Johnson, Alan W.; Potthoff, Sandra J. PhD; Carranza, Leslie MHS; Swenson, Heather M. MHA, MBA; Platt, Christine R. RN, BSN; Rathbun, Jon R. MHA, MBA
The Institute of Medicine's (IOM's) landmark work, To Err is Human, estimated that as many as 98,000 people die each year because of avoidable medical errors, attributed in part to poor systems design, a lack of teamwork, and distrust among health care professionals.1 The IOM's follow-up report, Crossing the Quality Chasm, identified clinical education and training—including systems and process design, improved communications with patients, and collaborative team-based care—as primary areas for change.2 These reports emphasized a profound need for meaningful interprofessional experiences in contemporary health professions education.
In 2001, mindful of the IOM's recommendations, health professions students at the University of Minnesota planned a day retreat for students and faculty to discuss their respective curricula and commonly held frustrations. These students and faculty were from the schools of medicine, pharmacy, and nursing and the university's Program in Health care Administration. The retreat was organized through the university's Center for Health Interprofessional Programs (CHIP), an organization that has supported myriad interprofessional efforts in the academic health center (AHC) for over 30 years. At the retreat students emphasized a notable lack of opportunities for collaboration with peers in other health professions schools. Faculty cited strained relations between professionals, especially between clinicians and administrators in work settings. Those in attendance sensed an opportunity to develop interprofessional training opportunities as a means to making patient care more efficient, safer, and more enjoyable. This meeting was the genesis of CLARION, or the CLinician/Administrator Relationship Improvement OrganizatioN.
In this article, we, a group of former CLARION executive board members, describe the development and impact of CLARION, a unique student-run organization dedicated to furthering interprofessional training for health professions students.
CLARION's mission statement, “Building a Better Health Care System – Together,” emphasizes interprofessional collaboration as its foundation. This mission has been supplemented by adopting the IOM's six aims for a new health care system as our own. The aims are health care that is safe, timely, equitable, patient-centered, effective, and efficient.2 While all of us who are involved in CLARION acknowledge that the academic/preclinical portion of health care training addresses these six aims in various forms, we firmly believe this education still occurs within each health profession only; educational programs rarely tackle these aims through interprofessional experiences. This “educational gap” is what we strive to fill through our mission and activities.
Recognizing that formal curricular change is slow, CLARION set about creating change in the extracurricular arena. Our first event was an interprofessional retreat focused on patient safety. This two-day event, held at a rustic camp outside of the Twin Cities, drew approximately 40 students and ten faculty members from throughout the University of Minnesota's AHC. Attendees participated in seminars led by patient-safety experts, took part in break-out sessions, and brainstormed ways to effect change. This first event galvanized a core group of students and faculty who quickly spread word of CLARION through the university's AHC.
Now in its fourth year, CLARION delivers interprofessional programming that reaches students in four separate schools at the university's AHC: medicine, nursing, pharmacy, and public health (which includes the university's Program in Healthcare Administration formerly housed in the Carlson School of Management). Each activity provides a forum for students to
* develop personal relationships with other health professionals, allowing understanding of others' training
* think critically about gaps in the health care system and identify collaborative solutions
* learn how to interact and communicate effectively with future colleagues, and
* develop future leaders who will maximize the shared leadership model emphasized in the contemporary health care structure.
All activities build toward our capstone event—the annual Interprofessional Case Competition, described below. Activities at this competition include:
* Friday Night at the E.R.® Simulation. Students play this professionally facilitated board game that models the challenge of managing a hospital during a typical 24-hour period. As a part of an interprofessional team, students learn systems concepts about patient flow, system bottlenecks, and communication and collaboration. According to the game's creator, multiple medical schools now use this tool to address the Accreditation Council for Graduate Medical Education's new requirements for systems-based practice.
* Crossing the Quality Chasm. Students, faculty, and health care practitioners from medicine, health care administration, pharmacy, and nursing assemble to brainstorm and discuss solutions to pertinent health care problems in the United States. The group uses A user's manual for the IOM's ‘Quality Chasm' report3 as a guide for discussion.
