Interprofessional transformation: are we making a difference?

(After completing an engaging and fruitful Winterthur Symposium; Interprofessional.Global recalls John H.V. Gilbert’s Keynote Presentation at All Together Better Health IX, Auckland NZ in September 2018, it provides an excellent perspective to guide our shared commitment and work moving forward)

Today I would like you to join me on a journey of exploration. The journey does not examine quantitative data. The journey is about viewing the past 50 years of interprofessional education for collaborative person centred practice as the development of a culture. A culture that has developed in many interesting ways that demonstrate the integrity of an academic discipline, and a mode of practice.

I’d like to address the development of this culture by posing, and attempting to answer, four questions that I have been grappling with since the first BEME (Best Evidence in Medical) analysis was published in 2007, and the latest published in 2016.

  • One: is there more learning together?
  • Two: are there are new forms of collaboration?
  • Three: are safety and quality of care improved?
  • Four: are new management structures steering change?

Today we hear much debate about the efficacy, sustainability, and value of interprofessional education, as viewed through the lens of quantitative measures. The quant studies miss the huge growth in the culture and read as though quantifiable evidence is the only measure of the effectiveness of a field of endeavour. I am tempted to remind those protagonists – that was then, this is now. The five turn 5 MB hard disk has been replaced by a flash drive that contains 1 million MB. The analogy is clear to me. In IPE huge developments have taken place across a wide spectrum of people, places and ideas. Those developments clearly demonstrate the many and varied ways in which interprofessional education, interprofessional learning, interprofessional practice, and interprofessional collaborative care have indeed grown into a culture of understanding. That culture is now the basis of an academic discipline.

So, let’s turn to the first question. “Is the transformation leading to more learning together?” In a sense we are revisiting the definition of interprofessional education. Learning “with, from and about” has been, and is being, tested in many different ways, a number of which are presented at this conference. I want to take an orthogonal to the usual methods of testing that notion.

To figure out whether it would be possible to have students learn together so that they could work together, one of the first problems we considered was that of the built environment in which postsecondary education was being provided for health and social care professionals.

The built environment has been described as “all the structures people have built when considered as separate from the natural environment, and surroundings created for humans by humans to be used for human activity”. All of us are familiar with rows of desks in a classroom. Clearly that particular built environment was not going to facilitate learning together to work together. So – we contemplated where the knowledge locations are in which we would be able to develop interprofessional learning and (incidentally) interprofessional practice. Those locations included classrooms, unassigned spaces, small rooms for studies, rooms for projects, and variety of workplaces and forums.

Over time, a number of institutions have successfully conceptualized the notion of a built environment to foster and develop interprofessional education and learning. On the left is the new College of Health Interprofessional Collaboration opened at Ball State University in Indiana in July this year. There is the Collaboration Health Education building at Dalhousie University in Halifax Canada, which was opened in 2016. And there’s the Daphne Cockwell Centre for Health Sciences at George Brown College in Toronto which was opened 2015. Both were built specifically to facilitate interprofessional education and learning. I’m also familiar with a similar development at the University of Colorado in Colorado. Any consideration of learning together would surely have to consider (and measure) whether facilitating this form of built environment does indeed result in more learning together.

But not only have evidence informed efforts been made to build the physical built environment, but literally hundreds of individuals from a wide diversity of disciplines and professions come together to explore ways in which we might educate, in the words of the Lancet report “Health Professionals for a New Century”, which appeared in the same year as the WHO Framework for Action”.

These developments then required the deliberations of large numbers of professionals from many different disciplines who attempted, and continue to figure out, how curriculum could be changed, how programs might be developed, and how the academic environment might be extended into the practice environment and other huge matters of policy and process in order to bring the reality of patient/client care into an interprofessional curriculum. To my knowledge, there are NO data on how many people have been involved in these efforts – but the numbers must be huge, and their effect has been to both deepen and broaden the culture so that solid learning and practice platforms are emerging, although not yet in a state where they can be easily or accurately quantified. But they are there.

