We know that teamwork, collaboration and communication between health care professionals can help patients. For example, medical errors are the third leading cause of death in the United States. And communication errors are the primary root cause reported to the Joint Commission. Interprofessional collaboration also promotes patient-centered care, reduces readmission rates and is more likely to address the patients’ needs. Because of this, many institutions provide interprofessional education—teaching us about the different health care professions and how to work together. 

However, an important piece is missing. No robust evaluation tools that we can use to assess interprofessional collaboration while providing clinical care to our patients exist. We need to develop a strategy to assess our learners’ ability to collaborate. As a Macy Faculty Scholar, I hope to develop such an assessment strategy with the help of an interdisciplinary team of experts across the health care professions.

The team includes experts in education in nursing, occupational therapy, pharmacy, physical therapy, primary care, respiratory therapy and social work. Many of our professions already have a framework for what collaboration with team members from other professions looks like. The team will review this and come up with a list of essential items. This will include the attitudes, skills and knowledge that one would need in order to collaborate well with others.

Once this list is generated, we will test it both in a simulated and an actual clinical learning environment. We will first check the list using videos where we know the “right answer” to make sure we are measuring what we set to measure. The videos will show examples of “good” and “bad” interprofessional behavior that the raters will watch to see if the tool works to distinguish between learners. We will then test it in the real world by observing teams caring for patients in the hospital. 

Interprofessional collaboration is essential to delivering quality patient-centered care. While many curricula and interventions have been proposed to improve such collaboration, no assessment tools with score reliability and validity are available to measure improvement or competence in this skill. The goal of my Macy Faculty Scholar work is to develop such an instrument to use across health care professions and settings in a real-time manner that will drive both formative feedback and competency assessment.

While I was most certainly paying closer attention to these interactions than most, the truth is that all patients expect that their doctors and nurses and other team members are on the same page about their care. They have good reason to demand this.  Better interprofessional collaboration is associated with a myriad of positive health outcomes including reduced mortality, reduced length of stay and readmission rates, and higher patient experience ratings.  Unfortunately, as I learned firsthand, this is not always the case. I am not alone. Data from Press Ganey patient experience surveys suggest that improving teamwork in hospitals is a key driver to improve patient satisfaction. 

Why is it so hard to achieve interprofessional care? Unfortunately, there are many barriers to achieving this vision, including the disparate training and practice silos between physicians and other allied health professionals, disparate rules and regulations that apply to different professional roles, as well as institutional policies and routine procedures governing workflow that may prevent team-based care. To make matters worse, all of these barriers to interprofessional team-based care are even more acutely evident in academic teaching hospitals where clinical learning is happening alongside delivery of patient care. This makes achieving the vision of the interprofessional clinical learning environment put forth by the Josiah Macy Jr. Foundation and the Accreditation Council of Graduate Medical Education (ACGME), which articulates the need to deliver patient-centered care in a team-based fashion where everyone is learning and teaching together, a challenge. 

How can we fix this?  At the University of Chicago, with the support of leaders from Nursing, Operational Excellence, and Graduate Medical Education, and additional support from the ACGME Pursuing Excellence Initiative, I am leading the implementation and evaluation of IGNITE (Improving GME Nursing Interprofessional Team-Based Experiences) as my Macy Faculty Scholars project. The premise is simple: there are positive exemplars of both residents and nurses who are exceptional at interprofessional care. What can we learn when we bring them together in interprofessional teams to redesign care? To improve their chances at implementing a successful and sustainable change, we will empower them with training in high reliability team performance principles and improvement science, and arm them with performance data to enable the creation of interprofessional clinical learning environments.

Lastly, to incorporate the patient voice, we plan to partner with patient experience representatives to ensure a patient-centered vision. Early IGNITE efforts have shown improved resident and nurse satisfaction, resident learning of team roles, and patient experience with their medical team. In addition to scaling up this vision to more clinical areas, I hope to deepen understanding of the impact of creating an interprofessional clinical learning environment using ethnographic data from direct observations of clinical teams with the assistance of colleagues from Sociology. 