* The future health care professional. This weekend getaway provides students key skills and knowledge that receive varying emphasis across the health professions. Speakers have included a leading patient safety executive, chemotherapy patients, and an emotional intelligence expert. Students report that they value the education offered through related discussions with students of other professions because of the varied viewpoints and approaches shared.
* Interprofessional Patient Safety Seminar. Hosted by the medical school class “Physician and Society,” students watch the video “First, Do No Harm®: A Case Study of Systems Failure.”4 Students then participate in interprofessional, small-group discussions with faculty, focusing on patient safety. In an effort to identify system failures and potential solutions, students conduct a brief root cause analysis, the formalized approach that the Joint Commission on Accreditation of Healthcare Organizations endorses for documenting and analyzing serious failures in patient safety.
* Woodwinds Health Campus Tour. Students tour this innovative Twin Cities health care center renowned for its healing environments and interprofessional approach. Hospital clinicians and administrators speak with the students about how the hospital's care model and unique environment affect patient care.
Interprofessional Case Competition
As mentioned above, CLARION's annual capstone activity is the Interprofessional Case Competition, an event that promotes interprofessional respect and understanding and helps students develop skills in teamwork, patient safety, critical analysis, and quality improvement. For this event, interprofessional teams of students compete over a six-week period to conduct and present a root-cause analysis of a fictitious sentinel event written by CLARION faculty advisors. A sentinel event is “any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.”5
Students who choose to participate in the Interprofessional Case Competition attend a day-long retreat at which they meet their assigned team members and participate in team building and skill development exercises. They are randomly assigned to teams after stratifying by profession, so that each team is comprised of four students from the AHC's schools of nursing, pharmacy, medicine, and public health. Over the next six weeks, teams conduct research by reading appropriate literature and contacting practitioners in the field to get advice and insights on the case. Team members meet frequently, each providing expertise specific to his or her education, as well as taking a systems-based approach to studying the sentinel event and its root causes. Teams develop a set of recommendations based upon their root-cause analysis and prepare a formal presentation.
On the day of the competition, each team presents its findings to a panel of judges in a boardroom-like setting, simulating a hospital task force reporting to a board of directors. The judges are all executive-level, community leaders from local health care organizations, including health care administrators and medical, nursing, and pharmacy directors. Teams have 25 minutes to present their findings followed by 15 minutes to field questions from the panel. Judges then deliberate for 20 minutes, assembling feedback and assigning rankings according to a formal evaluation protocol (see Table 1). The winning teams receive their awards at a banquet held that evening. The first-, second-, and third-place teams receive scholarships of $4,000, $2,000, and $1,000, respectively, with scholarship monies donated by local health care organizations through CLARION fundraising efforts. All teams receive formal feedback reports, consisting of the results of the evaluation protocol and written comments from the judges.
Impact of the competition
The competition has received significant attention from practicing professionals, both within and outside of the University of Minnesota. Competition judges invite winning teams to present their case recommendations to physician groups in the community. Minnesota and Wisconsin patient safety conferences have invited our members to share the CLARION concept to stimulate discussion of new approaches to patient safety. And CLARION recently presented to the deans of 16 U.S. medical schools at a conference hosted by the Institute for Healthcare Improvement (IHI).
Noting the outside interest CLARION has generated, the University of Minnesota's AHC provided resources and administrative support to enable CLARION to host a national version of the Interprofessional Case Competition. Seven universities from across the United States sent interprofessional teams of four students each to Minnesota to compete. Each of the teams conducted its own root-cause analysis for six weeks prior to traveling to present their recommendations. IHI endorsed the endeavor by providing scholarship money for the winning team and travel expenses for the top three teams to the IHI conference that was held in December 2005. Other funding for the national case competition was provided by the AHC and raised by CLARION from local and national health care organizations and professional societies.
The Student Experience
CLARION provides students with the kind of critical, early interprofessional experiences recommended in the IOM's 2003 report, Health Professions Education: A Bridge to Quality. This document recommends that health professions educators break down existing educational “silos” and encourage students to understand and appreciate what students in other professions contribute to the health care team, in order to optimize patient care.6 For many preclinical students, CLARION activities are the first and often only sustained interactions with their preclinical peers. Participating students inevitably develop a deeper understanding and respect for other's education. “I was amazed at the intensity of the PharmD program,” noted one medical student after participating in a CLARION event, “and surprised at the absolute lack of education in medical school about pharmacists' strengths.” Another added, “I had no knowledge about what health care administration students learn, or what challenges they face when considering business and ethical aspects of providing health care.”
