Literature Review: Context: the U.S. healthcare system and healthcare teams

As part of the big-picture approach, it is important to describe the current U.S. healthcare context. It is shaped by a series of very strong drivers. Some of these are:

• U.S. healthcare CME/CPD research culture is influenced by positivist, quantitative traditions.
• U.S. healthcare system is undergoing massive transformation. That process is heavily politicized.
• Professional education system is also going through changes, but those changes are not well-synchronized with changes to the healthcare system (Macy, 2013). QIE and IPL are important parts of those changes.
• Rise of such team-based, patient-centric and quality-focused healthcare delivery models as Perioperative Surgical Home has become a noticeable trend.
• Empowerment of patients: From passive recipients of healthcare services, patients have become well-informed team members.
• Professional identity, relationship and trust between different professions are cornerstones of successful team-based healthcare delivery. Historically, compensation models that promote competition among team members negatively influenced that trust.
• Maintenance of certification modalities and requirements for practicing clinicians, and their impact on clinical practices and outcomes, are heavily criticized in academic, professional and public debates.
• Technology has a huge impact on education, collaboration and how healthcare data is managed. In our private lives, we live in a networked world, while our professional systems are lagging behind.
• Quality improvement education initiative – headed by the national Alliance for Continuing Education in Healthcare Professions – perceived QIE and interprofessional, quality focused learning system (Diamond, Kues, & Sulkes, 2015).

Those drivers are very interrelated and each of them is going through changes – creating a very dynamic, ever-changing mosaic.

1     U.S. healthcare CME/CPD research culture

“There are no facts, only interpretations.”
(Nietzsche, Bittner, & Sturge, 2003)

Cultural elements have significant impact on how the areas this thesis investigates (healthcare education and quality improvement) are practiced and analyzed in the U.S. healthcare CME/CPD literature. Arguably, CME/CPD healthcare education literature is overly reliant on context-free, predominantly randomized controlled trials, and positivist and quantitative research used in medical research (D. E. Moore, Bennett, & Mann, 2012). On the other hand, social science education research usually uses context-specific qualitative methods and has a strong theoretical basis. Since qualitative and quantitative research traditions can be viewed as separate cultures marked by distinct norms, values and beliefs, as well as skepticism toward each other (Mahoney & Goertz, 2006), that gap can cause challenges. In the U.S. CME/CPD context, communication across those two cultures can be troublesome, with misunderstandings being common.
For example, recent literature review done by Cervero and Gaines (2014) showed that reliance on quantitative methodologies without theoretical background resulted in two huge groups of articles that answered the following questions: “Does CME have an impact?” and “Which methods can improve impact?” However, the articles did not provide a sound theoretical basis for future research, or explore impact in a specific context.

Elliott (2001) explains that the research design usually matches the professional practices and values. Medical professions desire very specific, quantitative data while dealing with human lives. Simultaneously, as the body of healthcare research exponentially grows, healthcare professionals rely on systematic literature review. Therefore, evidence-based medicine, built around randomized control trials (RCT) and systematic reviews based on RCT, is widely popular. It has provided a robust base for very specific clinical interventions (Clegg, 2005).

As a result, the design of healthcare educational research quite often follows the format used for quantitative clinical research, relying heavily on RCT or meta-analysis of RCT, while very often missing the theoretical background and analytical methods appropriate for educational research. The tendency of that approach is to reduce complex educational problems to simplified bulletproof and socially thin (reductionist and positivist) medical research models. In that context “hierarchy of study design” has been described.  According that hierarchy RCT are the gold standard (Concato, Shah, & Horwitz, 2000), while socially thick qualitative social science methods like methods used in this research – qualitative interviews and ethnography have least credibility.

There are two challenges associated with the very rigid hierarchy of evidence-based medicine:

• Validity of evidence-based medicine in healthcare is questionable. That is important for clinical practice and QIE.
• Validity of the same approach in educational contexts is very doubtful. That affects literature used in this review, and ultimately this research.

Numerous clinical practitioners argue that evidence-based medicine builds fake confidence; it does not enhance objectivity but it obscures the subjective elements that are associated with all types of human research (Donald M. Berwick, 2007; Goldenberg, 2006).

