Development of Health Professions Education Competencies for a National Fellowship Program: A Group Consensus Process.

ABSTRACT: Health professions educators need knowledge, skills, and attitudes to provide high-quality education within dynamic clinical learning environments. Although postgraduate training opportunities in health professions education (HPE) have increased significantly, no shared competencies exist across the field. This article describes the systematic development of postgraduate HPE competencies for the Health Professions Education, Evaluation, and Research (HPEER) Advanced Fellowship, a 2-year, interprofessional, post-master's degree and postdoctoral HPE training program funded through the Department of Veterans Affairs' Office of Academic Affiliations. Using a modified RAND/University of California at Los Angeles Appropriateness Method, the authors developed competencies from March 2021 to August 2021 that were informed by current practices and standards in HPE. Literature reviews were conducted of published literature from November 2020 to February 2021 and gray literature from February to March 2021, identifying 78 and 274 HPE training competencies, respectively. These competencies were combined with 71 competencies submitted by program faculty from 6 HPEER fellowship sites, resulting in 423 initial competencies. Competencies were organized into 6 primary domains and condensed by deleting redundant items and combining overlapping concepts. Eight subject matter experts completed 3 Delphi surveys and met during 2 nominal group technique meetings. The final 25 competencies spanned 6 domains: teaching methods and learning theories; educational assessment and program evaluation; educational research methods; diversity, equity, and inclusion; interprofessional practice and team science; and leadership and management. In addition to informing the national HPEER curriculum, program evaluation, and learner assessment, these advanced competencies describe the knowledge, skills, and attitudes health professions educators need to provide high-quality education with an emphasis on the global and societal impact of HPE. These competencies represent a step toward leveraging HPE expertise to establish competencies to drive HPE program changes. Other programs should report their competencies and competency development processes to spur further dialog and progress.

Developing an Interprofessional Health Care Improvement Portfolio: Results From a Consensus Panel Process.

The increased focus on professional-led, continuous health care improvement has not produced formalized processes for identifying, recognizing, and rewarding excellence in quality improvement. Moreover, the team-based nature of improvement requires a mechanism to document interprofessional contributions. In 2018, the authors created a health care improvement portfolio to document and demonstrate individual impact for the purpose of promotion. A draft portfolio was developed from a review of the literature and publicly available quality improvement and educational portfolios. The portfolio was further refined through a 2-round, modified Delphi consensus process with a panel of interprofessional experts across North America. In the first round, 35 panelists gave feedback through open-ended comments on the design and content of the portfolio. In the second round, 34 panelists rated the comprehensiveness and clarity of the portfolio on a scale of 1-9 (1 = lowest, 9 = highest) and provided comments. Consensus was defined as an average score over 8.0. Panelists in the second round achieved consensus, with average scores of 8.4 in comprehensiveness and 8.3 in clarity (range, 6-9). The finalized portfolio includes the following sections: personal statement; health care improvement training and certification; leadership and administrative roles; health care improvement project activities; health care improvement coaching, teaching, and curricular activities; health care improvement honors, awards, and recognitions; and supporting documents. The portfolio facilitates the documentation of health care professionals' contributions to and impact in health care improvement and covers the breadth of interprofessional health care improvement (i.e., projects, leadership, education, scholarship). The portfolio can be tailored to an individual's area of specific expertise. While this portfolio was originally developed for interprofessional faculty at academic institutions, the content and structure of the portfolio are easily adapted for health care providers in other health care settings.

Developing Leaders and Scholars in Health Care Improvement: The VA Quality Scholars Program Competencies.

Despite the need for leaders in health care improvement across health professions, there are no standards for the knowledge and skills that should be achieved through advanced interprofessional health care improvement training. Existing health care improvement training competencies focus on foundational knowledge expected of all trainees or for specific career pathways. Health care improvement leaders fill multiple roles within organizations and promote interprofessional improvement practice. The diverse skill set required of modern health care improvement leaders necessitates the development of training competencies specifically for fellowships in applied health care improvement. The authors describe the development of the revised national Veterans Affairs Quality Scholars (VAQS) Program competencies. The VAQS Program is an interprofessional, postdoctoral training program whose mission is to develop leaders and scholars to improve health care. An interprofessional committee of VAQS faculty reviewed and revised the competencies over 4 months beginning in fall 2018. The first draft was developed using 111 competencies submitted by 11 VAQS training sites and a review of published competencies. The final version included 22 competencies spanning 5 domains: interprofessional collaboration and teamwork, improvement and implementation science, organization and system leadership, methodological skills and analytic techniques for improvement and research, and teaching and coaching. Once attained, the VAQS competencies will guide the skill development that interprofessional health care improvement leaders need to participate in and lead health care improvement scholarship and implementation. These broad competencies are relevant to advanced training programs that develop health care improvement leaders and scholars and may be used by employers to understand the knowledge and skills expected of individuals who complete advanced fellowships in applied health care improvement.

