Interprofessional Collaborative Practice: The whole is greater than the sum of the parts

Prof Sarah Strasser Associate Vice President Academics & Interprofessional Practice Health Science North Academic Health Centre for NOSM

The Northern Territory

• Vast • Remote • Sparsely populated • Indigenous • Chronic health issues • Large disease burden • Tropical - desert

Interprofessional collaborative practice

Prof. Sarah Strasser

Northern Ontario

• Sioux Lookout

Southern Ontario

In, by and for Northern Ontario

27 – 30 October 27-30 October 2014 Uluru, Northern Territory, Australia

Latest Muster information is available at

www.flinders.edu.au/muster2014

[email protected]

Interprofessional Collaborative Practice: The whole is greater than the sum of the parts “A partnership between a team of health professionals and a client in a participatory, collaborative and coordinated approach to shared decision-making around health issues” (Orchard et al., 2005).

• • • There is a

set of competencies

practitioner at

a team level

.

that describe the desired collaborative The

knowledge, skills, and attitudes

that shape interprofessional practice are reflected in the competency framework which can

be applied in different situations.

There is a

sub-set of competencies TEAM and

challenges

individuals

collaborative practice skills.

that strives to put the

“I” back in

to take responsibility for their

Thanks to Lesley Bainbridge for sharing

Interprofessional Collaboration (IPC)

A.

B.

C.

D.

E.

An interprofessional process of communication and decision making that enables the separate and shared knowledge and skills of health care providers to synergistically influence the patient care provided. (Way et al, 2000) Occurs when multiple health care providers from different professional backgrounds provide comprehensive services by working with patients, their families, carers and communities to deliver the highest quality of care across settings. (WHO Framework for Action on IPE & CP,

2010)

A partnership between a team of health care providers and a client in a participatory, collaborative and coordinated approach to shared decision making around health and social issues. (CIHC Framework)

Interprofessional collaboration is a process through which clients and providers can examine different aspects of a problem and constructively explore their differences, searching for solutions that go well beyond their own vision of what is possible. (Gray, 1989)

Interprofessional collaboration implies interdependence among clients and providers, constructive handling of differences, joint ownership of decisions and collective responsibility for outcomes. (Hartman et al, 1999)

Canadian Framework:

      Patient/Client/Family/Community-Centered Care Role Clarification Interprofessional Communication Team Functioning Collaborative Leadership IP Conflict Resolution

Competency Domains

An Example

• Domain: Interprofessional Conflict Resolution • COMPETENCY STATEMENT: Learners/practitioners actively engages self & others including the client/patient/family, in positively & constructively addressing disagreements as they arise.

• DESCRIPTORS: To support interprofessional collaborative, team members consistently address conflict in a constructive manner by: – Valuing the potential positive nature of conflict – Recognizing the potential for conflict to occur & taking constructive steps to address it – Knowing & understanding strategies to deal with conflict – Setting guidelines for addressing disagreements – Establishing a safe environment in which to express diverse opinions – Developing a level of consensus among those with differing views; allowing all members to feel their viewpoints have been heard no matter what the outcome

Competency framework considerations

Background considerations: – Quality improvement – Simple through complex – Context of practice

Rather than focusing on demonstrated behaviours to determine competence, the framework relies on the ability to integrate knowledge, skills, attitudes, and values in arriving at judgments.

• • • • • Five characteristics complexity (the dynamic organization of components); additive (application of knowledge, skills, attitudes to formulate judgments) integrated (diversity of individual resources); developmental (over the lifespan); and evolutionary (within a given context; actualization creates new understandings).

Examples of application of a competency or other framework

• • • • • Capacity building Strategic planning Educational planning and implementation Team/Self assessment Organizational changes

Capacity building & strategic planning

Mastery Immersion Exposure

Interprofessional Collaboration

Complex Complicated Simple

Role Clarification

Education

Team / Self assessment

• • I. Role Clarification Learners/practitioners understand their own role and the roles of those in other professions, and use this knowledge appropriately to establish and achieve patient/client/family and community goals.

