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Health Professions Education: A Bricige to Quality Committee on the Health Professions Education Summit Board on Health Care Services Ann C. Greiner, Elisa Knebel, Editors t-2F THE ~~:~t A~ THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the Na- tional Research Council, whose members are drawn from the councils of the National Academy of Sci- ences, the National Academy of Engineering, and the Institute of Medicine. The members of the com- mittee responsible for the report were chosen for their special competences and with regard for appropri- ate balance. Support for this project was provided by the Health Resources and Services Administration, the Agency for Healthcare Research and Quality, the ABIM Foundation, and the California Healthcare Foundations The views presented in this report are those of the Institute of Medicine Committee on the Health Pro- fessions Education Summit, and are not necessarily those of the funding agencies. International Standard Book Number 0-309-08723-6 (book) International Standard Book Number 0-309-51678-1 (PDF) Library of Congress Control Number: 2003106403 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropoli- tan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2003 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and relig- ions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medi- cine is a relief carving from ancient Greece, now held by the Staatliche Museum in Berlin.

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nst HIPPO' Willis is not enough; we must do. ~ _c;~ ``I(nowin~ is not enon,gh, we .. ...... ........ ........................ . ......... .................................... ..... ................................................... ... ............. .............................. ................................................... .................. .................... ... .......................................... .. ............ ..... ..... .............. .......................... .................. ............... ................................................. ... ...................................................... ........................................................ ..................... ...... .................................................. ............... ........................................................ ................. ..................................................... ..... . . ............... . ............. :-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:--.-:-:-:-- .-:-:-:-:-:-:-:-:-:-:-:-:- :-:-: ..................................................... ...... . .................. . .................... ........ -.-.- - - . :.-.-.-.-.-.-.---------- : . :: -- - :::-::::-:- - --:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-: :-:-:-: .. ..... ........ :.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:-:-:-:-:-:-:: -:-:: ..::-:-:-:-:-:-:-:~::-:.::::-::-: .-:-::::::-:-: -:-:: :-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-: :-:-: i-:-:-:-:-:-:-:-:-- .-:-:-:-- . :-:-:-:-:-:-:-:-:-: :-:-. :-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:: :-:-: :::::::::::::::- ::::::: .:::::::::::::::::::::::::: ::::: -:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-: :-: :.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:. :.:. .............................. . ......................... . a.............. :-:-:-:-:-:-:-:-:-:-- ~-:-:-- ...... ............. ::-:-: : :: .-- : . -------------:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-: :-:-. .:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.: -a:.: :-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-: :-:-: ::: ::::.:::::::-::::::::::::::::: :::::::::::-::::.::: :~ -:: :.-. -. --::.: . -: . . . .-:-:-:-:-:-:-:-: .-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-: :-:-: -.:.... -::::: :.:.:-- - :: .. .:.: ... .. : :-- - .;- .:-- .:: - .. :: :-:- ?: .. --: .. :. .:.:. .. . :-:-- :-;; :.; ... :-- - .. ---:-::::::: ; : -.-:- -:- - - .. ::::::-: - --:-:-:-:-:-;- .... -.-:-:-:-- - - - - ------:-:-:-::: : ::: :-:-:-:---- - - - i ~ . ~ -.- .- . .-.-.-.-.-.- . . i :-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-: 4-:-:-:-:-: :-:-:- :.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:: :.:.:.:.:. :.:.:: :-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-.-:-:-:-:-: :-:-: .-.-.-.- . -:-:-:-:-:-:-:-:-:-:--. :-- ::::--- :--::- .-:-- :::: . ::: :::.: .. ::- ::: .-:-- ;; :... .:-. .-:: ::: -.. :-. :- :.- ... ... .-. :.- ;-- :-. OF THE NATIONAL ACADEMIES napln Ft2

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THE NATIONAL ACADEMIES Advisers lo the Nation on Science, Engineering, and Medirine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON THE HEALTH PROFESSIONS EDUCATION SUMMIT EDWARD M. HUNDERT (Co-Chair9, President, Case Western Reserve University MARY WAKEFIELD (Co-Chair), Director, Center for Rural Health, School of Medicine and Health Sciences, University of North Dakota J. LYLE BOOTMAN, Dean and Professor, College of Pharmacy, Arizona Health Sciences Center University of Arizona CHRISTINE K. CASSEL, Dean, School of Medicine, Oregon Health & Science University WILLIAM CHINO, Joint M.D.-Ph.D. Student, School of Medicine, New York University MARILYN P. CHOW, Vice President, Patient Care Services, Kaiser Permanente STEPHEN N. COLLIER, Director and Professor, Center for Health Policy and Workforce Research, Towson University JOHN D. CROSSLEY, Vice President for Operations and Nursing Practice, and Head, Division of Nursing, M.D. Anderson Cancer Center, University of Texas ROBERT S. CALVIN, Director Global Health, General Electric CARL J. GETTO, Senior Vice President for Medical Affairs, University of Wisconsin Hospital, and Associate Dean for Hospital Affairs, University of Wisconsin Medical School ROBIN ANN HARVAN, Director, Office of Education, University of Colorado Health Sciences Center POLLY JOHNSON, Executive Director, North Carolina Board of Nursing ROBERT L. JOHNSON, Professor and Interim Chair of Pediatrics, Professor of Psychiatry, Director, Division of Adolescent and Young Adult Medicine, New Jersey Medical School at UMDNJ DAVID LEACH, Executive Director, Accreditation Council for Graduate Medical Education JUDY GOFORTH PARKER, Professor, DepaWnent of Nursing, East Central University JOSEPH E. SCHERGER, Dean, College of Medicine, Florida State University JOAN SHAVER, Dean and Professor, College of Nursing, University of Illinois at Chicago DAVID SWANKIN, President and CEO, Citizen Advocacy Center v

