Collaborative governance of postgraduate medical education: Can it be achieved?

Faced with the need to modernize and improve the postgraduate medical education experience and to maintain the high quality of physicians that Canadians expect, in 2010, four organizations -Association of Faculties of Medicine of Canada (AFMC); Collège des Médecins du Québec (CMQ); College of Family Physicians of Canada (CFPC); and Royal College of Physicians and Surgeons of Canada (RCPSC) formed a consortium to conduct a review of Postgraduate Medical Education (PGME) in Canada. In 2012, the Consortium published the Future of Medical Education in Canada Postgraduate (FMEC PG) project's 10 recommendations for change in PGME. One of these recommendations was to 'Establish Effective Collaborative Governance in PGME'. The recommendation stated- 'Recognizing the complexity of PGME and the health delivery system within which it operates, integrate the multiple bodies (regulatory and certifying colleges, educational and healthcare institutions) that play a role in PGME into a collaborative governance structure in order to achieve efficiency, reduce redundancy, and provide clarity on strategic directions and decisions' The purpose of this paper is to describe the creation, function and dissolution of a collaborative governance structure within the complex system of PGME and the challenges that were faced in its sustainability. The lessons learned are applicable internationally where integration of multiple organizations is being attempted. A fundamental question remains as to whether a consensus-based decision-making process can ever be achieved among organizations with overlapping mandates and in some cases, hierarchical structures?

Development of accreditation standards for interprofessional education: a Canadian Case Study.

BACKGROUND: Academic institutions worldwide are embedding interprofessional education (IPE) into their health/social services education programs in response to global evidence that this leads to interprofessional collaborative practice (IPC). The World Health Organization (WHO) is holding its 193 member countries accountable for Indicator 3-06 ('IPE Accreditation') through its National Health Workforce Accounts. Despite the major influence of accreditation on the quality of health and social services education programs, little has been written about accreditation of IPE. CASE STUDY: Canada has been a global leader in IPE Accreditation. The Accreditation of Interprofessional Health Education (AIPHE) projects (2007-2011) involved a collaborative of eight Canadian organizations that accredit pre-licensure education for six health/social services professions. The AIPHE vision was for learners to develop the necessary knowledge, skills and attitudes to provide IPC through IPE. The aim of this paper is to share the Canadian Case Study including policy context, supporting theories, preconditions, logic model and evaluation findings to achieve the primary project deliverable, increased awareness of the need to embed IPE language into the accreditation standards for health and social services academic programs. Future research implications are also discussed. CONCLUSIONS: As a result of AIPHE, Canada is the only country in the world in which, for over a decade, a collective of participating health/social services accrediting organizations have been looking for evidence of IPE in the programs they accredit. This puts Canada in the unique position to now examine the downstream impacts of IPE accreditation.

Guide de pratique clinique fondé sur des données probantes pour l'examen périodique de la vue chez les enfants de 0 à 5 ans au Canada.

CONTEXTE: Étant donné que les maladies oculaires avant l'âge de 5 ans sont courantes, une certaine forme de dépistage des troubles de la vision devrait être effectuée chez les enfants avant qu'ils ne fréquentent l'école primaire. Cependant, l'absence de recommandations nationales cohérentes crée de la confusion chez les patients, les professionnels des soins oculovisuels et les gouvernements. MéTHODES: L'objectif de ce document est de fournir des recommandations quant aux types d'examens oculaires à pratiquer chez les enfants en bonne santé de 0 à 5 ans ainsi que sur le moment et la périodicité de tels examens. Une recension des écrits a produit 403 articles. Un comité d'experts multidisciplinaire (composé de deux optométristes, d'un ophtalmologiste effectuant des examens complets de la vue, d'un ophtalmologiste pratiquant en pédiatrie, d'un médecin de famille et d'un pédiatre) a établi de façon indépendante les articles jugés essentiels à la question clinique. Les articles se prêtant à un classement [n = 16] ont ensuite été soumis à une évaluation critique indépendante par un groupe externe, lequel a fourni un profil « GRADE ¼ des articles à utiliser et leur a attribué une cote. RECOMMANDATIONS: En plus du dépistage de routine effectué par les professionnels de première ligne, un examen complet de la vue mené par un professionnel possédant l'expertise nécessaire à la détection des facteurs de risque de l'amblyopie (comme un ophtalmologiste ou un optométriste) est requis durant la petite enfance. Les conclusions confirment l'importance de la détection précoce de l'amblyopie avant 36 mois et au plus tard 48 mois par le dépistage assorti d'au moins un examen complet de la vue avant l'âge de 5 ans. CONCLUSIONS: Le dépistage de la vue effectué chez les bébés et les enfants par les fournisseurs de soins de première ligne au cours des consultations de routine et des vaccinations périodiques est un élément essentiel de la détection des maladies oculaires. Toutefois, le potentiel de détection précoce est limité et un examen oculovisuel complet est également recommandé avant que l'enfant n'entre à l'école. Si l'amblyopie, le strabisme ou une autre pathologie oculaire est détecté ou soupçonné, et que le problème dépasse le champ de compétences du professionnel qui examine le patient, celui-ci peut être dirigé vers le spécialiste approprié, ce qui permet d'amorcer le traitement en temps opportun.

