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Chapter 1 Introduction Many organizations, experts, health professionals, and, increasingly, the American public question whether quality health care can be delivered under the existing health care system, noting that health care today harms too frequently and consistently fails to deliver its potential benefits (Blendon et al., 2001; Kaiser Family Foundation and Agency for Healthcare Research and Quality, 2000; Wirthlin Worldwide, 20014. Studies by expert bodies first documented the serious and pervasive nature of the quality problem with reports of overuse of services, such as excessive prescribing of antibiotics to children; misuse of services, such as incorrect dosages of drugs being administered to patients; and underuse of services, such as not employing effective prevention strategies with patients (Chassin, 1998; President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1998; Schuster et al., 19984. Such errors, as documented by the authors of To Err Is Human: Building a Safer Health System, result in tens of thousands of Americans dying each year and hundreds of thousands suffering or being sick (Institute of Medicine, 2000~. In the report Crossing the Quality Chasm: A New Health System for the 21st Century (Institute of Medicine, 2001) the same Institute of Medicine (IOM) committee that authored To Err Is Human emphasizes that such safety problems occur because of the system's inability to translate knowledge into practice, to apply new technology safely and appropriately, and to make best use of its resources both financial and human. In the face of these system failures, the Quality Chasm report stresses that the rapidly increasing chronic care population only compounds the need for a redesigned health system. Fully 40 percent of the U.S. population 125 million Americans live with some type of chronic condition, and about half of them live with multiple such conditions (Wu and Green, 2000~. The Quality Chasm report also emphasizes that blaming health providers or asking them to just 19

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HEALTH PROFESSIONS EDUCATION try harder is not the answer to addressing the health care system's current flaws and future challenges. Gaps in quality are occurring in the hands of health professionals highly dedicated to doing a good job, but working within a system that does not support them in achieving what they want and ought to be providing for patients. The Quality Chasm report sets forth an ambitious agenda for the redesign of this broken health care system. First, the system must be designed to provide care that achieves six national quality aims: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. The system must serve the needs of patients, ensuring that they are fully informed, retain control, participate in care delivery whenever possible, and receive care that is respectful of their values and preferences. Moreover, the system must facilitate the application of scientific knowledge to practice by providing clinicians with the tools and support necessary to deliver evidence-based care consistently and safely. Implementing this agenda has important implications for current and future health professionals. Such changes mean that health professionals need to be better prepared. They must be educated, trained, and regulated differently so they can function as effectively as possible in a reformed health system, a system founded on enhanced quality and safety as envisioned in the Quality Chasm report. Origins of the Study The Quality Chasm report emphasizes the need for additional study to understand the effects of the recommended changes on how the workforce is educated for practice, how it is deployed, and how it is held accountable. One recommendation of the report is that a multidisciplinary summit of leaders within the health professions be held to discuss and develop strategies for restructuring clinical education to be consistent with the six national quality aims outlined above across the continuum of education for the allied health, medical, nursing, and pharmacy professions. In 2001, the Health Resources and Services Administration (HRSA) within the Department of Health and Human Services (DHHS) asked the IOM's Board on Health Care Services to convene a committee that would be charged with coordinating the recommended summit and drafting a follow-up report. The Committee on the Health Professions Education Summit was formed for this purpose. The committee included members with expertise and experience in academic and continuing allied health, medical, nursing, and pharmacy education; multidisciplinary clinical training; health professions licensure and oversight processes; professional credentialing; and health care delivery and quality. Health Professions Education Summit Summit Planning The committee held three meetings during 2002 a planning meeting to review the literature and prepare for the summit, a meeting during the summit to identify major objectives for reform that would inform the specific actions proposed by participants, and a post- summit meeting. At this last meeting, the committee reviewed a draft of this report and its recommendations . In preparation for the summit, the committee reviewed the new or enhanced skills required by health professionals to function in the changing health care environment as cited in the Quality Chasm report (Chapter 94. (See Chapter 3 for a more in-depth discussion.) The committee grouped those skills and defined five overarching competencies needed by today's health care professionals: provide patient- centered care, work in interdisciplinary teams, employ evidence-based practice, apply quality improvement approaches, and utilize informatics. The committee then examined the extent to which students and practicing health professionals were required to receive education 20

