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Chapter 3 The Core Competencies Needed for Health Care Professionals Addressing the challenges outlined in Chapter 2 will require profound changes in how health systems are designed. At the heart of such systems are the skilled health care professionals without whom such a redesign could not take place. Preparing health care professionals to take on this task requires a common vision across the professions centered on a commitment to, first and foremost, meeting patients' needs as envisioned in the Quality Chasm report (Institute of Medicine, 20014. The committee recommends the following as an overarching vision for all programs and institutions engaged in the education of health professionals: Ad health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evid~ence-based~practice, quality improvement approaches, and informatics. To this end, the committee proposes a set of simple, core competencies that all health clinicians should possess, regardless of their discipline, to meet the needs of the 21 st-century health care system: · Provide patient-centered care identify, respect, and care about patients' differences, values, preferences, and expressed needs; relieve pain and suffering; coordinate continuous care; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, weliness, and promotion of healthy lifestyles, including a focus on population health. · Workin interdisciplinary teams cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous and reliable. · Employ evidence-based practice integrate best research with clinical expertise and patient 45

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HEALTH PROFESSIONS EDUCATION . . values for optimum care, and participate in learning and research activities to the extent feasible. Apply quality improvement identify errors and hazards in care; understand and implement basic safety design principles, such as standardization and simplification; continually understand and measure quality of care in terms of structure, process, and outcomes in relation to patient and community needs; design and test interventions to change processes and systems of care, with the objective of improving quality. Utilize informatics communicate, manage knowledge, mitigate error, and support decision making using information technology. Figure 3-1 depicts the relationships among these five core competencies. As a guide in formulating its five competencies, the committee examined core skills outlined in the Quality Chasm report and other core competencies formulated within and across the health professions. Following a brief Overlap of Com Co~mpetencies for Health P~rfe~i~nal~ ., , . ~ ~ ~ ~ ~ review of that committee process, this chapter describes each competency in greater detail and contrasts these competencies with the corresponding current approaches in practice. Also provided is a scenario illustrating the effect on patient care when health care professionals do not apply such competencies. See Chapter 4 for more detailed discussion of the current state of practice and the implications of integrating these competencies into health professions education. Origin of the Five Competencies As acknowledged in the Q2vaJ1ity Chasm report and in Chapter 2 of this report, there are many challenges facing health care in America. As a result, clinicians are increasingly being called upon to redesign better systems to address the health needs of the American population. The architects of the Quality Chasm report identify 10 important rules to guide the transition to a health system that better meets patients' needs (see Box 3-1~. The authors of the Q2vaJ1ity Chasm report also foresaw that health professionals would ~ I:: Figure 3-1 Relationship among core competencies for health professionals. 46 _F :_ ._ ._

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THE CORE COMPETENCIES have to perform differently to meet these rules. Thus in the chapter "Preparing the Workforce," they identified the key skills required by all health professionals to implement these new rules in the changing health care environment. The summit committee used this list of skills and the vision set forth in the Quality Chasm report as the foundation for its work, combining the list of skills into common groupings. The committee supplemented these groupings with a review of other seminal reform efforts that have articulated core competencies across or within the health professions. Many such efforts have emerged from the educational arena, both professional educational organizations and accreditation bodies, as well as from specialized private commissions, in response to the need to prepare the workforce adequately for the changing practice environment (ABIM Foundation, 2002; American Association of Medical Colleges, 2001; Brady et al., 2001; Center for the Advancement of Pharmaceutical Education tCAPE] Advisory Panel on Educational Outcomes, 1998; Halpern et al., ............................................................................................................................ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ............................................................................................................................ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ............................................................................................................................ ........................................................ a~ ~ 1 ~e-n~ mu- -es old e-no-rm-a-n-ce~ lint at—-c -eSlgnec -e-a- 1 Ma Ed ~~ -em ............................................................................................................................ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ............................................................................................................................ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::: ~ :::::::::::: A:::::::::::::::::: -:::::::::: ::::::::::::::::::::: :::::::::::::::::::::::::::::::::: :-:::::: are less Easter ~ on corn l-n-u-o-u-s~ Sea --l-n-g~ e- -a -l-o-n-s l"l"pS""""""""""""' --e-a 1 pro ................... .......... ................................................. ..................................... .......................................... ............................................................................................................................. ...................................................... 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HEALTH PROFESSIONS EDUCATION 2001; O'Neil and the Pew Health Professions Commission, 1998~. One such major effort was undertaken by the Pew Health Professions Commission, which in 1992 articulated 17 competencies for future clinicians (O'Neil, 1992) and later expanded the list to 21 (Lenburg et al., 1999; O'Neil and the Pew Health Professions Commission, 19984. Debates centered on how to evaluate competency, focusing on the reliability, validity, and predictive ability of related measures. Nursing groups and some physicians cautioned against including only competencies that can be measured, such as those based on technical skills, as opposed to those that rely more on cognitive and critical thinking and difficult-to- assess interpersonal skills (Benner, 1982; Epstein and Hundert, 20024. The five competencies are meant to be core and span the professions but are not intended as Table 3-1. Rules and the Core Competencies an exhaustive list. The committee recognizes that there are many other competencies that health professionals should posses, such as a commitment to lifelong learning. However, the committee believes the five competencies set forth in this report are most relevant across the clinical disciplines and best advance the 10 rules envisioned in the Quality Chasm report. (See Table 3-1 for how the competencies address the 10 rules.) The committee recognizes that each of the disciplines has its own contribution and unique skills to bring to patient care this is what makes the professions unique and valuable. The five core competencies are not discipline- specific and each profession will have its own way of operationalizing such competencies in practice. However, based on patient perspectives and needs, there are certain competencies that all health professionals Rules for the 215t-CenturyT Provide Patient- T Employ 1 Apply Quality 1 Work in Bern Utilize Health System Centered Care Evidence-Based Improvement disciplinary Informatics Practice Teams 1. Care is based on X X X X X continuous healing relationships. - 2. Care is customized XX X X according to patient needs and values. 3. The patient is the X X X source of control. . Knowledge is shared, X X X X X and information flows freely. . Decision makingis T T ~ x ~ x ~ x ~ ev~dence-based. 5. Safety is a system X X X property. 7. Transparency is X X X necessary. 3NeedsareanticipatedT x T x 1 x 1 x 1 x 1 9. Waste is continuously X X decreased. 10. Cooperation among X X X X clinicians Is a priority. 48

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THE CORE COMPETENCIES should possess, regardless of their title or discipline. The committee also recognizes that the definition of a professional's competency will change over time. Indeed, professionals will likely progress from novice, the stage of their initial academic preparation, to expert, the stage toward the end of their career when they have learned to do their work intuitively (Batalden et al., 2002~. However, the committee is also cognizant that the fundamental competencies that define health professionals over their career are unlikely to change greatly, even though the knowledge that they must acquire, and its application, will change dramatically. Several cautions are in order, however. First, the competencies are interrelated (see Figure 3-1), and therefore, the maximum benefit can be derived when they are applied together. Second, health professionals should apply these competencies to most clinical interactions, but they do not cover every possible clinical decision. For example, not all care is delivered by teams. Third, the following discussion of the state of application of the competencies today is not intended to be pejorative, but to capture common practices and contrast these with the committee's vision for the future. The Five Competencies in Practice Over the course of a lifetime, patients have numerous encounters with health care professionals. Often such encounters are effective, patients leave feeling satisfied with the care received, and their health improves. Unfortunately, this is not always the case, because health care professionals are often not supported by a system that aids them in providing optimum care. The scenario in Box 3-2, developed by the committee, is meant to illustrate some of the serious problems facing patients during an encounter with clinicians, and to show why the five core competencies outlined above are critical to improving health care. This scenario is not meant to be representative of all encounters, but is an example of a situation in which many elements have been problematic. 49

