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Interprofessionalism: The right answer to the right questions

at the right time

HealthForceOntario

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My Theory…

• Common view: We need Interprofessional Care and Education because there are not enough nurses and doctors

• My view: There are fundamental transformational changes at the system and individual level of health care which inexorably point to the need for IPC&E.

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Interprofessional Practice - Our Cornerstone

The provision of comprehensive health services to patients by multiple health caregivers who work collaboratively to

deliver quality of care within and across settings.

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Outline

• Forces of Change Leading to IPC • Health system challenges and evolution• HHR challenges and evolution

• Tools to Support an IPC Agenda• Conscious transformational change• Appreciative Inquiry• Focus on Value• Research• Leadership

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Caveats & Context

• One persons view:• ADM (Civil service not political)• FP • Strong rural and inner city practice background

• Not about:• OMA agreement• Minister’s Mental Health Agenda• E-HO, wait-times, OLG, Procurement

• Try to be evidence based

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Challenges for the Health Care System

• Increasingly more money but less productivity

• Aging population and a more expectant population

• Health is highly politicized and highly personal

• Health is global

• In the middle of a fundamental transformation

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• The system is designed to meet the needs of the provider

• System is fragmented and patients fend for themselves

• Sickness focused; episodic/individual

• Designed to facilitate freedom, independence and autonomy for individuals

• The system is designed to be customer-driven while incorporating the needs of all care-givers

• System is seamless and patients are supported as they move through it

• Health Status and outcomes focused; systemic & population based

• Designed to facilitate the best combination of independent and interdependent professionals

First Curve – Current System Second Curve - Emerging System

Adapted from M. Merry, M.D & Quantum learning systems

A System in Evolution/Revolution

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• Designed to encourage political behavior/power games

• Health is seen as a jurisdictional issue only and there is no co-ordination

• The system is designed to be complicated

• Despite increasingly massive investments productivity is declining and there are significant inefficiencies

• Designed to produce collaborative behavior and team work

• The national nature of the health care system and especially HHR is recognized and capitalized upon

• The system’s complexities and self-organizing potential is realized in a natural complex adaptive system

• Resources are freed for innovation and quality improvement. People and resources are leveraged and productivity improves

First Curve – Current System Second Curve - Emerging System

Adapted from M. Merry, M.D & Quantum learning systems

A System in Evolution/Revolution

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Challenges in Health Human Resources…

People will:

• be more numerous and older

• be more culturally diverse

• have more chronic than acute diseases

• be increasingly involved, informed consumers

• seek complementary and alternative care

• focus on wellness and disease prevention

Health service providers will:

•be older and seeking career transition and retirement

•continue to come from a range of other nations

•want more balance and flexibility in their careers

•work in a mobile, international and opportunity-laden market

•demand healthy and stimulating workplaces

•need new educational models to deal with a rapidly evolving base of knowledge and technology

Health services will:

• be increasingly based in the community setting

• be delivered by interprofessional teams

• focus on health promotion and disease prevention

• make greater use of new technology including tele-medicine and diagnostic imaging

…. New expectations, capacities and roles are demanded of our workforce

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Defensive Individual Behaviour

• Command & Control• Low Trust• High Blame• Alienation• Undertone of threats and fears• Anxiety• Guardedness• Hyperrivalry• Withholding• Denial• Hostile Arguments• Risk Avoidance• Cheating

• Highly participative• High Trust• Dialogue• Excitement• Honesty• Friendship• Laughter• Mutual Support• Sincerity• Optimism• Cooperation• Friendly Competition• Shared Vision• Flexibility

Collaborative Individual Behaviour

• Risk Taking• Tend to learn from

mistakes• Face difficult truths• Broad perspective• Open to feedback• Sense of contribution• Work experienced as

pleasurable• Internal motivation• Sense of purpose• Ethical behavior• Inspirational leadership• Authentic community

• Political Games• Greed• Attitude of entitlement• Deadness• Cynicism• Sarcasm• Tend to hide mistakes• Work experienced as

painful • Dependence on external

motivation• Self-serving leaders• Character Assassination

Adapted from R. Cooper & A. Sawaf – Executive EQ

HHR in Evolution/Revolution

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Five Tools To Support the Move to IPC

• Conscious Transformational Change

• Appreciative Inquiry

• Focus on Value

• Research

• Leadership

13Developmental Change

Improvement of what is: New state is aPrescribed enhancement of the old state

Transitional ChangeDesign and Implementation of a new state: Requires dismantling of the old state and Management of the transition (e.g hospital mergers)

Old New

Reactive Transformational ChangeOld state is forced to die: New state is unknown. Emerges via trial and error. New State Requires new organizing principles, behavior,culture, mindset

Death: forced change

Conscious Transformational Change

Planned/Natural death of old state

1998 Being First Inc (modified)And Ted Ball Managing Change

Wake up Calls

Wake up CallsInfo

Info

Info

Death of old state is required and supported.New state initially unknown. Principles driving changeare known and are the design criteria for the new stateand course correction. New State evolves as new information is generated and learning/course correction occurs

Learning/ course correction

Trial/Error emergence

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To Achieve IPE..

