Interprofessional Education: Enhancing Collaboration in Maternity Care

1. Where the rubber meets the road ACNM 64th Annual Meeting & Exhibition May 21, 2019 Melissa Avery, Kate Frometa, Elaine Germano, Susan Krause, Tonya Nicholson, Mark B. Woodland

2. Session Objectives • Define and describe the benefits of interprofessional education for health care professionals. • Describe IPE curriculum innovations as well as barriers and solutions to implementing an IPE curriculum for midwifery students and ob-gyn residents. • Analyze the potential for such a curriculum to be implemented at your sites or how midwifery students and ob-gyn residents could work side by side in your practice. • Describe highlights of IPE principles agreed upon by the accrediting and education standard setting organizations for midwifery students and obstetrician-gynecology residents.

3. Why interprofessional education? • If we want future collaborative teams of midwives and physicians providing optimal health care services to women → educate them in teams • Effective teams → better patient outcomes better working environment higher professional satisfaction

4. Team-based care • The team focus: meeting needs of the patient while maximizing expertise of all health care providers on the team • Work with patients and families to accomplish shared goals within and across settings • Provide coordinated, high-quality care

5. What is interprofessional education (IPE)? • “When students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes” (WHO 2010) • Different from midwives teaching ob-gyn residents or midwifery students attending lectures by ob-gyn physicians • Based on core principles defined by Interprofessional Education Collaborative (IPEC)

6. IPE Core Competencies* • Values and ethics: mutual respect and shared values • Roles and responsibilities: knowledge of own and others’ roles used to appropriately care for patients • Interprofessional communication: with patients, families, communities, and professionals in a team approach • Teams and teamwork: apply relationship-building values and principles of team dynamics *Interprofessional Education Collaborative (IPEC): Core Competencies for Interprofessional Collaborative Practice: 2016 Update

7. ACNM-ACOG Maternity Care Education and Practice Redesign • Developed from ACNM-ACOG IPE Workgroup of 2014 • Funded by Josiah Macy Jr. Foundation February 2017 – February 2020 • 4 Demonstration Sites, each with CNM and MD lead: • UMass/Baystate Medical Center: Sukey Krause, CNM and Heather Sankey, MD • Frontier Nursing University Partnership Site: Tonya Nicholson, CNM • Reading Hospital/Tower Health Systems: Robin Grant, CNM, Mark B. Woodland, MS, MD and Dominic Cammarano, DO • Drexel University: Sandra Friedman, CNM, Owen Montgomery, MD • University of CA San Francisco: Kim Dau, CNM, Meg Autry, MD • University of Minnesota: Melissa Avery, CNM, Phillip Rauk, MD

8. Objectives for the ACNM-ACOG funded IPE project • Develop/implement IPE curriculum for midwifery students & ob-gyn residents • Find solutions to site-specific barriers to fully implementing IPE curricula • Align accreditation criteria and core IPE competencies/objectives for ob-gyn residents and graduate midwifery students • Increase the number of midwifery graduates

9. ACNM-ACOG IPE Website

10. Core Modules • Introduction to Guiding Principles of Team-based Care • Patient Centered Care • Midwife and Ob-gyn role clarification • History and culture of both professions • Collaborative Practice • Care transition, situational leadership • Difficult conversations (between providers and with patients)

11. IPE Activities • Joint seminars between ob-gyn residents and midwifery students • TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) training for interprofessional groups • an evidence-based framework to optimize team performance across the healthcare delivery system • four primary skills: Leadership, Situation Monitoring, Mutual Support, and Communication • Joint skills labs • Joint simulation labs • Monthly interprofessional case studies/joint grand rounds

12. IPE Activities at Baystate Medical Center • UMMS-Baystate Medical Center has unique Department of OB/Gyn • OB Gyn residency since 1961 • Midwifery education program since 1991 • Midwifery Education Program housed in the academic medical center rather than a university • No true interprofessional education historically • Exception: pediatric residents and midwife students sharing newborn rounds since 1991

13. Three pronged approach Student midwife and OB/Gyn resident learners Inclusion in pre-existing education opportunities within BMC Capitalizing on existing clinical learning Creating didactic and simulation IPE to meet learning objectives of both groups

14. Simulation Curriculum • Communication Simulation • Low fidelity • One SNM and 2 residents with facilitator(s) • Practice presentation skills in consultation