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HEALTH PROFESSIONS EDUCATION ................................................. ......................................................................... ..... .................................... ... .............. .............. ........................................... .................... .... ........................................ ...... ... .. ............ .. ....... ........ ............... ~ . ~ . :::::::::::::::: ::::::::::::::::::::::: ::::::: :::::::::::::::::::::::: ::::::::::::::::::::::::::::: :::: ::::::: :::::::::::::::::::: ::::::::::::::::: :::::::::::::::: ::::::: :::::::::::::::::::: ~u--pd-at-i--n- e i e e i . . . . . . ............................................................................................................................. -f ~ i t Iu t il bl ~ th di ti ~ i b f ........... ............................... .... ... .... .... ...... ....... ...... .... ........... .... ... .. .. ................. ...... ....... ................. ............. ............. ........... B~ eca-u-se~ o ~ v ~m --o-n--n-so-n~ so n-e-cl-l-c~ s-c-n-ea-u-l-e~ l-n-e~ Tam-l-l-v --led T-re- ...................................................... ....... . . . . ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: .... . . . .. t-a---s-t t-o---o--~-s- -so t"""tll"""'l , - - . . . .. ,.,.,j .... .. . .. ... I, . ....... --~-I-a-~-el ---a- -~---e I -I--n-e-~-n~ W -es--- l-- - O~ all -Nat ends it-- - teal-- n~ ~ In-- I al ~ In Iln ................................................................... ................................................ .. ....... .............. .. .. ...j.. . I.. .. .. ....... ........ ..j.. .. . .. .. ....... .. .. ......... . . . .. .. ........ .. . ... 1 ....... .. .. I.. .. . ........ .. .. .. .......... .. ........ . . . .... .j....j... ...... ....... .. .j.~. ......... .. .. ...j.. .... dev:elo ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::: :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::~::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.::::::::: - ::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::::::: ::.::::::::::.::: :::::::::::::::::::::::::::::::::::::::::::: ::::::: .. . . . ~ -err us n--s- e eel e- t~ ~ I -- I -a-e-a w-n-eln-er~ singer s-n-o-u-l-a~ eta- e e-ml-s-l-n-~ wn-el-n-e-r~ sinker co-u-l-a~ ~ ............. ............................................. .~ ................................ ............ . --""c""o-""n"'""'e""""''""""ffi''"'"""""""""""' s"""'s'i"''T'T'i'''es""""''"""""''e''"""" ffi"i"l''"""""" ...................................................................................................................................................................................................................................................... 50

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THE CORE COMPETENCIES Mrs. Johnson's care failed on several accounts. efficacy of self-care along with other relevant health beliefs. Strategies to this end provide the patient the opportunity to demonstrate success First, the health professionals she saw d~d · ~ · ~ ~~ en ~ In the self-management of diabetes, such as not provide pat~ent-centerea care. ~ ney oTTerea mastery of the glucometer In dally usage. little education to help her understand her condition, such as the physical difference between Type I and Type II diabetes, the treatment process, and related complications. Mrs. Johnson and her health care providers lacked a partnering relationship in deciding how she should manage her diabetes. Her plan of care was not sufficiently individualized to account for her hectic lifestyle and issues related to being a wife, mother, and student. In addition, her providers did not address the impact the disease would have on the daily lives of her family and the family's need to understand the condition. Second, the various health professionals did not work as an interdiscip1/tinary team in the development of an individualized treatment plan for Mrs. Johnson. Her care was characterized by a lack of collaboration and communication among the doctor, laboratory personnel, the dietician, and the pharmacist. Because of the necessary interdisciplinary nature of diabetes management, a team approach is required to provide quality patient care and prevent associated long-term complications. The team must consist of the patient and all involved health care providers, for example a nurse to coordinate care, a diabetes educator for general education regarding the disease, a dietician for nutritional education, a pharmacist for medication review and education, a physician for primary care, a podiatrist for foot care, and perhaps a psychologist to address anxiety or other mental health issues. Third, the health professionals did not emp11toy evidlence-basehlpractice in Mrs. Johnson's care. The goal of diabetes education has been to promote self-management, but research has shown that knowledge alone is an insufficient predictor of an individual's ability to incorporate new self-care