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An Interprofessional Framework for the Future

D’Agostino introduced two speakers to present examples of interprofessional efforts that are under way during the COVID-19 pandemic. He underscored how these examples demonstrate the use of rapid cycle learning and a systems-based thinking approach to respond to the demands of the pandemic and the needs of both students and health care organizations.

STUDENTS ASSIST AMERICA

Robert Cain, American Association of Colleges of Osteopathic Medicine

In mid-March 2020, said Robert Cain, president and chief executive officer of the American Association of Colleges of Osteopathic Medicine

(AACOM), colleges of osteopathic medicine were faced with the challenge of continuing education for their students in the face of the unfolding pandemic. In particular, there was concern about the ability to continue clinical education in the absence of adequate personal protective equipment (PPE) and a disrupted learning environment. At the same time, there were unmet public health, community, and mental health needs arising out of the crisis, and there was an opportunity for students to help address these needs. AACOM, recognizing there was no organized response to the pandemic that included the medical student workforce, spearheaded the development of the Students Assist America initiative.

The original concept of the initiative, said Cain, was twofold. The first was to enable students to move forward on their clinical education path while traditional methods of learning were disrupted. The second concept was to create meaningful opportunities for students with valuable skills and knowledge to help during the pandemic. The COVID-19 pandemic is not just a medical challenge; instead, it arises out of a complex system of interconnected parts. Recognizing this, AACOM invited other health professions organizations to participate in creating a shared vision for an interprofessional initiative to combat the pandemic. Ten other organizations across the spectrum of health professions joined the effort (see Box 4-1). This initiative reflects the osteopathic philosophy of attention to the body, soul, and mind by seeking to address not just physical health, but also public health, community health, and mental health.

The group’s early conversations focused on sharing best practices across professions, developing shared content for educating students about

COVID-19, and developing a common curriculum that could be used in clinical settings. Cain said one major motivation for the initiative were concerns over the effect the pandemic was having or would have on students. “Faced with uncertainty, we knew it was important to provide students with a sense of purpose, helping them to have some sense of control when things seemed otherwise out of control,” he said. To this end, the initiative was developed with student safety, success, and security as key components. With 11 health professions organizations on board, the question they asked themselves was “What can we do with 1 million extra sets of hands?”

The organizations spent a significant amount of time identifying potential tasks that would fit the knowledge base and skill set of students across the professions, he said. Because of the lack of PPE, the group looked for tasks that were no-contact or low-risk roles, such as contact tracing, education via telephone, conducting well-elderly checks, and mental health screenings. Ultimately, the group decided their greatest contribution could be made by using students to expand the vaccination workforce. With the country about to undertake the largest mass-vaccination effort ever, he said, “Extra hands are going to be needed.” Cain quoted Ron Klain, chief of staff to President Joe Biden, who said in November 2020, “It’s great to have a vaccine, but vaccines don’t save lives. Vaccinations save lives. And that means you’ve got to get that vaccine into people’s arms all over this country.”

The group identified three necessary steps for expanding the vaccination workforce with health professions students. First, working with the governor of each state to address liability concerns and to facilitate creation of necessary institutional agreements. Second, prioritizing access to the COVID-19 vaccine for health professions students in clinical settings. Third, addressing issues at the federal level to simplify medical reserve corps recruitment, expand the Centers for Disease Control and Prevention’s definition of “provider” to include students, and coordinate with the Biden administration’s COVID-19 task force.

There were a number of lessons learned through this experience, said Cain. First, access to PPE and concerns about liability were major issues at the beginning of the pandemic and remain so today. Second, the lack of a national response to the pandemic slowed the ability to implement and scale up the initiative. Third, the potential mental health effects associated with the pandemic are real and warrant greater attention in the future. Fourth, the lessons from student experiences during the H1N1 pandemic could be applied today. Fifth, there is bias toward certain health professions, and this bias prevents the full potential of the student workforce from being realized. Sixth, there is a need for training in public health across all health professions education. However, despite these challenges, said Cain, another lesson learned was the commitment to interprofessional education

is real. The 11 involved organizations have met weekly since March, and this type of collaboration between health professions “must continue after the pandemic is resolved.”