While we are studying and improving teamwork, it is only fitting that I have a big team to thank for supporting the implementation of this project. “When the right people connect, they create a spark that ignites a flame.” -GB/Board of Wisdom

“The Macy Faculty Scholars Program introduced me to a new level of participation in interprofessional education and gave me the lens to see opportunities that I missed before. The mentors and colleagues have given real-time feedback and valuable support that allowed ongoing implementation of team-based palliative care education in our region, regardless of seemingly insurmountable barriers.”
—DorAnne Donesky, PhD, RN, University of California, San Francisco School of Nursing

“The Macy Faculty Scholars Program has had a wonderful influence on my career. I have grown as a medical educator and am poised to succeed in the next phase of my career. The mentorship from the National Advisory Committee and the previous Scholars has been amazing. I look forward to basking in the joy and opportunity being part of the Macy family provides as my career progresses.”
—Cristina M. Gonzalez, MD, MEd, Albert Einstein College of Medicine

“Joining the Macy Faculty Scholars family has been the professional opportunity of a lifetime. The program afforded me crucial time and support to advance a project I am passionate about and to grow individually as a health professions educator. Working within this network of Scholars has empowered me to pursue new leadership opportunities and to envision a different, better future for health professions education.”
—Temple Ratcliffe, MD, FACP, University of Texas School of Medicine at San Antonio

“Being selected as a Macy Faculty Scholar has had a significant impact on my career as an educator in the health professions. I have been able to participate in continuing education conferences that have influenced how I teach and lead in an interprofessional setting. I have been able to meet and network with colleagues from around the country who have extensive experience in the areas of education that are most interesting to me. Most importantly, the credibility and validation that the Macy Faculty Scholars Program bestowed on my project empowered me to implement a much bigger project with broader collaborations than I could have ever imagined. It is an enormous honor for me to be a part of the Macy family.”
—Tyler Reimschisel, MD, MHPE, Vanderbilt University Medical Center

“The Macy Faculty Scholars Program has been a life-changing experience for me, both personally and professionally. It broadened my view on the scope of health and healthcare transformation through interprofessional education and collaboration. It connected me with thought leaders in healthcare and brought me close friendship with other Scholars that are emerging national leaders in interprofessional education. The hands-on learning from mentors has inspired me to seek leadership positions and the project itself has led me to success in leading changes at my institution and the national level. I am forever appreciative of this amazing and transformational experience.”
—Jing Wang, PhD, MPH, MSN, RN, FAAN, University of Texas Health Science Center at San Antonio School of Nursing

This uniquely American epidemic is multi-factorial in origin, with the pharmaceutical industry, physicians and organized medicine all sharing the blame. While opioids are the current face of this epidemic, they are only one aspect of a larger crisis of unhealthy substance use and addiction.  We cannot afford to only address opioid addiction, since cessation of one drug without comprehensive care can simply result in substitution with another drug.  Fortunately, as Americans from all walks of life take increasing notice of the severity of the crisis, the healthcare industry is marshaling all its resources to help combat the epidemic.

The Response
Perhaps the most important component of the response to the crisis has been the ascendance of America’s newest multi-specialty subspecialty, addiction medicine. In 2015, addiction medicine became the newest medical specialty, recognized by the American Board of Medical Specialties (ABMS) as a sub-specialty of the American Board of Preventive Medicine (ABPM). This landmark achievement heralds a new era in the field of organized addiction medicine as physicians are now able to become board certified in addiction medicine via the gold standard ABMS designation. The first ABPM Addiction Medicine board exam was administered in the Fall of 2017, and over 1,000 physicians became board certified. Many more have applied for the upcoming exam this fall.

Building the workforce of addiction medicine physicians is essential if we are to address unhealthy substance use and addiction as the public health and medical problems they are, and to assure that all in need of help receive quality prevention and treatment services.  This is done by creating and sustaining fellowship training programs. Fellowships are the lifeblood of any medical specialty, as they provide the educational pathway wherein physicians become experts in their field. These fellowship graduates become the natural champions, researchers and change agents who proliferate throughout the field and help spread best practices throughout the entire healthcare arena. In addition to providing front-line clinical care, fellowship graduates become advocates at the local, state and national level to inform policy and guide legislators as they do their part to combat the ongoing crisis.

At present, there are 52 fellowship programs in the United States and 3 in Canada that have been accredited by The Addiction Medicine Foundation. It is expected that the majority of US-based addiction medicine fellowship programs will apply for ACGME accreditation throughout the next few years.

