of Nursing, Baltimore,Maryland.

Ms. Muganlinskaya is a graduate nursingstudent, Johns Hopkins University, School of Nursing,Baltimore, Maryland.

Ms. Shepherd is administrative fellow, JohnsHopkins Hospital, Baltimore, Maryland.

Dr. Awad is general surgery, Fellow, Johns HopkinsHospital, Baltimore, Maryland.

Dr. Reuland is administrator, Department ofMedicine, Johns Hopkins Hospital, Baltimore,Maryland.

Dr. Makary is assistant professor, Johns HopkinsUniversity, School of Medicine, Baltimore, Maryland.

Dr. Kravet is assistant professor, Johns HopkinsUniversity, School of Medicine, Baltimore, Maryland.

Correspondence should be addressed to Dr. Walrath,Johns Hopkins University School of Nursing, Room445, 525 North Wolfe Street, Baltimore, MD. 21205;e-mail: (jmwalrath@jhmi.edu).

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and an administrative residency programimplemented and evaluated this type ofcurriculum, the Achieving CompetencyToday II Program (ACT II), a structuredand interdisciplinary approach tolearning QI that was piloted at varioussites around the United States. We alsoshare key lessons learned.

The Program

Partnerships for Quality Education(PQE) is an initiative of the Robert WoodJohnson Foundation. From October 2004to June 2005, the PQE collaborated withthe Association of American MedicalColleges (AAMC) and the AmericanAssociation of Colleges of Nursing on apilot program, ACT II, which targetedresidents and graduate nursing studentsin major teaching hospitals.11 JohnsHopkins Medicine (JHM), through itssubsidiaries, The Johns HopkinsUniversity Schools of Medicine andNursing and its two major teachinghospitals, was one of twelve pilotinstitutions selected to participate. Theprogram was designed to meet theACGME core competencies of systems-based practice and practice-basedlearning and improvement. The expectedoutcomes of ACT II for learners andfaculty were to use the knowledge andskills gained in the learning experience todevelop a systems perspective in dailypractice and to design QI projectsaddressing active institutional needs. Thelearners and the faculty were then toevaluate the applicability of the coursecontent and help to tailor the programfor future participants.

Curriculum

The ACT II curriculum was Web-basedand required self-directed learning. Theoutcomes were met through readings andaction learning strategies focused on themacro U.S. health care system, andthrough learner-identified micro systemissues, using a patient’s hospitalexperience as the lens to vieworganizational or practice problems. Theprogram at our institutions devoted aweek each to four content areas:

Week one: The structure of the U.S.health care system and how it affectshospital functioning and the provisionof patient care.

Week two: the financing andpurchasing of health care in the United

States and its effect on care delivery.

Week three: The hospital’sorganization, culture and financingand how these support or act asbarriers to the implementation of aquality improvement project

Week four: The translation of thecurriculum content from week one toweek three; application of knowledgeto development of the qualityimprovement project plan11

Participating institutions

Johns Hopkins Medicine (JHM) iscomposed of The Johns HopkinsUniversity (JHU) and the multipleinstitutions within The Johns HopkinsHealth System. For this program bothThe Johns Hopkins Hospital (JHH), a1,051-bed academic teaching center, andJohns Hopkins Bayview Medical Center,a 335-bed community academic teachingcenter, were used as the teaching sites.The JHU School of Medicine hostsaccredited training programs in 78disciplines including most medical andsurgery specialties. The JHU School ofNursing prepares advanced practicenurses in the areas of health care systemsand management and clinical nursespecialties, and as nurse practitioners.JHM also provides an administrativeresidency program for recent graduatesor current students from healthadministration masters programs, whocome to JHM to gain hands-onexperience in hospital administration.

Team design and selection ofparticipants

The chief operating officer (COO) ofJHH assumed leadership as the principalinvestigator for the ACT II program anddelegated program coordination to asenior director of operations. The COOhad the explicit support of the academicdeans of both professional schools andwas in the best position to assureimplementation of projects acrossdisciplines. The leadership team alsoincluded subsets of faculty (JW, SK) andprogram directors.

After open solicitation, residencyprogram directors from the Departmentsof Surgery, Medicine, and Anesthesia-Critical Care expressed interest in havingtrainees participate. Since residencyprogram schedules were already in place,several strategies were used for team

member selection. Directors of residencyprograms selected and assigned eitherresidents who were currently on aresearch rotation or those with electiveblocks available during the projectedtimeframe of the program. Graduatenursing students from each of thepreviously described advanced practiceprograms were identified by their facultyfor participation based on interest andavailability during the project timeframe.Senior hospital leadership also selectedadministrative residents according totheir availability during the projecttimeframe.

