Culture change and lessons learned from ten years in the VA centers of excellence in primary care education.

BACKGROUND: Team-based care is critical to achieving health care value while maximizing patient outcomes. Few descriptions exist of graduate-level team training interventions and practice models. Experience from the multisite, decade-long Veterans Affairs (VA) Centers of Excellence in Primary Care Education provides lessons for developing internal medicine training experiences in interprofessional clinical learning environments. METHODS: A review of multisite demonstration project transforming traditional silo-model training to interprofessional team-based primary care. Using iterative quality improvement approaches, sites evaluated curricula with learner, faculty and staff feedback. Learner- and patient-level outcomes and organizational culture change were examined using mixed methods, within and across sites. Participants included more than 1600 internal medicine, nurse practitioner, nursing, pharmacy, psychology, social work and physical therapy trainees. This took place in seven academic university-affiliated VA primary care clinics with patient centered medical home design RESULTS: Each site developed innovative design and curricula using common competencies of shared decision making, sustained relationships, performance improvement and interprofessional collaboration. Educational strategies included integrated didactics, workplace collaboration and reflection. Sites shared implementation best practices and outcomes. Cross-site evaluations of the impacts of these educational strategies indicated improvements in trainee clinical knowledge, team-based approaches to care and interest in primary care careers. Improved patient outcomes were seen in the quality of chronic disease management, reduction in polypharmacy, and reduced emergency department and hospitalizations. Evaluations of the culture of training environments demonstrated incorporation and persistence of interprofessional learning and collaboration. CONCLUSIONS: Aligning education and practice goals with cross-site collaboration created a robust interprofessional learning environment. Improved trainee/staff satisfaction and better patient care metrics supports use of this model to transform ambulatory care training. TRIAL REGISTRATION: This evaluation was categorized as an operation improvement activity by the Office of Academic Affairs based on Veterans Health Administration Handbook 1058.05, in which information generated is used for business operations and quality improvement (Title 38 Code of Federal Regulations Part 16 (38 CFR 16.102(l)). The overall project was subject to administrative oversight rather Human Subjects Institutional Review Board, as such informed consent was waived as part of the project implementation and evaluation.

Promoting Quality Improvement in Primary Care Through a Longitudinal, Project-Based, Interprofessional Curriculum.

Introduction: Health professionals must demonstrate competencies in quality improvement (QI) and interprofessional (IP) practice. Yet few curricula are designed to address these competencies in an integrated, longitudinal way. Our experiential IP QI curriculum addresses this gap. Methods: The IP QI curriculum was part of a San Francisco VA Health Care System training program for second-year internal medicine residents and adult gerontology primary care nurse practitioner students, pharmacy residents, and postdoctoral psychology fellows. Trainees worked in mentored IP teams to select, design, implement, evaluate, and present a project as part of a 9-month curriculum. Teaching methodologies included didactics and project-based skills application. Curriculum evaluation included trainees' QI knowledge and skills self-assessments, trainee satisfaction, mentor appraisals, and project results and impact assessments. Results: From 2011-2012 to 2017-2018, 242 trainees completed the curriculum and 41 QI projects. Trainees reported high satisfaction with the introductory sessions (M = 4.4, SD = 0.7). They also reported improvement in comfort with QI knowledge and skills by the curriculum's completion. QI mentors (n = 23) observed growth in trainees' QI knowledge and skills, felt confident in trainees' ability to orchestrate a QI initiative, and believed their mentored QI projects added value to the organization. Thirty-eight projects resulted in system modifications. Discussion: This IP QI curriculum offers team-based, workplace experiences for trainees to learn and apply QI knowledge and skills. Leading factors for successful implementation included attention to team-building and faculty development. Challenges included reliably collecting evaluation data, accurately measuring ongoing systems changes, and variable trainee engagement.

Creating change, challenging structure: graduate and faculty perspectives on the implementation of an interprofessional education program in veterans affairs primary care.