Just three examples (I know there are others), the University of Montréal and McGill University have developed curricula that are based on the competencies of the Canadian Interprofessional Health Collaborative. The National Health Professional Education Foundation in Thailand earlier this year produced its Conceptual Framework of Interprofessional Education also built around IPE competencies.

The conclusion I draw from these various activities is that the culture of IPE is being built by as yet an unquantified number of people talking, planning, building which has certainly brought about a huge amount of more learning together, together.

So, let me move to my second question: “Is the transformation leading to new forms of collaboration”. In some ways this is an extension of my first question. When I pondered this question, I recalled the work of our colleague Mattie Schmidt on coordination cooperation and collaboration and how those ideas have evolved in the WHO Venn diagram for the interactions that we envisage with respect to new forms of collaboration across the social determinants of health, all of which are interprofessional in some way or another. This Venn diagram is the product of enormous interactions between many different participants, from many different professions, in many countries attempting, in response to my question, new forms of interprofessional collaboration.

I’m often asked, as I’m sure you are where do professional’s professional associations, stand with respect to their uptake of interprofessional education. I’ve chosen two very distinct and different organizations. In Germany the committee for interprofessional education in the health professions was established by the German medical associations organization, that organizes medical education. This group is composed of experts from Germany, Austria and Switzerland. This surely is incredibly encouraging and again indicates the development of the culture of IPE which has reached across national boundaries. Like you, I’m often asked where the medical establishment stands, I found it interesting that the American College of surgeons has established a committee on interprofessional education and practice – surely another huge step in the development of the culture.

We talk about students as being the champions for our efforts around interprofessional education. A recent publication that deals with in this respect Canadian student leaders’ perspective on IPE. Then my last point about this question is it leading to new forms of collaboration? If we think about social media and the ways in which interprofessional programs have been building through websites and Facebook and even Twitter it’s very clear that we are reaching a vast number of people who now have at least the word interprofessional, as part of their vocabulary.

The Canadian interprofessional health collaborative has 4100 members signed up. At the moment we don’t charge people to be members but for every person who signed up to be a member has meant a visit to the CIHC website. I know because I keep count of those who come in for everyone who signs up for membership in CIC there are 10 more that have visited the site. These are large numbers associated with the development of our culture.

Let’s then turn to my third question “Is the transformation leading to improved safety? Quality of care?” I sit on the BC Patient Safety and Quality Council and literally all our work is interprofessional. Our agency did early work on the checklist. Looking back, it is clear that the checklist has played a very large and significant role in the development of interprofessional collaboration. The checklist has an august history dating back to 1935 when it was first introduced by Boeing after a fatal crash of a Flying Fortress. It was determined that the flight crew had simply forgot to release the flight control gust locks, causing the plane to nose dive into the ground, immediately after takeoff. Today checklists are a common interprofessional activity in almost all surgical environments.

The international patient safety goal is surely an amazing example of why it is that inter-paraprofessional collaborative practice is so important. I simply tracked out the various parts of that mission because each one of those has, in every jurisdiction of which I am aware, involved two or more health and social care professionals to determine whether the goal is being met.

And then within the context of that goal has been the development of a movement called the Patient’s Voice. I’m proud of the fact that the first of those meetings on the patient voice was held at the University of British Columbia and that 10 years later there was a look at what had been achieved in that 10-year period. What has happened in British Columbia is the development of the patient voices network which now actually, extends across Canada. It is the transformation leading to improved safety and improve quality of care? I suggest that through the efforts of large numbers of health professionals this interprofessional approach to the patient’s voice has become a very significant important part of our efforts. And I recommend Jill Thistlethwaite’s article to you for a more coherent and comprehensive look at this issue.

So, let me turn now to my fourth question “Is the transformation leading to new management structures?” Clearly the development of new management structures takes an enormous amount of interprofessional interaction. I have chosen just two examples: the first is from Canada where the Western Canadian Interprofessional Health Collaborative worked on that important topic (for a country which depends on immigration) that is, how do we recognize credentials of internationally trained health professionals? Then the work conducted in Australia, around how to develop curricula that are truly interprofessional.