Students across the health professions, said Cain, can contribute in meaningful ways to the U.S. health care system in times of both crisis and stability. To make this kind of contribution possible, “We just need to open the pathways.” There is a need to develop a more structured way for institutions of higher learning to respond to public health needs to fully capitalize on the potential. Health professions programs are spread across the country, even in some of the most remote parts, Cain said. If one imagines a circle of influence around each of these programs, there is enormous potential to make an impact. However, there is a need for a coordinated, structured way for institutions and students to be engaged.

Another needed shift, he said, is improved and expanded interprofessional education and practice. Cain added that students in all health professions should learn about and work with other professions, particularly public health. For example, he said, a team of students from medicine, nursing, public health, social work, pharmacy, and other professions could conduct wellness checks for elderly patients with chronic disease, with each bringing their own area of expertise to the table. There are challenges associated with this approach, such as supervision and accreditation, but it is an idea worth exploring.

In conclusion, said Cain, the COVID-19 pandemic has brought uncertainty and challenges to health professions education, but it has also given students an opportunity to contribute. Students have demonstrated their passion by choosing to get involved in the response, and this willingness shows that we will be in good hands when these students move into the workforce.

INTERPROFESSIONAL LEARNING AT THE POINT OF CARE: SALVAGE, SUSTAIN, AND REPACKAGE POST-COVID-19

Vineet Arora, University of Chicago School of Medicine Mary Jo Bondy, Physician Assistant Education Association

In this workshop session, Bondy interviewed Vineet Arora, associate chief medical officer and assistant dean for scholarship and discovery at the University of Chicago School of Medicine (UChicago Medicine). Arora shared examples of the innovations that have happened at her institution throughout the COVID-19 pandemic. The interview was divided into three topics: bridge leadership, interprofessional collaboration, and a case study.

Bridge Leadership

Bondy asked Arora to describe the concept of “bridge leadership” and to explain why connecting practice to education is critical during the COVID-19 pandemic as well as for the future of health care. Arora explained that a bridge leader is one who not only thinks about the health system but also about the entire health professions education and training system, and sees the benefits of aligning education with clinical priorities, goals, and opportunities. Arora said “where you train matters,” and she noted that other speakers at this workshop shared powerful stories about the value students and residents can add in health care organizations. Bridging education and practice requires changes to health professions education curricula, changes to systems in health care, and the bridging leadership to align these efforts (see Figure 4-1). Arora said one of the keys to bridging leadership is to be open to the ideas of students, residents, and health professions trainees; she noted that learners often have innovative ideas about changes that could be implemented. Arora said these “zero gravity thinkers”—nonexperts who are open to new ideas and new ways of doing things—are the key to innovation (Rabe, 2006).

To illuminate the concept of bridging leadership, Arora described innovations that occurred during the COVID-19 pandemic at her institution. At the beginning of the pandemic, it became clear that educating students, residents, and clinicians around the proper use of PPE was going to be a challenge, she said. There were multiple signs around the hospital, each with slightly different information. The Hospital Incident Command

System (HICS) distributed multiple messages per day via email and hospital intranet; among these messages were policies and procedures about PPE. Clinicians found it difficult to learn using these methods, and expressed anxiety about not knowing how to don and doff PPE correctly. To address this challenge, medical students were deployed as “PPE observers” to help with the process and to ask people how signage could be improved.

One approach that was suggested, she said, was to use a checklist with pictures to make the procedures clearer. In addition, they partnered with a design think tank to test which signs were more effective, and with which groups. For example, they found that nurses preferred one sign while physicians preferred another, and residents were more comfortable donning and doffing than faculty. This demonstrates, said Arora, the importance of educating for the entire health system.

Arora described another approach they used for improving PPE education involving an application that delivered information about PPE at the point of care. People were overwhelmed by the multiple emails per day sent out by HICS, said Arora, and asked for something they could use on their phones. The information technology team was unavailable to help because they were overwhelmed themselves with updating the electronic health record with COVID-19-related changes. A “zero gravity thinker,” who was both a cardiology fellow and a health informatics student, had already developed and deployed an app to improve communication on the frontlines. The app was modified to include continuously updated PPE protocols and instructions; this allowed people to access the information at home before work, while donning and doffing, or whenever necessary. This highlights the role that bridging leaders can play at a very high level at an organization, by thinking about education not just for students but also for clinicians who need new information, said Arora.