Interprofessional clinical education programs have the potential to impact participants' professional expectations and practices related to team-based care. In this qualitative study, research team members interviewed 38 graduates and 19 faculty members from such an interprofessional training program, the Department of Veterans Affairs (VA) Centers of Excellence in Primary Care Education (CoEPCE). Semi-structured interviews with participants enquired about skills gained, impact on career expectations, and barriers to implementing interprofessional skills in the post-training workplace. Data were coded and analyzed using a hybrid inductive/deductive approach. Participants perceived that the program was successful in creating new norms of flattened team hierarchies, broadening graduates' understanding of role interaction, and teaching interactional skills involving teamwork. Participants reported organizational and systemic barriers to changing existing primary care practice. Interprofessional clinical education programs may help new professionals recognize and act on opportunities for improvement in existing practice. Healthcare employers must recognize changed expectations and provide opportunities for interprofessional collaboration to attract graduates from such programs.

Higher Perceived Clinic Capacity to Address Patients' Social Needs Associated with Lower Burnout in Primary Care Providers.

PURPOSE: Primary care physicians (PCP) experience high rates of professional burnout. These symptoms may be magnified in underserved populations. This study explores relationships between clinic capacity to address patients' social needs (SN) and PCP burnout. METHODS: We conducted a cross-sectional survey of PCPs from three delivery systems in San Francisco. Surveys included three components of burnout, measured by the Maslach Burnout Inventory (MBI) and a four-item instrument exploring attitudes, confidence, individual skills and organizational capacity to address patients' SN. RESULTS: Provider perception of higher clinic capacity to address patients' SN was the strongest independent predictor of lower burnout. Providers who perceived high clinic capacity and resources to address SN reported significantly greater professional efficacy (p <.01), lower emotional exhaustion (p <.05), and lower cynicism (p <.05). CONCLUSIONS: Provider perceptions of greater clinic capacity to address SN are significantly associated with lower burnout. Devoting organizational resources to address SN may reduce PCP burnout.

Team Retreats for Interprofessional Trainees and Clinic Staff: Accelerating the Development of High-Functioning Teams.

Introduction: Teams are critical to managing the health care needs of patients with part-time trainee providers. High-functioning teams require trusting relationships among trainees and staff and opportunities to learn and practice skills together. Irregular trainee schedules, time-limited training programs, and lack of protected time for team development during clinic can hinder development of high-functioning teams. Methods: To provide time for team development, we created an annual half-day team retreat for interprofessional trainees and staff at three San Francisco Veterans Affairs primary care clinics. We used principles of high-functioning teams and relationship-centered communication to develop retreat content, then trained interprofessional faculty members to facilitate and role-model this content. Retreat objectives and content focused on building relationships, establishing team goals, clarifying roles, and learning communication skills. Postretreat surveys and qualitative content analysis of comments and team goals evaluated retreat objectives and opportunities for improvement. Results: Between 2011 and 2017, 16 team retreats were attended by 232 interprofessional trainees and 77 unique staff (some attended multiple times). Thirty-seven faculty facilitated. Most participants strongly agreed that they knew their team members better personally and professionally after the retreat (M = 4.7 out of 5, n = 368); 78% of teams (n = 65) submitted SMART goals addressing high-functioning teams. Participants' comments consistently reflected the benefits of protected time for team building. Discussion: This team retreat supports team development among trainees and staff on primary care teams by promoting relationship building, role clarity, communication, and team processes. It can be valuable for all interprofessional participants.

Huddling for High-Performing Teams.

In short team huddles, trainees and PACT teamlets meet to coordinate care and identify ways to improve team processes under the guidance of faculty members who reinforce collaborative practice and continuous improvement.

Twelve tips for delivering successful interprofessional case conferences.