I was also delighted to see, just a couple of weeks ago, this statement from the Association of colleges of pharmacy in the United States very strong statement about interprofessional education. And as I was writing this presentation to see how interprofessional education is developing in South America. Brazil has made enormous strides in developing learning together interprofessionally (Richard Pitt and I are privileged to be part of these initiatives). The development of these new management structures, and others in other parts of the world, are the necessary cultural basis IPE.

We came to realize some time ago that the development of sustained interprofessional learning and practice would require some profound changes around accreditation and legislation – which would again, require the involvement of large numbers of health and social care professionals.

In Canada, AIPHE – the Accreditation of Interprofessional Health Education was successful in addressing the issue of accreditation across at least 12 regulated health and social care professions. Those professions now have a statement about interprofessional education in their accreditation documents. And in the past two months, the release of the report of the Council for Continuing Medical Education with a clear statement about IPOE. Equally important with respect to this transformation of management structures concerned the necessary to set legislation in place that would facilitate interprofessional collaborative practice. In Canada we’ve been very fortunate that one province, Nova Scotia has done an enormous amount to embed interprofessional education in legislation. Efforts to move IPE forward in accreditation and licensure have taken an enormous effort, by large numbers of people from all kinds of health professions who understand why these two issues are so important in effecting transformation in management structures, which again contribute to building the culture of IPE.

If we look, globally, at outcomes of these changes, we see the development of centres of interprofessional education and collaborative practice, not only in the academic environment of universities colleges and institutes but also within the practice community.

We see academic and clinical leadership positions created in order that taking the message forward is in the hands of individuals who understand what is involved. We see an ever-increasing number of doctoral students enrolled in IPE scholarship, and funding for such students. Equally as interesting has been the development of an understanding at the World Health Organisation about how interprofessional education for collaborative practice is really part of the way in which we envisage the development of the health and social care workforce – from the 2010 report, through a success of other and now clearly stated in the Framing the Health Workforce Agenda. Again – hugely significant building of the culture for IPE.

And so, to our final question: “Is the transformation steering the management of change?” It’s important to recognize Hugh Barr’s 2015 review in which he looks at the way in which IPE has spread across the globe. The countries that now have some programs of IP in place, is impressive and another clear indication that the cultural transformation of IPE is indeed steering the management of change. We see this here, at this conference, where the WCC, a federation of organizations around the globe brings us together so that we can share ideas, data and advances with respect to all aspects of interprofessional education.

It’s important to remember that the first statement about educating for the health team was produced by the Institute of medicine in 1972, then a WHO statement about interdisciplinary teams in the 1980’s, and then in 2010 the WHO Framework for Action on Interprofessional Education and Collaborative Care. But if you look at other areas in which management changes taking place you can again see it in for example, South America although similar transformation is taking place in sub-Saharan Africa, India, the middle east, Malaysia, Thailand and other places where we might least expect it.

Through the use of webinars, teleconferences, Zoom, email, social media – the numbers involved in effecting and steering management change, are enormous. And let’s not forget that there have been a number of systematic reviews of interprofessional education which have dealt with the quantitative data of change looking at some very specific aspects of what that engages – the recent paper by Guraya and Barr is but one example. And then on July 24 of this year a further report about progress in Brazil.

A final indication of the transformation steering the management of change can be seen in the number of newsletters that are now produced with respect to interprofessional education and collaborative practice. I’ve chosen 3 (from many) from Jefferson University, the University of Toronto, and the latest one from Qatar University in Doha, published in June.

Again, I urge you to think of the number of people who have to be engaged in developing these newsletters. They are but yet another indication of how the culture is growing and deepening its effects on management. And then there are, course the many, conferences and meetings that deal with IPE. Again, from Philadelphia University and Jefferson University, and indication of how one (of many IPE programs) who, in 2017 reflected on the effectiveness of the Jefferson Centre for Interprofessional Education over the past 10 years and have shown how the number of people involved is growing and growing and growing in all aspects of this field. AND – how are we ever going to calculate the number of people who have visited the CAIPE website, or the huge numbers who have benefitted from, and continue to benefit from the National Centre for Interprofessional Practice and Education in Minnesota.