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~ NTRODUCTION in these areas. To perform this examination, the committee worked with IOM staff on papers that surveyed the published literature and existing requirements and standards promulgated by the accrediting and licensing bodies of various health professions, consulted with experts in clinical education, and gathered input from other interested organizations. An examination of available evaluation data provided insight into what is and is not working, as well as the limitations of education efforts to date. Background papers on each of the five competencies were provided to summit participants. The committee endeavored to make the most ofthe evidence and substantial experience available, but found in its review of the available literature, consultation with experts, and input from other interested parties that the evidence base needed to assess the current status of education and oversight processes of the health professions in each of the five competencies is limited. There have been few rigorous long-term evaluations of any aspect of health professions education, much less evaluations related to the five competencies (Furze and Pearcey, 1999; Murray et al., 20004. It is difficult to locate even a single evaluation that measures changes in patient outcomes or satisfaction as a result of any revision of curriculum. Most studies of clinical education are qualitative, employing anecdotal observation of student performance or self- assessments by learners of changes in knowledge, skills, and attitudes For the quantitative studies available, less-rigorous evaluation measures, such as student satisfaction, are often employed (Belfield et al., 2001; Cooper et al.,2001; Jordan, 2000; O'Brien et al., 20014. The majority of documented experiences come from medicine, fewer from nursing and pharmacy, and very few from allied health (Department of Health and Human Services, 19984. In planning the summit and identifying a list of participants, the committee sought input from the Council on Graduate Medical Education and the National Advisory Council on Nurse Education and Practice, advisory committees to HSRA. They provided input that led to the summit participants' encompassing a multidisciplinary group of allied health, nursing, medical, and pharmacy educators and students; health industry representatives; regulators and accreditors; health organization representatives; consumers; and policy leaders. Care was taken to include professionals from diverse occupations. Individuals from other key organizations also were consulted during the planning process. The names and affiliations of the more than 150 attendees are listed in Appendix D. Summit Execution The summit began with plenary sessions led by noted health experts, including Kenneth Shine, then president of the IOM; William Richardson, president of the W. K. Kellogg Foundation; and Donald M. Berwick, president of the Institute for Healthcare Improvement. These sessions were designed to set the context of the current reality of health professions education and the new health care environment that future health professionals must be educated to address. Included was a panel discussion on educational implications of caring for the chronically ill. The full summit agenda is provided in Appendix B. Following the plenary sessions, participants worked in small interdisciplinary groups to draft proposed strategies for integrating one of the above five competencies into clinical education (see Box 1-1~. The committee then reviewed and synthesized these strategies and, using prioritization tools, chose seven priority strategies for the reform of health professions education on which summit participants focused for the next day. On day two of the summit, participants drafted actions to advance these strategies for reform. The main strategies, aggregated into five groups, are detailed in Appendix C. 21

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HEALTH PROFESSIONS EDUCATION Post-Summit Activities The committee's final meeting was held to review a draft of this report and its recommendations. This review was based on an examination of the salient literature, as well as consideration of the strategies and actions proposed at the summit. Scope of the Report The content of this report reflects the committee's commitment to carrying out its stated charge. Although a number of important and often controversial areas were discussed during the committee's deliberations and are briefly mentioned in the report, recommendations related to those issues falling outside the scope ofthe committee's charge are not addressed. These issues include the distribution, composition, and shortages of the health care workforce; issues related to education preparation and entry into practice; the financing of health professions education; changing skill requirements for new occupations; and student recruitment and admissions policies. These issues remain important, and the committee hopes this report will influence or shape deliberations in these other areas. Building Upon Previous Reform Efforts In carrying out its charge, the committee was cognizant of the many outstanding efforts that have been made to articulate a vision for the reform of health professions education (Beliack and O~eil, 2000; Council on Graduate Medical Education, 1999; Halpern et al., 2001; Harmening, 1999; Hegge, 1995; Long, 1994; Mennin, 1998; O~eil and the Pew Health Professions Commission, 19984. There has been no shortage of good ideas on how to reform clinical education, the striking feature of these ideas being their similarity with regard to ~ A current Institute of Medicine study addressing academic health centers is considering financing questions. 22