Interprofessional case conferences (ICCs) offer an interactive, practical way to engage members of two or more health professions in discussions that involve learning and working together to improve patient care. Well-orchestrated ICCs provide opportunities to integrate interprofessional (IP) education into routine clinical practice. The authors provide 12 tips to support the conceptualization, planning, implementation, facilitation, evaluation, and sustainability of ICCs. They draw from extensive experience as IP educators and facilitators of ICCs and from literature on IP education, case-based learning, small-group facilitation, peer-assisted learning, and learner engagement - all of which offer insights into ICCs but have not been integrated and applied to this context.

Does Research Training During Residency Promote Scholarship and Influence Career Choice? A Cross-Sectional Analysis of a 10-Year Cohort of the UCSF-PRIME Internal Medicine Residency Program.

PROBLEM: The Association of Program Directors in Internal Medicine, the Accreditation Council for Graduate Medical Education, the Alliance for Academic Internal Medicine, and the Carnegie Foundation report on medical education recommend creating individualized learning pathways during medical training so that learners can experience broader professional roles beyond patient care. Little data exist to support the success of these specialized pathways in graduate medical education. INTERVENTION: We present the 10-year experience of the Primary Care Medicine Education (PRIME) track, a clinical-outcomes research pathway for internal medicine residents at the University of California San Francisco (UCSF). We hypothesized that participation in an individualized learning track, PRIME, would lead to a greater likelihood of publishing research from residency and accessing adequate career mentorship and would be influential on subsequent alumni careers. CONTEXT: We performed a cross-sectional survey of internal medicine residency alumni from UCSF who graduated in 2001 through 2010. We compared responses of PRIME and non-PRIME categorical alumni. We used Pearson's chi-square and Student's t test to compare PRIME and non-PRIME alumni on categorical and continuous variables. OUTCOME: Sixty-six percent (211/319) of alumni responded to the survey. A higher percentage of PRIME alumni published residency research projects compared to non-PRIME alumni (64% vs. 40%; p = .002). The number of PRIME alumni identifying research as their primary career role was not significantly different from non-PRIME internal medicine residency graduates (35% of PRIME vs. 29% non-PRIME). Process measures that could explain these findings include adequate access to mentors (M 4.4 for PRIME vs. 3.6 for non-PRIME alumni, p < .001, on a 5-point Likert scale) and agreeing that mentoring relationships affected career choice (M 4.2 for PRIME vs. 3.7 for categorical alumni, p = .001). Finally, 63% of PRIME alumni agreed that their research experience during residency influenced their subsequent career choice versus 46% of non-PRIME alumni (p = .023). LESSONS LEARNED: Our results support the concept that providing residents with an individualized learning pathway focusing on clinical outcomes research during residency enables them to successfully publish manuscripts and access mentorship, and may influence subsequent career choice. Implementation of individualized residency program tracks that nurture academic interests along with clinical skills can support career development within medicine residency programs.

Panel management, team culture, and worklife experience.

Burnout and professional dissatisfaction are threats to the primary care workforce. We investigated the relationship between panel management capability, team culture, cynicism, and perceived "do-ability" of primary care among primary care providers (PCPs) and staff in primary care practices. We surveyed 326 PCPs and 142 staff members in 10 county-administered, 6 university-run, and 3 Veterans Affairs primary care clinics in a large urban area in 2013. Predictor variables included capability for performing panel management and perception of team culture. Outcome variables included 2 work experience measures--the Maslach Burnout Inventory cynicism scale and a 1-item measure of the "do-ability" of primary care this year compared with last year. Generalized Estimation Equation (GEE) models were used to account for clustering at the clinic level. Greater panel management capability and higher team culture were associated with lower cynicism among PCPs and staff and higher reported "do-ability" of primary care among PCPs. Panel management capability and team culture interacted to predict the 2 work experience outcomes. Among PCPs and staff reporting high team culture, there was little association between panel management capability and the outcomes, which were uniformly positive. However, there was a strong relationship between greater panel management capability and improved work experience outcomes for PCPs and staff reporting low team culture. Team-based processes of care such as panel management may be an important strategy to protect against cynicism and dissatisfaction in primary care, particularly in settings that are still working to improve their team culture.

