The Development and Implementation of Interprofessional Practice Councils in the Hospital Setting : Embarking on the Journey-Experience and Lessons Learned

Collaborative Practice has been identified as playing an important role in improving patient outcomes, strengthening health care services and improving health workforce satisfaction. This pilot project explores one organization’s experience developing and implementing Interprofessional Practice Councils (IPPCs) as a means of enhancing the culture of collaboration and implementation of best practices for three programs in the organization. Three key themes were identified as essential to the design of a successful comprehensive IPPC: 1) structure; 2) values; and, 3) education. Results suggest that the core content of focus for IPPCs be composed of collaborative practice, and evidence-based practice and knowledge translation, and that key components for sustainability include: i) senior team support; ii) accountability and decision-making; iii) medical staff engagement; iv) relationship to the strategic plan; v) clear leadership and training for council members; vi) clear principal statement and council terms of reference; vii) demonstration of positive outcome and value; and, viii) defining expectations. In addition, readiness assessment and strong leadership which includes allocation of resources for focused start-up to ensure sustainability appear to be necessary requirements for successful council integration. Received: 09/04/2014 Accepted: 05/27/2014 Published: 07/18/2014 © 2014 Harper et al. This open access article is distributed under a Creative Commons Attribution License, which allows unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. H IP & Interprofessional Practice Councils EDUCATIONAL STRATEGY 2(2):eP1058 | 2 Introduction Rising healthcare costs place pressure on healthcare systems worldwide. In ensuring the greatest benefit for resource expenditures, healthcare must become increasingly more efficient. Collaborative practice has become a high priority for healthcare leaders, government funders, and decision-makers as a means of improving the efficiency of healthcare delivery because it “strengthens health systems and improves health outcomes” (World Health Organization, 2010). Interprofessional collaboration is relational and requires professionals to work together for patients. In 2010, the Credit Valley Hospital (CVH) (now part of Trillium Health Partners) committed itself to integrating collaborative practice throughout the organization (Credit Valley Hospital 2010). To shift the institutional culture towards collaborative practice at CVH, Interprofessional Practice Councils (IPPCs) were initiated. The development of IPPCs was an evidencebased initiative focused on optimizing the culture of collaboration while implementing best practices. IPPCs are based on a model of shared governance intentionally incorporating the underpinning principle of an “unconditional positive regard for one another” (Knickel and McNaughton, 2011). IPPCs give responsibility for practice-related decisions to those in direct patient care. This responsibility is intended to empower front-line healthcare workers from all disciplines and ensures accountability for quality and safety. Collaborative decision-making through the shared governance of councils promotes collaborative practice as care givers come together to decide the best way to deliver healthcare, and implement decisions for best practices locally. In this paper we describe the design, implementation and initial outcomes of establishing IPPCs; as well as lessons learned and implications for future council integration in three programs at CVH, namely the Emergency Department, Mental Health Program and Obstetrics/Gynecology Program.


Introduction
Rising healthcare costs place pressure on healthcare systems worldwide.In ensuring the greatest benefit for resource expenditures, healthcare must become increasingly more efficient.Collaborative practice has become a high priority for healthcare leaders, government funders, and decision-makers as a means of improving the efficiency of healthcare delivery because it "strengthens health systems and improves health outcomes" (World Health Organization, 2010).Interprofessional collaboration is relational and requires professionals to work together for patients.
In 2010, the Credit Valley Hospital (CVH) (now part of Trillium Health Partners) committed itself to integrating collaborative practice throughout the organization (Credit Valley Hospital 2010).To shift the institutional culture towards collaborative practice at CVH, Interprofessional Practice Councils (IPPCs) were initiated.The development of IPPCs was an evidencebased initiative focused on optimizing the culture of collaboration while implementing best practices.
IPPCs are based on a model of shared governance intentionally incorporating the underpinning principle of an "unconditional positive regard for one another" (Knickel and McNaughton, 2011).IPPCs give responsibility for practice-related decisions to those in direct patient care.This responsibility is intended to empower front-line healthcare workers from all disciplines and ensures accountability for quality and safety.Collaborative decision-making through the shared governance of councils promotes collaborative practice as care givers come together to decide the best way to deliver healthcare, and implement decisions for best practices locally.
In this paper we describe the design, implementation and initial outcomes of establishing IPPCs; as well as lessons learned and implications for future council integration in three programs at CVH, namely the Emergency Department, Mental Health Program and Obstetrics/Gynecology Program.

