The difficulties with Quality Improvement in health and social care

The focus on industrial quality improvement (QI) and teamwork emerged in the 1940s in response to the need for high quality, low cost materials for World War II.  The quality improvement approach was subsequently popularised in the Japanese automobile manufacturing industry in the 1960s and 1970s.  Supported by influential organisations such as the Institute for Healthcare Improvement (IHI) and the Joint Commission for Accreditation of Healthcare Organizations (JCAHQ), quality improvement principles have been widely employed in the US over the past decade or so, among a growing variety of health and social care providers.  This expansion has also been witnessed in a number of other countries’ health and social care systems, including Australia, Canada, and the UK.  Arguably, the use of QI approaches within health and social care context can be problematic.  As QI approaches are rooted in private sector organisations whose aim it is to offer a relatively limited range of services and products, with a narrow range of variability in quality, at a competitive cost to consumers who can choose among many suppliers, they do not necessarily match the more variable processes of care delivery.  This is not to say that there are no activities in the health and social care which are amenable to QI processes.  Laundry services, laboratory specimen processing and catering, for example, can more easily be organised in more standardised, efficient and reliable fashion.  But providing care involves a range of complex professional, economic and organisational factors.  In addition, unlike consumers, patients are usually unique, with differing co-morbidities and social conditions, different values and personal support systems, all which challenge the ethos of QI.  

(Scott Reeves, Editor-in-Chief)

To read more see: Reeves S, Zwarenstein M, Espin S, Lewin S (2010) Interprofessional Teamwork for Health and Social Care. Blackwell-Wiley, London. 

Challenges with Crew Resource Management

One of the foremost efforts by the aviation community to develop safe teams is the training program known as CRM.  This approach originated from work undertaken by  NASA who identified that the primary cause of the majority of aviation accidents was human error, and that the main problems were failures of communication, leadership and decisions making in the cockpit.  CRM training was subsequently adopted by the aviation industry. It is now a mandated requirement for commercial air crews working under most regulatory bodies worldwide.  Despite a paucity of evidence, CRM has been widely adopted by many health care organisations.  In many respects, this approach has a good fit with a number of care settings such as emergency rooms, intensive care units and operating rooms/theatres.  In these locations, the interprofessional team takes responsibility for the patient’s defined problems and deals with them in priority order, under the leadership of a physician or surgeon.  There are (usually) standardised procedures, protocols and algorithms that can be followed.   However, with more than 90% of health and social care provided in less structured, low intensity settings like clinicians’ offices, patients’ homes, hospital outpatient departments or inpatient wards, the applicability of CRM may be more limited.  The differences between health and social care and the airline industry also extend to the nature of tasks.  While most patients have common diagnoses, every case is rendered unique by the interaction of multiple problems and with personal and social situations.  As a result, a standardised CRM approach to delivering care in these situations is inappropriate.  Indeed, the challenge for delivering care is that patient care tasks can be complex, evolving and difficult to specify.  Moreover, with severely ill patients, there is variability in the kind of teamwork they need.  Variability is also linked to where the patients are in their care trajectory.  The complexity in a single patient hospital stay may, for example, fluctuate back and forth over time in terms of medical need in the early days to social need in the latter days, and back again. 

(Scott Reeves, Editor-in-Chief)

To read more see: Reeves S, Zwarenstein M, Espin S, Lewin S (2010) Interprofessional Teamwork for Health and Social Care. Blackwell-Wiley, London. 

