Report - Center for Integrated Healthcare Delivery Systems - Penn ...

Project Summary 2010 - 2011
Participants:
Development of an Interprofessional Student-led Quality Improvement Project
Scholars Advisors Collaborators
Staja Booker, Nursing
Jillian Harvey, HPA
Teja Kadire, IE
Michael McShane, Medicine
Harriet Black Nembhard
Diane Brannon
Paul Haidet
N/A
Introduction:
The following is a manuscript of the process and progress of, the development of our framework
to facilitate interprofessional quality improvement learning. This manuscript consists of three major
sections: (1) Background and Rationale, (2) Guiding Framework, and (3) Program Theory. Background
and Rationale summarize the steps taken by the CIHDS Curriculum Development Team up to the steps of
development of the logic mode. In Section II, Guiding Framework, we detail the steps taken to develop
the logic model specific for the student-led quality improvement project. Finally, in Section III, we
describe in detail the reasoning behind specific aspects of the logic model.
Section I: Background and Rationale:
We began our project by discussing the rationale of why quality improvement and
interprofessionalism are important to graduate students at Penn State. We next completed a general needs
assessment of the current educational landscape within each department. We looked specifically at Penn
State University to see how students within the identified professions interact and engage in the topic of
quality. Finally, we identified how all of the preceding work led to the identification of the need to
develop a framework to facilitate interprofessional projects in quality improvement.
General Needs Assessment and Problem Identification:
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Since the release of the Institute of Medicine Reports “To Err is Human” and “Crossing the
Quality Chasm”, quality improvement has become a major focus in health care (IOM, 2000; IOM, 2001).
Quality improvement carries a multitude of denotations dependent upon the context in which it is applied.
However, in general terms, quality improvement is an ongoing attempt to improve the quality and
delivery of health services along the continuum of care. The concept of quality improvement has led to
many changes in healthcare, and has shifted focus from independent/individual provision of care to open
interdependency among professionals. Quality improvement demands teamwork, cooperation,
collaboration, and consultation, thus the creation of interprofessional and interdisciplinary collaboration.
Interprofessional and interdisciplinary collaboration or teamwork, in health care, describes the integrative
working relationships of professionals across various disciplines in efforts to enhance the safety,
efficiency, patient-centeredness, timing, equity, and effectiveness of health care (IOM, 2000). Moreover,
interprofessional collaboration plays an integral role in health systems quality improvement as well. The
goal of such joint collaboration is the promotion of patient activism (i.e. safe, effective, and cost-efficient
delivery of care to all patients; reduction in pharmacological errors and delay of treatment; improved
communication and transparency); innovative solutions to problems within healthcare practices and
administration; and health care sustainability (i.e. cost of health care, retention rate of medical
professionals, impact of healthcare on the environment). Herbert (2005) describes collaborative patientcentered
practice as “the continuous interaction of two or more professionals or disciplines, organized
into a common effort, to solve or explore common issues…” (p. 2).
Because interprofessional education and learning is now a rapidly emerging area in health care
practice and policy, it is imperative that standard competencies and programs be developed, evaluated,
and implemented at academic and medical institutions. It has been recognized that many health care
professionals lack the education, expertise, and tools needed to partake in quality improvement
enhancements (Ladden, Bednash, Stevens, and Moore, 2006). For this reason, the Institute for Healthcare
Improvement (IHI) developed the IHI Open School for Professionals which bolsters interprofessional
education in areas such as quality improvement, patient safety, teamwork/collaboration, leadership, and
patient-centered care, and systems improvement (Institute for Healthcare Improvement, 2010).
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Additionally, Leape, Berwick, Clancy, Conway, Gluck, Guest, Lawrence, Morath, O’Leary, O’Neill,
Pinakiewicz, and Isaac (2009) discuss 5 concepts for transforming healthcare in hopes of cultivating
competence in healthcare practice: “1. Transparency must be a practiced value in everything we do; 2.
Care must be delivered by a multi-disciplinary teams working in integrated care platforms; 3. Patients
must become full partners in all aspects of healthcare; 4. Healthcare workers need to find joy and
meaning in their work; and 5. Medical education must be redesigned to prepare new physicians to
function in this new environment” (p. 425). Although Leape et al.’s reference to modification of medical
education, this idea applies to all areas of health sciences and associated disciplines.
