Quality Improvement Education and Interprofessional Learning of the Perioperative Team [From Theory to Reality] Vjekoslav Hlede, DVM, CHCP Friday, June 7, 2019 This thesis is submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy This thesis was completed as part of the Doctoral Programme in e- Research & Technology Enhanced Learning. Department of Educational Research, Lancaster University, UK. Declaration This thesis results entirely from my own work and has not been offered previously for any other degree or diploma. I declare that the word-length of this thesis 54,792 words (prior Viva), conforms to the permitted maximum. Excerpts of this thesis have been published in the following conference manuscripts and academic publications. • Hlede, V. (2019). I Think, Therefore I Am Biased, and How reflecting on our ontological and epistemological positions can improve our research. Poster presented at the Society for Academic Continuing Medical Education 2019 Annual Meeting, Charleston, North Carolina. • Hlede, V. (2017). Professional Development of Winning Teams: A Complex Solution for a Complex Task. Poster presented at the American Board of Medical Specialties Conference 2017, Chicago, September 25-27, 2017. • Hlede, V. (2016). Networked Learning―an Omnipresent but Unrecognized QI Tool. Poster presented at the 2016 Forum on Quality Improvement―Engaging Medical Professionals in Program Quality and Performance Improvement, Chicago, Illinois, USA. • Hlede, V. (2016). Leveraging Technology to Engage Members―Importance of Theory. Paper presented at the Illinois Alliance for Continuing Medical Education 2016 Annual Meeting, Chicago, Illinois, USA. • Hlede, V. (2015). Interprofessional Learning: The Physician Anesthesiologist Perspectives. Poster presented at the Society for Academic Continuing Medical Education 2015 Spring Meeting, Tampa, Florida. Part of the thesis is available at the thesis website located at CPD.us. Vjekoslav Hlede, DVM, CHCP 2 The philosophers have only interpreted the world, in various ways. The point, however, is to change it. ― Karl Marx, Theses on Feuerbach 3 Abstract Context. Complex societal factors have been obstructing implementation of quality improvement education (QIE) and interprofessional learning (IPL) of perioperative teams. Mistrust between physician anesthesiologist and nurse anesthetist, and payment models that promote competition instead of teamwork, are two of the drivers that shape that picture. Methodology. In the first part of this critical-realist case study, thematic analysis and activity theory draw a complex picture of how perioperative clinicians perceive QIE, IPL, and technology-enhanced learning (TEL). Following that, critical realist abduction and retroduction logic define one mechanism shaping perceptions of QIE, IPL, and TEL in perioperative context. Findings. Perceptions of QIE, IPL, and TEL of perioperative teams are intertwined, and perception of one phenomenon can have a transformative impact on perceptions of other phenomena in the context, creating a very dynamic picture. On the other hand, a learning healthcare system (LHS) is not part of the picture since technocentric and managerial visions of LHS promoted by the Institute of Medicine don’t support social complexity of QIE and IPL. The mechanism shaping complexity of perceptions is: Our world acts as an agglomeration of nested learning systems. On each level, the mechanism is guiding ontological and epistemological transformation of the learning system, through four phases: egocentric ➔ technocentric ➔ ecocentric ➔ holocentric. Those transformations emerge on any level of agglomeration: from cells gathered to create the first multicellular organism to networks of individuals and groups creating professional societies or perioperative teams. The thesis contributes to knowledge by shedding additional light on how the complex world of perioperative healthcare is structured and how various systems involved in perioperative care interact. On a practical level, the map of QIE, IPL, and TEL perceptions, and insight into one mechanism that is shaping those perceptions, can help perioperative leaders better navigate the transformative changes affecting perioperative teams. 4 Acknowledgements Research is a social activity focused on addressing a shared question and crafting a story to persuade the audience. While the PhD journey is designed to enhance development of the individual researcher, it takes a village to make that happen. I want to thank many people who supported me, advised me, and provided encouragement during this process. I want to thank my small global village! Especially: • I thank the research participants for finding the time to talk about QIE, IPL, and TEL; for sharing their insight, enthusiasm, and concerns. • I thank my supervisor, Dr. Jan McArthur, for the expert guidance, patience, and encouragement through all the stages of this thesis development. • I thank my examiners, Dr. Murat Öztok and Dr. Petar Jandrić for critical and constructive assessment of my thesis, and for the chance and directions to improve the thesis. • I thank the academic staff on the e-Research & Technology Enhanced Learning doctoral programme for supporting me and my peers through this doctoral journey. I thank my peers on the doctoral programme, for insightful discussions, camaraderie, and friendship. • I thank the American Society of Anesthesiologists and my peers at my workplace for creating an environment that encourages learning and research. I thank many others who supported me during my PhD journey. • I thank my parents, Stefanija and Zoran, who throughout my entire life did their best to support me in my academic, professional, and life endeavors. • I thank my partner Tania and friends and family for all their support, encouragement, and patience. Especially: Tania, Kreso, Dubravko, Dubravka, Korie and Rie. 5 Table of Contents Introduction & Background ............................................................................................. 12 1.1 Research questions ............................................................................................................... 13 1.2 Contribution to knowledge and practice .............................................................................. 14 1.3 About QIE and IPL ................................................................................................................. 14 1.4 Research and researcher ...................................................................................................... 15 1.5 Motivation for the research .................................................................................................. 15 1.6 Researcher’s background ...................................................................................................... 16 1.7 Research context and complexity ......................................................................................... 18 Political-cultural discourse ................................................................................................................. 20 1.8 Structure of the thesis .......................................................................................................... 21 Literature Review ............................................................................................................. 23 2.1 Introduction .......................................................................................................................... 24 2.2 Context: the U.S. healthcare system and healthcare teams ................................................. 25 Simple or complicated solutions for complex challenges ................................................. 26 U.S. healthcare CME/CPD research culture ...................................................................... 28 Political context ................................................................................................................ 31 Professional politics .......................................................................................................... 34 Roles and academic degrees ............................................................................................ 36 Medical home ................................................................................................................... 38 CME/CPD of Perioperative Team in the U.S. ...................................................................................... 41 Organizational and learning technology context ............................................................. 41 Evolution of technology-enhanced learning used by U.S. anesthesiologists .................... 42 Transformation of healthcare CPD ................................................................................... 44 Failure of didactic format and perpetual status quo .................................................... 47 Back to performance .................................................................................................... 48 2.3 Quality improvement education and interprofessional learning ......................................... 50 Learning health system―context where QIE and IPL are happening ............................... 52 Networked learning and quality ....................................................................................... 53 Theories behind QIE and IPL .............................................................................................................