Why we need to problematise the interprofessional field

Established academic fields such as education and sociology have regularly problematised a range of common place issues.  However, to date, within the interprofessional field there has been little effort to problematise key interprofessional concepts, the interprofessional activities (courses, workshops) that have been produced, or the evaluative approaches employed.  The lack of problematisation within the interprofessional field may be due to its relatively recent arrival as an area of academic inquiry.  Indeed, both interprofessional education and practice are still relatively newcomers as areas of scholarship in comparison with disciplines like sociology or education.  The unproblematised nature of this field may also stem from the fact that so much of what we do interprofessionally is usually undertaken on top of profession-specific responsibilities and workloads.  As a result, one could argue that much of the work which has been undertaken in this field has been done so by interprofessional enthusiasts.  While we clearly need enthusiasts to initiate and (attempt to) sustain a range of interprofessional education and practice activities, arguably, the result is a tendency to accept, at face value, a range of interprofessional concepts and activities, which have now become normalised into our everyday thinking.  This uncritical approach can generate a number of difficulties in our work as we fail to understand the nature of interprofessional phenomena as they are designed, implemented and evaluated.

(Scott Reeves, Editor-in-Chief)

To read more see: The need to problematize interprofessional education and practice activities.
Journal of Interprofessional Care; 24:333-335.

Empirically and theoretically - where next?

Empirically, I would argue that there are four key areas which we need to concentrate on in order to develop the interprofessional field in the next five to ten years.  

First, we need to employ more qualitative work to generate more data related to actually observing the interactive processes which occur during interprofessional activities – learning, facilitating and collaborating.  

Second, we need to focus our empirical work to provide a better understanding of the translation of interprofessional activities into collaborative behaviour, enhanced practice and the delivery of care.  

Third, we need to undertake economic analyses of IPE and IPP to begin to generate data into the actual costs and benefits of these activities.  

Fourth, we need to move beyond single site studies, to engage with colleagues in other organizations and undertake multi-institution studies that will provide broader empirical inferences that can build a more comprehensive evidence base.  Theoretically, I would argue we need to ensure that such perspectives become a core part of the work which is undertaken developing and studying IPE and IPP activities.  Also, that such work begins to problematize (our everyday assumptions) in order to generate a more critical approach to understanding the field. 

(Scott Reeves, Editor-in-Chief)

To read more see: Ideas for the development of the interprofessional field. Journal of Interprofessional Care; 24:217-219.

The need for sociological theories

Theoretically, within the interprofessional field we still have some way to travel. Encouragingly, in the past decade we have seen a steady growth in the literature of adult learning principles, social psychology theories, organizational theories, systems approaches and psychodynamic perspectives.  Although the use of these different theories has been enhancing and deepening our knowledge about IPE and IPP, the still field remains, in large part, under-theorized, as authors continue to overlook the use of theory in their work.  A further issue compounds this situation.  In general, there is one perspective – sociology – which has traditionally been poorly represented in the field.  The limited use of sociological perspectives within the interprofessional field is noteworthy as it has further limited our understanding of some key dimensions of IPE and IPP.  For example, the use of this perspective can provide some informative insights into the evolution of the health and social care professions and how interprofessional hierarchies and imbalances of legitimacy emerged and continue to thrive.  Importantly, sociology can provide some much needed critical framing of interprofessional activities to understand how micro interactions between professions are enacted within larger political, social and economic structures.

(Scott Reeves, Editor-in-Chief)

To read more see: Ideas for the development of the interprofessional field. Journal of Interprofessional Care; 24:217-219.

Podcast

We welcome you to listen to the new and innovative Journal of Interprofessional Care audio podcast, where we will be interviewing different people in the field of IPE and IPC.


JIC podcast now available at:
http://informahealthcare.com/loi/jic

Welcome!

Welcome to the new Journal of Interprofessional Care blog!  

Our aim with this blog is to provide a range of insights about a variety of critical issues affecting the interprofessional field. Specifically, the blog will explore, assess and discuss areas linked to both interprofessional education and interprofessional practice such as assessment approaches, evaluation designs, research methodologies, use of theories, conceptual developments. We also aim to cover a broad range of health, social care and welfare sectors, contexts and countries. We hope you enjoy the blog and feel able to join us in examining and debating the key areas linked to interprofessional care. 

(Scott Reeves, Editor-in-Chief)