The interprofessional Veterans Affairs Quality Scholars program pre- and postdoctoral nurse fellow outcomes.

BACKGROUND: The Department of Veterans Affairs (VA) Quality Scholars (VAQS) program, an interprofessional fellowship that includes pre- and postdoctoral nurses, aims to inspire practice change leaders. Fellows participate in a national curriculum, lead improvement/research teams, and establish professional development plans with expert mentor guidance. PURPOSE: To describe the distinctive elements of the VAQS program, nurse fellow outcomes, and accomplishments of nurse alumni as leaders, researchers, and educators. METHODS: Data were reviewed and aggregated from past and current fellow surveys. FINDINGS: Nurse fellows completed research and improvement projects that benefitted both the VA and the local health systems. Scholarly outcomes include publications, conference presentations, grant submissions, teaching/leading quality improvement, and research initiatives. Graduates transition to positions as nurse scientists, academic faculty, and operational leaders. DISCUSSION: Fellows contribute to the strategic priorities of local and national VA and external health care organizations providing a pipeline of health system expert leaders, educators, and researchers. CONCLUSION: Doctoral nursing fellowship experiences build human capital for enhancing the science of improvement and implementation, interprofessional collaboration, and leadership.

Using a Logic Model to Design and Evaluate a Quality Improvement Leadership Course.

Strong leadership is an essential factor in the success of quality improvement (QI) initiatives that generate and sustain improvements in patient outcomes. Notably, there is a rising need for frontline clinicians, who are often charged with leading QI efforts, to receive training in blended QI and leadership methods and skills. The Leading Healthcare Improvement (LHI) course is a longitudinal leadership course embedded within the Department of Veterans Affairs Quality Scholars (VAQS) program, a multisite interprofessional QI fellowship program. The LHI course was developed to provide frontline clinicians who are emerging QI leaders with the skills to lead and advance improvement efforts at their institutions. It consists of eight 60-minute online sessions and was implemented and delivered to a cohort of interprofessional fellows at 9 sites during the 2017-2018 academic year.This article describes the use of a logic model as a framework to guide the planning, implementation, and evaluation of the LHI course. The authors developed 5 logic model components: inputs, activities, outputs, short-term outcomes, and long-term outcomes. They defined the short-term outcomes using feedback from fellows and an evaluation of the fellows' abstract submissions to the VAQS Summer Institute. Submissions were reviewed to identify how fellows applied the LHI course concepts to QI projects at their respective sites. The authors also collected preliminary impact data from fellows to determine long-term outcomes.Finally, they used the logic model to inform changes to the LHI course based on the evaluation data they collected and developed plans to measure the impact of the course on learners, patients, and the health care system. The authors conclude with lessons learned to guide others who are implementing similar QI efforts.

Home-based psychoeducational and mailed information programs for stroke-caregiving dyads post-discharge: a randomized trial.

PURPOSE: This randomized trial compared 6- and 12-month outcomes of a home-based psychoeducational program to mailed information provided to 159 survivors of stroke (SS) and their spousal caregivers (CG). METHODS: SS (age 50+) and CG were recruited as dyads post-discharge from inpatient rehabilitation. All dyads received mailed information for 12 months. Dyads randomized to the home-based group received an average of 36.7 h of psychoeducation over 6 months. Health status, depression, stress, burden, coping, support, mutuality and function were obtained on all dyads. Repeated measures analysis with linear mixed models was used to compare the groups for change over time in the outcome variables. RESULTS: Both groups demonstrated less depression and stress over time. Compared to the mailed information group, SS in the home-based group demonstrated significantly improved self-reported health and cognitive function; CG demonstrated significantly improved self-reported health and coping strategies. Mutuality and social support decreased in both groups. CONCLUSIONS: The home-based intervention was effective in improving self-reported health, coping skills in CG and cognitive functioning in SS. However, the finding that dyads in both groups demonstrated decreased depression and stress suggests that providing repeated doses of relevant, personalized information by mail may result in positive changes. IMPLICATIONS FOR REHABILITATION: A stroke affects both the stroke survivor and the spousal caregiver, so nurses and therapists should use multicomponent strategies to provide education, support, counseling and linkages to community resources to ease the transition from hospital to home. Stroke may have a negative impact on the dyad's relationship with each other and also on the availability of support people in their lives during the 12 months after hospital discharge. Comprehensive stroke programs should encourage dyads to attend support groups and to seek individual and group counseling, as needed. Establishing an ongoing relationship with stroke survivors and their spouses and providing relevant and engaging information by mail can reduce stress and depression over 12 months post-discharge at a minimal cost. Nurses and therapists should consider home visits post-discharge to reinforce education and skills taught in the hospital, increase self-reported health in stroke survivors and spousal CG, increase coping skills and to link the couple to community resources.