behaviors. Educational programs that promote effective self-care among people with Type II diabetes should be designed to foster a belief in the Fourth, the clinic did not apply quantity improvement methods. A diabetes registry had been implemented, but it was not being used to improve the quality of care provided to patients. The diabetes team attempted to monitor the number of patients entered into the registry, the services they received, and outcomes related to changes in their health status. Since the registry was not continuously updated, the key measures for individuals, subpopulations, and the total population were incorrectly reported. As a result, trends could not be monitored. If the diabetes registry had been continuously updated, the provider's office manager would have printed out the encounter form upon a patient's visit and clipped it to the front of the chart. This form would have provided various graphs displaying a 6-month history of care while alerting health care providers to needed tests and services. In the paper-based system that characterizes the scenario in Box 3-2, patient input depends on each health care provider's remembering to update encounter forms and office staffs having time for data entry. Finally, health professionals did not utilize informatics in the clinic visited by Mrs. Johnson. Administrators in the clinic had implemented the diabetes registry, but they had not designated a specific individual to be responsible for monitoring data entry and disseminating output reports. As a result, it was impossible to know whether health care providers had failed to update the encounter forms at the time of patient visits or had delegated the paperwork to their staff, who may not have completed it correctly, if at all. When inquiries were made about updating of the encounter forms, all the health care providers stated they were positive the necessary paperwork had been completed after each visit. Yet when they received monthly reports, they believed the statistics did not correctly reflect 51

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HEALTH PROFESSIONS EDUCATION their patient load or the number of services provided; they thought the numbers should be higher in both areas. Without an effective monitoring system in place, however, it was difficult to validate those beliefs. In sum, the paper-based system limited the health care providers' ability to search, retrieve, and manage client data from the diabetes registry. In the following subsections, the rationale and a detailed definition for each of the five core competencies identified by the committee are presented. It should be noted that there is not in all cases a strong evidence base supporting the view that adopting a competency would result in better patient and population outcomes. Where such evidence is available, it is cited; where it is not, this lack is indicated, and the rationale for the committee's espousal of the competency is provided. Provide Patient-Centered Care Shifting health care needs for the American population have added a growing need for care for chronic conditions to the once predominant need for acute, episodic care. Today, 4 in 10 Americans report having a chronic condition, and by 2020, this proportion will increase to half of the nation's population (Wu and Green, 2000~. Unlike those who receive acute, episodic care, patients with many coexisting conditions see a variety of health providers, in a multitude of settings, over an extended period of time. Disease-focused and clinician-centered care, which emphasizes treating a disease without attention to the needs of the patient and centers on the health professional as the sole source of control, is out of step with changing patient needs and demands. Patients are increasingly interested in customized treatment recommendations that are responsive to their preferences and beliefs and reflect an understanding of their environment, including home life, job, family relationships, cultural background, and other factors. The health care financing syste~which largely does not reimburse professionals for time spent coordinating and integrating care or providing care through alternative vehicles, such as over the Internet or via telephone- further constrains clinicians' efforts to care for patients (Institute of Medicine, 20014. Significant work done by researchers and experts in this competency area reveals specific skills needed by today's health professionals to be more responsive to patient needs (Gerteis et al., 1993; Halpern et al.,2001; Institute of Medicine, 2001; Lewin et al., 2001; Mead and Bower, 2000; O'Neil, 1992; Pew Health Professions Commission, 1995; Stewart, 20014: · Share power and responsibility with patients and caregivers. Engage in an ongoing dialogue with patients that brings about understanding, acceptance, cooperation, and identification of common goals and related care plans. Guide and support those providing care to patients (e.g., family members, friends) by involving them as appropriate in decision making, supporting them as caregivers, making them welcome and comfortable in the care delivery setting, and recognizing their needs and contributions. Understand and respect patients' self- management activities. Provide physical comfort and emotional support. Ease pain and suffering. Provide timely, tailored, and expert management of symptoms. Relieve fear and anxiety. · Communicate with patients in a shared and fully open manner. Allow patients to have unfettered access to the information contained in their medical records. Communicate accurately in a language that patients understand. Offer trustworthy information using patients' preferred communication channels (e.g., 52