Evidence-based medicine is rooted in positivism. Simultaneously, the positivistic view of scientific methodology has been challenged over the last half century in two respects (Goldenberg, 2006):

1. Our observations and conclusions are heavily influenced by our personal and societal background, theories, knowledge and values. Therefore, even in an ideal situation they cannot deliver an absolute picture of the world (Clark, 1998)
2. Link between “the evidence” and selected theories is never absolute (Duhem, 1991)

Donald Berwick explained that although rigorous randomized control trials can neutralize variations and deliver answers to very specific questions, they cannot be used to assess complex activities like perioperative teams or QI collaborative. We cannot remove variations without ignoring the context. Dr. Berwick explains: “We need evidence… We can’t allow subjective hopes, wishes and dreams to pretend to be truth when unforgiving nature is at work, or we will… do harm. But the harm is equal if we treat a very complex world as if it were simple, if we treat each other as less than whole people and complex systems as simple and separate from us, and thereby reduce our capacity to learn, to converse, to explore and to grow.”(Donald M. Berwick, 2007)

Arguably, that common mismatch between research topic and methodology had influenced outcome of CME research and practices. A significant number of papers attempted to analyze very complex social phenomena through the lens of one-dimensional, context-free qualitative research. As a result, the research did not deliver good, actionable data, and CME/CPD providers have been forced to “improvise.” For example  Fox (2012, p. 192) explains that CME practices are “primarily a function of mimicry, rather that investigation and systemic learning,” and “isolated findings from small, poor studies become justification for adoption of ‘innovative’ educational methods.” In the same manner, Dr. Janet Grant[1] concluded: “There are a lot of declamatory statements and a lot of assertions made about continuing medical education, but not a lot of evidence, no common rationale, no systematic relationship to need, and no robust evidence of beneficial effects on a doctor’s practice” (Hawkes, 2013, p. 4255).

This paper analyzes phenomena that are deeply embedded into the social, cultural, economic, technological and educational mosaic of the U.S. healthcare system. Therefore context-free quantitative RCT and rule-driven meta analysis can be of limited use.

The aforementioned divide can explain debate over the change from the term CME to CPD. The change reflects a significant cultural and epistemological shift in the ways majority stakeholders envision lifelong learning of medical professionals (Karle, Paulos, & Wentz, 2012). It is a move from formal, unprofessional content-focused didactic lessons toward an interprofessional team and student-focused learning system. The process started in 1993 when the UK Standing Committee on Postgraduate Medical and Dental Education proposed the term CPD, reasoning that the CME approach was not enough to cover the complete development needs of modern health professionals. Although we now know the direction in which we are going, the debate is far from settled.

The table below illustrates the divide is widespread. It is affecting significant amounts of our activities.  Epistemological differences between literature review approached in CME and social science as described by Singh, McPherson, and Sandars (2014) are added under epistemology.

Tabel 1.

2     Political context

The U.S. healthcare environment is going through massive, complex, dynamic changes. The drivers of those changes are multiple and strong. For example, the analysis provided by the Commonwealth Fund, a U.S.-based private foundation supporting independent research on healthcare practices, showed that while the U.S., with yearly healthcare cost per capita of $8,508, has the most expensive healthcare, the  system underperforms when compared to other industrialized countries on most measurements (Davis, Stremikis, Schoen, & Squires, 2014). As the table below illustrates, the scale is significant: U.S. healthcare costs are 50% more than the second-most expensive system – Switzerland, and 2.5 times more than the best-performing county – the UK. As a result, the Institute of Medicine reports that Americans suffer from more illnesses and injuries and have shorter life spans than people in other high-income countries. That is happening despite well-described ways to address those issues and the enormous healthcare costs (Woolf & Aron, 2013).

Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally

Figure 1. 2014 Update: How the U.S. Health Care System Compares Internationally. Source (Davis et al., 2014). Used with permission of the Commonwealth Fund.

Performance trends

The diagram below illustrates that age-adjusted mortality rates per 100,000 population have been falling steadily in the 34 Organization for Economic Cooperation and Development (OECD) countries, and in the U.S. 1986 is the year when the U.S. started underperforming in comparison with other OECD countries.