The Future
The Addiction Medicine Foundation is providing frontline support for the migration of fellowships into ACGME accreditation and continues to support the creation of additional high-quality, sustainable fellowship programs, with an ultimate goal of 125 fellowship programs by 2025.

In addition to helping to create fellowships, the Foundation has established a National Research Center in collaboration with the University of Tennessee Health Science Center to study all aspects of addiction medicine fellowships, their graduates, the impact of the fellowships and matters related to the addiction medicine workforce. The Addiction Medicine Foundation also facilitated the establishment of the independent Addiction Medicine Fellowship Directors Association (AMFDA) and has brought together its members for three annual meetings to discuss all topics relevant to addiction medicine training. In 2019, The Addiction Medicine Foundation and Addiction Medicine Fellowship Directors Association will merge into a combined successor organization known as the American College of Academic Addiction Medicine (ACAAM), continuing and advancing their work.

Many medical schools, federal agencies, philanthropies and other organizations are asking themselves how they too can help combat the ongoing crisis. The most important and critical step is to help build the addiction medicine workforce by establishing and providing resources to support fellowship training programs.  Only by providing a spectrum of science-informed prevention, early intervention, evidence-based treatment and comprehensive disease management can we hope to stem this crisis and prevent the next.  To do this, we need trained physicians and educators to train other health care professionals; we need champions to educate the public and reduce stigma; and we need funding. America deserves nothing less.

Hardly.

The report was the product of an invitational conference that we co-chaired in June 2017 in Atlanta, Georgia. The conference was developed at a time when the Affordable Care Act (ACA) was requiring people to have health coverage with minimum benefits that included primary care services. The nation had come to realize that building this capacity was essential, but physicians were continuing to prefer more lucrative specialty practices. While there were projections by the Health Resources and Services Administration (HRSA) that the supply of primary care physicians would remain inadequate, the supply of nurse practitioners and physician assistants would exceed the demands by 2025. The HRSA report noted that using these clinicians to meet the nation’s primary care needs would have to be accompanied by a reorganization of primary care. It did not address the role of Registered Nurses who are not nurse practitioners.

Our conference was predicated on the assumption that primary care needed to be transformed to have a stronger focus on health promotion, chronic care management, care coordination and patient engagement. We also recognized that primary care needed to incorporate ways to help individuals and families to address the social determinants of health that so often get in the way of healthy living, such as secure housing, access to healthy foods at an affordable price, or safe communities. We saw the potential for not just building primary care capacity, but doing so in a way that could transform this essential health service.

Registered Nurses: Partners in Transforming Primary Care awakened the worlds of primary care and nursing to the possibilities for building our nation’s capacity for comprehensive primary care through better use of registered nurses. It called for RNs to be able to practice at the top of their education and training: providing care coordination, chronic care teaching and counseling, health promotion services, and addressing population health for a practice.
The conference participants ranged from academic and clinical nurses, physicians, a social worker, health care administrators, a student, a regulator, health services researchers and other key stakeholders who have become champions of moving the report’s recommendations forward. These recommendations called for:

1. leaders in schools of nursing, primary care practices and health systems to lead culture change that will be necessary to prioritize primary care;
2. primary care practices to redesign their care models in ways that tap into the special skills and knowledge of registered nurses;
3. schools of nursing to expand and elevate primary care content and experiences at the undergraduate level;
4. retooling existing RNs for practicing in primary care;
5. partnerships between schools of nursing and primary care practices to provide opportunities for nursing faculty to be able to teach primary care to nursing students.
6. academic nursing leaders and faculty to provide opportunities for interprofessional education and teamwork in the primary care nursing curriculum.

These are substantial recommendations that will require a persistent vision for what primary care should deliver, how RNs can best be utilized, how best to prepare RNs for new primary care roles, and addressing the barriers that stand in the way (e.g., payment for RN services).

We heard from participants about the examples that already illustrate how to use RNs to transform primary care. Some of these examples are included in the report. All illustrate the importance of building an interprofessional primary care team.

The report also includes examples of schools of nursing that have already changed their curricula to incorporate a strong focus on primary care.