One model of interprofessional learning was developed at Harvard Medical School, where it was
observed that interprofessional collaboration was inadequately taught and understood (Ladden et al.,
2006). This model, titled Achieving Competence Today (ACT), was composed as the model standard for
interprofessional education on improvement of quality, safety, health and patient systems (Ladden et al.,
2006). ACT consists of three main components in which learners from across various disciplines such as
medical residents, nurses, pharmacists, physical therapists, and health administration work jointly to
develop quality improvement projects. The ACT curriculum’s components: 1. Preceptor meeting to
discuss quality and safety issues; 2. Active engagement in a four-module course; and 3. Development of
a Quality Improvement Plan (QIP) (Ladden et al., 2006). The goal of this curriculum was to bring “health
professional learners” together to learn and engage in solving real problems (Ladden et al., 2006, p. 501).
The Pennsylvania State University’s Need for Inter-professional Curriculum Development:
It has been identified that interprofessional collaboration positively impacts health care. Until
recent years, students and professionals rarely collaborated or were educated uniprofessionaly. Lack of
knowledge in interdisciplinary care and lack of cooperation among professions contributed to the
collaboration barrier (Headrick, 2000). By assembling students from different fields of study relevant to
health care, discipline-specific education, skills, ideas, theories, and practices can be shared and further
developed. At Penn State, there has been an urging to develop an interprofessional curriculum where
students can receive quality improvement (QI) knowledge and skills (such as leadership, teamwork, and
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listening) before entering the workplace. A small group of students from the departments of Medicine,
Nursing, Health Policy and Administration, and Industrial Engineering have joined together to begin the
preliminary work towards an interprofessional education collaboration curriculum.
With a project based focused on quality and interprofessionalism, we felt that it was imperative
that the structure of our team reflected these concepts. After the identification of student leaders and
faculty leaders, we began our collaboration by defining the goal of our project:
CIHDS Interprofessional Collaboration Goal: Identify a way to promote quality
improvement in an interprofessional environment.
Drawing from prior research, we began to identify how other universities have confronted this goal.
Interestingly, our search provided few answers, with much of the results either focusing on
interprofessionalism within a classroom setting or uniprofessional quality improvement projects.
However, our general assessment also highlighted the recommendations by many important institutions
suggesting both interprofessional collaboration and quality improvement [Table 1].
Table 1: Organizations Promoting Interprofessional Learning
Organization
Collaboration Competency or Recommendation
Association of
American Medical
Colleges &
Association of
Colleges of
Nursing
"Interprofessional Education appears to maximize the strengths of individual disciplines within the
integrated delivery of relevant and optimum care. While the benefits of implementing IPE programs
may be well recognized, its implementation is not without challenges. For successful IPE, all
stakeholders (including health professional organizations, policymakers, insurers, academic
institutions, CE providers, the public, and licensing and accrediting bodies) need to embrace a multiprofessional
framework of and a shared value for IPE. Any effective IPE model should be patientcentered
and nimble, and provide a required and measurable component across the health professional
educational continuum, from entry and throughout one’s practice career. In addition, innovative
methods for engaging in interprofessional education need to be designed and tested in order to provide
opportunities for health professional students in diverse institutions and settings to participate in
interprofessional education in a meaningful way."
American
Organization of
Nurse Executives
Build trusting, collaborative relationships with: Staff, peers, other disciplines, physicians, vendors,
community leaders, legislators, nursing and other educational programs
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Institute for
Healthcare
Improvement
Changing paradigms of patient care requires new approaches to the education of health professionals
for the improvement of care. These approaches include vertically integrated undergraduate curricula,
inter-professional learning, redesigned residency programs, the development of exemplary clinical
settings where optimal patient care and education take place in a seamless fashion, practice-based
learning and improvement throughout the entirety of one’s professional career, and the creation of an
academic base to facilitate these goals.
Institute of
Medicine
Recommends the establishment of a national inter-professional Continuing Education (CE) Institute to
advance the science of CE by promoting the discovery and dissemination of more effective methods of
educating health professionals over their professional lifetimes, by developing a research enterprise
that encourages increased scientific study of CE, by developing mechanisms to assess research
applications, by stimulating new approaches to both intra- and inter-professional CE, and by being
independent and composed of individuals from the various health professions.
Liaison
Committee on
Medical Education
The curriculum of a medical education program must include specific instruction in communication
skills as they relate to physician responsibilities, including communication with patients and their
families, colleagues, and other health professionals.