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~ NTRODUCTION the problems identified and proposed solutions (Beliack and O'Neil, 2000; Christakis, 1995; Enarson and Burg, 1992; Rivo et al., 19934. Unfortunately, reform of health professions education can be exceedingly slow and difficult to accomplish. A number of reasons have been cited for the lack of reform. Health professions education frequently occurs in an environment of separately housed professional schools and separate clinical arenas governed by separate deans, directors, and department chairs, often resulting in the protection of specific specialties or interests at the cost of the educational goals ofthe school (Enarson and Burg, 1992; Regan- Smith, 1998~. Another reason is the financing of academic centers which has resulted in many institutions valuing research and clinical activities at the expense of education (LuUmerer, 1999; Regan-Smith, 1998~. This complex web of competing educational and oversight systems and processes has made it difficult for successful institution- or cIassroom- based innovations to diffuse on a widespread basis. Many reform efforts have also not taken root among the professions because there has been little motivation to change and a lack of the leadership needed to carry the reforms forward. This lack of motivation and leadership in turn reflects the absence of a clear understanding of why such changes would be any better than current practice or how they could be accomplished comprehensively. Finally, coordination and collaboration within and among the professions has been extremely difficult to achieve, and this has posed a key barrier to reform. For these reasons, the committee believes a more intense and coordinated effort will be needed that spans the various health professions and those entities responsible for shaping education in each field. The committee believes the time is ripe to build upon previous reform efforts, galvanizing the education, practice, and oversight communities. First, these groups increasingly understand the extent of quality problems and recognize that the system needs wholesale restructuring; an essential aspect of that restructuring is reform of the content, skills, and values taught to students and faculty. In a 2001 survey of more than 1,000 health care professionals, 58 percent of providers and administrators rated health care in the United States as not very good, and 4 of 5 respondents said they believed fundamental changes are needed in the U.S. health care system (Wirthlin Worldwide, 20014. In another survey, more than half of physicians said they believe their ability to deliver quality care has decreased in the past 5 years (Blendon et al., 20014. Second, health professionals are dissatisfied with their working and training conditions, and recruitment difficulties and personnel shortages have become pressing issues (Hart et al., 2002; Sochalski,2002~. This dissatisfaction is driven in part by the mismatch between what health professionals are called upon to do and what they are educated to do (Blumenthal et al., 2001; Cantor et al., 1993; Weissman et al., 20014. Indeed, two-thirds of physicians in a recent study reported that their training was inadequate to enable them to coordinate care for patients or educate patients with chronic conditions (Partnership for Solutions, 20024. Finally, the health care industry has identified shortcomings of recent graduates, stating that an increasing amount of time and resources must be spent to teach new professionals the competencies required in today's workplace (Institute of Medicine, 2000; National Council for State Boards of Nursing, 2001~. Change is needed at all levels, including, among others, the culture and values of educational institutions, the infrastructures in which professions are educated, curricula and teaching methods, the standards and guidelines governing education, the ways in which faculty are prepared and rewarded, and the leadership in schools and oversight organizations. Definitional Issues To address health professions education, it is necessary to clarify several key terms. To this end, the committee established common descriptions and terms for the key entities and concepts involved in its work, as described below. 23

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HEALTH PROFESSIONS EDUCATION Health Professions This report places special emphasis on the following health professionals: nurses (both registered and advanced practice), pharmacists, physician assistants, physicians, and others that sometime come under the rubric of a1/~1/tied hea1/tth. However, the observations, conclusions, and recommendations in this report will be of value to all health professionals caring for patients, including, for example, psychologists, counselors, and social workers. The committee acknowledges that defining what is meant by the term added hea1/tth and specifying the disciplines it encompasses is problematic. Understandably, many of the disciplines wish to avoid being categorized under such a catch-all term. When possible, therefore, this report refers to health professionals by their specific names (e.g., occupational therapists or dental hygienists). In some cases, however, when brevity is of concern, the committee employs the term added hea1/tth to refer to the 10 fields recognized by the IOM's Committee to Study the Role of Allied Health Personnel (Institute of Medicine, 1989) as the largest and best known: clinical laboratory technology, dental services, dietetic services, emergency medical services, medical records/health information management, occupational therapy, physical therapy, radiological services, respiratory therapy, and speech-language pathology/ audiology. Yet it must be recognized that these disciplines vary greatly in the amount and level of education required, the nature of clinical involvement, and the ability to practice independently as opposed to working only under the direct supervision of others. Education, Competency, and Oversight The term education as used in this report refers to formal efforts to provide information and experience and develop new skills and competencies among students or practicing health professionals. Continuing education refers to organized educational activities undertaken by health professionals who have graduated from their respective degree programs and are already in professional practice. Facility comprise the teaching staff and members of the administrative staff having academic rank in an educational institution, and include clinician teachers and residents. Currently there is no agreed-upon definition of competency in health professions education. For the purposes of this report, the committee defines professional competence as the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individuals and community being served (Hundert et al., 19964. Competency-based education refers to educational programs designed to ensure that students achieve prespecified levels of competence in a given field or training activity. A core competency is the identified knowledge, ability, or expertise in a specific subject area or skill set that is shared across the health professions. In this report, competency denotes an individual clinician's actual performance in a specific job function or task, and competencies or competency areas are skills considered necessary to perform a specific job or service (Kelly-Thomas, 19984. The term oversight processes denotes the array of mechanisms and rules meant to ensure that health professionals are properly educated and competent to practice. It encompasses accreditation of educational programs serving health professionals, as well as professional licensure and certification. The spectrum of oversight processes can also include organizational accreditation, which serves to accredit practice institutions and health plans, but has some impact on the continuing competence of practicing professionals as well through the standards imposed. Organization of the Report This report offers a vision of a better- prepared health workforce and specific strategies, actions, and related recommendations for achieving that vision. Specifically, the report provides: 24