Schools of Nursing Seize a Leadership Role

The American Academy of Nursing was a partner on this conference and report. It committed to holding a special session on it at its 2016 Annual Policy Conference. The Academy comprises fellows who are selected to join because of their substantial and enduring contributions to nursing and health care. As such, the Policy Dialogue on RNs and Primary Care had a packed room of key thought nursing leaders in service and academia. The overwhelming response was that the report was welcomed as an overdue challenge to better using RNs in primary care. In addition, the Academy held regional mini-conferences to present the results and spark conversations among key stakeholders.

Subsequently, a number of schools of nursing and associations invited participants to speak about the report at their own events and conferences. For example, Diana was invited to speak at the National Forum on State Nursing Workforce Centers and subsequently at the Indiana Center for Nursing Workforce. These resulted in other invitations for speakers and consultants to help schools of nursing rethink their curricula and with redesigning primary care practices. For example, the Indiana University School of Nursing is working on a novel idea with a large public hospital with 11 community-based clinics. They are structuring an experience for their Doctorate of Nursing Practice students “to serve as consultants/leaders and work with the system across 2 semesters to develop a detailed blueprint for implementing the Macy report recommendations in the clinics. The students will work in teams to tackle the various recommendations of the report.” 

The Macy report lead to a competitive grant program under the Health Resources and Services Administration for schools of nursing to improve their curricula on primary care and work to advance the use of RNs in primary care practices. The University Southern Indiana School of Nursing has been awarded one of these grants to expand its primary care curriculum, with particular attention to building partnerships with the primary care practice sites in rural areas.  The University of Utah was also the recipient of one of the grants to increase the access to community-based primary care to residents of Utah living in rural and underserved areas through strengthening the capacity and competencies of primary care nurses through education and professional development.

Arizona State University College of Nursing held a faculty workshop to develop a plan for responding to the recommendations and has developed a partnership with the local Veterans Administration hospital to collaborate on care delivery and clinical practicums.

One associate degree nurse educator attended a leadership development institute sponsored by the National League for Nursing (represented at the Macy conference) where the report was presented and discussed. She returned home to organize an interprofessional meeting to examine how their region could enact the recommendations.

These are just a few examples of the early impact of the 2017 Macy report. This work will take time, but schools of nursing seem ready for it. The greater challenge is likely awakening primary care practices to how RNs can help them to see more patients, improve patient satisfaction, improve health outcomes, and contain costs. We eagerly await the outcomes from efforts by those schools of nursing that are partnering with health systems to implement the Macy report’s recommendations.

The changes to the ACA in the past two years—including the provision in the 2017 tax bill that repealed the penalty for not having insurance coverage and other actions that are increasing the cost of insurance premiums—have substantially weakened its provisions for expanding primary care. But the nation cannot afford to continue a health care system that has acute care, rather than primary care, as its foundation. We expect that the future will see a renewed emphasis on primary care as the nation realizes that universal coverage is an essential way to contain healthcare costs and improve the health of the nation. Registered nurses will be ready. 

A recording from the July 18 discussion is available below.

With support from Macy and the Institute on Medicine as a Profession, 19 academic health centers established novel programs to teach professionalism at the undergraduate and graduate levels.

Learn about their innovative approaches and what it will take to build professionalism programs at other institutions.

• Read: Report from a Convening of Grantees on Educating and Training to Professionalism

Watch what some of the grantees have to say about medical professionalism.

• Vineet Arora, MD, MAPP, University of Chicago Medicine
• C. Jessica Dine, MD, MSHP, Perelman School of Medicine at the University of Pennsylvania
• Cynthia Foronda, PhD, RN, CNE, CHSE, ANEF, University of Miami School of Nursing and Health Studies
• Coretta Jenerette, PhD, RN, AOCN, CNE, FAAN, University of South Carolina College of Nursing
• Daniel J. Schumacher, MD, MEd, University of Cincinnati College of Medicine

Each Scholar will engage in activities to enhance their career as an educator while pursuing a mentored educational innovation project at their home institution. Their projects deal with important themes spanning interprofessional education and practice, clinical competency, simulation and telehealth technology, and the social determinants of health.

“The Macy Faculty Scholars are change agents for health professions education. I look forward to seeing the impact they will have on students and faculty across the country and the patients under their care,” said Dr. Holly J. Humphrey, President of the Josiah Macy Jr. Foundation.

Learn more about the 2018 Macy Faculty Scholars and their projects.