Interprofessional Curriculum Delivery: Experience of a Primary Care Education Program.

Few post-graduate training programs offer a comprehensive curriculum that includes structured clinical experiences to teach interprofessional care. To address this need, the United States Department of Veterans Affairs, Office of Academic Affiliations funded the Centers of Excellence in Primary Care Education (CoEPCE) from 2011-2019 to provide interprofessional curricula for health profession trainees (HPTs), including physician residents, nurse practitioner residents, pharmacy residents, and psychology residents. We examined changes over time in curricular domains, system impacts, and program practices based on HPT survey data and the qualitative evaluation of narrative feedback. An annual survey was administered to participants. Indirect standardized ratios were calculated for interprofessional professional education (IPE) program domains, system impacts, and program practices. Qualitative responses were coded based on curricular domains and key program components. The study cohort included 369 HPTs. Site and profession standardized indirect ratios across all professions indicated improvements in curricular domains, system impacts, and program practices, with significant differences observed for associated health HPTs as compared to other HPTs for performance improvement. Qualitative data indicated that profession was associated with differences in perceptions of the curriculum. Although improvements occurred over time, our findings support the need for the thoughtful consideration of profession-specific identity characteristics when designing interprofessional curricula.

Interprofessional transformation of clinical education: The first six years of the Veterans Affairs Centers of Excellence in Primary Care Education.

This paper describes the Centers of Excellence in Primary Care Education (CoEPCE), a seven-site collaborative project funded by the Office of Academic Affiliations (OAA) within the Veterans Health Administration of the United States Department of Veterans Affairs (VA). The CoEPCE was established to fulfill OAA's vision of large-scale transformation of the clinical learning environment within VA primary care settings. This was accomplished by funding new Centers within VA facilities to develop models of interprofessional education (IPE) to teach health professions trainees to deliver high quality interprofessional team-based primary care to Veterans. Using reports and data collected and maintained by the National Coordinating Center over the first six years of the project, we describe program inputs, the multicomponent intervention, activities undertaken to develop the intervention, and short-term outcomes. The findings have implications for lessons learned that can be considered by others seeking large-scale transformation of education within the clinical workplace and the development of interprofessional clinical learning environments. Within the VA, the CoEPCE has laid the foundation for IPE and collaborative practice, but much work remains to disseminate this work throughout the national VA system.

Impact of clinical training on recruiting graduating health professionals.

OBJECTIVES: Recruiting professional staff is an important business reason for hospitals allowing health trainees to engage in supervised patient care. Whereas prior studies have focused on educational institutions, this study focuses on teaching hospitals and whether trainees' clinical experiences affect their willingness to work (ie, recruitability) for the type of healthcare center where they trained. STUDY DESIGN: A pre-post, observational study based on Learners' Perceptions Survey data in which respondents served as their own controls. METHODS: Convenience sample of 15,207 physician, 11,844 nursing, and 13,012 associated health trainees who rotated through 1 of 169 US Department of Veterans Affairs (VA) medical centers between July 1, 2014, and June 30, 2017. Generalized estimating equations computed how clinical, learning, working, and cultural experiences influenced pre-post differences in willingness to consider VA for future employment. RESULTS: VA recruitability increased dramatically from 55% pretraining to 75% post training (adjusted odds ratio [OR], 2.1; 95% CI, 2.0-2.1; P <.001) in all 3 cohorts: physician (from 39% to 59%; OR, 1.6; 95% CI, 1.5-1.6; P <.001), nursing (from 61% to 84%; OR, 2.5; 95% CI, 2.4-2.6; P <.001), and associated health trainees (from 68% to 87%; OR, 2.7; 95% CI, 2.6-2.9; P <.001). For all trainees, changes in recruitability (P <.001) were associated with how trainees rated their clinical learning environment, personal experiences, and culture of psychological safety. Satisfaction ratings with faculty and preceptors (P <.001) were associated with positive changes in recruitability among nursing and associated health students but not physician residents, whereas nursing students who gave higher ratings for interprofessional team culture became less recruitable. CONCLUSIONS: Academic medical centers can attract their health trainees for future employment if they provide positive clinical, working, learning, and cultural experiences.