Figure 2. Trends in mortality rates. Mortality rates have been falling steadily in the U.S. and comparable OECD countries. 1986 was the year when U.S. started underperforming in comparison to OECD average. Source healthsystemtracker.org (2016) (CC BY-NC-ND 3.0 US)

Figure 2. Trends in mortality rates. Mortality rates have been falling steadily in the U.S. and comparable OECD countries. 1986 was the year when U.S. started underperforming in comparison to OECD average. Source  healthsystemtracker.org (2016) (CC BY-NC-ND 3.0 US)

In an attempt to improve the U.S. healthcare, the U.S. government adopted the Affordable Care Act (ACA), also known as Obamacare, on March 23, 2010. The law is described as “the most sweeping legislation affecting every individual in the United States in the last century.” (Diaz, 2015, p. 81).

Knowing the important role healthcare has in the lives of individuals as well as society, it is fair to say that this reform is profoundly affecting everybody in the U.S.: healthcare providers, patients, government and U.S. society in general. For example, it is estimated that in the first three years of the ACA, 50,000 patient deaths were prevented and $12 billion was saved (ahrq.gov, 2014; Kessler, 2015).

Strong political-economic and social factors shape CPD of healthcare professionals in the U.S. (Balmer, 2013; Cervero & Moore Jr., 2011) and have obstructed QIE and IPL for decades (Hayes, 2012). As history shows, those factors (pay-for service, siloed guilds or accreditation systems, for example) may have a stronger impact than professional and educational factors.

Interprofessional relationship. This research is done in the context of the perioperative care team (surgery and anesthesia professionals). The literature suggests that due to rivalry between professionals or specialties, learning and change in networked practices may be difficult (Norman, 2013). That may be very noticeable in this context, where one very relevant issue is a long, intense and passionate debate between physician anesthesiologists and nurse anesthetists (NAs) over nurse scope of practice (Hayes, 2012). Nurse scope of practice defines procedures nurses are permitted to undertake in keeping with the terms of professional nursing license. The primary debate is over actions nurses can take without physicians’ supervision.
In addition to the main factor – patient safety – nurse scope of practice directly influences positions and payment of physician anesthesiologists and NAs, making it a strong political-economic factor (with a huge impact on social capital). For example, in a recent article Johnstone (2015) showed that, in addition to high membership fees ($665 + membership in local state society), one of the main reasons cited by anesthesiologists for not joining the American Society of Anesthesiologists (ASA) was related to the ASA’s policy toward NAs. What is especially interesting, the article showed that while some non-member anesthesiologists think the ASA is working too closely with NAs, others think it is not working closely enough.

Socio-economic, professional identity drivers and changes in roles and degrees bring a few additional layers of complexity that influence the relationship between anesthesiologist and nurse anesthetists’ professional groups.

For example, from a socio-economic perspective:

• Physicians start their anesthesiology career in their early 30s or later, after 12 years of highly competitive higher education (4 undergraduate, 4 graduate and 4 residency) and with average student debt of $176,348, where 10% of graduates have debt of $300,000+ (AAMC, 2014).
• Fee-for-service is still the dominant payment method in the healthcare setting (Schroeder & Frist, 2013). In that context, if somebody else wants to provide the same service as you do, that person is a competitor who may reduce your income (and your ability to repay your student loan).
• Debate about NAs’ role in the anesthesia process (scope of practice) contributes to disagreements between physicians anesthesiologists and nurse anesthetists (Hayes, 2012). In most states, NAs work under supervision of anesthesiologists. However, 17 states do not have that safety requirement. In addition to being a patient-safety issue (Hansen & Philp, 2014), that is perceived as unfair competition, because NAs’ certification requires six fewer years of education. Since education of NAs is evolving to all-doctorate programs by 2022 (COA, 2007) – we may expect this debate to continue.

On the other hand, recent political-economic and social factors started changing that power dynamic. Rising costs of U.S. healthcare-associated quality and patient safety issues (Donald M Berwick & Hackbarth, 2012; Davis et al., 2014) have triggered massive changes in the U.S. healthcare system. For example, the fee-for-service model is being replaced by pay-for-performance. In that model, healthcare teams are rewarded for doing good work, and penalized for poor performance. Therefore, other professions have shifted from being competitors to being valuable members of your high-performing team; your team will succeed (and be properly rewarded) only if all of your team members succeed.