Evidence-based clinical practice guidelines for the periodic eye examination in children aged 0-5 years in Canada.

BACKGROUND: As eye disease before age 5 years is common, some form of vision screening should be performed on children before attending primary school. However, the lack of consistent national recommendations creates confusion for patients, eye care professionals, and governments alike. METHODS: The objective of this document is to provide guidance on the recommended timing, intervals, and types of ocular assessments for healthy children aged 0-5 years. A literature search yielded 403 articles. A multidisciplinary expert committee (comprising 2 optometrists, a comprehensive ophthalmologist, a pediatric ophthalmologist, a family physician, and a pediatrician) independently determined those articles deemed to be key to the clinical question. Articles that were gradable (n = 16) were then submitted for independent critical appraisal by an external review group, which provided a Grading of Recommendations Assessment, Development and Evaluation profile of the reviewed articles to use for assigning a grade of evidence. RECOMMENDATIONS: In addition to routine screening by a primary health care professional, a comprehensive eye examination by an individual with the expertise to detect risk factors for amblyopia-such as an ophthalmologist or optometrist-is required in early childhood. The findings support the importance of early detection of amblyopia before 36 months and no later than 48 months of age via screening with at least 1 comprehensive eye examination before age 5 years. CONCLUSIONS: Vision screening performed by primary health care providers during routine well-baby/child visits and scheduled vaccinations is an essential part of the detection of ocular disease. However, this early detection potential is limited, and a full oculovisual assessment is also recommended before the child entering the school system. If amblyopia, strabismus, or other eye pathology is detected or suspected that is beyond the scope of the eye care professional examining the patient, a referral to the appropriate specialist can be made, allowing treatment to be initiated in a timely fashion.

Exploring Context and the Factors Shaping Team-Based Primary Healthcare Policies in Three Canadian Provinces: A Comparative Analysis.

This paper discusses findings from a high-level scan of the contextual factors and actors that influenced policies on team-based primary healthcare in three Canadian provinces: British Columbia, Alberta and Saskatchewan. The team searched diverse sources (e.g., news reports, press releases, discussion papers) for contextual information relevant to primary healthcare teams. We also conducted qualitative interviews with key health system informants from the three provinces. Data from documents and interviews were analyzed qualitatively using thematic analysis. We then wrote narrative summaries highlighting pivotal policy and local system events and the influence of actors and context. Our overall findings highlight the value of reviewing the context, relationships and power dynamics, which come together and create "policy windows" at different points in time. We observed physician-centric policy processes with some recent moves to rebalance power and be inclusive of other actors and perspectives. The context review also highlighted the significant influence of changes in political leadership and prioritization in driving policies on team-based care. While this existed in different degrees in the three provinces, the push and pull of political and professional power dynamics shaped Canadian provincial policies governing team-based care. If we are to move team-based primary healthcare forward in Canada, the provinces need to review the external factors and the complex set of relationships and trade-offs that underscore the policy process.

Advancing team-based primary health care: a comparative analysis of policies in western Canada.