Development and Transition are not enough

We need Conscious Transformational Change

1998 Being First Inc (modified)And Ted Ball Managing Change

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Appreciative Inquiry

• Appreciative Inquiry rejects the more traditional ‘problem-focused’ approach and instead seeks to identify what is working well or opportunities for positive change. It is an engagement approach to encourage imagination, innovation and flexibility by building upon the positives that already exist

• AI focuses on what works rather than trying to fix what doesn’t. It means asking different questions and drawing from stories of concrete success. Asking questions that strengthen a system’s ability to apprehend, anticipate and heighten positive potential

• If you pay attention to problems you emphasize and amplify them – look for what works in the system/organization

• AI is core aspect of new MOH stewardship role

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Appreciative Inquiry Approach to HHR

• Paramedics

• Rural Settings

• Midnight - 8am

• Geriatric, Mental Health, Oncology and primary care teams have strong history and good evidence around IPC

• 85-90% of home care delivered by family care givers/volunteers

• Looked to other places for inspiration

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Increase Supply

• Today there are more:• Nurse Practitioners

• International Medical Graduates

• Family Medicine Residents

• Medical Residents

• Midwives

…In training than ever in the history of Ontario(But largely achieved in new ways…)

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New Roles and Responsibilities: Unlocking existing potential

Physician Assistant

Nurse Endoscopist

Surgical First Assist

Clinical Specialist Radiation Therapist

Scaling and Planning for Dental Hygienists without an order, limited rx authority

Enhanced role: radiation technologists, dieticians, podiatrists, physiotherapists, midwives

Anaesthesia Assistants

Pharmacy Assistants

Prescribing authority for Optometrists

RN-EC: New classes (3), prescribing authority and roles/powers

Remote pharmacy

Pharmacy renewal and rx powers

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Patient Value Care Delivery IPC is logical support

1. Goal is value for patients• Value= (All) health outcomes/total costs (in and outside of health care)• True health outcomes not process or indicators

2. Improved quality (i.e health outcomes) will contain costs3. Organize care around medical conditions, from the patient’s perspective,

over the full cycle of care4. Improve value by increasing provider experience, scale and learning at the

medical condition level5. Integrate Health care delivery across facilities and regions – don’t duplicate

– providers can cross geography6. Value must be measured and reported by every provider for each medical

condition7. Reimbursement must be aligned with value and reward innovation8. IT can help restructure care delivery and measure results but is not a

solution in isolationMichael E. Porter, Redefining Health Care2006

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Research

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Research to date:• Providers see improvements in patient morbidity and mortality.

• Help reduce errors, better coordination, enhanced working environments, better staff morale and increased patient satisfaction.

• Increased access to health care.

• Improved outcomes for people with chronic diseases.

• Less tension and conflict among caregivers.

• Better use of clinical resources.

• Easier recruitment of caregivers.

• Lower rates of staff turnover.

22IP Intervention

Stage

Participants

Intervention types

IP objectives

Intermediate outcomes

Patient outcomes

System outcomes

Reeves S, Goldman J, Zwarenstein M, Gilbert J, Tepper J, Beardall S, Silver I, Suter E (May 2009)

Interprofessional Education

Pre-licensure (37) Post-licensure (44)

Interprofessional Practice Interprofessional Organization

Post-licensure (9)Post-licensure (32)

Health care providers from

different organizations

(1)

Health care providers from

same site

(8)

Health care providers from

same site

(30)

Health care providers from

different organizations

(2)

Students from different health

and human programs (37)

Health care providers from

same site

(28)

Health care providers from

different organizations

(16)

Simulation (1)Seminar/workshop/

Course (24)Placement/fieldwork

(12)

Simulation (5)Seminar/workshop (34)

Degree/course (5)

“Teamwork”(45), “Communication”(28), “Role understanding” (24), “Collaboration”(18), “Leadership”(4), “Interdisciplinary

understanding/care/interaction”(5), “Cooperation”(4), “Interagency working”(3), “Interprofessional

working/practice/approach”(3), “Relationship skills”(1), “Coordination”(1)

Reactions (23)Attitudes (16)Awareness/

Knowledge (16)Skills (4)

Practice (1)

Reactions (21)Attitudes (5)

Stress/life satisfaction (2)Knowledge (14)

Skills (2)Behaviour (22)Satisfaction (1)

Patient outcomes (1)

IP checklists, Meetings, Rounds,

Communication tools, Briefings,

Forms, Pathways(30)

Referral process, Case

navigation binder, Weekly updates

(2)

StaffingPolicies

Work spaceCulture

(8)

Consultation arrangements

(1)

“Communication”(22), “Teamwork”(17), “Collaboration”(9), Coordination”(3), “Roles”(1), “Cooperation”(1)

Reactions (4)Attitudes (2)

Awareness and Knowledge (5)Behaviour (21)Satisfaction (3)

Quality of audit (1)Clinical processes (20)

Patient outcomes (16)

Economic (4)

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Leadership

• The critical success factor for Conscious Transformative Change, Value for Patients and AI

• Need transformational not transactional leadership• Conscious of structure, process, culture• Adaptive Leadership – Ask the ‘wicked questions’, don’t give answers, frame

the questions to spur innovation• Focus on Quality and CQI• Often ignored part of creating, sustaining tranformational change• Needs time and resources to nurture

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The New Leadership Qualities• Dialogue/Team Learning and effective dialogue• Emotional Intelligence and Political Intelligence• Integrated and systems thinking• Change Management/Adaptive leadership• Collaboration/Teamwork/Innovation• Facilitate/Coach/Reframe• Leveraged thinking• Lean Thinking, CQI• Risk Management and Conflict Resolution• Stewardship and Talent Management• Organizational Alignment and Strategic Budgeting

Ted Ball, Managing Change 2008

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Leadership

• Currently a significant paucity of investment in leadership

• Starting to change …very fashionable

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Conclusion

• The system is under tremendous pressure• A system under pressure is an opportunity• Interprofessional education and care is a key response to these

pressures• IPC can be supported by:

• Conscious transformative change - different approach to planning• Appreciative Inquiry - different way of addressing problems• Focus on value – Different motivation for change• Leadership – different people leading differently

• This conference is not about the past of mental health care but the future

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We are what we repeatedly do. Excellence then is not an act but a habit- Aristotle

Thank You