15. Simulation Curriculum • Obstetrical Emergencies • SNM and 4 residents • High fidelity with mannequin • Teamwork, communication, handoffs

16. IPE Seminar Series • Topics identified from ACGME Milestones and ACNM Core Competencies • Four hour afternoon education sessions on 5th Wednesdays Day 1 • Intimate Partner Violence • Neurobiology of sexual assault Day 2 • Support of physiology labor • Non-pharmaceutical pain relief in labor • Pudendal anesthesia Day 3 • Bereavement support • Post-partum mood disorders Day 4 • Cultural humility • Unconscious bias Day 5 • Racial Disparities in obstetrical outcomes • Racism in healthcare

17. Shared Learning Experiences • Poverty Simulation • Neonatal Resuscitation • Obstetrical “Boot Camp” • Team STEPPS

18. Clinical Learning • Morning rounds on labor and delivery • OB Safety rounds • Huddles • Pediatric rounding team

19. Capitalizing on Medical Center Learning Opportunities • Weekly Grand Rounds • Include physician and midwife driven topics • Weekly MFM Rounds • Twice monthly OB Case Reviews • Schwartz Rounds • Monthly ethics driving topics • Other department Grand Rounds

20. Frontier + Drexel U + Reading Hospital-Tower Health

21. IPE Activities Frontier Nursing - Reading Hospital/Tower Health • OB Triage/OB Birth Center Monthly Stats • Morning and midday inpatient and outpatient huddle • Interprofessional Case studies - monthly • ALSO (Advanced Life Support and Obstetrics course) – yearly • TeamSTEPPS Department • ACOG TV 2017 IPECS Video:https://www.youtube.com/watch?v=YvLoXvEwyGs

22. IPE Activities Frontier Nursing –Drexel University Current: Interprofessional Simulation Days twice a year Student populations: nursing, PA, WHNP, CNM, Residents Inpatient and outpatient scenarios Debriefing with good judgement New Additions (coming soon) New SNM student clinical placement huddles opportunities for IP management and learning Virtual IPE simulation experience

23. Drexel/FNU IPE sim days

24. Web based communication services, regular meetings Group web based meeting space Development of IPE virtual sims Champion faculty and communication with PI People engage differently Challenges Solutions Multisite collaboration Learner collaboration Partner engagement

25. IPE Activities at University of CaliforniaSan Francisco • TeamSTEPPS • Birth Equity Training • Centering Pregnancy facilitation • Jointly hosted Grand Rounds • Shared didactic sessions

26. IPE Activities at University of CaliforniaSan Francisco • Interprofessional clinical rotations • SNMs do 5-week IP clinical rotations at university teaching hospital • Part of a team that includes • Ob-Gyn residents, midwifery students, medical students, attending midwives and attending physicians • Providing care side by side and in collaboration

27. IPE Activities at University of Minnesota Skills lab for 1st year ob-gyn residents and 2nd year midwifery students • Labor support skills • AROM, scalp lead placement • Dilation, effacement, station, IUPC placement • Bimanual compression, manual removal of placenta *thank you to Becky Bagley, DNP, CNM, FACNM

28. IPE Activities at University of Minnesota OSCE with three IPE cases for 3rd year midwifery students and 2nd year ob-gyn residents • Transfer from a birth center for lack of progress • Post-partum case with worry about milk supply, return to work • History of shoulder dystocia, current estimated large baby

29. IPE Activities at University of Minnesota New activity planned for completion later in 2019. Simulation with very complex cases, midwife consultation with ob-gyn. Practice consulting and being consultant. Final semester midwifery students, 3rd or 4th year residents • Preeclampsia with severe features • Serious PPH

30. IPE Activities at University of Minnesota • Midwifery students present DNP QI projects AM rounds on labor unit • Piloting clinical partnership, midwife student with ob attending and resident when med student not scheduled • Midwifery students, 1-2 days in MFM clinic with MD, MFM fellow, RN • Optional resident suturing lab, midwife students invited • Upcoming simulation on transgender care with midwifery students, residents, WHNP students • Journal club, QI projects