Developing Interprofessional Primary Care Teams: Alumni Evaluation of the Department of Veterans Affairs Centers of Excellence in Primary Care Education Program.

PURPOSE: The Centers of Excellence in Primary Care Education (CoEPCE) is an interprofessional graduate training program within the Department of Veterans Affairs (VA). In this project, we describe career paths of CoEPCE graduates, their perceptions of CoEPCE program value, their overall satisfaction with the training, and suggestions for program improvement to enhance interprofessional education and workforce development. METHODS: The Graduate Participant Survey was developed and administered in 2018 to CoEPCE graduates from 2012 to 2017. Quantitative data from closed-ended questions were analyzed through descriptive and non-parametric statistics to test for significant differences by profession. Qualitative data from the single open-ended question were analyzed using content analysis with inductive and deductive approaches. RESULTS: The survey was completed by 180 graduates. Greater proportions of pharmacists and psychologists than nurse practitioners and physicians were employed in VA, and greater proportions of nurse practitioners and pharmacists than physicians and psychologists were employed in primary care. Although smaller proportions of physicians were currently employed in primary care (P < .0001), a greater proportion completed advanced training programs (P < .0001). Overall, graduates perceived that their CoEPCE training was highly valued by advanced training programs and employers and improved their chances of finding a job. They reported high levels of satisfaction (mean = 4.3 ± 0.9 out of 5 total) with the training program, continued to use skills they learned during training, and believe their CoEPCE experiences made them better health care providers. CONCLUSIONS: Ninety-four percent of the CoEPCE graduates were employed at the VA and/or primary care at the completion of their training, although there were significant differences by profession. Graduates continued to practice interprofessional skills learned during their training and were highly satisfied with the program. Taken together, the findings indicate that continued enhancements to the interprofessional clinical learning environment are warranted.

Curriculum Development and Implementation of a National Interprofessional Fellowship in Patient Safety.

OBJECTIVES: Developing a workforce skilled in improving the safety of medical care has often been cited as an important means to achieve safer care. Although some educational programs geared toward patient safety have been developed, few advanced training programs have been described in the literature. We describe the development of a patient safety fellowship program. METHODS: We describe the development and curriculum of an Interprofessional Fellowship in Patient Safety. The 1-year in residence fellowship focuses on domains such as leadership, spreading innovations, medical improvement, patient safety culture, reliability science, and understanding errors. RESULTS: Specific training in patient safety is available and has been delivered to 48 fellows from a wide range of backgrounds. Fellows have accomplished much in terms of improvement projects, educational innovations, and publications. After completing the fellowship program, fellows are obtaining positions within health-care quality and safety and are likely to make long-term contributions. CONCLUSIONS: We offer a curriculum and fellowship design for the topic of patient safety. Available evidence suggests that the fellowship results in the development of patient safety professionals.

Has Interprofessional Education Changed Learning Preferences? A National Perspective.

OBJECTIVE: To assess how changes in curriculum, accreditation standards, and certification and licensure competencies impacted how medical students and physician residents value interprofessional team and patient-centered care. PRIMARY DATA SOURCE: The Department of Veterans Affairs Learners' Perceptions Survey (2003-2013). The nationally administered survey asked a representative sample of 56,569 U.S. medical students and physician residents, with a comparison group of 78,038 nonphysician trainees, to rate satisfaction with 28 elements, in two overall domains, describing their clinical learning experiences at VA medical centers. STUDY DESIGN: Value preferences were scored as independent adjusted associations between an element (interprofessional team, patient-centered preceptor) and the respective overall domain (clinical learning environment, faculty, and preceptors) relative to a referent element (quality of clinical care, quality of preceptor). PRINCIPAL FINDINGS: Physician trainees valued interprofessional (14 percent vs. 37 percent, p < .001) and patient-centered learning (21 percent vs. 36 percent, p < .001) less than their nonphysician counterparts. Physician preferences for interprofessional learning showed modest increases over time (2.5 percent/year, p < .001), driven mostly by internal medicine and surgery residents. Preferences did not increase with trainees' academic progress. CONCLUSIONS: Despite changes in medical education, physician trainees continue to lag behind their nonphysician counterparts in valuing experience with interprofessional team and patient-centered care.