Students are forced to confront their own biases, which we believe have been reinforced by the formal, segregated curricula of the health professions. One health care administration student commented, “Many of these misconceptions would be removed if we had more opportunities to collaborate and learn about each other's curriculum.” A medical student expressed her dissatisfaction by indicating that “our knowledge of other professions is exceedingly underdeveloped, and it is partly due to our unwillingness to spend the time to get to know each other.”
Students learn the essential components of each team member's education, including curriculum components, educational settings, and prerequisite experience. This sparks open dialogues about how to maximize what each profession has to offer. Should the physician be the team leader when the nurse has more skills in a certain area? What role should be played by the pharmacist, who has extensive training in drug interactions and potential side effects, when formulating a complex medication regimen?
Moreover, students realize that by ceding some of their perceived autonomy, they realize an expansion of their roles. “I now recognize the huge significance of the nurse's role in [preventing] medical errors,” shared one nursing student. “This makes me feel like my profession is more valuable than I had previously thought.”
Finally, CLARION students develop a common vocabulary and motivation through which to begin bridge-building across the professions. They have early exposure to concepts such as sentinel events, adverse drug reactions, and root-cause analysis, giving CLARION “graduates” common terminology they can use to describe systems-based problems. More important, participants come to understand how each team member contributes to and is responsible for the safety of the patient.
What Makes CLARION Successful
As a student-driven organization, CLARION pursues its mission under the premise that interprofessional experiences will facilitate the development of future leaders who will make the changes needed to provide high-quality, safe, and effective health care. The structure of the CLARION executive board provides the mechanism for students to develop leadership skills through collaboratively developing programming and making policy decisions. The board features a unique, nonhierarchical structure consisting of the following student positions and roles: education, coordination, events, professional relations, finance, fundraising, information technology, public relations, case competition, and membership. Moreover, the board has a diverse mix of students, with men and women being fairly equally represented, along with equal student representation from four academic programs: medicine, nursing, pharmacy, and public health. Lastly, the board does not make major decisions without a quorum of representation from each of the professions. This “interprofessional equality” models the respectful and team-oriented environment needed to effectively solve problems in the health care system.
Strong faculty and university support
CLARION's executive board receives strong support from faculty advisors who represent each of the organization's four academic programs. While faculty members volunteer for the advisor role, the deans of these programs have supported CLARION by encouraging tenure-track assistant professors, tenured professors, and even program directors to serve in advisor positions. These faculty advisors serve as sources of knowledge, provide guidance to refine students' ideas, help students plan innovative events, and connect students with practitioners outside academia to facilitate both experiential and fundraising opportunities. Additionally, they help the students navigate potential difficulties in the broader university and health care environments, such as understanding Health Insurance Portability and Accountability Act (HIPAA) regulations, learning the structural and political difficulties that are inherent to a large AHC, and understanding fundraising realities. However, the role of the faculty advisor is clearly that of a facilitator; students drive the programming.
In addition, the University of Minnesota's AHC supports CLARION financially through CHIP, which has promoted AHC student interaction across professions for the past 30 years. CHIP provides initial seed money and other vital resources, including lounge and meeting space, office supplies and equipment, which help groups carry out efficient planning. Most important, CHIP employs a full-time director and half-time assistant who strongly support student group initiatives. Having its operations housed within CHIP allows CLARION to maintain ownership of its programs and to operate independently from the participating schools (see 〈http://www.chip.umn.edu/CHIP/committees/clarion.html〉 for more information).
CLARION's main fundraising challenges are obtaining support for sizable case competition scholarships, competing for grants, and procuring funds for operational costs. To tackle these challenges, students, under the guidance of the faculty advisors, implement multiple levels of fundraising strategies, utilizing resources from the alumni network and benefiting from CLARION's relationship with CHIP, which has facilitated interactions with current and potential donors. CLARION has developed a concise and powerful marketing message, as well as a fundraising proposal comprising an executive summary, program descriptions, detailed budgets, a list of donors with amount pledged, and instructions on how to make a tax-deductible donation. This document provides a solid foundation for funding requests and gives the board a realistic picture of our budget constraints. In the 2003–04 academic year, CLARION raised in excess of $15,000, providing $7,000 for scholarship awards.