Literature Review
A literature review was conducted to ensure the most successful strategies were incorporated into the councils during their design.The literature search was conducted combining the search terms governance and interprofessional, governance and interdisciplinary, practice committee and hospital.The results were narrowed to articles which focused on nursing and/or interprofessional councils as a major theme of the article.A matrix of elements for successful implementation of councils was identified through content analysis of relevant literature.When no significantly unique new elements were identified, we considered we had reached saturation in the literature evaluation.Saturation was reached with nine articles (Braithwaite & Travaglia, 2008;Brody, Barnes, Ruble, & Sakowski, 2012;Dunbar, et al., 2007;Greenfield, Nugus, Fairbrother, Milne, & Debono, 2011;Howell et al., 2011;Hoying & Allen, 2011;Pinkerton, 2008;Scally & Donaldson, 1998;World Health Organization, 2010).
Individual elements of the matrix were grouped into themes, to form a framework for design of the IPPCs allowing us to focus on the major themes and minimize elements which may not be relevant to all contexts.From the literature review, three key themes were identified as essential to the design of a successful and comprehensive IPPC.These key themes are: 1) structure; 2) values; and, 3) education.These themes were almost universally identified, and in many cases included similar elements from one article to the next.For example, attention to education of council members was universally addressed in the literature on practice councils, yet individual elements in the education plans, while often similar, were not identical.

Structure
A structure that incorporates shared governance, accountability, support from the senior level, and the reporting of outcomes was identified as integral to the success of councils.The IPPCs were designed to incorporate these structural elements.
The IPPCs are based on a model of shared governance, which "gives those in direct patient care the responsibility for decisions related to their practice, " (Howell et al., 2001as cited in Hoying & Allen, 2011, p. 252).Common to successful governance structures is the capacity of councils to provide evidence-based recommendations to change practice.Clinical Governance, a term coined by the United Kingdom's National Health Service, has at its heart collaboration, partnership, and locally implemented evidence-based practice (Scally & Donaldson, 1998).Clinical governance is "intended to bring about accountability for the quality and safety of health care by creating an environment in which excellence in clinical care will flourish" (Scally & Donaldson, 1998as cited in Greenfield et al., 2011).
Organizations with successful councils have strong governance and reporting mechanisms for their councils.Ensuring adequate reporting mechanisms and reviewing performance via the governance structure and associated accountability using accurate data were described as preconditions to effective leadership (Braithwaite & Travaglia, 2008).The ability to demonstrate that the activity of the councils results in beneficial outcomes through accurate reporting of data is important for council sustainability (Campbell, Stowe, & Ozanne, 2011).Reporting mechanisms mentioned in the literature differed based on the structure and function of the council, with some councils reporting through already established structures (i.e. to Senior Management/Board or a Nursing or Professional Practice Committee) and some reporting to newly established corporate councils.Although the exact reporting structure differed the common elements of accountability, reporting, and management support were identified as key components necessary for practice councils.
At the Cincinnati Children's Hospital Medical Centre shared governance was incorporated into the strategic plan (Hoying & Allen, 2011), and the entire management team was taught problem solving and innovation as part of the kick-off for the program councils.Another example of shared governance comes from Northern California, where the Chief Nursing Executive (CNE) of each hospital was the authority to empower nursing staff to lead the nursing councils (Brody et al., 2012).
Structure and governance are essential elements for the development of a successful IPPC, as demonstrated repeatedly as a theme in the literature on practicebased councils.It is important to carefully consider and plan the structure early in the design phase of the development of IPPCs.