Health systems engineering fellowship: curriculum and program development.

Industrial engineering and related disciplines have been used widely in improvement efforts in many industries. These approaches have been less commonly attempted in health care. One factor limiting application is the limited workforce resulting from a lack of specific education and professional development in health systems engineering (HSE). The authors describe the development of an HSE fellowship within the United States Department of Veterans Affairs, Veterans Health Administration (VA). This fellowship includes a novel curriculum based on specifically established competencies for HSE. A 1-year HSE curriculum was developed and delivered to fellows at several VA engineering resource centers over several years. On graduation, a majority of the fellows accepted positions in the health care field. Challenges faced in developing the fellowship are discussed. Advanced educational opportunities in applied HSE have the potential to develop the workforce capacity needed to improve the quality of health care.

Connecting the dots: interprofessional health education and delivery system redesign at the Veterans Health Administration.

Health systems around the United States are embracing new models of primary care using interprofessional team-based approaches in pursuit of better patient outcomes, higher levels of satisfaction among patients and providers, and improved overall value. Less often discussed are the implications of new models of care for health professions education, including education for physicians, nurse practitioners, physician assistants, and other professions engaged in primary care. Described here is the interaction between care transformation and redesign of health professions education at the largest integrated delivery system in the United States: the Veterans Health Administration (VA). Challenges and lessons learned are discussed in the context of a demonstration initiative, the VA Centers of Excellence in Primary Care Education. Five sites, involving VA medical centers and their academic affiliates in Boise, Cleveland, San Francisco, Seattle, and West Haven, introduced interprofessional primary care curricula for resident physicians and nurse practitioner students beginning in 2011. Implementation struggles largely revolved around the operational logistics and cultural disruption of integrating educational redesign for medicine and nursing and facilitating the interface between educational and clinical activities. To realize new models for interprofessional teaching, faculty, staff, and trainees must understand the histories, traditions, and program requirements across professions and experiment with new approaches to achieving a common goal. Key recommendations for redesign of health professions education revolve around strengthening the union between interprofessional learning, team-based practice, and high-value care.

Veteran Affairs Centers of Excellence in Primary Care Education: transforming nurse practitioner education.

To integrate health care professional learners into patient-centered primary care delivery models, the Department of Veterans Affairs has funded five Centers of Excellence in Primary Care Education (CoEPCEs). The main goal of the CoEPCEs is to develop and test innovative structural and curricular models that foster transformation of health care training from profession-specific "silos" to interprofessional, team-based educational and care delivery models in patient-centered primary care settings. CoEPCE implementation emphasizes four core curricular domains: shared decision making, sustained relationships, interprofessional collaboration, and performance improvement. The structural models allow interprofessional learners to have longitudinal learning experiences and sustained and continuous relationships with patients, faculty mentors, and peer learners. This article presents an overview of the innovative curricular models developed at each site, focusing on nurse practitioner (NP) education. Insights on transforming NP education in the practice setting and its impact on traditional NP educational models are offered. Preliminary outcomes and sustainment examples are also provided.

A cancer genetics toolkit improves access to genetic services through documentation and use of the family history by primary-care clinicians.

PURPOSE: We developed, implemented, and evaluated a multicomponent cancer genetics toolkit designed to improve recognition and appropriate referral of individuals at risk for hereditary cancer syndromes. METHODS: We evaluated toolkit implementation in the women's clinics at a large Veterans Administration medical center using mixed methods, including pre-post semistructured interviews, clinician surveys, and chart reviews, and during implementation, monthly tracking of genetic consultation requests and use of a reminder in the electronic health record. We randomly sampled 10% of progress notes 6 months before (n = 139) and 18 months during implementation (n = 677). RESULTS: The toolkit increased cancer family history documentation by almost 10% (26.6% pre- and 36.3% postimplementation). The reminder was a key component of the toolkit; when used, it was associated with a twofold increase in cancer family history documentation (odds ratio = 2.09; 95% confidence interval: 1.39-3.15), and the history was more complete. Patients whose clinicians completed the reminder were twice as likely to be referred for genetic consultation (4.1-9.6%, P < 0.0001). CONCLUSION: A multicomponent approach to the systematic collection and use of family history by primary-care clinicians increased access to genetic services.