Faculty were also recruited based uponinterest and availability from therespective schools as well as from JHMadministrative leadership. Faculty werenot required to be experts in quality orsystems improvement; however all facultyparticipants had been involved in QI intheir clinical or academic practices. Whenrecruitment was complete there were 18learners organized into six teams, each ofwhich was a triad of three persons: amedical, nursing, and administrativeparticipant. Eighteen matching facultymembers were chosen so that each facultyteam also had a triad of medical, nursing,and administrative faculty.

Program implementation

The PQE gave participating sites thefreedom to implement the curriculumbased on their own organizationalconstraints and culture. Because ACT IIwas incorporated into the existingacademic schedule, to avoid “losing thelearners” in other clinical and academicresponsibilities, the planning groupdecided to limit the experience to onefour-week block. This also allowed theCOO and faculty to focus theirinvolvement with learners moreintensely.

The program called for moreindependent learning by participantsduring week one, mostly focused onbackground readings and on interviewswith a patient and members of the healthcare team regarding concerns thatimpede quality practice within thehospital environment. Toward the end ofweek two, learners transitioned to a teamfocus within their triads when the qualityimprovement deliverables drove most ofthe process. Project themes were selectedbased on institutional or academicinterest in a topic, issues identified by

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stakeholders during interviews, and issuesthat learners independently identified ascommon in their clinical experiences.Not surprisingly, the final QI projects(see List 1) were easily encompassed inthe existing broad quality and safetyagenda of JHM. By the end of week four,each of the triads had completed theirassessments and presented them to theJHM leadership. Upon completion of thefour-week process, the institutions’ QIcommittees took over implementation ofeach of the projects, whenever possiblewith continued participation of the teammembers.

Program evaluation

There were weekly meetings facilitated bythe COO, where each of the teams sharedexperiences, discussed their progress, andreviewed assigned articles. Each meetingserved as a type of focus group, wherebyfeedback was collected and the processwas refined while the program wasoccurring. At the completion of theprogram, formal questionnaires were sentto faculty and learners asking severalquestions, including “Do you feel thiswas a useful learning experience?,” “Whathas been the most enlighteningexperience to date?,” and “What were theproject concerns and frustrations?”Responses to the questions were analyzedfor common themes by programleadership. Some representative quotes,linked to common themes, are presentedin Table 1. Further, at the completion ofthe project, faculty and programleadership participated in a series ofdebriefings where these and other lessonswere consolidated into concrete plans forthe next implementation year.

Lessons Learned

Valuable positive experiences

Value of interdisciplinary participation.Most of the learners did not previouslyknow one another or work together, yetACT II gave these learners a structuredopportunity to become acquainted and towork across the typical professionalboundaries. Learners gained a newappreciation for the strengths andperspectives of learners from otherdisciplines and the greater effectiveness ofa team approach to problem solving.Learners also commented on howvalidating it was to have the COO besidethem supporting their efforts to improvethe quality of care.

Value of patient and family perspectiveon the health care system. The patientand family add an important perspectivefrom which to view our health caresystem. Learners valued the patient andfamily interactions as they gatheredevidence on system issues. Learnersrealized that through the lens of thepublic they are able to better questiontheir assumptions of the most basichospital systems and processes.

Value of thinking from a systemsperspective. Teaching about systemspractice and quality improvement addsan important dimension to traditionalclinical training. Clinicians in nursingand medical training programs havetraditionally been taught to approachpatient care from an individualperspective, focusing on how they canprovide the best care for patients. ACT IItaught learners to look at the system

failures. Learners were surprised to findthere is a science to QI and that smallprojects can have potentially greatimpact. The learners particularly enjoyedselected readings that focused on QI skillsand how to approach a problem from asystems perspective.

Challenges encountered

Balancing competing priorities proveddifficult to meet. Scheduling teamplanning meetings and finding time forgroup work were major challenges.Finding time to meet in interdisciplinaryforums was difficult due to varyingschedules. Despite our expectations toprotect time, the resident’s research andclinical work and the administrativefellow’s departmental work ultimatelydistracted them from this project, thegraduate nurses had to balance workcommitments against the academicschedule, and faculty had to juggleteaching, clinical, and administrativeassignments. The pace of the projectoutstripped the depth required to bestabsorb some of the new concepts.