BACKGROUND: We analyzed and compared primary health care (PHC) policies in British Columbia, Alberta and Saskatchewan to understand how they inform the design and implementation of team-based primary health care service delivery. The goal was to develop policy imperatives that can advance team-based PHC in Canada. METHODS: We conducted comparative case studies (n = 3). The policy analysis included: Context review: We reviewed relevant information (2007 to 2014) from databases and websites. Policy review and comparative analysis: We compared and contrasted publically available PHC policies. Key informant interviews: Key informants (n = 30) validated narratives prepared from the comparative analysis by offering contextual information on potential policy imperatives. Advisory group and roundtable: An expert advisory group guided this work and a key stakeholder roundtable event guided prioritization of policy imperatives. RESULTS: The concept of team-based PHC varies widely across and within the three provinces. We noted policy gaps related to team configuration, leadership, scope of practice, role clarity and financing of team-based care; few policies speak explicitly to monitoring and evaluation of team-based PHC. We prioritized four policy imperatives: (1) alignment of goals and policies at different system levels; (2) investment of resources for system change; (3) compensation models for all members of the team; and (4) accountability through collaborative practice metrics. CONCLUSIONS: Policies supporting team-based PHC have been slow to emerge, lacking a systematic and coordinated approach. Greater alignment with specific consideration of financing, reimbursement, implementation mechanisms and performance monitoring could accelerate systemic transformation by removing some well-known barriers to team-based care.

Exploring the experience of residents during the first six months of family medicine residency training.

BACKGROUND: The shift from undergraduate to postgraduate education signals a new phase in a doctor's training. This study explored the resident's perspective of how the transition from undergraduate to postgraduate (PGME) training is experienced in a Family Medicine program as they first meet the reality of feeling and having the responsibility as a doctor. METHODS: Qualitative methods explored resident experiences using interpretative inquiry through monthly, individual in-depth interviews with five incoming residents during the first six months of training. Focus groups were also held with residents at various stages of training to gather their reflection about their experience of the first six months. Residents were asked to describe their initial concerns, changes that occurred and the influences they attributed to those changes. RESULTS: Residents do not begin a Family Medicine PGME program knowing what it means to be a Family Physician, but learn what it means to fulfill this role. This process involves adjusting to significant shifts in responsibility in the areas of Knowledge, Practice Management, and Relationships as they become more responsible for care outcomes. CONCLUSION: This study illuminated the resident perspective of how the transition is experienced. This will assist medical educators to better understand the early training experiences of residents, how these experiences contribute to consolidating their new professional identity, and how to better align teaching strategies with resident learning needs.

Building capacity for interprofessional practice.

BACKGROUND: Evidence indicates that professional development focused on collaborative practice can improve the quality of care and patient outcomes in specific populations. However, current educational knowledge does not include how to teach professionals to provide interprofessional collaborative care. METHODS: This paper discusses the design, implementation and evaluation of the Interprofessional Collaborative Learning Series (IP-CLS), which provides clinicians with interprofessional professional development that promotes interprofessional competencies, allowing them to incorporate elements of interprofessional collaboration into practice, and creates leaders for interprofessional collaborative practice. The IP-CLS was piloted at a regional health centre in Ontario. Participants completed an online retrospective before and after self-assessment to determine the extent to which the IP-CLS contributed to changes in participants' behaviours related to interprofessional collaboration. A focus group further explored the extent to which the IP-CLS fostered change. RESULTS: Online survey results and an analysis of focus group transcripts reveal the strengths of the IP-CLS and the elements that could be improved upon. Findings indicate that the IP-CLS has the potential to build capacity for interprofessional collaboration. DISCUSSION: The findings indicate that the IP-CLS has the potential to build capacity for interprofessional collaborative practice, and to help participants incorporate elements of interprofessional collaboration into practice.

Collaborative practice in a global health context: Common themes from developed and developing countries.

This paper reports on a study commissioned by the World Health Organization (WHO) to explore common themes of collaborative practice. The WHO requested global clarification of (1) the nature of collaborative practice, (2) its perceived importance, and (3) strategies for systematizing collaborative practice throughout national health systems. While there are many interpretations of collaborative practice around the world, there was a need to ascertain common underlying themes that illustrate good practice in both developed and developing countries to inform an international Framework for Action. A multiple case study design was used to examine collaborative practice in primary health care and commonalities across countries. Staff at each of WHO's six regional offices invited key informants in one or two primary health care organizations where collaborative practice was the model of care to complete case studies. Ten case studies were received from ten different countries, representing all six WHO regions. The results are described according to the study's three areas of focus: describing collaborative practice globally, the shared importance of collaborative practice, and systematizing collaborative practice. Collaborative practice requires a strong political framework that encourages interprofessional education and teamworking. Shared governance models and enabling legislation are required. At a practical level, interprofessional health care teams function most efficiently with shared clinical pathways and a common patient record.