National Center
for Healthcare
Leadership
Penn State
Nursing
Quality & Safety
Education for
Nurses
The ability to work cooperatively with others as part of a team or group, including demonstrating
positive attitudes about the team, its members, and its ability to get its mission accomplished.
Collaborate with medical and other health care professionals across diverse settings to meet the health
care needs of individuals, families, and communities.
Function effectively within nursing and inter-professional teams, fostering open communication,
mutual respect, and shared decision-making to achieve quality patient care.
Targeted Assessment:
Drawing from the recommendations of major representative many important bodies within our
respective disciplines and our literature review, a targeted assessment of our own curricula was performed
and identify areas of overlap. It was clear that graduate students from each of our disciplines were
engaging in the topic of quality improvement; however, they were doing so in a uniprofessional manner.
Interestingly, many students were performing these projects in order to fulfill a research requirement
within their degree. This overlap in research requirements appeared to be an ideal target for curricular
redesign.
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A clear challenge presented itself early on in our collaboration: implementing such a curriculum
between students at distant campuses. Medical students and a few graduate nursing students are primarily
located at the Hershey Medical Center campus, located over 100 miles southeast of the University Park
campus, which comprises the major location of most graduate students. Another very important barrier is
the silo nature of our disciplines, thus interactions between students of the different health profession
majors are limited. Students are challenged with their own disciplines course work and opportunities
remain limited for interaction between professions.
However, even with these challenges, we felt that the content of quality improvement and current
structure within the various disciplines provides a reasonable target to implement an interprofessional
collaboration. At the core of quality improvement is the acknowledgement of interprofessionalism. Also,
the current structure of the various disciplines’ curricula has a distinct overlap in the research
requirement. Specifically, all of the graduate programs identified have a research requirement built into
their degree. Our project attempts to target this overlap to create a cohesive framework that will allow
any student from each of the identified programs enter into the system and fulfill those degree
requirements.
Section II: Guiding Framework: The Kellogg Foundation Logic Model Guide:
Using the W. W. Kellogg Foundation Logic Model (Figure 1), we have designed a framework
designed to facilitate interprofessional quality improvement projects between graduate students in four
Pennsylvania State University departments: College of Medicine, School of Nursing, Health Policy and
Administration Department, and Industrial Engineering Department.
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Figure 1: Logic Model Guide
Selection of a Logic Model Approach: An Outcomes Approach Model:
In creating our logic model, we used the outcomes approach model. In this approach, focus is
placed on the early aspects of planning in an attempt to connect resources and activities with desired
outcomes. This approach was chosen for several reasons. First, this approach was developed with the
theory of change in mind. We expect that this curriculum will require modifications throughout its
implementation and beyond in order to meet the needs of students, faculty, and key stakeholders.
Therefore, we selected an approach most conducive to the dynamic nature of this curriculum. Second,
outcomes approach is most useful in designing effective evaluation and reporting strategies. With the
logistical challenges of such a curriculum, we must attempt to show that our intended outcomes are being
met. If this is not the case, we hope that our evaluation will allow us to critically analyze the pieces of the
framework and target change in a logical manner. Finally, the outcomes approach model allows us to
look specifically at the pieces of the framework and relate them to their outcomes. This targeted approach
fits best with out goal of continuous evaluation of the program.
Development of our Logic Model:
The creation of our logic model began first with defining the goal of this new curriculum. Our
defined goal statement was:
Design a framework that could facilitate interprofessional quality improvement projects
that would fulfill the research degree requirements of students from the College of
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Medicine, School of Nursing, Health Policy and Administration Department, or
Industrial Engineering Department.
We began the design by selecting specific outcomes we hoped to achieve. In creating the outcomes
portion of the logic model, we first made clear a specific assumption. This assumption was that each
student would have a different experience, with a dynamic mix of teaching strategies and learning
environments. With this in mind, we wanted to develop outcomes that could encompass the total
experience that we had hoped to provide for students. Following the completion of deciding upon a list of
learning objectives, specific outputs of the framework were selected that would specifically target these
outcomes. After a list of outputs was compiled, we then looked at what activities would be required for
students to complete those outputs. Finally, we then collaborated with key faculty stakeholders in order
to determine what types of resources we would need to provide to students in order for them to adequately
achieve those activities identified. Below is the breakdown of the logic model:
Table 2: CIHDS Interprofessional Collaboration Team Logic Model
Resources
What resources are available to
your program to support the
specific activities you have
planned to do (for some
programs, it may also be
important to state those influential
factors you are counting on to
support your work)
IDENTIFICATION OF RESOURCES:
Personnel:
Faculty advisor to monitor project: A project advisor
must be identified to provide expertise and
guidance for the team as well as to ensure that team
members are working efficiently to complete the
project.