Values
An aspect of effective teamwork that has been identified in the literature is person-environment fit (Kristof-Brown, Barrick, & Kay Stevens, 2005 as cited in Mitchell, Parker, Giles, Joyce, & Chiang, 2012).In terms of fit, value congruence has been identified as an important element "because values are relatively enduring and guide attitudes and behavior" (Chatman, 1991;Schein, 1992as cited in Mitchell, et al., 2012, p. 627).Value congruence increases trust and cooperation (Tsui & O'Reilly, 1989as cited in Mitchell, Parker, Giles, Joyce, & Chiang, 2012) as team members are more likely to be attracted to and trust those they perceive to hold similar values (Festinger, 1954;Williams & O'Reilly, 1998as cited in Mitchell, et al., 2012).
A successful council is built upon a set of agreed upon values.These values are articulated in the literature in a various number of ways such as ground rules, statements of purpose, team declarations, etc.The values most commonly identified for council success were active participation, care-givers' autonomy to make decisions, accountability, evidence-based practice and patientfocused care (Table 1).Values are an essential element required to formulate group identity.Mitchell et al. (2012) provide evidence that common identity is an essential component of the interprofessional team, with a correlation between common group identity and team innovation: When members perceive that the team shares values that are central to their task, their perceptions of cooperation is enhanced, and the importance of each member's contributions to the team's goal is reinforced.This builds commitment and develops a shared team identity, which stimulates collaborative interpersonal interaction and constructive analysis of member's diverse perspectives.(p.639)

Education
The third theme essential to the development of practice councils is education, particularly to address baseline perceptions and ensure minimum understanding on specific topics.This is essential to the effective functioning of the council, as members may come with varying skill sets.The most comprehensive description of the educational program we found was described by Brody et al (2012) and would be useful for anyone establishing curricula for councils to review.
Educational topics described in the literature varied according to the needs of the councils being described.
Frequently identified educational topics included: • Knowledge: Critical Appraisal and Evidence-Based Medicine Theory, Human Factors Theory; Scopes of Practice • Skills: Conflict Resolution; Decision-Making; Data analysis The education topics most relevant to our local context included understanding of the professional roles of all team members (Campbell, Stowe, & Ozanne, 2011), the role of evidence-based practice and decisionmaking (Newhouse, Dearholt, Poe, Pugh, & White, 2007), and developing ways to encourage decisionmaking at all levels through the use of data analysis (Braithwaite & Travaglia, 2008).Education needs to be an ongoing consideration and managing/reshaping culture is critical to maintaining momentum for shared governance, and the creation of decision-making councils (Dunbar et. al., 2007).All the successful councils described in the literature incorporate some sort of a baseline education program for council members to facilitate decision-making.
In summary, the successful councils described in the literature were designed around common themes, with flexibility to account for local context.The themes included: • Structure: which almost universally included shared clinical governance, accountability to report outcomes and adequate support; • Values: including evidence-based practice, respect, participation and quality improvement; and, • Education tailored to the needs of the councils.
As supported by the literature, the transformation of clinical practice through councils is a journey, rather than a project with a defined end.The destination for the journey is a practice culture of respect through shared governance, evidence-based practice through quality improvement and measurable accountability for outcomes.Every step the councils take towards this practice results in improved patient care and allows those engaged in direct patient care to make practicerelated decisions.

Methods
The three key themes identified from the literature review: 1) structure; 2) values; and, 3) education were intentionally integrated into the design of the IPPCs and associated curriculum.

Pre-Knowledge Acquisition Assessment
Eight key components were identified for sustainability of IPPCs.These components are: • Structure: i) senior team support; ii) relaitionship to the strategic plan; iii) clear terms of reference; iv) accountability and decision-making structure; • Values: v) demonstration of positive outcome and value vi) physician engagement; vii) defined expectations and clear principle statement; • Education: viii) Clear leadership and training for council members These components align with the three key themes identified in the literature as essential to the development of a comprehensive interprofessional practice council: Structure, Values and Education.

Structure i. Senior Team Support
Councils need to be supported openly by the senior leadership.Additional support including re-moving barriers to participation such as backfill for staff to attend council meetings, and additional administrative support is important to ensure ongoing participation (Dunbar et al., 2007;Hoying & Allen, 2011).Over and over, the planning group heard the need for resources to support council members' time on the council and associated project work.This required budgetary allocation to permit meeting attendance and continued in kind support from other departments.

ii. Relationship to the strategic plan
The CVH strategic plan incorporates interprofessional collaboration and care as an important component of patient-centred care.Alignment with the strategic plan is essential for sustainability and continued support from senior leadership as well as increasing staff buy-in.