3     Maintenance of board certification – Another political-economic factor

Turbulent changes that affect Maintenance of Board Certification (MOC) of physicians in the U.S. may significantly influence the context and implementation of QIE/IPL. Current MOC learning and assessment practices are to a significant degree developed around multiple-choice questions (MCQ) and credit hours. Criticism of MOC has been building during the past few years (Gray et al., 2014; Kempen, 2012, 2014; O’Gara & Oetgen, 2014; Strasburger, 2011). In 2014, the Association of American Physicians and Surgeons took the American Board of Medical Specialties and MOC to court, claiming that MOC “imposes enormous ‘recertification’ burdens on physicians, which are not justified by any significant improvements in patient care” (AAPS, 2014). The beginning of 2015 was marked by a nationwide revolt against MOC. Significant criticism was supported by the current educational theory and online learning formats that QIE/IPL will promote. Critics argue that the authoritarian, one-size-fits-all approach rooted in behavioristic principles should be replaced with more collaborative, outcomes-focused and constructive methods (Brooks, 2009). Instead of policing bad physicians (or physicians that are not good with MCQ), the system should foster development of physicians as knowledge workers, as professionals who safely and effectively use knowledge to lead their team and deliver optimal care (Centor, Fleming, & Moyer, 2014; Cook, Holmboe, Sorensen, Berger, & Wilkinson, 2015).  As a result, a majority of the boards started reorganizing their MOC programs (Baron, 2015).

Grounded theory research done by Cook et al. (2015) found that most internal medicine and family medicine physicians perceive MOC as an unnecessarily cumbersome process that does not properly support individual and group professional development needs. Physicians perceive a lack of meaningful learning in MOC activities. Therefore, instead of being intrinsically motivated, the need for CME credits is physicians’ main motivation to participate. To address that, Cook, et al., proposed a series of changes: better integration with clinical practice, better integration between different MOC modules, relevance to individual needs, and meaningful learning.
One important finding was that physicians stated that “all phases of MOC were more effective and efficient when done as a group” (Cook et al., 2015).

Maintenance of Certification in Anesthesiology (MOCA) is being transformed to address those challenges. In 2011, the American Board of Anesthesiologists (ABA) pioneered researching ways to improve the process, and the next year it hosted a learning technology summit to discuss the best ways to utilize technology to enhance the program (ABA, 2015). Consequently, the ABA is recognized as the leader in delivering innovative MOC products, and presentations on changes they are making are being well-received. But there is still a long way to go. While ABA diplomats are concerned about the MOC formatting, they respect ABA certification, and 80% of respondents find it valuable for daily practice (Culley, Sun, Harman, & Warner, 2013). They also recognize that the ABA is investing significant efforts in improvement. As a result, McEvoy, Niconchuk, Ehrenfeld, and Sandberg (2015, p. 171) invited anesthesiologists to “think of the current MOCA system as an imperfect but evolving system that itself is under continuous QI,” and to join the efforts to improve the program.

4     Organizational and learning technology context

Thus far, a majority of CPD providers rely on a Learning Management System (LMS – if they use LMS), which has limited functionality. Such LMS systems are built around a combination of SCORM modules + files + quiz + survey + certificates, and often completely lack support for collaborative education. They can address needs of content-focused education, but cannot address needs of collaborative or networked learning. The ASA’s leadership has recognized that gap, and the ASA implemented a new Moodle-based LMS – Totara – in August 2015. Totara comes with all the collaborative features of Moodle. Therefore, it is a big change. In addition, Totara provides strong support for learning plans and organizational structure/hierarchies.^[2] Through the Totara hierarchies’ framework, the ASA can assign specific competencies and courses to specific roles in a team/organization. That feature may enable the ASA to deliver programs for multiprofessional teams.