31. IPE Activities at the national level • Advocacy: National Partnership for Women & Families, created Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing • Across multiple health professions: Health Professions Accreditors Collaborative (HPAC), created Guidance on Developing Quality IPE for the Health Professions • Within midwifery and obstetrics/gynecology: reps from ACME, ACNM DOE, ACGME RRC for Ob-Gyn, CREOG* • White paper under development *See notes for abbreviations spelled out

32. National Partnership for Women & Families • Advocacy group working on equality, repro rights, health care, fair pay, and paid leave for women & families • Strategy 4 of Blueprint focused on interprofessional education for maternity care providers

33. HPAC • Members include ACME and LMIC (Liaison Committee on Medical Education) • Purpose: to provide guidance →students in both functional and graduate education programs prepared for interprofessional practice • Does not replace individual accreditors’ standards for IPE

34. Integration of competencies

35. ACNM, ACME, CREOG • Meetings of reps from ACNM DOE, ACME, CREOG, ACGME RRC for Ob-Gyn during second year of project • Compared ACNM Core Competencies with ACGME Ob-Gyn Milestones • Extensive overlap between ACNM Hallmarks and Ob-Gyn Milestones for Professionalism • Frequent similarities between midwifery competencies and Levels 1 and 2 Ob-Gyn milestones • Agreed to create White Paper on shared principles

36. ACNM, ACME, CREOG • ACNM DOE: revised core competencies for midwifery includes IPE competencies • ACME: revised criteria for accreditation of midwifery education programs includes IPE competencies • CREOG: • Reviewed milestones for ob-gyn residents to emphasize IPE competencies • Expand CREOG Council Representation to include all educators • Jointly developed IPE core modules to be demonstrated to ob-gyn residency program directors at upcoming educational meeting • CREOG Post-match Curriculum

37. ACOG: Life Span of an OBGYN ACOG UME Med Students GME Residents CME Fellowships/Practicing Attendings 8 years 37+ years Clinical Learning/Practice Environment ACOG 2018 | Annual Meeting

38. Opportunities: Transition to Residency (T2R) ACOG APGO & CREOG UME Med Students GME Residents Pre-Match “Right Resident, Right Program” Post-Match “Residency Ready” Clinical Learning/Practice Environment CREOGAPGO 2019 | Annual Meeting

39. Post-match Curriculum • AIUM Module • FHR Module • Surgical 1st Assist Module • IPE Module • Wellness Module

40. Challenges • Program differences • Midwifery = didactic + clinical • Ob-Gyn = primarily clinical • Different start times, semester vs. residency year • Geography • Distance-based vs. institution-based • Synchronous vs. asynchronous learning

41. Questions?

42. References • Health Professions Accreditors Collaborative (2019). Guidance on developing quality interprofessional education for the health professions. Chicago, IL: Health professions Accreditors collaborative. • Hollier LM1, Promecene PA, Owens MY, Hampton M, Gala R, Kulbida N, Tomich P, Gregg L, Rothenberg J, Phelan ST, Jennings JC. 2015 Obstet Gynecol. 126(6):1285-9. doi: 10.1097/AOG.0000000000001153. Women's Health Care Teams and the Future of Obstetrics and Gynecology. • Jennings J, et.al. Executive summary: Collaboration in Practice: Implementing Team-Based Care: Report of the American College of Obstetricians and Gynecologists' Task Force on Collaborative Practice. Obstet Gynecol. 2016 Mar;127(3):612-7. doi: 10.1097/AOG.0000000000001304 • Reeves S, Perrier L, Goldman J, Freeth D, Zwarenstein M. Interprofessional education: effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD002213. DOI: 10.1002/14651858.CD002213.pub3.

43. References • Shaw- Battista J, Belew C, Anderson D, van Schaik S. Successes and Challenges of Interprofessional Physiologic Birth and Obstetric Emergency Simulations in a Nurse-Midwifery Education Program. J Midwifery Womens Health 2015; 60:735-743. • Scott Reeves, Simon Fletcher, Hugh Barr, Ivan Birch, Sylvain Boet, Nigel Davies, Angus McFadyen, Josette Rivera & Simon Kitto (2016) A BEME systematic review of the effects of interprofessional education: BEME Guide No. 39, Medical Teacher, 38:7, 656-668, DOI: 10.3109/0142159X.2016.1173663 • Smith, Denise C. Midwife-Physician Collaboration: A Conceptual Framework for Interprofessional Collaborative Practice. J Midwifery Women’s Health 2015; 60:128-139.