Lynne Stevens Memorial Program

Education: Training for Integrated Multidisciplinary Care

By Ramon Cancino, MD, MSc

As a medical student rotating through outpatient clinics and hospitals in Ohio in 2008, I felt underwhelmed by the initial experience. In both settings, I witnessed employees working incredibly hard with little interdepartmental communication—even when taking care of the same patients. Sure, there were inpatient “teams,” but these were made up of individuals from similar disciplines. In the ambulatory setting, the patient-centered medical home movement was gaining momentum, but  providers and front desk staff members remained separated and, sometimes, at odds. I witnessed a healthcare system struggling to communicate with itself. Physical and virtual walls separated departments from each other, making it impossible, for example, for a front desk staff member to communicate with a nurse about an insurance issue or for a primary care physician to find evidence of the behavioral health treatment his or her patients received within the same institution.

Sensing my frustration, a mentor introduced me to the Institute for Healthcare Improvement (IHI) Open School, a multidisciplinary online, educational community, which delivers content about quality improvement and teamwork in order to advance healthcare improvement and patient safety competencies. Shortly after being exposed to improvement principles as a fourth-year medical student, I returned to medical school to find a group of like-minded people. This group included hospital and medical faculty and staff, as well as other students. Together, we started one of the first hospital-based chapters of the Open School and educated ­hospital staff about the power of checklists, medication reconciliation, and Plan-Do-Study-Act cycles. Following medical school, my career path included a family medicine residency, an academic medicine fellowship, and a master’s degree in health services research. Along the way, I helped start chapters in Florida and Minnesota, because, like the hospital at which I trained, there were employees and students who wanted to improve but needed a starting point. For them, as for me, the Open School became that starting point.

Today, I am the chief medical officer and chairman of the quality improvement (QI) committee of a community health center that serves a diverse inner-city population in Massachusetts. The principles I learned at the Open School are proving more valuable than ever. In fact, I have used these experiences to develop a curriculum that enhances our staff through multidisciplinary education. Through these efforts, we hope to improve the quality of care we provide and to prepare staff for the evolution of healthcare in the United States.

Approaching healthcare as a system of processes rather than a series of individual events was the first step in helping staff members understand their importance to high-quality care. At our first QI committee meeting, I told staff, “The registration process can affect diabetes.” That dramatic statement, when one considers a systems focus, is not far from the truth. Our QI committee receives a standardized monthly curriculum, which begins in January with lectures entitled “What Is Quality?” and “What Is a Metric?” and ends with QI team presentations in November and December. During the year, members create process maps, review their departments’ metrics, and split up into QI teams. They shadow departments that are not their own, review each other’s metrics, and learn how metrics relate to health outcomes and reimbursement. At the year-end presentations, team members describe the QI projects they developed, implemented, and analyzed over the course of the year. The health center’s QI committee is now made up of stakeholders representing every department in the health center, from patient scheduling to behavioral health.

Focusing on teamwork and allowing difficult conversations to occur can help overcome the challenges of QI culture implementation. Large health centers are not the only places where silos develop between departments. “This was not nursing’s fault,” “It was my day off,” and “This was not a medical patient” represent statements I frequently heard early in the development of the QI program at my health center. Encouraging the use of teamwork skills away from QI committee meetings is integral to taking advantage of the physical closeness of departments and building trust away from meetings.

Another method of developing QI culture is to allow difficult conversations to occur among committee members. These conversations must be about quality issues, data, and the best improvement methods. It can be uncomfortable and difficult to have such conversations in a public forum, because staff members can become defensive—they want to protect their own departments or reputations. It is my role to ensure these conversations are focused and goal-driven. It is not my role to end these conversations prematurely. The immediate result of these conversations is the development of a shared action plan. The ultimate result, though, is the development of something deeper: a shared systems-level perspective and the ability to think critically as a group about data and problem-solving methods. Although the results are not felt by the end of the first meeting, I have seen much more honest and open data-driven discussions occur as a result.

True Integration
Multidisciplinary education can result in true integration. The current emphasis on population-based quality metrics increases the need to integrate health services because reimbursement and outcomes can be influenced by more than just the occurrence of a provider-patient visit. To be sure, process metrics can be improved by ancillary staff education, and open communication between different departments can improve outcome metrics in patients with comorbid conditions (for example, patients with both diabetes and depression). Multidisciplinary QI committee meetings allow barriers to high-quality care to be addressed at all levels and enable us to officially empower staff to address quality issues. QI committee meetings attempt to take the strengths of a well-run organizational culture and dispense with the communication barriers that tend to create silos.

Much has been written about barriers to creating and sustaining a successful culture of teamwork and QI, and I will take a brief moment to address two large barriers: time and money. At our health center, staff often learn QI methods during lunch and do QI projects in the course of their daily work. We do not have full-time QI staff. The reason for this is that we, like many health centers, have not traditionally reserved funds to invest in robust QI activities. Therefore, QI committee activities become miniscule components of an employee’s full-time position, and, without the right motivation, sustaining momentum can be difficult. Under traditional fee-for-service payment methodologies, those priorities can often be justified. Yet the increasing trend toward capitated and quality-based payments has increased both the urgency of developing and sustaining QI programming and the ability to pay employees appropriately for devoting time to this activity.

Foremost, we are doing all of this so that our patients will be healthier. Healthcare is changing in the United States, and the question of whether a health center has successful ­relationships with its patients is now determined both at the individual and the population level. Using QI committee meetings to promote data-driven discussion among health center staff and multidisciplinary team-based improvement has allowed the health center to change its perspective on health as well—from individuals to populations, from silos to communication, and from individual experience to systems and processes. The room I sat in as a medical student learning about quality from Dr. Don Berwick at the first IHI Open School Congress is a 20-minute drive from my health center. Today, that room feels a lifetime away, but the tools I acquired that day are needed more than ever before. Our health center has greatly improved its childhood immunization processes, triage protocols, behavioral health integration, integrated team meetings, and blood pressure control. Those tools will benefit a whole population of patients who may not understand the work it takes to deliver high-quality multidisciplinary care seamlessly. ❙
Ramon Cancino is chief medical officer and chairman of the quality improvement committee at the Mattapan (Massachusetts) Community Health Center. He is also an assistant professor at the Boston University School of Medicine and staff physician at Boston Medical Center. He may be contacted at ­ramon.cancino@gmail.com.