Interprofessional Collaboration

UChicago Medicine, said Bondy, has a history of investing in interprofessional education such as the IGNITE (Improving GME-Nursing Interprofessional Team Experiences) initiative, and integrating medical librarians into interprofessional teams. Bondy asked Arora to explain how they sought to salvage, sustain, and repackage these efforts during COVID-19. Arora began by describing the benefits of interprofessional collaboration: reduced medication errors, improved patient satisfaction, decreased inpatient mortality, and shorter length of stay. However, she said, it has been challenging to achieve these benefits owing to some of the characteristics of UChicago Medicine. It is located in a health care desert and runs at 98 percent capacity on a regular day; in addition, there is no nursing school associated with the institution.

These circumstances led to the creation of the IGNITE initiative. The idea, said Arora, was to marry residency programs with nursing units so people would take ownership of the patients and the service line and would feel a shared responsibility to each other. Nurses nominate residents for the program, and they work as a team to identify areas that need improvement. This work has resulted in many innovations and improvements in patient care, she said. For example, one challenge at the institution was bringing nurses and physicians together for rounds. An obstetric nurse suggested having physicians press a button on an existing console in the unit in order to inform nurses of their arrival. Out of this idea came the “MD in the room communication workflow” that allows nurses and providers to touch base at the bedside or in the hallway. A postimplementation survey of the program found improved resident satisfaction, greater interprofessional collaboration, decreased length of stay, and decreased paging volume. When COVID-19 hit, this whole process needed to be reimagined, said Arora. While teamwork is even more critical during COVID-19, there were challenges caused by social distancing, PPE, and the use of alternatives such as web rounding. The program fell by the wayside early in the pandemic but was relaunched in July 2020, with nurses meeting physicians at a safe distance in the hallway or at the bedside.

Another interprofessional initiative at UChicago Medicine is the use of clinical librarians rounding with the teams, said Arora. In this program, a librarian joins the team once per week for patient rounds to offer research support to faculty, residents, and medical students. An evaluation of the program found that it improved learning and did not increase rounding length. At the beginning of the pandemic, librarians stopped attending rounds but were eventually redeployed to serve as an educational support team to keep clinicians educated and updated on COVID-19 related issues. During the redeployment, the librarians collaborated with medical students to synthesize information and answer questions. Arora reported that 22 clinicians were assisted, 80 questions answered, and 325 articles summarized. One clinician said the services were “incredibly helpful in facilitating data-driven clinical practice.”

Case Study: Family-Centered Rounds in Pediatrics

Arora concluded with a brief description of an innovation that allowed family-centered rounds to continue in pediatrics during COVID-19. The pediatric team used a rapid cycle plan-do-study-act approach to develop the plan for rounding. They used an iPad clipped onto an IV pole, and learners used the iPad to join the rounds virtually. This rounding approach, said Arora, is called the “leapfrog” model because learners switch off and on between joining in person and joining virtually (see Figure 4-2). For example,

one intern will attend in person for the first patient, then join Zoom for the next patient while another intern attends in person. Before this innovation, traditional virtual rounds were not working well, said Arora. Using this hybrid model improved education during rounds as well as communication between clinicians, residents, and patients.

MOVING FORWARD

Darrin D’Agostino, Kansas City University

At the conclusion of the workshop, D’Agostino offered his thoughts and polled participants on the main lessons from the sessions. D’Agostino said that speakers had emphasized the need for leadership to support innovation, the need for collaboration between academia and practice settings, and the need to use a systems-based approach to designing interprofessional

HPE. Participants were asked to answer two poll questions. Bondy reported that many participants indicated their intent to “definitely” get involved with implementing similar programs at their institutions. Several participants also endorsed continuing the dialogue and expressed a desire to move forward with a focus on interdisciplinary teams, promoting wellness, telehealth, evidence-based practice, and systems thinking. D’Agostino closed by expressing his hope that COVID-19 and this workshop would serve as the “scratch on the beaker wall” to crystallize and scale up these innovations.

REFERENCES

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