IHI Open School PSU Chapter Leadership: Needed
to coordinate project activities
Facilities:
Video conferencing rooms for conference calls
Fall Patient Safety Symposium at Hershey Campus
and its necessary facilities (secured by IHI Open
School PSU Chapter Leadership)
Funding/Costs:
Funding to support the individual efforts of team
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members
Online Resources:
Online resource to complete project:
Checklist to completion of research requirement
Defining Team Roles Template
Schedule of Team Meetings and Events
Online resources to complete IHI Open School
Training Modules: QI 101-106
Forum for project postings for both faculty and
students
Activities
Knowing what you know about
what works to solve problems or
build assets as specified in the
theory of change for your
program, what specific activities
have you planned to do
Activities to complete QI project:
Conference calls involving all team members
Bimonthly reports of progress to Principal
Investigator
Activities to complete required research assignment:
Discipline specific checklist of requirements that
must be included for successful fulfillment of
research requirement
Activities to complete IHI Open School Training
Resources:
Attendance at the Patient Safety Symposium to
count as completion of training modules QI 101-
102
Output
For each of the specific activities
that you have planned to do, what
outputs (service delivery or
implementation targets) do you
hope to reach through the
operation of your program
QI Interprofessional Project completion and
presentation
Research assignment requirement fulfilled
Completed IHI Open School Training Modules
Outcomes
For each of the specific activities
you have planned to do, what
short-term and then long-term
outcomes do you expect to
achieve as indicators of the
At the conclusion of this course experience, we hope
that students will:
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progress made by your program
toward its desired results
Foundational Knowledge:
Identify the key elements of a PDSA cycle.
Describe the commonly used framework for
improving healthcare quality in the U.S.
Application:
Use PDSA cycle to improve a particular aspect of
medical care.
Evaluate the effectiveness of an improvement
project.
Analyze data collected from an improvement
project.
Select appropriate process, outcome, and balancing
measures for a given quality improvement project.
Integration:
Connect the model for improvement to application in
the students’ everyday personal life.
Integrate ideas about quality improvement from
medicine, nursing, engineering, and/or health
policy and administration.
Human Dimension:
Interact with people from other disciplines in regards
to quality improvement projects in the future.
Come to see themselves as more educated in systems
thinking.
Understand other health profession's contribution to
quality improvement.
Attitudinal:
Value the expertise of other health professions.
Become more interested in quality improvement.
Become more interested in participating in future
quality improvement projects.
Learning How to Learn:
Be able to identify several useful resources to help
them continue to learn about quality improvement.
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Impact
For each of the specific activities
you have planned to do, what
impact do you expect to achieve
in your community
N/A
Section III: Program Theory:
Before describing implementation of this framework, we detailed the reasoning and theory behind
the formation of the different aspects of our logic model. We will first begin by describing how the
outcomes and outputs were formed. We will then describe the process involved in determining the
activities and resources needed to complete the outcomes and outputs.
Desired Results:
As listed, our desired results can be broken down into the output and outcomes. We began by
describing the outcomes of this project. Although the model suggests looking at the impact of such a
project on the community, we felt, in order for us to better understand the scope of the project, to focus on
the framework users (i.e. graduate students) and less on its impact outside of this population.
Outcomes: Our outcomes list is a set of learning objectives that we hope the students involved
will achieve by the completion of their project. Noting the importance of evaluating the whole experience
of the student participating in a quality improvement project, we decided to select a template designed by
educator Dee Fink. Fink describes a new taxonomy of learning that suggests that a learning experience
involves more than just the three taxonomies of cognitive, affective, and psychomotor, described by
Benjamin Bloom. Fink’s taxonomy also has a very important element: its construction is based on the
assumption that learning must be defined in terms of change. Similarly, quality improvement projects
aim to measure change. Keeping in mind our plans to evaluate the effectiveness of our program by
measuring change in the learner, we have selected the template described by Fink. Fink describes six
major educational goal categories, as outlined in the logic model (Fink, 2003).