Achieving broad curricular goals provedchallenging. The short four-weekduration of the program impeded thelearner and faculty teams in thoroughlydiscussing the ACT II reading materials.While the intent of the ACT IIcurriculum was to ground the learner inan understanding of both the macro andmicro health care systems, constrainedtimelines resulted in learners’ primarilyfocusing on the readings and activitiesthat directly affected the final QI project,such as development of a QIP, a 2 � 2matrix (effort versus yield), and a fishbone diagram. Attempting to link in thebroader health system learning objectivesproved confusing to the learners, whohad difficulties making the curricularconnection between QI and the macrohealth care system.

Discussing team process and groupdynamics was difficult. While all teammembers had been exposed to theconcepts of effective teamwork, there wasinadequate time to discuss and learnfrom team dynamics and behavior. Someteam dynamics were compromised bylearner’s competing demands, resultingin uneven work distribution. Learnersoccasionally had difficulty taking a broadview on issues and, instead, defaulted totheir comfort zones, focusingimprovement strategies on their own

List 1Interdisciplinary Quality Improvement Projects Carried Out by Participants inthe Achieving Competence Today Program, The Johns Hopkins UniversitySchools of Medicine and Nursing, and The Johns Hopkins Medical Institutions,October 2004 to June 2005*

1. Improve thermoregulation of surgery patients to reduce the incidence of surgical site infections.

2. Decrease number of last-minute elective surgery case cancellations.

3. Relieve emergency department congestion by improving direct from clinic admissions.

4. Improve hospital throughout by improving communication and teamwork associated with thepatient discharge process.

5. Improve the efficiency of hospital inpatient discharge process by identifying a dischargecoordinator.

6. Improve communication during patient transfer between a medical intensive care unit and theemergency department.

* Each project description represents the final project plan completed by each of the six teams of medical,nursing, and administrative participants.

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professional interests. For example, inone group, the medical resident andgraduate nurse concentrated mostly onclinical issues related to dischargeplanning, albeit from their owndisciplines’ perspectives, while theadministrative fellow focused on thecost implications of the proposedinterventions. This was also evidenced inthe QI presentations, where most of thegroups defaulted to having the physicianbe the main presenter, reinforcing a long-standing hierarchal disparity in clinicalteam leadership.

Implementing QI proved morechallenging than anticipated. Once thelearners completed the four-weekprogram, the institutions were to moveforward to implement the projects, butthis occurred at various rates of speed.Leadership hypothesized that onesignificant root cause of such variabilitywas inadequate time to really engage keystakeholders in new processes. In severalteams, learners were not key members ofthe units where the QIP was beingproposed, effectively being viewed as“outsiders” and unable to partner with

“insiders” to garner support beyond theinitial planning and discussion.

Sustaining this curricular changerequires large-scale integration andmore faculty expertise. Whereas facultyexpertise was not integral to selection tothis project, each faculty member wasactively engaged in QI to some level in hisor her department. The fact that there arerelatively few faculty, even at our largeinstitution, who serve in QI roles mayexplain why we didn’t receive a largenumber of residency training programsinterested in participating in the four-week program or beyond. Further,because the planning group decentralizededucation into the six teams, there wasinconsistent teaching of the corecurricular components.

Next Steps

ACT II challenged faculty and learners toevaluate the feasibility of this curriculumin a complex academic environment withclinical, educational and researchdemands. There appears to beunanimous agreement amongst

participants and leadership that theprogram is valuable and can be modifiedto meet the needs of the learners. Thedean and CEO of JHM and the dean ofthe nursing school reviewed the programand strongly encouraged our continuedparticipation. Subsets of faculty from theprofessional schools are currently in theprocess of developing a modified versionof ACT II, which we will implement as apilot program. The major challengecontinues to be how to integrate thiscurriculum into the academic calendarsof medicine and nursing, whoseschedules are more complex than theadministrative residents. In spite of thisbarrier, faculty has agreed on thefollowing key principles:

▪ Continue to incorporate thiscurriculum into the nursing, medical,and administrative residency programs,maintaining the interdisciplinaryexperience.

▪ Train more faculty members and betterweave the concepts of the curriculuminto the fabric of each trainingenvironment; this is integral to thedissemination of these change-producing concepts. We plan to offerfaculty development modules insystems thinking and QI and promotethem across the schools.

▪ Standardize core curricular teaching.We plan to create centralized classroomeducation on broad concepts of systemsthinking, QI, and teamwork andcommunication for the entire group.We also plan to reduce the content ofthe Web-based curriculum to make itmore manageable, given our timeconstraints.

