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

1. Interprofessionalism: The right answer to the right questions at the right time HealthForceOntario

2. 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.

3. 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.

5. 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

6. 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

7. 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

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

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

10. 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 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 • 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 Challenges in Health Human Resources… …. New expectations, capacities and roles are demanded of our workforce

11. 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 HHR in Evolution/Revolution Collaborative Individual Behaviour Defensive Individual Behaviour • 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 • 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 Adapted from R. Cooper & A. Sawaf – Executive EQ

12. Five Tools To Support the Move to IPC • Conscious Transformational Change • Appreciative Inquiry • Focus on Value • Research • Leadership

13. 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

14. To Achieve IPE.. Development and Transition are not enough We need Conscious Transformational Change 1998 Being First Inc (modified) And Ted Ball Managing Change

15. 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

16. 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

17. 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…)

18. 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 New Roles and Responsibilities: Unlocking existing potential

19. 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 patient’s 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 – don’t 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

20. Research

21. 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.

22. IP Intervention InterprofessionalEducation InterprofessionalPractice Interprofessional Organization Pre-licensure (37) Post-licensure (44) Post-licensure (32) Post-licensure (9) Stage Students from different health and human programs (37) Health care providers from same site (28) Health care providers from different organizations (16) Health care providers from same site (30) Health care providers from different organizations (2) Health care providers from same site (8) Health care providers from different organizations (1) 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)

23. 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

24. 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

25. Leadership • Currently a significant paucity of investment in leadership • Starting to change …very fashionable

26. 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

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

28. Thank You