This research is located in the context of the perioperative team. Therefore, in addition to learning technology and practices used by anesthesiologists, the technology and practices used by nurse anesthetists, surgeons and anesthesia assistants will have an impact. The American Association of Nurse Anesthetists selected new Moodle-based LMSs in 2015. Therefore their LMS is compatible with ASA’s LMS. That opens numerous possibilities for collaboration; from cooperative course development to establishing a dynamic directory of courses that will list courses from both LMSs. The American College of Surgeons are just finalizing its LMS selection. Finally, the American Academy of Anesthesiologist Assistants plans to use the ASA’s LMS. Those selections may significantly influence the context and perspectives interviewees have on QIE/IPL. This research will help to better navigate toward improved and coordinated utilization of learning technology available to members of the perioperative team.

5     Roles and academic degrees

Understanding the evolution of roles and academic degrees in healthcare is important:

• They reflect how public and peers perceive individuals and professions.
• They involve a social contract that defines how healthcare teams work.
• The situation is rapidly changing. For example, nurse anesthetists are becoming doctors, teams are being reorganized, and interprofessional collaboration is becoming standard.

Roles and qualifications of healthcare providers have been evolving throughout history, from priests, shamans and healers, through physician-centric, patient-centric and team-based models, and finally to networked care. Arguably, different individuals and organizations may be at different stages (physician-centric, patient-centric, team-based, networked care). The stages are described below:

Physician-centric. During late 18th century, we started understanding the mechanism of diseases, and hospitals emerged as places patients were treated (Wall, 2012). The authority of the healer started to increase and the economic, social and political distance between healers and patients began to grow. Therefore, healers started to be recognized as doctors (lat. teachers) of medicine. With the increasing amount of required knowledge and tools (pharmacy and surgery, for example) the gap between what physician and patients know has also been on the rise. Furthermore, healthcare has become more complex, more industrialized. The widespread belief was that patients were too ignorant to make or participate in medical decisions (Rose, 1998). Therefore, presenting details about limitations and risks of the interventions could not only be a time-consuming endeavor, it could undermine the patient’s faith in the proposed therapy. That resulted in a very physician-centric model, where doctors would make decisions, and patients (and support staff) would silently comply with the instructions.

Patient-centered. Today, the doctor-dominated, one-sided mode is being replaced with a patient-centered alliance built upon cooperation between the doctor and the patient. In that alliance, the doctor is not only the technical expert, but also the teacher and coach helping patients to understand and manage their role in healthcare process and cope with strong emotions and dilemmas. Patients, on the other hand, can become experts in managing their chronic disease (Tattersall, 2002). Therefore, mutual respect, active participation of all parties, and shared decision-making is replacing patient passivity (Kaba & Sooriakumaran, 2007). The doctor serves as a teacher-expert who is the connection between the world of medicine and the patient’s experiences and needs.
My most recent visit to a doctor was a perfect example. After thoughtful explanation of the issue and addressing my questions, my doctor handed me a piece of paper with handwritten keywords. “Here is a list of things you can Google to learn more about the things we discussed today,” he said. “Prepare questions for the next visit.”

Team-based care has evolved as an advanced model of the patient-centered approach, where the healthcare team and patients work together to deliver optimal patient-centered care. Goldberg, Beeson, Kuzel, Love, and Carver (2013) describe it as the most important, practice-transforming tool used to provide patient-centered care. Lin, Schillinger, and Irby (2014) convincingly argue that to address extensive changes needed in practice redesign and medical education, a “share the care” paradigm is necessary. “Share the care” means empowering teams made of clinicians, non-clinicians (nurses, educators, pharmacists and medical assistants), and patients to share responsibility – so each team member can contribute to his or her maximum potential. That paradigm includes a cultural shift from “I” to “we” (Ghorob & Bodenheimer, 2012). “I” stands for the lone doctor-with-the-helpers model, where the clinician makes all decisions, assumes all responsibility and delegates tasks to other team members – helpers. On the other hand, “we” stands for sharing responsibilities, not just tasks.  “We” also stands for team-based learning where the doctor, in addition of consulting and coaching patients, teaches and mentors team members.

