Interprofessionalism: The right answer to the right questions at the right time

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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 IPCE.

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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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(No Transcript)
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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
• Ministers 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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A System in Evolution/Revolution
First Curve Current System
Second Curve - Emerging System

• 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

Adapted from M. Merry, M.D Quantum learning
systems
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A System in Evolution/Revolution
First Curve Current System
Second Curve - Emerging System

• 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 systems 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

• 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

Adapted from M. Merry, M.D Quantum learning
systems
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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
HHR in Evolution/Revolution
Collaborative 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

• 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
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Five Tools To Support the Move to IPC

• Conscious Transformational Change
• Appreciative Inquiry
• Focus on Value
• Research
• Leadership

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Developmental Change
Improvement of what is New state is a Prescribed
enhancement of the old state
Transitional Change
Design 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 Change
Old state is forced to die New state is unknown.
Emerges via trial and error. New State Requires
new organizing principles, behavior, culture,
mindset
Trial/Error emergence
Wake up Calls
Death forced change
Conscious Transformational Change
Death of old state is required and supported. New
state initially unknown. Principles driving
change are known and are the design criteria for
the new state and course correction. New State
evolves as new information is generated and
learning/course correction occurs
Learning/ course correction
Info
Wake up Calls
Info
Info
Planned/Natural death of old state
1998 Being First Inc (modified) And Ted Ball
Managing Change
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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 doesnt. It means asking different
  questions and drawing from stories of concrete
  success. Asking questions that strengthen a
  systems 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

• Goal is value for patients
• Value (All) health outcomes/total costs (in and
  outside of health care)
• True health outcomes not process or indicators
• Improved quality (i.e health outcomes) will
  contain costs
• Organize care around medical conditions, from the
  patients perspective, over the full cycle of
  care
• Improve value by increasing provider experience,
  scale and learning at the medical condition level
• Integrate Health care delivery across facilities
  and regions dont duplicate providers can
  cross geography
• Value must be measured and reported by every
  provider for each medical condition
• Reimbursement must be aligned with value and
  reward innovation
• IT can help restructure care delivery and measure
  results but is not a solution in isolation

Michael E. Porter, Redefining Health Care 2006
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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.

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IP Intervention
Interprofessional Education
Interprofessional Practice
Interprofessional Organization
Pre-licensure (37)
Post-licensure (44)
Post-licensure (9)
Post-licensure (32)
Stage
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)
Participants
Intervention types
Simulation (1) Seminar/workshop/ Course
(24) Placement/fieldwork (12)
Simulation (5) Seminar/workshop
(34) Degree/course (5)
IP checklists, Meetings, Rounds, Communication
tools, Briefings, Forms, Pathways (30)
Referral process, Case navigation binder, Weekly
updates (2)
Staffing Policies Work space Culture (8)
Consultation arrangements (1)
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)
Communication(22), Teamwork(17),
Collaboration(9), Coordination(3),
Roles(1), Cooperation(1)
IP objectives
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)
Reactions (4) Attitudes (2) Awareness and
Knowledge (5) Behaviour (21) Satisfaction
(3) Quality of audit (1) Clinical processes (20)
Intermediate outcomes
Patient outcomes
Patient outcomes (1)
Patient outcomes (16)
Economic (4)
System outcomes
Reeves S, Goldman J, Zwarenstein M, Gilbert J,
Tepper J, Beardall S, Silver I, Suter E (May 2009)
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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,
  dont 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
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Thank You