• Describes own role and that of others – Never – Rarely – Sometimes – Almost Always – Does Not Apply

One size does not fit all: IP team needs to fit the purpose

Comprehensive patient centred care on a consistent basis (same team): Rural practice Palliative Care Cancer Care Stroke Care Care of the elderly – COACH Team

Care of the elderly: Coach team 48/5

48/5 for >65

• • • • • Bowel & bladder Management Cognitive functioning Functional mobility Medication management (+ pain) Nutrition & hydration

“many things wrong, all at once”

Dr Janet McElhaney

Mastery Immersion Exposure

Coach team Interprofessional Collaboration

Complex Complicated Simple

Role Clarification

Intermittent IP team – pockets of care/education & training

• • • • Operating theatre Out patient clinics – based on a scenario: pain, diabetes, bariatric surgery Technology enabled – Virtual ICU, telehealth Simulation Lab

Virtual Intensive Care Unit

HSN Helicopter pad

Mastery Immersion

Virtual ICU

Exposure

Interprofessional Collaboration

Complex Complicated Simple

Role Clarification

HSN Simulation Lab: Anaesthetic Boot Camp

Beyond clinical care

• • • Quality Improvement Patient safety Health Care Management (allocation of resources) – quality based funding/procedures (QBF/QBP)

Organizational Excellence training Quality Improvement

Mastery Immersion Exposure

OE Interprofessional Collaboration

Complex Complicated Simple

Role Clarification

Quality Based Funding/Procedure

• Health Service Providers will be reimbursed for the types and volumes of patients they treat, using rates based on efficiency and best practices that are adjusted for each procedure.

QBP Equation = Price X Volume

•

Adjusted for:

– – Patient complexity Quality of health care delivered 5

QBPs Addressed in the NE LHIN Clinical Services Review 1. Medical

I.

CHF II.

III.

COPD Stroke

2. Surgical

I.

II.

Cataracts Total Joints Replacement ( Knee and Hip)

III. Hip Fractures (2014/15)

IV. Vascular Surgery

3. Outpatient

I.

II.

Endoscopy Chemotherapy 9

QBP – Hip Fractures HUB Hospital (4)

For most part all hip fractures will be done at HUB (except Parry Sound as they do total joints) Transfer from the Emergency to the Operating Room goal is within 48 hours After Acute Hospital stay for fracture is complete, patient will be transferred to home hospitals for inpatient rehab.

Smaller Hospital (21)

If they do total joints, they must do hip fractures!

Transfer from the Emergency to the Operating Room goal is within 48 hours After Acute Hospital stay for fracture is complete, patient will be transferred to home hospitals for inpatient rehab - with telemedicine support from HUB rehab outreach.

18

Mastery Immersion Exposure

Interprofessional Collaboration QBF

Complex Complicated Simple

Role Clarification

Risk of team working - knotworking

Engestrom 1999

Organizational support: access to resources (time & money), senior management commitment

• • • • Improved quality of team work: teamwork: Organizational rewards for improvements in work practices Encourage use of innovation & implementation of change High support for team innovation Support to implement team changes Xychris & Lowton 2008

No hard evidence of patient outcomes (other than patient safety)

• • • • • Lack of consensus, focus & vision Lack of consistent funding & short funding cycles Lack of leadership & succession planning Lack of incentives/ perverse funding/ ‘work arounds’ Not all positive outcomes

• • • • • • • • • •

“If you don’t control the money you don’t control anything”

IP Competencies/capabilities & supervision IP communication & trust Physician & patient engagement Clinical Leadership & governance Regulations & organizational support Scaling up/ UHC/ transprofessional care Health literacy PCM & End of life care Context, complexity & costs Team changes, space and EMRs

Call to action

Health care in NZ in 2012

• Challenges: – Focal deficiencies and shortfalls; – Falling productivity; – Unsustainable reliance on immigrant health workers; – Costs of health care growing faster than national wealth ; • D. Gorman 2014 Challenges: – Ageing of the community and growing demand for health care; and – Ageing of the community and retirement of the ‘baby boomer’ generation of health care providers.

Jaws of death NZ:

D. Gorman 2014

400,000 350,000 300,000 250,000 200,000 150,000 100,000 50,000 0

NZIER (2005) NZ Population Projections by Age Cohort (Assuming medium population growth)

2001 2011 2021 D. Gorman 2014

Towards a sustainable and fit-for-purpose NZ health system

D. Gorman 2014 • • • • A shared care record.

A new way of funding services and of rewarding providers and consumers.

A diversified and fit for purpose community based health workforce that works as much as is possible at the “top end of their licence.” Genuine patient-directed and centred care – Advanced care planning

Rogue physicians

• Health is too diverse to have one person making decisions any more, in fact negative when one is left alone: Canada, Globe & Mail 2014:

Reports solo physician renders vaccines ineffective

by mixing them, for over 20 years.

Putting the “I” back in team.

SOCIAL CAPITAL RELATION SHIP BUILDING RHETORIC (FRAMING) PATIENT CENTRED COLLABORATIVE PRACTICE ADDRESSING CONFLICT NEGOTIATING PRIORITIES PERSPECTIVE TAKING

The alternative lens

G. Regehr

Differing forms of interprofessional work

networking coordination collaboration teamwork Integration & interdependence S. Reeves

Thank You