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~ NTRODUCTION Discussion of the challenges facing the reform of the health system and their implications for health professions education (Chapter 24. Explication of the core competencies needed by health professionals to be effective in the 21 st-century health system (Chapter 3~. Assessment of the extent to which the committee's vision is currently addressed by academic education programs among selected health professions (Chapter 4~. Assessment of the extent to which this vision is currently addressed by licensure, accreditation, and certification bodies of selected health professions (Chapter 5~. Recommendations developed by the committee for the reform of clinical education (Chapter 6) The committee's conclusions and recommendations in these areas are presented in the respective chapters, highlighted in bold print. The appendices contain more-detailed information about the summit, a list of participants, and strategies and actions proposed by summit participants. It was not possible to present the over 200 actions identified by the summit participants in the report, but those at the national level and a small number at the institutional level are included. References Belfield, C., H. Thomas, A. Bullock, R. Eynon, and D. Wall. 2001. Measuring effectiveness for best evidence medical education: A discussion. Medical Teacher 23 (24: 164-70. Bellack, J.P., end E.H. O'Neil. 2000. Recreating nursing practice for a new century: Recommendations and implications of the PEW health professions commissions final report. Nursing&Health Care Perspectives 21 (1~:14- 21. Blendon, R.J., C. Schoen, K. Donelan, R. Osborn, C. M. DesRoches, K. Scoles, K. Davis, K. Binns, and K. Zapert. 2001. Physicians views on quality of care: A five-country comparison. Health Affairs 20 (3~:233-43. Blumenthal, D., M. Gokhale, E.G. Campbell, and J. S.Weissman. 2001. Preparedness for clinical practice: Reports of graduating residents at academic health centers. Journal of the American Medical Association 286 (9~: 1027- 34. Cantor, J.C., L.C. Baker, and R.G. Hughes. 1993. Preparedness for practice. Young physicians views of their professional education. JAMS 270 (94:1035-40. Chassin, M.R. 1998. Is health care ready for Six Sigma quality? Milbank Quarterly 76~4~:565- 91, 510. Christakis, N.A. 1995. The similarity and frequency of proposals to reform U.S. medical education: Constant concerns. Journal of American MedicalAssociation 274~94:706-11. Cooper, H., C. Carlisle, T. Gibbs, and C. Watkins. 2001. Developing an evidence base for interdisciplinary learning: A systematic review. JournalofAdvancedNursing 35~2~:228-37. Council on Graduate Medical Education. 1999. Physician Education for a Changing Health Care Environment. Rockville, MD: Health Resources and Services Administration. Counsell, S., R. Kennedy, P. Szwabo, N. Wadsworth, and C. Wohlgemuth. 1999. Curriculum recommendations for resident . . . . . . . . . tra~n~ng ~n genatr~cs ~nterd~sc~pl~nary team care. Journal of the American Geriatrics Society 47 (9~:1145-48. Depardnent of Health and Human Services, Health Resources and Services Administration, Bureau of Primary Health Care. 1998. Health Center Program Expectations. Bureau of Primary Health Care Policy Information Notice: 98-23. Enarson, C., and F.D. Burg. 1992. An overview of reform initiatives in medical education. 1906 through 1992. [Review] [22 refs]. Journal of American Medical Association 268 (9~: 1141 - 43. Furze, G. and P. Pearcey. 1999. Continuing education in nursing: a review of the literature. Journal of Advanced Nursing 29 (2) Halpern, R., M.Y. Lee, P.R. Boulter, and R.R. Phillips. 2001. A synthesis of nine major reports on physicians competencies for the emerging practice environment. Academic Medicine 76 (64:606-15. 25