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Study Staff ANN C. GREINER, Study Director, Deputy Director, Board on Health Care Services ELISA KNEBEL, Program Officer RACHEL COLLINS, Senior Project Assistant Health Care Services Board JANET M. CORRIGAN, Director ANTHONY BURTON, Administrative Assistant DANITZA VALDIVIA, Senior Project Assistant Consultants ROBERT KING, Goal QPC RONA BRIERE, Briere Associates, Inc., Editor ELIZABETH ARMSTRONG, Harvard Medical International and Harvard-Macy Institute JAMES BARRON VICKIE SHEETS, National Council of State Boards of Nursing V1

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REVIEWERS This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institu- tional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: GERALDINE BEDNASH, American Association of Colleges of Nursing LINDA BOLTON, Cedars Sinai Medical Center ERIC J. CASSELL, Minisink Hills COLLEEN CONWAY-WELCH, Vanderbilt University DON DETMER, University of Cambridge KEVIN GRUMBACH, San Francisco General Hospital and University of California RALPH HALPERN, Tufts Health Care Institute LINDA A. HEADRICK, University of Missouri-Columbia HAROLD JONES, University of Alabama TIMOTHY JOST, Washington and Lee University School of Law LUCINDA MAINE, American Association of Colleges of Pharmacy EDWARD O'NEIL, University of California DEBRA ROTER, John Hopkins School of Public Health GAIL WARDEN, Henry Ford Health System Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Harold Fallon, School of Medi- cine, University of Alabama (emerita) at Birmingham, and Paul Griner, University of Rochester School of Medicine and Dentistry. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Re- sponsibility for the final content of this report rests entirely with the authoring committee and the institu- tion. . . V11

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Preface Health Professions Education: A Bridge to Quality makes the case that reform of health professions educa- tion is critical to enhancing the quality of health care in the United States. In laying the footings for this bridge, the committee that produced this report wishes to underscore that any such reform effort must encompass all health professionals, recognize each profession's contribution, and include those outside education who, to more and lesser degrees, shape what health professionals are taught. The members of our committee represent a broad range of health-related professions and occupations, and we collectively owe a debt to the diverse group of 150 leaders who attended the Institute of Medicine's Health Professions Education Summit in June 2002 and informed our thinking. Repeatedly we heard from the work- ing groups at the summit about the value of collaborating across the professions to understand the nature of the problems facing health professions education and the importance of designing solutions together. Many la- mented the absence of existing interdisciplinary forums, and a number of the proposed strategies and actions developed by summit participants explicitly span the professions. Although the academic environments of the various health professions generally are not interdisciplinary, practice environments are increasingly so, posing a serious disconnect. In the future, we expect more, not less, overlap and some fusion of roles. Ideally, collaboration among clinicians in practice settings draws upon each profession's strengths and therefore optimizes care for patients. We believe the same can be true in the realm of health professions education and that it is high time to em- brace a collaborative approach to educational reform. The professions and, most important, patients will be the beneficiaries. Edward M. Hundert, M.D. Co-Chair March 2003 1X Mary Wakefield, Ph.D., R.N. Co-Chair March 2003

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X1 Foreword Health Professions Education: A Bridge to Quality represents the third phase of the Institute of Medicine's quality initiative, which was launched in 1996. This initiative is central to our mission of advancing and dissemi- nating scientific information to improve human health. In the first phase of the IOM's quality initiative, we documented the serious and pervasive nature of the qual- ity problem, concluding that "the burden of harm conveyed by the collective impact of all of our health care quality problems is staggering." In the second phase of our quality initiative, spanning 1999-2001, an IOM committee laid out a vision for how the system must be radically transformed in order to close the chasm that exists between what we know to be good quality care and what actually exists in practice. The committee that authored the two reports released during this phase To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century stressed that reform around the margins would be inadequate. Phase three of the quality initiative is focused on implementing the vision of a future health system laid out in Crossing the Quality Chasm, a system characterized by an unrelenting focus on reducing the burden of illness, in- jury, and disability, and thereby enhancing the health status, functionality, and satisfaction of the U.S. population. The IOM is not alone in trying to make this vision a practical reality, and acknowledges the dedication and hard work of a vast array of organizations focused on redesigning care delivery, implementing innovative financing, and seeking to standardize information technology platforms, among other efforts. Implementing such a vision cannot be done without skilled personnel. Just as the health system must be trans- formed in order to advance quality, so must health professions education. The initial blueprint for such a transfor- mation can be found in the following pages. It is a guide produced by a knowledgeable and diverse IOM commit- tee, which benefited from the wisdom of an interdisciplinary group of experts who offered their advice at an IOM Health Professions Summit held this past June. Our hope is that this guide will aid anyone dedicated to reforming health professions education. Harvey Fineberg, M.D., PhD President, Institute of Medicine March 2003 .