Huddle-coaching: a dynamic intervention for trainees and staff to support team-based care.

Many outpatient clinics where health professionals train will transition to a team-based medical home model over the next several years. Therefore, training programs need innovative approaches to prepare and incorporate trainees into team-based delivery systems. To address this need, educators at the San Francisco Veterans Affairs (VA) Medical Center included trainees in preclinic team "huddles," or briefing meetings to facilitate care coordination, and developed an interprofessional huddle-coaching program for nurse practitioner students and internal medicine residents who function as primary providers for patient panels in VA outpatient primary care clinics. The program aimed to support trainees' partnerships with staff and full participation in the VA's Patient Aligned Care Teams. The huddle-coaching program focuses on structuring the huddle process via scheduling, checklists, and designated huddle coaches; building relationships among team members through team-building activities; and teaching core skills to support collaborative practice. A multifaceted evaluation of the program showed positive results. Participants rated training sessions and team-building activities favorably. In interviews, trainees valued their team members and identified improvements in efficiency and quality of patient care as a result of the team-based approach. Huddle checklists and scores on the Team Development Measure indicated progress in team processes and relationships as the year progressed. These findings suggest that the huddle-coaching program was a worthwhile investment in trainee development that also supported the clinic's larger mission to deliver team-based, patient-aligned care. As more training sites shift to team-based care, the huddle-coaching program offers a strategy for successfully incorporating trainees.

Developing educators, investigators, and leaders during internal medicine residency: the area of distinction program.

BACKGROUND: Professional organizations have called for individualized training approaches, as well as for opportunities for resident scholarship, to ensure that internal medicine residents have sufficient knowledge and experience to make informed career choices. CONTEXT AND PURPOSE: To address these training issues within the University of California, San Francisco, internal medicine program, we created the Areas of Distinction (AoD) program to supplement regular clinical duties with specialized curricula designed to engage residents in clinical research, global health, health equities, medical education, molecular medicine, or physician leadership. We describe our AoD program and present this initiative's evaluation data. METHODS AND PROGRAM EVALUATION: We evaluated features of our AoD program, including program enrollment, resident satisfaction, recruitment surveys, quantity of scholarly products, and the results of our resident's certifying examination scores. Finally, we described the costs of implementing and maintaining the AoDs. RESULTS: AoD enrollment increased from 81% to 98% during the past 5 years. Both quantitative and qualitative data demonstrated a positive effect on recruitment and improved resident satisfaction with the program, and the number and breadth of scholarly presentations have increased without an adverse effect on our board certification pass rate. CONCLUSIONS: The AoD system led to favorable outcomes in the domains of resident recruitment, satisfaction, scholarship, and board performance. Our intervention showed that residents can successfully obtain clinical training while engaging in specialized education beyond the bounds of core medicine training. Nurturing these interests 5 empower residents to better shape their careers by providing earlier insight into internist roles that transcend classic internal medicine training.

Using the american board of internal medicine practice improvement modules to teach internal medicine residents practice improvement.

BACKGROUND: Although residency programs must prepare physicians who can analyze and improve their practice, practice improvement (PI) is new for many faculty preceptors. We describe the pilot of a PI curriculum incorporating a practice improvement module (PIM) from the American Board of Internal Medicine for residents and their faculty preceptors. METHODS: Residents attended PI didactics and completed a PIM during continuity clinic and outpatient months working in groups under committed faculty. RESULTS: All residents participated in PI group projects. Residents agreed or strongly agreed that the projects and the curriculum benefited their learning and patient care. A self-assessment revealed significant improvement in PI competencies, but residents were just reaching a "somewhat confident" level. CONCLUSION: A PI curriculum incorporating PIMs is an effective way to teach PI to both residents and faculty preceptors. We recommend the team approach and use of the PIM tutorial approach especially for faculty.