The Veterans Affairs National Quality Scholars program: a model for interprofessional education in quality and safety.

The Quality and Safety Education for Nurses (QSEN) project is enhancing the emphasis on quality care and patient safety content in nursing schools. A partnership between QSEN and the Veterans Affairs National Quality Scholars program resulted in a unique experiential, interdisciplinary fellowship for both nurses and physicians. This article introduces the Veterans Affairs National Quality Scholars program and provides examples of learning activities and fellows' accomplishments. Interprofessional quality and safety education at the doctoral and postdoctoral levels is germane to improving the quality of health care.

The learners' perceptions survey-primary care: assessing resident perceptions of internal medicine continuity clinics and patient-centered care.

BACKGROUND: In 2010, the Department of Veterans Affairs (VA) implemented a national patient-centered care initiative that organized primary care into interdisciplinary teams of health care professionals to provide patient-centered, continuous, and coordinated care. OBJECTIVE: We assessed the discriminate validity of the Learners' Perceptions Survey-Primary Care (LPS-PC), a tool designed to measure residents' perceptions about their primary and patient-centered care experiences. METHODS: Between October 2010 and June 2011, the LPS-PC was administered to Loma Linda University Medical Center internal medicine residents assigned to continuity clinics at the VA Loma Linda Healthcare System (VALLHCS), a university setting, or the county hospital. Adjusted differences in satisfaction ratings across settings and over domains (patient- and family-centered care, faculty and preceptors, learning, clinical, work and physical environments, and personal experience) were computed using a generalized linear model. RESULTS: Our response rate was 86% (77 of 90). Residents were more satisfied with patient- and family-centered care at the VALLHCS than at either the university or county (P < .001). However, faculty and preceptors (odds ratio [OR]  =  1.53), physical (OR  =  1.29), and learning (OR  =  1.28) environments had more impact on overall resident satisfaction than patient- and family-centered care (OR  =  1.08). CONCLUSIONS: The LPS-PC demonstrated discriminate validity to assess residents' perceptions of their patient-centered clinical training experience across outpatient primary care settings at an internal medicine residency program. The largest difference in scores was the patient- and family-centered care domain, in which residents rated the VALLHCS much higher than the university or county sites.

Training satisfaction for subspecialty fellows in internal medicine: findings from the Veterans Affairs (VA) Learners' Perceptions Survey.

BACKGROUND: Learner satisfaction assessment is critical in the design and improvement of training programs. However, little is known about what influences satisfaction and whether trainee specialty is correlated. A national comparison of satisfaction among internal medicine subspecialty fellows in the Department of Veterans Affairs (VA) provides a unique opportunity to examine educational factors associated with learner satisfaction. We compared satisfaction across internal medicine fellows by subspecialty and compared factors associated with satisfaction between procedural versus non-procedural subspecialty fellows, using data from the Learners' Perceptions Survey (LPS), a validated survey tool. METHODS: We surveyed 2,221 internal medicine subspecialty fellows rotating through VA between 2001 and 2008. Learners rated their overall training satisfaction on a 100-point scale, and on a five-point Likert scale ranked satisfaction with items within six educational domains: learning, clinical, working and physical environments; personal experience; and clinical faculty/preceptor. RESULTS: Procedural and non-procedural fellows reported similar overall satisfaction scores (81.2 and 81.6). Non-procedural fellows reported higher satisfaction with 79 of 81 items within the 6 domains and with the domain of physical environment (4.06 vs. 3.85, p <0.001). Satisfaction with clinical faculty/preceptor and personal experience had the strongest impact on overall satisfaction for both. Procedural fellows reported lower satisfaction with physical environment. CONCLUSIONS: Internal medicine fellows are highly satisfied with their VA training. Nonprocedural fellows reported higher satisfaction with most items. For both procedural and non-procedural fellows, clinical faculty/preceptor and personal experience have the strongest impact on overall satisfaction.