▪ Overcome the barrier of teams beingspread too thin by competing demands.We plan to increase the size of eachteam, maintaining the interdisciplinarymix, hoping to establish a greater unitywithin teams.

▪ Consolidate faculty time in order toimprove sustainability of the program.We plan to decrease the faculty-to-student ratio in each group, and makethe group portion of the faculty rolemore facilitative.

▪ Achieve effective handoffs of futureprojects to the institutions. We plan tobetter focus on stakeholder engagementand choosing projects that can be morerealistically achieved with limited timeand resources.

▪ Facilitate discussions on teamwork andcommunication in order to break down

Table 1Selected Quotes (Organized by Themes) from Participants in the AchievingCompetence Today Program, The Johns Hopkins University Schools of Medicineand Nursing, and The Johns Hopkins Medical Institutions, October 2004 to June2005*

Quote Theme

�Interacting with clinical residents has been the most enlightening becauseit made me think of issues that I could have otherwise missed from a purelyadministrative perspective.�

Value ofinterdisciplinaryparticipation

.........................................................................................................................................................................................................�What I like the most is that [the chief operating officer] is personallyinvolved in the project. Any project is very appealing when leadership goesout of the way to get involved in such initiatives. I think this dedicationmotivates everyone.�

Value ofinterdisciplinaryparticipation

.........................................................................................................................................................................................................�Most enlightening was [my time] with the patient’s family. They made mequestion previous assumptions about the system and specifically thedischarge process.�

Benefits of patientand familyperspective

.........................................................................................................................................................................................................�The fact that although many fragments of record keeping (i.e., data) exist,it [record keeping] has not been reviewed in the fashion that we proposeto do in this project. This will invariably allow us explore new approaches toold and continued problems.�

Value of thinkingfrom a systemsperspective

.........................................................................................................................................................................................................�If the weeks’ assignments could be spread out to either bi-weekly ormonthly [due to conflicts in students’ workloads], I think the studentswould have a greater appreciation for the value of the project and be ableto contribute more.�

Challenge of timeconstraints

.........................................................................................................................................................................................................�The other potential frustration may be the short time we have to analyze afair amount of data, draw conclusions, and suggest or implement changes.Our theme and the work that could be drawn from it could easily take halfa year or more.�

Challenge of timeconstraints

.........................................................................................................................................................................................................�I think there is a big disconnect between our required readings, thedeliverables, and the QIP [quality improvement project] in general.�

Challenge of broadcurricular goals

* These selected comments were collected during the interdisciplinary meetings and through formal surveys at thecompletion of the program.

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some of the power gradient perceivedbetween health care disciplines.

Summing Up

Implementation of the ACT II programat our institutions provided the learners astructured approach for gaining corecompetencies in systems thinking and QItechniques. The faculty and learnersevaluated the program by identifyingvaluable experiences and challengesthroughout the implementation.Interdisciplinary learning, patient focus,and systems thinking stimulated ourlearners and resulted in an overallpositive experience.

There is unanimous support forinterdisciplinary education at JohnsHopkins; however, the challenge remainshow to effectively implement this intodaily practice, changing it from apotential action item to a critical workprocess. Just as many health professionalsfind lack of time to be a barrier tointerdisciplinary work,12–14 so too did theJohns Hopkins ACT II participantsdiscussed in this article; a similar barrierwas encountered at the other ACT II sitesas well. This and other challenges,including a need to focus on faculty,project scope, and teamwork skills havelaid the foundations for furtherdevelopment and enhancement of thenew curriculum. By sharing ourexperience we hope to provide insightwith hope that we and others cancontinue to improve the interdisciplinary

educational infrastructure necessary toreduce the quality chasm.

AcknowledgmentsThe authors want to acknowledge Dr. Judy Reitzfor her support throughout the implementationof ACT II. Dr. Reitz is the vice president/chiefoperating officer of the Johns Hopkins HealthSystem and the principle investigator for the ACTII program.

The authors acknowledge the Robert WoodJohnson Foundation and the Partners for QualityEducation for making this grant opportunityavailable to us.

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Correction

In the June 2006 Supplement to Academic Medicine, Petra Clark-Dufner, MA, should have been listed as a coauthor of thecase study entitled “University of Connecticut HPPI Pipeline,” pp. S25–S27. At the time the article was written, she was aneducation and development specialist for the Department of Health Career Opportunity Programs at the University ofConnecticut Health Center in Farmington, Connecticut. She is now an administrative officer and AHEC program officer,Connecticut Area Health Education Centers, University of Connecticut Health Center.

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