Networked care. Finally, networked care, or technology-enhanced team-based care, is where all participants – healthcare providers, patients and their families – collaborate on healthcare delivery. It is increasingly seen as the model of the future (Bornkessel, Furberg, & Lefebvre, 2014; Gaugler & Kane, 2015). It uses digital social media platforms and networks to connect patients and healthcare providers, empowering patients to be more involved in their personal health activities, and driving providers to improve quality of their service. That aligns perfectly with the findings by (Little et al., 2001) that, from the patients’ perspective, the three main domains of patient centeredness are: communication, partnership and health promotion. Patients perceive lack of communication as the biggest issue. For example, on average U.S. healthcare users spend 52 hours a year using online healthcare information and networks, and only one hour talking with a physician (Makovsky Health, 2013). As a result, the majority of patients experience challenges using available health information.

That is a huge opportunity. A significant body of evidence shows that engaged patients have better healthcare experiences and better health outcomes (Hibbard & Greene, 2013). Networked care can engage them and empower them to make better-informed decisions.

Proper usage of social media can help the providers address that gap. Bornkessel et al. (2014) suggests:

• Be active on social networks; listen to patients and observe trends.
• Use information therapy – prescribe appropriate information to your patients (or peers).
• Actively build opportunities for people-centered, collaborative, networked care.
• Learn about it and use it for learning.

A few issues associated with networked care, which should be addressed in advance, are confidentiality, privacy and liability. If not addressed properly, they can become minefield of legal issues. (Moses, McNeese, Feld, & Feld, 2014).

Mayo Clinic is an excellent example of networked care. They created a Social Media Network because (mayoclinic.org, 2016):

At Mayo, we believe individuals have the right and responsibility to advocate for their own health, and it’s our responsibility to help them use social networking tools to get the best information, and connect with providers as well as one another.

The migration toward networked care aligns well with what Allen and Cherrey (2000, p. 1) described 16 years ago: “Two major shifts occurring in the world are having a significant effect on how we work together, influence change and lead our organizations. The first shift is from a world of fragmentation to one of connectivity and integrated networks. The second shift is from an industrial to a knowledge era…All of us need to explore new ways of working that keep pace with this networked knowledge era.”

That is exactly what this thesis is doing – exploring how anesthesia teams can work and learn better in an era of networked knowledge.

6     Medical home

That leads us to another trend, with arguably the same direction – medical home. Medical home is a team-based healthcare delivery model that utilizes collaboration to deliver high-quality, comprehensive and continuous care. Medical home is a microsystem made up of groups that participate in immediate delivery of care and interact directly with patients. The structure comprises physicians, nurses or pharmacists, and groups that support the microsystem, like laboratory, IT and leadership professionals (Batalden, Nelson, Edwards, Godfrey, & Mohr, 2003).

The ASA recently launched for surgical care a specific version of medical home called perioperative surgical home (PSH). Schweitzer, Fahy, Leib, Rosenquist, and Merrick (2013, p. 58) describes PSH is a collaborative, interprofessional and “team-based system of coordinated care that guides the patient throughout the entire surgical experience,” from diagnosis to recovery (Figure 4). The PSH model of care is receiving significant attention. As of now, PSH is one of the ASA’s top priorities. For example, it was the official theme of the ASA’s 2014 Annual Meeting (~15,000 participants), and the dominant theme during the 2015 Annual Meeting.

Perioperative Surgical Home (ASAHQ.org, 2014)

Figure 3. Perioperative Surgical Home (ASAHQ.org, 2014)

Where did the medical home idea start? What can we learn from history?
Since PSH is a new version of medical home, we can learn a lot from the history of medical home.
Patient-centered medical home was first introduced by the American Academy of Pediatrics (AAP). In 1974, the AAP Council on Pediatric Practice proposed a policy statement titled “Fragmentation of Health Care Services for Children”(AAP, 1974). The policy statement was not accepted, but the document clearly indicated that 1) fragmented care is inefficient, expensive and can be harmful for health, and 2) medical home is an important tool to address fragmented care. (Sia, Tonniges, Osterhus, & Taba, 2004).