Accessibility, usability, and usefulness of a Web-based clinical decision support tool to enhance provider-patient communication around Self-management TO Prevent (STOP) Stroke.

This article reports redesign strategies identified to create a Web-based user-interface for the Self-management TO Prevent (STOP) Stroke Tool. Members of a Stroke Quality Improvement Network (N = 12) viewed a visualization video of a proposed prototype and provided feedback on implementation barriers/facilitators. Stroke-care providers (N = 10) tested the Web-based prototype in think-aloud sessions of simulated clinic visits. Participants' dialogues were coded into themes. Access to comprehensive information and the automated features/systematized processes were the primary accessibility and usability facilitator themes. The need for training, time to complete the tool, and computer-centric care were identified as possible usability barriers. Patient accountability, reminders for best practice, goal-focused care, and communication/counseling themes indicate that the STOP Stroke Tool supports the paradigm of patient-centered care. The STOP Stroke Tool was found to prompt clinicians on secondary stroke-prevention clinical-practice guidelines, facilitate comprehensive documentation of evidence-based care, and support clinicians in providing patient-centered care through the shared decision-making process that occurred while using the action-planning/goal-setting feature of the tool.

Long-term health-related quality of life of stroke survivors and their spousal caregivers.

Because treatment for stroke has improved, individuals are living longer with the effects of a stroke. The resulting long-term impairment can affect both stroke survivors' and their caregivers' health-related quality of life (HRQOL). Few studies have examined the HRQOL of stroke survivors and their caregivers greater than 2 years poststroke. The stroke survivors and their spousal caregivers (n = 30 dyads) who had previously completed a 12-month study after discharge from inpatient rehabilitation were assessed at 3-5 years poststroke. The HRQOL and related outcomes were measured for stroke survivors and caregivers. Data from baseline to 12 months were used in conjunction with data from this study. Linear mixed models were used to analyze the change in repeated measures over time. Multiple linear regression was used to analyze the relationship of generic HRQOL to related psychosocial outcomes. The stroke survivors were an average of 4.68 years poststroke. The mean age for stroke survivors and caregivers was 70.8 and 64.9 years, respectively. Most stroke survivors were men (80%) and non-Hispanic White (70%). Among stroke survivors, depression decreased from baseline to 12 months (p = .04) but increased from 12 months to the end of follow-up (p = .003). The caregivers' depression decreased from baseline to all time points (p = .015). Stroke-specific HRQOL showed statistically significant (p < .03) decreases between 12 months and end of follow-up. Increased number of illnesses and older age were associated with caregivers' lower physical HRQOL score (p = .004). Higher depression was associated with lower mental HRQOL score for both caregivers and stroke survivors (p = .003 and p = .011, respectively). Both stroke survivors and caregivers continue to experience negative stroke-related health outcomes for many years after the initial stroke; some of these outcomes even worsen over time. These findings illustrate the need for ongoing psychological and medical evaluation for both long-term stroke survivors and caregivers. Development and testing of targeted behavioral interventions are also warranted.

Examining the cost per caregiver of an intervention designed to improve the quality of life of spousal caregivers of stroke survivors.

BACKGROUND AND PURPOSE: There is a growing consensus among healthcare researchers that, within the field of family caregiving, cost-effectiveness research is needed to determine which programs have the greatest benefit for family members. This study examines the cost per caregiver of an intervention designed to improve the quality of life of spousal caregivers of stroke survivors. METHOD: Cost data from the CAReS study were analyzed to determine the cost of the intervention per caregiver. RESULTS: The cost of the intervention per caregiver was $2,500 at the 2009 median wage estimate. It was $1,700 at the 2009 10 percentile wage estimate and $3,500 at the 2009 90 percentile wage estimate. CONCLUSIONS: This study provides a prototype cost analysis from which researchers can build. In future analyses, costs should be tracked at a participant level so uncertainty can be calculated using the bias-corrected percentile bootstrapping method and plotted to calculate cost-effectiveness acceptability curves, enabling cost-effectiveness comparisons between interventions.