iii. Clear Council Terms of Reference
The Terms of Reference forms the understanding of the purpose and accountability of the council.
It is important to ensure that all council members understand their function, and that the council's role is to address practice issues, not operational issues.Initial and annual review of the Terms of Reference is necessary to ensure awareness and understanding with ongoing training for new members.

iv. Accountability and Decision-Making Structure
All members of the council need to understand and appreciate accountability.While the councils should not have direct accountability to approve and implement practice changes without senior level review and approval, their authority to recommend those changes should be clear.
Practice changes that affect multiple programs require the endorsement from all affected program councils and steering committees before being presented for approval.This necessitates a communication process between councils to share ideas and proposed practice changes (See Figure 1).require further action which may require additional administrative support.

vi. Physician engagement
As part of the care delivery team, the physician is an integral component.Practice change recommendations will undoubtedly affect how the physician provides care to their patient.Hence, a parallel process should be in place for practice changes recommended for approval to the Professional Practice Committee (PPC) and the Medical Advisory Committee (MAC) as required (see Figure 1).and time allotted for each session "I think there was too much information presented during this session that created confusion for people" and that staff still did not have a clear understanding of what their role is on the council and how to proceed.This feedback is further supported by narrative from the survey that stated "The session could have been shorter" and "I am still somewhat unclear as to my role on the team" and "I still feel vague about what exactly this council is supposed to do."

Core Content
The importance of training and education for the successful implementation of interprofessional, shared governance and evidence-based decision-focused work is supported by the literature (Campbell, Stowe, & Ozanne, 2011;Dunbar et al., 2007;Newhouse et al., 2007), "to ensure participants had the skills needed to participate fully and productively on a council, " (Dunbar et al., 2007, p. 197).As a result, curriculum and training was purposefully developed focusing on the core content of: collaborative practice; and, evidence-based practice and knowledge translation.
Although participants attending the rollout sessions gained knowledge about the core content, concerns about the length of time to deliver the content and amount of information being delivered indicate there is a need to refine the content in such a way as to be meaningful without being overwhelming.Finding just the right amount of time to deliver just the right amount of content is a common educational concern, further complicated by time constraints associated with health care delivery and the capacity to liberate staff to attend sessions.Additionally, considerations should be given to the current team function and their experience of learning in an interprofessional environment which may require exploration prior to rollout and customization to meet the specific needs of the audience.
Clarity of purpose was a sub-theme identified with the content rollout for some participants who expressed ambiguity about their individual roles on the council and the role of the IPPC itself.It is uncertain if this lack of clarity was associated with core content delivery or the newness of councils within the organization and the usual growing pains associated with any new strategy, for with culture change comes a natural confusion and abiguity (Dunbar et al., 2007).Further evaluation of these councils down the road when they become deeply involved in addresing practice issues, may provide the best opportunity to determine if the delivered core content was helpful in supporting their processes.This is supported by narrative from the survey stating, "I think until we get started and develop our first item to tackle, the application of what was learned will be even more clear and understandable."That being said, further refinement of the content with the intent of clarifying roles may address these indicated shortcoming immediately for other councils slated for the rollout process.
Review of the rollout program by the development team identified a failure to address Interprofessional Communication despite it being one of the 6 CIHC Core Competencies.As a result, the core content requires amendment to ensure a comprehensive delivery of the core competencies for future councils.

Understanding Each Others' Professional Roles
A surprising theme identified in this pilot project was the lack of understanding of each others' professional roles.With a great deal of IPE/IPC work being done locally and globally over the past few years, it would seem a reasonable assumption that individuals would have an understanding about each others' roles.
During the rollout, however, it became very clear that despite working together on a daily basis, professionals often have limited knowledge of the scopes of practice or education of their colleagues.their roles, scopes of practice, knowledge, skills and judgement capacities; and/or our perceptions of their profession are not comprehensive.Often what seems self evident and obvious is not and requires considerable routine practice to be habituated.Caregivers need to be given the opportunity to work and learn about, from and with each other on a continuous basis with a culture of inquiry in a safe environment that encourages them to ask one another, "how would you approach this issue from your professional perspective?"and "who else ought we engage in this discussion?"