During the following decade, as the medical home concept gained greater recognition, obstacles to implementing it become noticeable. B. Moore and Tonniges (2004) explained that three major barriers were 1) unfamiliarity of pediatricians with the medical home concept; 2) communication and coordination between professionals; and 3) reimbursement for new tasks associated with medical home.  (Kain et al., 2014) reports that the same challenges face implementation of PSH today. Therefore, it is fair to assume that insight in medical home implementation can enhance implementation of PSH.

It is interesting to notice how the term medical home has evolved since 1974.
At first, it was envisioned as a physical place that provided all medical information relevant to that patient ( i.e., centralized medical records). Between the 1960s and the 1980s, gaining access to healthcare data was a bottleneck and the medical home model then provided a workable answer to that challenge. As we were improving access to healthcare data, it become obvious that consolidated healthcare data is just a first step; better coordination among healthcare professionals, families and patients was and is still needed. That is especially noticeable now, when technology can provide instantaneous access to needed medical information.
Therefore the term medical home now means a comprehensive, team-based healthcare delivery system, where well-coordinated multiprofessional healthcare teams, in partnership with patients and their families, deliver healthcare that is accessible, coordinated, comprehensive, compassionate, culturally effective, cost-effective and, most importantly, centered on the patient and the patient’s family (AAP, 2002; Sia et al., 2004).

That evolution is in many ways similar to the evolution described under roles and degrees, and if we assume that participants communicate via social media, it leads to networked care.

Table 2. Evolutions of healthcare team roles and medical home – different origins, but the same end.

PSH Collaborative. ASA initiated a PSH learning collaborative (ASAHQ.org, American Society of Anesthesiologists, 2014a) to bring together healthcare organizations from across the U.S. to work on development, testing and implementation of the PSH model. It provides face-to-face and online networked and collaborative learning opportunities. It has two generations/classes. Learning Collaborative 1.0 was launched on July 1, 2014, and was scheduled to end by the beginning of 2016. Learning collaborative 2.0 is scheduled to start in April 2016 and last for two years. Each collaborative is a time-limited (2 years) community of practice, where numerous institutions work together mainly via live, phone and web conference meetings.
Opportunity? The existing learning collaborative framework can serve as a springboard for a more open, continuous and technology-enhanced community of practice. Use of asynchronous online collaborative tools (social media) will be the main addition to the existing toolset. Until August 2015, the ASA didn’t have technology that could support such a community. During 2016, significant efforts were invested in customizing and learning about the framework so a collaborative learning community could be properly supported. We have the technology and intention in place. Therefore, at this moment, the critical elements needed are people. This is ultimately a social endeavor, and for successful outcomes we need an engaged and properly supported learning community. This paper will research what PSH professions think about that option.

PSH and IPL. Since effective IPL enables effective collaborative practice (WHO, 2010) we can assume that IPL may be an important part of this interprofessional model. PSH has the same three goals as the national healthcare transformation (ASAHQ.org, American Society of Anesthesiologists, 2014b): 1) improving health care delivery (patient experience); 2) improving health; and 3) reducing cost. That suggests that the stated goal of the Macy conference of Aligning IPL with Clinical Practice Redesign and reforming CPD to incorporate IPL can be achieved  in this context (Macy, 2013).

However, probably due to the aforementioned challenges associated with QIE/IPL in the U.S., QIE/IPL in the U.S. anesthesiology context is in its early stages.

ASA’s cautious approach to IPL may be a reflection of the extensive efforts needed to make it happen and potential mistrust between anesthesiologists and nurse anesthetists described earlier. In addition to that, the Institute of Medicine (IoM) workshop on IPL and collaboration has recognized that successful implementation of IPL requires these essentials: leadership from the top, extensive planning, repeated IPL experience through the educational continuum, focus on real-life work, utilization of new technologies, and strong faculty development (IoM & 2013). Strong faculty development and repeated IPL experiences seem to be the biggest obstacles at this moment. To address that, ASA plans to create a faculty development course in 2016.

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[1] Educational psychologist Director of The Centre for Medical Education in Context (CenMEDIC) and Emeritus Professor of Education in Medicine at The Open University in the United Kingdom.

[2] Totara: Frequently Asked Questions for Positions, Organizations and Competency Hierarchies http://help.totaralms.com/FAQs_for_Hierarchies.htm