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HEALTH PROFESSIONS EDUCATION Harmening, D.M. 1999. "Pioneering Allied Health Clinical Education Reform. A National Consensus Conference." Online. Available at Up ://ftp.hrsa. gov/bhpr/publications/cerpdf.pdf [accessed Aug., 20023. Hart, L.G., E. Salsberg, D.M. Phillips, and D.M. Lishner. 2002. Ruralhealth care providers in the United States. Journal of Rural Health 18 Suppl:211-32. Hegge, M. 1995. Restructuring registered nurse curricula. [Review] [41 refs]. Nurse Educator 20 (6):39-44. Hundert, E.M., F. Hafferty, and D. Christakis. 1996. Characteristics of the informal curriculum and trainees ethical choices. Academic Medicine 71 (64:624-42. Hyde, R.S., and J.M. Vermillion. 1996. Driving qualify through Hoshin planning. Joint Commission Journal on Quality Improvement 22 (14:27-35. Institute of Medicine. 1989. Allied Health Services Avoiding Crises. Washington, DC: National Academy Press. 2000. To Err Is Human: Building a Safer Health System. Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, eds. Washington, DC: National Academy Press. . 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press. Jordan, S. 2000. Educationalinput and patient outcomes: Exploring the gap. Journal of Advanced Nursing 31 (24:461-71. Kaiser Family Foundation and Agency for Healthcare Research and Quality. 2000. "National Survey on Americans as Health Care Consumers: An Update on the Role of Quality Information." Online. Available at http://www. kff.org/content/2000/3093/AHRQToplines.pdf [accessed Oct. 14, 20023. Kelly-Thomas, K. 1998. Clincial and Nursing Staff Development. Philadelphia, PA: Lippincott. Long, K.A. 1994. Masters degree nursing education and health care reform: Preparing for the future. Journal of Professional Nursing 10 (24:71 -6. Ludmerer, K. 1999. Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. New York, NY: 26 Oxford University Press. Mennin, S., and S.P. Kalishman. 1998. Issues and strategies for reform in medical education: Lessons from eight medical schools. Academic Medicine (Supplement) 73 (9) Murray, E., L. Gruppen, P. Catton, R. Hays, and J.O. Woolliscroft. 2000. The accountability of clinical education: Its definition and assessment. Medical Education 34 (10~:871-79. National Council for State Boards of Nursing. 2001. Report of Findings from the 2001 Employers Survey. Chicago, IL: National Council for State Boards of Nursing. OBrien, T., N. Freemantle, A.D. Oxman, F. Wolf, D. A. Davis, and J. Herrin. 2001. Continuing education meetings and workshops: Effects on professional practice and health care outcomes. Cochrane Database System Review (2~: CD003030. ONeil, E. H. and the Pew Health Professions Commission. 1998. Recreating health professionalpractice for a new century - The fourth report of the PEW health professions Commission. San Francisco, CA: Pew Health Professions Commission. Partnership for Solutions. 2002. "Physician Concerns: Caring for People with Chronic Conditions." Online. Available at http://www. partnershipborsolutions. org/pdf_files/2002/ physicianccern.pdf [accessed Oct. 8, 20023. Platt, D., and C. Laird. 1995. CQI: Using the Ho shin planning system to design an orientation process. Radiology Management 17 (24:42-50. President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. 1998. "Quality First: Better Health Care for All Americans." Online. Available at http://www.hcqualitycommission.gov/final/ [accessed Sept. 9, 20003. Regan-Smith, M.G. 1998. "Reform without change": update, 1998. Academic Medicine 73 (54:505-7. Rivo, M.L., J. Debbie M., and C.F. Lawrence. 1993. Comparing physician workforce reform recommendations. JournalofAmerican Medical Association 270 (9~: 1083-84. Schuster, M.A., E.A. McGlynn, and R.H. Brook. 1998. How good is the quality of health care in

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~ NTRODUCTION the United States? Milbank Quarterly 76 (4~:517-63, 509. Sochalski, J. 2002. Nursing shortage redux: Turning the corner on an enduring problem. Health Affairs 2 1 (5~: 1 57-64. Weissman, J.S., E.G. Campbell, M. Gokhale, and D. Blumenthal. 2001. Residents preferences and preparation for caring for underserved populations. Journal of Urban Health 78 (34:535-49. Wirthlin Worldwide. 2001 . "Pursing Perfection-- Research Conducted for the Robert Wood Johnson Foundation." Online. Available at h t t p : I I w w w . i h i . o r g / p u r s u i n g p e r f e c t i o n / n e w s / PP_Researchslides.ppt [accessed Oct. 14, 20023. Wu, S., and A. Green. 2000. Projection of Chronic Illness Prevalence and Cost Inflation. California: RAND Health. 27

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