Readiness to Rollout
Of the three pilot groups, the Emergency Department was not able to participate in the rollout during the scheduled time frame due to acuity, over admissions and staffing shortages.The rollout occurred during the winter months at CVH, which are months known for high admissions, bed shortages, and staffing issues.
Prior to rollout in the Emergency Department, it was identified that staff could not be liberated from the clinical care areas to attend the required sessions.Upon reflection, the development team felt that given previous years data, this barrier may have been identified early on prompting recommendation that a readiness to rollout assessment be developed and carried out for future areas specifically reviewing: acuity, competing demands and staffing.As rollout of the IPPCs requires a great deal of coordination and commitment from educators, readiness to rollout assessments have the potential to maximize the resources associated with rollout and help the development team focus on areas more likely to support the process and subsequently succeed as a collective.

Leadership
Reflection of the two remaining pilot groups' leadership was an important factor in determining success.The group that was engaged and had greater clarity also had strong prior involvement from its program leadership and a strong chair/co-chair dyad defined early on in the process before rollout of the councils.For the group that was feeling challenged about moving forward with its councils, its leadership involvement had been inconsistent, and the group had not yet identified a chair/ co-chair dyad even after the rollout had commenced.These results suggest a correlation between rollout success and confidence of the team moving forward with strong dedicated and supportive leadership.

Physician Engagement
As identified in the pre-knowledge acquisition phase of this project, physician engagement is a key component necessary for sustainability.The model of care of this community hospital does not include protected time and physicians identified this as a barrier to their engagement.To-date, there is inconsistent physician engagement on the IPPCs of these three pilot areas.Furthermore, the rollout team was met with an unexpected outcome from the physician groupobstruction.In determining the root of this issue it became apparent that each of the three pilot areas' physicians groups saw evidence-based practice as their exclusive domain and expressed concern with the interprofessional team taking on this role.
Despite the best efforts of IPE and IPC, healthcare has its historical foundations in the hierarchical and somewhat patriarchal medical model.Having "carve[d] a distinct and prestigious niche" (Whitehead 2007(Whitehead , p. 1011)), physicians are socialized into roles of responsibility and authority that creates barriers to collaboration (power, status, professional socialization, decision-making responsibility) that may limit their engagement and make it difficult for interactions that involve sharing responsibility (Whitehead, 2007).The move to a flattened hierarchical model, where healthcare professionals interact as a system of "cooperating independent equals who contribute to a common vision of health" (Herbert 2005, p.1), is one that is appealing and sought after for, arguably, the majority of professionals within healthcare.If, however, this model implies a reduction of physicians' traditional status, power and decision-making responsibility, "it is critical to contemplate how doctors will be encouraged to engage in this process" (Whitehead 2007(Whitehead , p.1011)).Whitehead (2007) suggests that physician engagement might be improved by demonstrating improved patient outcomes.Arguably, that is indeed the intention of the IPPCs-to address practice with the most relevant evidence and best practice approach to provide the best possible care and hence, improve patient outcomes, particularly in environments that have failed to utilize best evidence previously.Without a doubt, physicians are an integral part of the healthcare team and as such it would follow that a team approach to evidencebased practice via the IPPCs would include their skills.
Engaging the physician group to see the value of its involvement in terms of improving patient outcomes rests in testing an interprofessional approach to practice versus a uniprofessional one which is, ironically, dependent upon physician involvement.

Limitations
The findings associated with this project come from the limited data of one organization's experience with councils in three pilot areas of the organization.Further exploration with additional areas of this organization and other organizations with varied structures would be valuable in supporting our observations.

Conclusions
In summary, designing IPPCs has provided valuable information for future organizations considering similar structures.From the literature, we identified three key themes essential to the design of a successful comprehensive IPPC: 1) structure; 2) values; and 3) education.
Our experience in implementing and evaluating IPPCs suggests that the core content of focus for IPPCs be composed of collaborative practice, and evidencebased practice and knowledge translation.The key components for sustainability include: i) senior team support; ii) accountability and decision-making; iii) medical staff engagement; iv) relationship to the strategic plan; v) clear leadership and training for council member; vi) clear principal statement and council terms of reference; vii) demonstration of positive outcome and value; and viii) defining expectations.In addition, readiness assessment, physician engagement and strong leadership appear to be necessary requirements for successful council integration.

v.Figure 1 .
Figure 1.Proposed Process of Recommending and Approving Practice Changes