Identifying Occupational Performance Barriers of Stroke Survivors: Utilization of a Home Assessment.

BACKGROUND: Stroke survivors often have impairments that make it difficult for them to function safely in their home environment. PURPOSE: The purpose of this study is to identify occupational performance barriers in the home and describe the subsequent recommendations offered to stroke survivors and their caregivers. METHODS: An occupational therapist administered a home safety tool to assess stroke survivors' home environments, determine home safety problems, and provide recommendations. FINDINGS: Among 76 stroke survivors, the greatest problems were indentified in the categories of bathroom, mobility, and communication. Two case studies illustrate the use of the home safety tool with this population. IMPLICATIONS: The home safety tool is helpful in determining the safety needs of stroke survivors living at home. We recommend the use of the home safety tool for occupational therapists assessing the safety of the home environment.

Cost associated with stroke: outpatient rehabilitative services and medication.

PURPOSE: This study aimed to capture direct costs of outpatient rehabilitative stroke care and medications for a 1-year period after discharge from inpatient rehabilitation. METHODS: Outpatient rehabilitative services and medication costs for 1 year, during the time period of 2001 to 2005, were calculated for 54 first-time stroke survivors. Costs for services were based on Medicare reimbursement rates. Medicaid reimbursement rates and average wholesale price were used to estimate medication costs. RESULTS: Of the 54 stroke survivors, 40 (74.1%) were categorized as independent, 12 (22.2%) had modified dependence, and 2 (3.7%) were dependent at the time of discharge from inpatient rehabilitation. Average cost for outpatient stroke rehabilitation services and medications the first year post inpatient rehabilitation discharge was $17,081. The corresponding average yearly cost of medication was $5,392, while the average cost of yearly rehabilitation service utilization was $11,689. Cost attributed to medication remained relatively constant throughout the groups. Outpatient rehabilitation service utilization constituted a large portion of cost within each group: 69.7% (dependent), 72.5% (modified dependence), and 66.7% (independent). CONCLUSIONS: Stroke survivors continue to incur significant costs associated with their stroke for the first 12 months following discharge from an inpatient rehabilitation setting. Changing public policies affect the cost and availability of care. This study provides a snapshot of outpatient medication and therapy costs prior to the enactment of major changes in federal legislation and serves as a baseline for future studies.

Predictors of life satisfaction in stroke survivors and spousal caregivers after inpatient rehabilitation.

A global measure of life satisfaction has become increasingly important as an adjunctive outcome of healthcare interventions for people with disabilities, including those caused by stroke. Life satisfaction of stroke survivors mayaffectcaregivingspouses, as well. The purpose of this study was to identify, among many physical and psychosocial variables, specific variables that were associated with life satisfaction at 12 months after discharge from inpatient rehabilitation, and variables that were predictive of life satisfaction 1 year later (at 24 months). Between 12 and 24 months, life satisfaction decreased for stroke survivors, while it increased for caregiving spouses. The relationship between the couple (mutuality) was the only variable that was a significant predictor of life satisfaction for both stroke survivors and their spouses.

Predictors of resuming therapy within four weeks after discharge from inpatient rehabilitation.

PURPOSE: To identify the percentage of persons with stroke resuming therapy within 4 weeks of inpatient rehabilitation discharge, to compare the characteristics of those who did and did not resume therapy, and to determine the predictors of resuming physical (PT), occupational (OT), and speech (ST) therapy. METHOD: Sociodemographic, stroke-related, and therapy data for persons with stroke (N = 131) were abstracted from inpatient rehabilitation charts. FIM, Stroke Impact Scale, Geriatric Depression Scale, and data on therapy received after discharge were also collected. RESULTS: Logistic regression models demonstrated that minorities were less likely to resume PT (odds ratio [OR] = 0.30) and OT (OR = 0.25). Survivors with neglect/visual-field cut/spatial-perceptual loss were 2-3 times more likely to resume PT, OT, and ST. Survivors with higher scores on the SIS Physical domain subscale were less likely to resume PT (OR = 0.98) and OT (OR = 0.97). Men were 3.3 times more likely to have OT than women. Those with comprehensive health insurance were 11.2 times more likely to receive ST. CONCLUSIONS: The benefits of outpatient therapy are not universally available to all persons with stroke. Further research needs to explore the factors that hinder the prompt resumption of therapy for minority and female persons with stroke and to test appropriate interventions.