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Acknowledgments The Committee on the Health Professions Education Summit wishes to acknowledge the many people whose contributions and support made this report possible. A number of experts in federal departments, federal agencies, and other organizations were important sources of information, generously giving their time and knowledge to further the committee's aims. The project proposal was developed by Richard Diamond, formerly of the Dental and Special Projects Branch, Division of Medicine and Dentistry, and Madeline Hess, Nursing Special Initiatives and Program Systems Branch, Bureau of Health Pro- fessions, within the Health Resources and Services Administration, Department of Health and Human Services. They were aided in planning the project by Elaine Cohen, Forest Calico, and Patricia Calico, all of the Health Re- sources and Services Administration. The summit was expertly facilitated by Robert King, Goal QPC, and thirteen other facilitators who work for or with Mr. King. Heidi Hess, Kaiser Family Foundation, graciously facilitated webcasts and transcripts of the sum- mit, which are freely accessible at www.kaisernetwork.org. The committee commissioned two papers that provided important background information and insights for this report. Vickie Sheets, National Council of State Boards of Nursing, authored a very helpful paper on accredi- tation and licensure. Elizabeth Armstrong, Harvard Medical International and Harvard-Macy Institute, and James Barron authored a paper on case studies of cultural reform, which served as the basis for several of the case exam- ples highlighted in the report. Additionally, Loretta Heuer, University of North Dakota College of Nursing and Migrant Health Service, and Thomas Maddox, Gustav Leinhard Fellow in Health Sciences Policy Institute of Medicine, provided valuable input for the report's vignettes. The committee also benefited from the work of other committees and staff of the Institute of Medicine that conducted studies referenced in this report, in particular, the committee on Quality of Health Care in America, which produced the 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century. Finally, the committee wishes to acknowledge the public and private organizations that provided support for the summit and follow up report, namely the Health Resources and Services Administration (HRSA), the Agency for Healthcare Research and Quality (AHRQj, the ABIM Foundation, and the California HealthCare Foundation (CHCF). HRSA, part of the U.S. Department of Health and Human Services, directs programs that improve the nation's health by expanding access to comprehensive, quality health care for all Americans. AHRQ, also part of the U.S. Department of Health and Human Services, provides evidence-based information on health care outcomes, quality, cost, use, and access to help people make more informed decisions and improve the quality of health care services. The ABIM Foundation is a nonprofit organization whose mission is to advance medical professionalism and physi- cian leadership in quality improvement and assessment. And, the CHCF is a nonprofit philanthropic organization whose mission is to expand access to affordable, quality health care for underserved individuals and communities, and to promote fundamental improvements in the health status of the people in California. . . . x~

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Contents EXECUTIVE SUMMARY Building a Bridge to Cross the Quality Chasm 2 Health Professions Education Summit 3 A New Vision for Health Professions Education Next Steps 1 INTRODUCTION 19 Origins of the Study 20 Health Professions Education Summit 20 Scope of the Report Building Upon Previous Reform Efforts Definitional Issues Organization of the Report 24 2 CHALLENGES FACING THE HEALTH SYSTEM AND IMPLICATIONS FOR EDUCATIONAL REFORM 29 Current Challenges Implications for Health Professions Education 37 Conclusion 38 3 THE CORE COMPETENCIES NEEDED FOR HEALTH CARE PROFESSIONALS 45 Origin of the Five Competencies 46 The Five Competencies in Practice 49 A Vision of the Prepared Health Care Professional 65 Conclusion ~ 4 CURRENT EDUCATIONAL ACTIVITIES IN THE CORE COMPETENCIES 75 Provide Patient-Centered Care 75 Work in Interdisciplinary Teams 79 Employ Evidence-Based Practice 81 Apply Quality Improvement 83 Utilize Informatics 85 A Vision of the Future Health Professions Student 87 Outcome-Based Education v, Conclusion.................... . 91 5 HEALTH PROFESSIONS OVERSIGHT PROCESSES: WHAT THEY DO AND DO NOT DO, AND WHAT THEY COULD DO 97 Overview F`l,~cn.ti onn.1 A ccrerlitn.ti on xv

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XVI CONTENTS Licensure ~ ~ . Certification 1V`J Organizational Accreditation - Demonstration and Maintenance of Competence............. Cnnr~.lll~inn .109 .............. 111 ~~$ ~~ 1 1 3 6 RECOMMENDATIONS FOR REFORM 121 Common Language and Adoption of Core Competencies 122 Integrating Competencies into Oversight Processes 125 Training Fn`7ironment~ Research and lntormahon Providing Leadership Conclusion............................................................................................................................ .133 .137 APPENDIX A 145 APPENDIX B 153 APPENDIX C 156 APPENDIX D 170