The road to collaboration: developing an interprofessional competency framework.

In the absence of an interprofessional competency framework in Canada, the College of Health Disciplines (CHD) at the University of British Columbia developed a universally applicable framework. This article discusses the development of the "BC Competency Framework for Interprofessional Collaboration". Building on a Health Canada funded initiative through the Interprofessional Network of British Columbia (In-BC), the CHD compared and contrasted existing competency frameworks and consulted curriculum and IP experts throughout British Columbia. The resulting framework is designed to inform curriculum development for health and human service professionals throughout the continuum of learning, starting with pre-licensure education and extending into continuing professional development. The framework will serve as a foundation for future curriculum reform by health and human service educators, practitioners and decision-makers throughout BC and will contribute to the competency literature in Canada.

What attracts students to interprofessional education and other health care reform initiatives?

BACKGROUND: An international consensus has emerged that interprofessional education (IPE) and other health care reforms are necessary to address the increasing complexity of patients' health needs. Despite overwhelming barriers to its system-wide implementation, health professional students worldwide have organized themselves to promote IPE and have achieved considerable attention. This study seeks to offer insights into what attracts students to IPE and other health care reform initiatives and how advocates of change can stimulate this interest. METHODS: Using a qualitative research methodology, 69 students representing 25 disciplines from 22 institutions across North America were interviewed and surveyed on why and how they became interested in IPE. RESULTS: Students were attracted to the possibility of enhancing patient care (n=17), advancing their careers (n=17) and learning more about the issue (n=15). The participating students first became involved in IPE after they joined a student organization (n=21), attended an IPE conference (n=10) or received personal encouragement to do so from a dean (n=2), instructor (n=3), school administrator (n=7) or peer (n=11). These findings point to several strategies that advocates can use to capitalize on the potential of student advocacy to gain support for IPE and new health care innovations. CONCLUSION: This study is the first of its kind to delineate how clinicians, educators, researchers and policymakers can attract students to health care reform initiatives. This work can inform the strategic efforts of advocates to make the idea of IPE and health care reform more attractive to students (as both learners and leaders) and enlist their help in achieving it in the future.

Continuing professional development and social accountability: a review of the literature.

The idea that health professionals should be accountable to the society they serve is not a new concept and by the 1990 s, the continuing professional development (CPD) of health professionals was being seen as one way in which Canadians' level of health could be improved. The public was, and is still today, increasingly demanding a system that is more responsive to regional and community needs. As a result, there is a need for more health professional education at all stages of the education continuum - undergraduate, postgraduate, and continuing professional development - that meets the health and social needs of the populations being served. The trend is now towards 'socially accountable' health care, meaning that the broader context of CPD must also include the personal, social, and political aspects of health care and as such, involve a widening of accountability to patients, the community, managers and policymakers. CPD planning must take into account local and national priorities as well as personal learning needs. However, the definition of social accountability and the stages at which it is addressed is sometimes vague and this added to the difficulty of identifying relevant studies in the literature. Nonetheless, there were some "best practices" evident via Canadian and American studies which focused on models of socially accountable CPD, as well as examples of interdisciplinary collaboration in Canada, the United States, Australia, Great Britain, and the United Arab Emirates. However, there is a definite need for increased research and publication of such "best practice" initiatives. There is also a need for Canadian health professional schools to facilitate this process by sharing their experiences and resources if possible. An extensive literature review was conducted between January and March 2004. Due to time constraints, it was limited to articles written in the English language. The databases/sources utilized included: Medline (now known as Pubmed), CINAHL, ERIC, PsychInfo, Canadian Business & Current Affairs (CBCA) Full-text Education (now known as CBCA Education), Research and Development Resource Base in Continuing Medical Education (RDRB/CME) at the University of Toronto, EMBASE (Excerpta Medica). This literature review was one of the first activities conducted under the auspices of "Issues of Quality and Continuing Professional Development: Maintenance of Competence", a national project funded by the Primary Health Care Transition Fund, Health Canada. The purposes of this review were to identify literature which focuses on aspects of continuing professional development, social accountability, and determinants of health; "best practices" of socially accountable CPD and inter/intra-disciplinary collaboration, and the critical success factors and challenges to implementing CPD, especially CPD that meets the needs of both health professionals and the populations they serve.