The Impact of VA's geriatric research, education and clinical centers on academic affiliates.

The education mission of the Department of Veterans Affairs (VA) is to train health professionals to benefit VA and the United States. One approach for achieving that mission, along with VA's research and clinical missions, was the establishment of Geriatric Research, Education and Clinical Centers (GRECCs) in 1975. These were developed at VA hospital sites that had existing strong partnerships with schools of medicine already engaged in research on aging. GRECCs were funded to enhance those research enterprises, to expand health professions education in geriatrics, to expand interest in geriatrics among medical faculty and to support them to become more expert in geriatrics, to develop new approaches to care of the aging, and to disseminate the lessons learned within VA and beyond. Using 2001 and 2008 data from two surveys of U.S. medical schools' geriatrics programs, this article explores the impact of GRECCs on geriatric programs at their affiliated schools of medicine. It demonstrates how VA's academic mission through GRECCs has benefited VA and its affiliates and how it has benefited the nation through the growth of geriatric medicine as an academic enterprise and a legitimate clinical specialty.

Measuring the intensity of resident supervision in the department of veterans affairs: the resident supervision index.

PURPOSE: To develop a survey instrument designed to quantify supervision by attending physicians in nonprocedural care and to assess the instrument's feasibility and reliability. METHOD: In 2008, the Department of Veterans Affairs (VA) Office of Academic Affiliations convened an expert panel to adopt a working definition of attending supervision in nonprocedural patient care and to construct a survey to quantify it. Feasibility was field-tested on residents and their supervising attending physicians at primary care internal medicine clinics at the VA Loma Linda Healthcare System in their encounters with randomly selected outpatients diagnosed with either major depressive disorder or diabetes. The authors assessed both interrater concurrent reliability and test-retest reliability. RESULTS: The expert panel adopted the VA's definition of resident supervision and developed the Resident Supervision Index (RSI) to measure supervision in terms of residents' case understanding, attending physicians' contributions to patient care through feedback to the resident, and attending physicians' time (minutes). The RSI was field-tested on 60 residents and 37 attending physicians for 148 supervision episodes from 143 patient encounters. Consent rates were 94% for residents and 97% for attending physicians; test-retest reliability intraclass correlations (ICCs) were 0.93 and 0.88, respectively. Concurrent reliability between residents' and attending physicians' reported time was an ICC of 0.69. CONCLUSIONS: The RSI is a feasible and reliable measure of resident supervision that is intended for research studies in graduate medical education focusing on education outcomes, as well as studies assessing quality of care, patient health outcomes, care costs, and clinical workload.

Measuring progressive independence with the resident supervision index: theoretical approach.

BACKGROUND: Graduate medical education is based on an on-the-job training model in which residents provide clinical care under supervision. The traditional method is to offer residents graduated levels of responsibility that will prepare them for independent practice. However, if progressive independence from supervision exceeds residents' progressive professional development, patient outcomes may be at risk. Leaders in graduate medical education have called for "optimal" supervision, yet few studies have conceptually defined what optimal supervision means and whether optimal care is theoretically compatible with progressive independence, nor have they developed a test for progressive independence. OBJECTIVE: This research develops theory and analytic models as part of the Resident Supervision Index to quantify the intensity of supervision. METHODS: We introduce an explicit set of assumptions for an ideal patient-centered theory of optimal supervision of resident-provided care. A critical assumption is that informed attending staff will use available resources to optimize patient outcomes first and foremost, with residents gaining clinical competencies by contributing to optimal care. Next, we derive mathematically the consequences of these assumptions as theoretical results. RESULTS: Under optimal supervision, (1) patient outcome is expected to be no worse than if residents were not involved, (2) supervisors will avoid undersupervising residents (when patients are at increased risk for poor outcomes) or oversupervising residents (when residents miss clinical opportunities to practice care), (3) optimal patient outcomes will be compatible with progressive independence, (4) progressive development can be inferred from progressive independence whenever residents contribute to patient care, and (5) analytic models that test for progressive independence will emphasize adjusting the association between length of graduate medical education training and supervision for case complexity and clinic workload, but not patient health outcomes. CONCLUSION: An explicit theoretical framework is critical to measure scientifically progressive independence from supervision using graduate medical education data.