CLARION board members take a personal approach to recruitment and advertising. Promoting the organization through individual discussions with classmates and in-class announcements has proven essential, as many students have never been exposed to concepts such as systems-based practice, sentinel events, and root-cause analysis. Board members largely recruit from within their own professions. However, sending CLARION members to make announcements in another profession's class is a successful strategy in itself. In the 2003–04 academic year, CLARION membership increased from 60 to 90 students and expanded to include students in the University of Minnesota's School of Public Health program in Public Health Administration and Policy.
Another key factor in CLARION's success stems from actively engaging community practitioners from across the health care professions, without requiring lengthy time commitments. This strategy has allowed the development of high-quality programs and effectively “tap” busy health care professionals as an underutilized educational resource.
A major challenge in sustaining CLARION is that as a student-run organization, the board membership changes every year. To provide institutional memory, the current board provides an orientation for the incoming board soon after the board elections are completed each spring. In addition, CLARION members continue to improve their documentation of all events-planning to enable each successive board to build on the experience of the previous one. Being located in CHIP, with faculty advisors who have been with the organization since its inception, also provides institutional memory. Finally, each board tries to ensure that there are adequate carry-forward funds to the incoming board so that activities at the start of the new academic year have adequate resources.
The CLARION model suggests several possibilities for the future of clinical and managerial health sciences education, both within the formal academic experience, and in extracurricular programming. Within the formal academic experience, interprofessional student experiences, taught by interprofessional teams of faculty and practitioners, need to become part of the curriculum if students are really to grasp the role and expertise that each profession contributes. The health professions schools currently teach ethics, team performance, end-of-life care, systems concepts, and other important health care topics in their respective professional curricula. Yet, many of the most challenging dilemmas in health care happen at the intersection of professions.
Problem-based learning that spans the professions, as demonstrated by the case competition, has enabled the participating students to appreciate the expertise that other professions bring to a variety of problems and their solutions. What the participating students fear, as expressed in their exit interviews after their presentations, is that the faculty will somehow “screw up the great experience that this was” if it ever becomes part of a required curriculum. Faculty need to display what they expect of students—the ability to work together as interprofessional teams to help produce the graduates that will work together as teams to build a better health care system.
CLARION has provided a forum for students to develop and practice leadership skills. Throughout its history, those involved in leading CLARION have had to set priorities, work through disagreements, raise money, and implement programming—experiences that have helped everyone involved better understand his or her own personal strengths and weaknesses that help and hinder leadership. In the future CLARION should provide additional formal leadership training for our executive board members, including leadership assessments and feedback, practitioner mentors, and board development activities.
As CLARION members graduate and become alumni, its charge now is to establish how “the CLARION experience” fosters improved attitudes and performance of young health care professionals. While we possess initial data about the attitudes of CLARION students and the perceived benefits of CLARION activities, we are just starting to graduate enough members to generate data focused on how CLARION enables them in the workforce.
Those members who have graduated reflect enthusiastically on the experience and have eagerly opened additional links to local and national health care entities that continue to enhance CLARION students' experience. The faculty advisors have also developed friendships with each other that facilitate informal discussions and pilots for curricular change. CLARION has enabled continued professional development of students, faculty, and practitioners as well as the opportunity for interprofessional networking and idea sharing. As CLARION's reputation has spread both within the AHC and in the broader practice community, it has become a grassroots catalyst that has prompted faculty to examine the traditional curricula and look for ways to integrate more interprofessional opportunities. Students are an active barometer for knowing what is not working in their curricula. Organizations like CLARION can proactively challenge the status quo and lead by example.
The authors wish to acknowledge the following people, who all made special contributions to this article: Barbara F. Brandt, PhD, Jenny M. Meslow, Rachael L. Albertson, MHA, Karin L. Alaniz, RN, PhD, Karyn D. Baum, MD, Donald L. Uden, PharmD, Geoffrey Kaufmann, MHA, and Christine E. Bartels, PharmD.