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THE CORE COMPETENCIES face-to-face, e-mail, other Web-based communication technologies). Explore a patient's main reason for a visit, associated concerns, and need for information. · Take into account patients' individuality, emotional needs, values, and life issues. Provide care for patients in the context of the culture, health status, and health needs of the population of which each is a member. Provide care that reflects the whole person. · Implement strategies for reaching those who do not present for care on their own, including care strategies that support the broader community. Accept responsibility for enrolled members of a health plan, and consider the needs of underserved members of a community who do not initiate visits or present for care. · Enhance prevention and health promotion. Apply population-based strategies to identify and reduce risk factors and to improve patients' use of and access to appropriate services and providers. Define and describe populations by health status. Deliver health care services intended to prevent health problems or maintain health. Understand and apply principles of disease prevention and behavioral change appropriate for specific populations with which patients may identify. Understand the links among healthy lifestyles, prevention, and the cost of health care. Multiple studies demonstrate that meeting the aim of patient-centeredness can improve health status and other outcomes desired by patients (Benbassat et al., 1998; Henbest and Stewart, 1990; Kaplan et al., 1989; Lewin et al. 2001; Roter et al., 1995; Stewart et al., 1999~. Evidence demonstrates that patients who are involved in their care decisions and management have better outcomes, lower costs, and higher functional status than those who are not so involved (Gifford et al., 1998; Superio- Cabuslay et al., 1996; Von Korff et al., 1998; Wagner et al., 20014. In a randomized controlled trial of a self-management program for chronic disease patients, participants who received the intervention showed improvement as compared with the control group in health behaviors such as frequency of exercise and improved communication with health providers, as well as improved health status and reduced hospitalization (Lorig et al., 20014. Providing patient-centered care also has been shown to lead to greater clinician satisfaction, a reduction in malpractice claims, and patient loyalty to the clinician (Meryn, 19984. Box 3-3 describes an example of care from the patient's perspective. Providing patient-centered care is particularly important in light of the ethnic and cultural diversity that increasingly characterizes much of the United States. Although minority populations represent less than 30 percent of the national population, they constitute about 50 percent of the population in some states, such as California (Institute for the Future, 20004. A culturally diverse population poses challenges that go beyond simple language competency and include the need to understand the effects of lifestyle and cultural differences on health status and health-related behaviors; the need to adapt treatment plans and modes of delivery to different lifestyles and familial patterns; the implications of a diverse genetic endowment among the population; and the prominence of nontraditional providers, as well as family caregivers (Institute of Medicine, 20024. Box 3- 4 presents an example of a system of care that is designed to respond to cultural diversity. Researchers caution, however, that though scattered studies demonstrate positive outcomes with the provision of patient centered care, more attention needs to be paid to the methodological quality of such studies. Currently there is no 53

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HEALTH PROFESSIONS EDUCATION gold-standard measure for patient-centeredness. The absence of valid, reliable, and appropriate tools to assess the effects of interventions to promote patient-centered care has been a large obstacle in performing such assessments uniformly (Mead and Bower, 2000~. Another obstacle has been associated with the definition of terms related to this competency. Though a widely used phrase, patient-centered care has little shared meaning within and across the health professions. In their systematic review, Lewin and colleagues (2001) note that more work needs to be done on defining common language and terms related to patient-centered care that can be operationalized in effectiveness studies. Work in Interdisciplinary Teams An interdisciplinary team is composed of members from different professions and occupations with varied and specialized knowledge, skills, and methods. The team members integrate their observations, bodies of expertise, and spheres of decision making to coordinate, collaborate, and communicate with one another in order to optimize care for a patient or group of patients. It should be noted that, although patients and their caregivers are increasingly performing tasks once performed strictly by health professionals (Hart, 1995; Lorig et al., 1999; Von Korff et al., 1997) and so could be considered part of the larger health care team when they so desire, this report focuses on the educational needs of trained health professionals. Thus this competency refers to the various disciplines working together to address the needs of patients. Interdisciplinary teams are critical in dealing with the increasing complexity of care, coordinating and responding to multiple patient needs, keeping pace with the demands of new technology, responding to the demands of payers, and delivering care across settings (Bluml et al., 1999; Hall and Weaver, 2001; Institute of Medicine, 2001~. Teams tend to reduce the utilization of redundant or duplicate services, and they also tend to develop more creative solutions to complex problems because of their members' diverse academic backgrounds and experience. Patients needing chronic care, critical acute care, geriatric care, 54

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THE CORE COMPETENCIES and care at the end of life require smooth team functioning because of the complexity of their needs. Different means and settings for delivering care, such as managed care, community-based care, rehabilitation centers, and critical pathway systems, are gaining momentum and require interdisciplinary teams to provide the necessary coordination (Amsterdam et al., 1980; McDonough and Doucette, 2001; Weingart, 19964. Most but not all care should be delivered by teams, either formally or informally organized. Interdisciplinary teams have been shown to enhance quality and lower costs in some studies (Baldwin, 1996; Burl et al., 1998; Curley et al., 1 998; McDonough and Doucette, 2001; Shortell, 1994; Wagner et al., 20014. The identification or addition of team members to achieve greater concordance with complex treatment protocols on the part of both providers end patients has improved outcomes for several chronic conditions (Wagner, 20004. Studies have also demonstrated a relationship between better interaction among team members in intensive care units and decreased risk-adjusted length of stay (Shortell, 19944. Still other studies have demonstrated some impact of effective team care on patient safety and reduction of medical errors (Silver and Antonow, 2000; Weeks et al., 2001~. However, more research is needed to fully explore the effect of teams on patient outcomes and cost, as well as the effectiveness of teams in ambulatory settings (Cooper and Fishman, 2003~. Summit participants suggested making systematic evaluation a part of all interdisciplinary team 55

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HEALTH PROFESSIONS EDUCATION .............................................................................................................................. ............................................................................................................................. .-.-T-h-''e~ '''m.2c0'' I""""'al'' '' """"'' '' '' 'h' ' i' ' ' """"'i'' te' d'i' ' i'' 'l'i'' '' ' ""' ............................................................................................................................ ................ .... ............................... .... ~ . . ~ .-.-.p.~ 3 .~ m-s ~ al -Ed o ~-~-r~ pup ~ess-l-o-n-a- -so so pep-or ~ pa I-en ~ sat- , ma-~-a-g-em--e . . ....................... .. ................. ...~ ~ _ ~ — .-.-.H-'I'S" -a-- l --l-atl-- -no a-- ~ ~ Ed Hi-- l ~ l -e- tinted ~--l-a-Dete- -l-l-ao- all- e In lYUd ::::::::::::::: :::::::::::::::::::::::: ::::::::: :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: — ~ ~ H~m-l-e~ Mellon ................................. ....................... ......................... ...................................... .... ..... .................................. it. ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ~ e ~ a ~ Inieg area n-ea-l-t-n~ terms l-t-n~t~ n-- -Ilal Juu l al- aml--e~ Al-- 9 terms arena-- IIIt ..... .. ..... I n-co-rpo-ml.e-s~ l-ne~ g-u--l-a-e-l-l-n-e-$~ l--nlo~ l-n-e~ a-a lo- a-ay~ ca- e~ oT~ a--la-~-e l-c~ pall-e-n-ls~ p~v-l-a-e-rs~ ,,a- e~ a-ol-e--- .................................................................................................................................. ........................ . . .... to --su--p-p-o-~ p-at-l-e-n-t~ se-l-~-m-a-n-ag-e-m-e-n-t~ l--n-cl-u-~--l--n-g~ l-n-~--l-v-lo-u-al~ a-n-~ g-rou--p~ cl-as-s-es~ a-n-~ ll-o~n-ans--- . .. .. ....................................................................................................................................... -.-.o-n.~ ~-r.l-l-c.r.-l.~ @-a-l-l-e-n-s~ re-co-~ l-r-l-e-l-~ ow-n~ l-a-~o-ra-to-ry~ .............................................. .............................................................................. ............................................................................................................................. , . . . . . .-.-.n.n-vS.lclans ana nU seS work lo monitor lne alaceles Tlow snee s~ uo-m--n-u-te-rlzea~ m-e-a-l-cal~ ::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::.:::::::::::::::::.:::::::::::::::::::::.::::::::::::::::::::::::.::::::::::::::::.:::::::::::::::::: mc ~ l l -n~ l ~l t' """"' -n-- l l lil ~ t' """'' " """'U"1' 'D'' t' ' "' ...................................................................................... . - - ...- _.._.._..- .-.-...-. - ._..- ...... i . - ..~......._..- ._......~.