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Outputs: Our outputs were relatively simple, as it was clear that a major goal of the framework
was to have students complete a degree research requirement by the end of their time within the
framework. Two other outputs we hoped would be completed by the end of the project included the
completion of an interdisciplinary QI project and the completion of an educational requirement, through
the completion of IHI Open School Training Modules. We felt that is was necessary to be sure that users
of the framework had an adequate foundational knowledge in QI before completing a project.
Needs and Assets Assessment:
Surveying key faculty stakeholders in our respective disciplines, we identified a list of resources
and activities that would be needed to facilitate this project. In our logic model, we first defined the
activities that would be needed to fulfill our outputs. Finally, we compiled the necessary resources that
would be needed to help to facilitate the completion of the activities identified. Below is a detailed
description and categorization of our identified resources and activities.
Activities: We identified three major activity categories that would be necessary for a student in
any particular discipline to reach our three main outputs: (1) Activities to complete QI project, (2)
Activities to complete required research assignment, and (3) Activities to complete IHI Open School
Training Resources. Within these categories, activities have been identified that would be facilitated by
the IHI Open School PSU Chapter Leadership. This new interprofessional graduate student interest group
focuses on promoting quality improvement and patient safety through an interprofessional environment.
Within the group, one leader is assigned to facilitating student-led quality improvement projects.
Therefore, the coordination of this project will fit well within the role of the IHI Open School PSU
Chapter leadership.
Resources: We have identified four major categories necessary to allow for students to complete
the outlined activities. These categories include: (1) personnel, (2) facilities, (3) funding/costs, and (4)
online resources.
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(1) Personnel: Both faculty and students will be required to facilitate this framework. A faculty
advisor will need to be identified to monitor the project. This mentor will help to provide
expertise and guidance to the team as well as to ensure that the team members are working
efficiently to complete the project. A student leader from the IHI Open School PSU Chapter
will be needed to coordinate all project activities. This will include sending out meeting
reminders, monitoring other resources, and facilitating activities.
(2) Facilities: In order to allow for meetings to take place, videoconference rooms must be
secured to allow for meetings. We expect that team members will be unable to meet in
person on a monthly basis due to other obligations at their main campuses and the distance
between University Park campus and the Hershey campus. We also must plan for the first
meeting of the team at the Patient Safety Symposium. This facility requirement will be
facilitated by the event planners, the IHI Open School PSU Chapter leadership.
(3) Funding/Costs: We plan to try to secure funding to support the efforts of the team members
involved in the pilot interprofessional project. We also plan to secure funding for the
framework development team to support their efforts of evaluation and implementation. This
will help to maintain resources for the team and to support data collection and analysis of the
framework evaluation plan.
(4) Online Resources: We have created a website to essentially be a hub for communication for
the team as well as a central location of major resources to help facilitate the completion of
their research requirements. The list of resources includes those outlined in the logic model.
These resources are to serve as suggestions and not as a necessity. They provide a concrete
list that, if completed, will fulfill the degree requirements of each major.
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Figure 2: CIHDS Student Quality Collaborative Website
Implementation Strategy:
The next step in our project is to implement this framework. Our plan is to identify one interested
student from each discipline and pilot this framework on one interprofessional team. The selection of
interested students would occur in early May to June 2011. The team would first begin to collaborate and
have a first introductory meeting in August 2011 during the 2 nd Annual Patient Safety Symposium at the
Hershey Medical Center. Students would collaborate throughout the next year and be required to present
at the next Patient Safety Symposium in August of 2012.
Next Steps:
With the completion of the development of our framework, the next step in the process is to
develop the evaluation methods. We plan to implement various measures of evaluation through the
assessment of the students participating in the projects. After development of the necessary evaluation
tools, we then plan to implement this framework as a pilot project between one group of interprofessional
students. This project would run throughout the year, as described by the implementation strategy. At
the conclusion of the year, the necessary data would be collected and analyzed by the team.
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At the conclusion of this investigation, we hope that our framework will provide future curricular
designers with insight on how quality improvement education may look like in an interprofessional
environment. We hope the implementation of this framework will shed light on unexpected challenges.
We also hope that the evaluation will help to target specific portion of a project that require improvement
in order for interprofessional collaboration to run more smoothly.
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