Please forgive me for NOT mentioning the 500 and more IPE initiatives that I have received through my Google search and most of which I have posted to the CIHC website over the past five years.

Finally, I’ve been thinking more and more about the growing culture. About what it means in terms of all the people who see power for system change in this work and who, despite the logistical complexity of trying to change education and practice numbers all this work that is going on that is gone on and that will undoubtedly go on. Dr. Samuel Johnson is reputed to have said “We see a little and form and opinion, we see more and change it”.

If I do some simple back of the envelope calculations, and think back to 1998, the time of the first ATBH meeting in London, I guestimate that there were maybe a thousand people globally engaged in IPE.

By 2008 I guesstimate there were possibly 50,000 people. Today, I would guesstimate that there are more than 200,000 people actively engaged in the culture of IPE, and for each of those 200,000 another person is being recruited in. This quotation from Bill Gates, captures my own perceptions about where the culture of IPE is headed and how fast it is now moving forward.

I am a huge fan of the late and great Hans Rosling. His observation “Keep track of gradual improvements. A small change every year can translate to a huge change over decades” is, in my view, a wonderful reflection of where we have come from, and where we are going. His son Ola Rosling makes a point that perceptively captures a response to sceptics about the power of IPE “You have to realize that development takes a hundred years. You want it to happen in 10.”

The criticisms levelled at interprofessional education for collaborative person centred practice are based on estimates of quantitative data of interactions, within a very small scope. We certainly need to keep pushing the research agenda harder and harder on the continuity of the definition of IPE – with, from, about – for collaboration – for improved quality of care. It is taking time to amass such data, scarcely surprising given the complex interactions captured in the definition. Given the huge numbers of people who are now engaged in interprofessional education for collaborative person centred practice, we can no longer simply look at quantitative data about interactions across a very narrow scope of what is that we are engaged in – and characterize that data as the discipline. In my view that is looking at a small number of trees and missing the increasing size of the forest.

We have come an enormous distance on this journey toward an academic discipline. I recall when the study of child language, and the study of neuropsychology were in a similar place. It is self-evident that IPE is logistically complex and costly – but so is medical education. It is too early to claim that IPE is developmentally inappropriate – as yet there is virtually data which follows interprofessional learning through to improved quality of care. As I have tried to show, in order for IPE to have moved in the multiple spaces that it now occupies, its advocates have done a remarkable job of addressing issues of power and conflict in building those spaces. No one would claim other than that health and social care are incredibly complex systems that have been developed in a quasi-random fashion over the past 100 years. It is a bold and unsubstantiated claim that IPE is unlikely to change that system. As we observe major developments in collaborative care, it is clear that the central place of interprofessional understanding is playing a major role in system change.

What I have tried to show on this journey with you this morning is that we now have the culture of an academic discipline clearly demonstrated through the papers and workshops being presented at this meeting, and in the many ways and means that I have presented.

I recently came across a quote from Michelangelo which, in my view captures hopefully our vision of where we are attempting to go: “I saw an angel in the stone, and carved set to set it free’. 

We are now in a new place, we are no longer at the edge of an old place, and I find this place a very exciting place to be.

Thank you for your attention, all my relations.

References

Scott Reeves, Simon Fletcher, Hugh Barr, Ivan Birch, Sylvain Boet, Nigel Davies, Angus McFadyen, Josette Rivera & Simon Kitto (2016): A BEME systematic review of the effects of interprofessional education: BEME Guide No. 39, Medical Teacher, DOI: 10.3109/0142159X.2016.1173663

Hammick M, Freeth D, Koppel I, Reeves S, Barr H. 2007. A best evidence systematic review of interprofessional education. Med Teach. 29:735–751.