~..- . - ......._...- . i ..-...-...- ..~._.._.....~..- ...... - . - ._.-.-...-... i ..- . - i ...................~. .... ~.1 ~ ~.~.u ~.~ ~ ~-.r-l-~ ~-~ ~.-l-~-.r-l~ ul-~Uu-l-~-L~-~ lo~ ~-~.v.Iu-~-~ j , . . . ~ """"""""'Q'' 't' ' ' -e """t' ''"""D' tn enl 9 Ce lDen an e na e n n ~ tantlal :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::: :: ::i:::::::A:::~:: ::::::::::::::::::::~::::::::::::::~::::::::,::::::::::::: :::::~:::: :::::::::::::::::::::::::::::::::::: .,.,.,,,~,,,,,.9.,,,a,,,,,,,.,,J,,,.,u,,,,,,, ana sunslanilal Incmase$ 1n lne pemenlage ~ ~ . ..... n-e-m-oq--l-o-~-ln tesls wltnln a ~ar t~ooennelmer et al ~ ~-uu- -;~ l--n~t-l-t-u-te~ ~-r~ H--e,,a,l-~-n-ca-re~ l-m--p-rove~ ::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ~ l~ The---~---Di" ' ' i' ' ""' ' ' ' ' ' i' ""i' ""'."' '' :::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :: :::::::::::::~:::: :~:::::::::~::::::::::::::::~:::::::: :: - :::::::::::::::::::::.:::::::::: ~:::::::::::::~::::::~::::::::::: ~--o~uabon~ s---p --t--~ -~ -~m --U --~-D d--W- O--J- ~ -~- O~1 ---~UUz)~ th --l td~ --t --n Hh ~ 1 .... .. ..... .... 64

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THE CORE COMPETENCIES A Vision of the Prepared Health Care Professional The core competencies described in this chapter can lead to fundamentally better care. Having begun in this chapter with a scenario that depicts a patient encountering significant deficits and gaps in care (Box 3-2), we conclude with a scenario developed by the committee that depicts care as it could be if health care providers exhibited the five competencies (Box 3-10~. Mrs. Johnson's health care needs were met in several ways. First, health professionals provide~patient- centerec! care as they shared information on the decision-making process and the management of diabetes with the patient. It was evident that Mrs. Johnson valued her education and family. In the interdisciplinary team meeting, she voiced her frustration regarding the amount of time it was taking her to learn how to self- manage her diabetes while attempting to meet her responsibilities as wife, mother, and graduate student. She was fearful that she would have to quite graduate school. The interdisciplinary team members reviewed Mrs. Johnson's short-term self-management goals with her and emphasized her successes. In addition, they discussed options that would allow her to meet her varied responsibilities. By the end of the interdisciplinary team meeting, Mrs. Johnson felt confident that she was making progress in the self-management of her condition. In addition, she and her husband decided that instead of quitting graduate school, she should decrease her course load to one class per semester until she felt comfortable with juggling the self-management of her diabetes and her other responsibilities. Second, the health professionals worked in an interbliscip11tinary team in approaching Mrs. Johnson's care. She was referred to a number of health care providers who offered education 65

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HEALTH PROFESSIONS EDUCATION ...................................................................................................................................................................... ............................................................................................................................ . . 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I n a.~.~ l.l.lo.n --- t-n-e~ a--l-a-Dele-s~ ::::::::::::::::::::::::::::::::::::::::::::::7 :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: - - i - - r - - n-e-r~ e- m-a-l-l~ aa- '-re-ss-- Tor qE -esl-lons ana Scneaulea a T0110W U"E """'a'i po-E-nl,-m-e-n-l~ To-i ~ l~ m-o-n-T-n- A team meetl 1 .... .. ............................................................................................................................. ~ mil i mb -r- ~ "d -atl-- -a-l~ ~ ~ a-- ~ i i p ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ - ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ~ l~ ne~ ~--l-etl-c-l-a-i ~ ~-n-a-- -~ a~ a--l-~a-~ ~- -al~ a~l-on~ a-n-a~ pm- -lo-~-a~ n-- -t-rl-tl-o-' -al~ ~-- -cat-l-o-n~ ~--n-e :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :2:2:2:2:2:~2:n2:2:~ ::::::::: ::: :J::::::::::::::::::: :J:::::: d:: CISC sse0 tne relatlons'nip i eween IoCa lnta~ ano olooU s ga' le els wnen tne Cleticlan :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::: ''x 'I=^I''i'~= x'''Ti ~''''1' immi =-n .~..~ ^T~ ~-rm..l£-~ l~-~l'--~ l-^n-n-~-~-i ''''£'M'1'~''''=i ^'''l'AI~'nT~ x'''T^''''d T=x ''''~i ''''=~. ''~'1'~' - " - ~ - '~'''' Li''i'W''''l l'l'l'" V I''t E:l':':l':~ - ':':':':Vl:':':':':~:E:': - i' - ~.:''':':':':'I:'Y':I'i':'~''':':':':'V V'I''I'I''I ~ V I'I'''' - ='I - ''''~'i''i'W'''''Y'V'd :I':':I':L - '~':':':':LV '' x :::::::::::::::::::::::::::::::::::::::::::::: i::::::::::::::::i: ::::::d: ::::: :::::::::::::::::::::::::::::~:::::~:::::::::i:: ..... p.~ g.rai.r.i ~ l~ n-e~ a--l-el-lcl-a-i ~ a6-s-l-sle-a~ n-e-i~ wll-n~ ln-e~ a-e e-l-o-p-m-e-nl-- ::::::::: :::: :::::i:::::::::::: ::::::::::::::::::::::::::::::::::: - :::::::::::::: ::::d:: ::::::::::::::::::::i: - :::::::::::::: ....w....n..lcn~ s-n-e~ em-rcl-sec~ t-n-- e-e~ ll-m-es~ a~ wee-K~ to-i~ ~-u~ m--l--n--u-le-s~ l~ n-e~ a-l-et-l-~-la-i ~ a-l-s-o~ ' mv- ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::: :::::::::::::::::::::::::::::::::x: :~:::::: ::::::::::::::::::::::::::::::::::: :~::::::::::::- JO-h---$~ t,' he~e--- alau~ess .nE---ete---e0~i-e~ t~ eb--te~t'--.t~'~ ~---~ ~--m-at~ ::::::::: ·::::::::::: :::::::::::::::::::::~:::::::::::::::::::::::~: ::d :::::::::::::::::::~::::::::::~::::::::::::::::::::::::::::~:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: .