Measuring progressive independence with the resident supervision index: empirical approach.

BACKGROUND: A Resident Supervision Index (RSI) developed by our research team quantifies the intensity of resident supervision in graduate medical education, with the goal of testing for progressive independence. The 4-part RSI method includes a survey instrument for staff and residents (RSI Inventory), a strategy to score survey responses, a theoretical framework (patient centered optimal supervision), and a statistical model that accounts for the presence or absence of supervision and the intensity of patient care. METHODS: The RSI Inventory data came from 140 outpatient encounters involving 57 residents and 37 attending physicians during a 3-month period at a Department of Veterans Affairs outpatient clinic. Responses are scored to quantitatively measure the intensity of resident supervision across 10 levels of patient services (staff is absent, is present, participated, or provided care with or without a resident), case discussion (resident-staff interaction), and oversight (staff reviewed case, reviewed medical chart, consulted with staff, or assessed patient). Scores are analyzed by level and for patient care using a 2-part model (supervision initiated [yes or no] versus intensity once supervision was initiated). RESULTS: All resident encounters had patient care supervision, resident oversight, or both. Consistent with the progressive independence hypothesis, residents were 1.72 (P  =  .019) times more likely to be fully responsible for patient care with each additional postgraduate year. Decreasing case complexity, increasing clinic workload, and advanced nonmedical degrees among attending staff were negatively associated with supervision intensity, although associations varied by supervision level. CONCLUSIONS: These data are consistent with the progressive independence hypothesis in graduate medical education and offer empirical support for the 4-part RSI method to quantify the intensity of resident supervision for research, program evaluation, and resident assessment purposes. Before informing policy, however, more scientific research in actual teaching settings is needed to better understand the relationships among patient outcomes, clinic workload, case complexity, and graduate medical education experience in resident supervision and professional development.

The Department of Veterans Affairs National Quality Scholars Fellowship Program: experience from 10 years of training quality scholars.

The Department of Veterans Affairs (VA) National Quality Scholars Fellowship Program (VAQS) was established in 1998 as a postgraduate medical education fellowship to train physicians in new methods of improving the quality and safety of health care for veterans and the nation. The VAQS curriculum is based on adult learning theory, with a national core curriculum of face-to-face components, technologically mediated distance learning components, and a unique local curriculum that draws from the strengths of regional resources. VAQS has established strong ties with other VA programs. Fellows' research and quality improvement projects are integrated with local and regional VA leaders' priorities, enhancing the relevance and visibility of the fellows' efforts and promoting recruitment of fellows to VA positions. VAQS has enrolled 98 fellows since 1999; 75 have completed the program and 24 are currently enrolled. Fellowship graduates have pursued a variety of career paths: 17% are continuing training (most in VA), 31% hold a VA faculty/staff position, 66% are academic faculty, and 80% conduct clinical or research work related to health care improvement. Graduates have held leadership positions in VA, Department of Defense, academic medicine, and public health agencies. Combining knowledge about the improvement of health care with adult learning strategies, distance learning technologies, face-to-face meetings, local mentorship, and experiential projects has been successful in improving care in VA and preparing physicians to participate in, study, and lead the improvement of health care quality and safety.

The need for specialty curricula based on core competencies: a white paper of the Conjoint Committee on Continuing Medical Education.

INTRODUCTION: At present there is no curriculum to guide physician lifelong learning in a prescribed, deliberate manner. The Conjoint Committee on Continuing Medical Education, a group representing 16 major stakeholder organizations in continuing medical education, recommends that each specialty society and corresponding board reach consensus on the competencies expected of physicians in that specialty. Experts in a specialty will define content-based core competencies in the areas of patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. These competencies, when cross-referenced with expertise, comprise a framework for specialty curricula and board maintenance of certification programs. The American Academy of Ophthalmology and the American Board of Ophthalmology already have implemented this recommendation. Their work is reported as a model for further development. A competency-based curriculum framework offers a foundation for continuing medical education in diverse practice settings and provider organizations.