Speaking of Education
Quality in health care has received increased attention since the Institute of Medicine (IOM) published "To Err is Human." This seminal report concluded that health-care errors result in hundreds of thousands of Americans being injured, and in tens of thousands of deaths. A subsequent report, "Crossing the Quality Chasm" (IOM, 2001), asserted that errors were only the "tip of the iceberg"--that the gap in quality between what is and what could be is a chasm. It noted a lack of science-based practice and promoted a redesign of our nation's health-care system to provide safe, effective, patient-centered, timely, efficient and equitable care for a diverse population. The IOM then convened a meeting to address how academic and clinical education in the health professions should be restructured for a redesigned health-care system. Our focus at the Health Professions Education Summit was on the new or enhanced competencies required of all health professionals described below.
Experts agreed that an information infrastructure is critical to crossing the quality chasm. Efforts to build a national infrastructure will start with the priority areas identified in "Priority Areas for National Action: Transforming Health Care Quality" (IOM, 2003). Among those are major depression, severe mental illness, tobacco dependence and obesity as well as a number of chronic diseases in which behavioral components play a prominent role. Psychologists will need to use and to contribute to these knowledge systems. Our trainees also need to learn to translate the results of psychological science to information that has relevance for all health-care providers.
Given the complexity of patients' needs and current care, health professionals need to work in interdisciplinary teams where optimal patient care is more important than professional prerogatives and roles. Interprofessional care is prevalent in many primary-care settings and in some programs such as pain management and organ transplantation. Yet many teams fall short in terms of turf issues and lack of cooperation. Barriers can include unprepared faculty who teach in disciplinary silos or who fear the dilution of professional identity. The new Graduate Psychology Education program (see article, page 74) is an example of federal policy promoting change; eligibility for funding for this and other Bureau of Health Professions programs requires interdisciplinary training. An important question for psychology is: At what stage of professional development are these efforts best focused?
Health professionals must learn evidence-based practice. Although APA accreditation criteria require this in training, psychologists must also develop the capability to deliver evidence-based care throughout their careers. This requires more than competencies in particular procedures; it requires knowledge and skills in the formulation of clinical questions, search for evidence-based answers, assessment of study quality and nature of evidence, and identification of those findings that have direct implications for patient outcomes. This capability to develop competencies in evidence-based care requires attention to training in skills for lifelong learning during graduate education.
Improving quality of care
We need to create a culture of continuous quality improvement in training in which professionals develop both an individual and a systems perspective. Psychologists need to be able to identify best practices, identify gaps in current practice, develop relevant policies and procedures and monitor outcomes through quality indices and self-assessment. New accreditation criteria in medical education actually require residents to evaluate their own care and to design related improvements. How do we best educate students to reflect on their own performance, to identify learning needs and to assess improvement? We can model it through continual improvement of the educational process itself, and promote training in self-assessment in graduate education. We know that biases in self-assessment exist (e.g., gender differences) and that systematic training using external checks is required for accuracy.
Patient-centered care requires skills in interpersonal communication, addressing patients' emotional needs and beliefs, shared decision-making, teaching skills for self-management of illness and applying principles of primary prevention and behavioral change. Such care requires applying knowledge of cognitive, affective and sociocultural bases of behavior to health care. The values and components that are fundamental to education and training in professional psychology are becoming an integral part of the foundation for other health professions as well.
Which brings me to my final point--what are the distinctive competencies that psychology can contribute to the health-care system of tomorrow? In addition to services, society wants accountability for professional competence.
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