-.-.n-OW-- lo make EiTesl~e cnanges ............................................................................................................................ ... ~ , _ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ................................................................................................................................ ....... ..... . . ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: and support according to the recommended standards ofcare. The team members, including Mrs. Johnson and her husband, met to communicate and coordinate the treatment plan. Third, the health care professionals emp1/toyed evidenced-basedpractice. Health professionals frequently expect newly diagnosed diabetics to change multiple behaviors to decrease their risk of complications. Patients often fail at self- management because they are overwhelmed by the number of changes. In accordance with the current literature, the diabetes educator and dietician each had Mrs. Johnson choose one basic self-management goal. They provided her with the information and tools necessary to be successful, and then on her follow-up visits, they reviewed her progress. Fourth, the team app11tieh1 qua11tity improvement in the provision of care through use of the diabetes registry. Key outcome measures were tracked for individual patients, a subpopulation, or the general registry population. At Mrs. Johnson's next 66

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THE CORE COMPETENCIES appointment, health care providers will print out a record that displays data and graphs of visits and care provided for the past 6 months. Doing so allows providers and patients to note trends. addition, care reminders can be printed out and given to health care providers to remind them of needed services, or a letter can be sent to the patient as a reminder for care. Finally, health care providers utilized informatics as a way to communicate and manage Mrs. Johnson's diabetes care. All the health care providers used PDAs to input data into the diabetes registry so they had continual access to updated information. Mrs. Johnson was able to obtain results of her EKG and laboratory tests from an automatic recorded information system. If she had questions related to diabetes and self-management, she had e- mail access to her health care team. In addition, she was encouraged to seek out current diabetes information on the Web while obtaining support Tom others with diabetes through a chat room. Conclusion In conclusion, the committee stresses that narrowing of the quality chasm can be realized, at least in part, by reforming health professions education: · For health professionals, there is a set of core competencies that can advance adherence to the rules of a redesigned health care system as envisioned in the Quality Chasm report: provide patient-centered care, work in interdisciplinary teams, employ evidence-based practice, apply quality improvement, and utilize informatics. · The extent to which current health professionals are implementing these competency areas does not meet the health care needs of the American public. References ABIM Foundation. 2002. Medical professionalism in the new millennium: A physician charter. Annals of Internal Medicine 136 (3~:243-46. Agency for Healthcare Research and Quality. 2002. "Evidence-based Practice Centers." Online. Available at http://www.ahrq.gov/clinic/epcix. him [accessed Dec. 1, 20023. American Association of Medical Colleges. 2001. "Medical School Objectives Project." Online. Available at http://www.aamc.org/meded/msop/ start.htm [accessed Sept., 20023. American Cancer Society. 2002. "No Matter Who You Are. We Can Help." Online. Available at http://www. cancer. org/docroot/home/index. asp [accessed Dec. 1, 20023. American College of Physicians. 2002. "ACP Journal Club." Online. Available at http://www. acpj c. org/shared/purpo se_and~rocedure. him [accessed Dec., 20023. Amsterdam, J.T., D.K. Wagner, and L.F. Rose. 1980. Interdisciplinary training: Hospital dental general practice/emergency medicine. Annals of Emergency Medicine 9 (6~:310-313. Bader, S.A., and R.M. Braude. 1998. "Patient informatics": Creating new partnerships in medical decision making. Academic Medicine 73 (44:408-11. Balas, E.A. 2001. Information systems can prevent errors and improve quality. Journal of the American Medical Informatics Association 8 (44:398-99. Baldwin, D. 1996. Some historical notes on interdisciplinary and interprofessional education and practice in health care in the U.S. Journal of Interprofessional Care 10: 173-87. Batalden, P., D. Leach, S. Swing, H. Dreyfus, and S. Dreyfus. 2002. Generalcompetencies and accreditation in graduate medical education. Health Affairs 21 (5~:103-11. Bates, D.W., L.L. Leape, D.J. Cullen, N. Laird, L.A. Petersen, J.M. Teich, E. Burdick, M. Hickey, S. Kleefield, B. Shea, M. Vander Vliet, and D.L. Seger. 1998. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. Journal of American MedicalAssociation 280 (154: 1311-16. 67

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