The International Journal of Psychosocial Rehabilitation

Optimizing System & Patient RecoveryRediscover & Recovery:
The Shared Journey Project


Cindy K. Malachowski, B.Kin, BHSc OT, MRSc

Whitby Mental Health Centre





Citation:
Malachowski.  (2009).Optimizing System & Patient RecoveryRediscover & Recovery:
 The Shared Journey Project
. International Journal of Psychosocial Rehabilitation. Vol 13(2).   49-64







Correspondence

Cindy K. Malachowski, B.Kin, BHSc OT, MRSc
cinmala@hotmail.com




Abstract
CONTEXT:    Healthcare quality improvement initiatives have become a priority issue across organizations and systems internationally.  Ontario is developing a strategic initiative to systematically improve the quality of healthcare delivery.  Mental health reform is of specific interest.
METHODS:    Whitby Mental Health Centre has launched a quality improvement initiative entitled "Rediscover & Recovery: The Shared Journey Project".  The objective of this project is to transform the Centre's organizational culture and improve patient care by connecting frontline clinicians with the values and beliefs inherent in the recovery philosophy and interprofessional care.  
FINDINGS:    The following paper offers a comparison of the shared values and principles of the recovery philosophy and interprofessional care, and will describe facilitators and barriers to their implementation.  
CONCLUSIONS:    The benefits of the project will be discussed, as well as implications for rehabilitation practitioners.
KEY WORDS:    Interprofessional Care, Recovery Philosophy, Quality Improvement, Mental Health


Introduction
Whitby Mental Health Centre (WMHC), located in Central-Eastern Ontario, employs over 1,200 people and offers a range of specialized tertiary care mental health programs for individuals living with mental illness (Whitby Mental Health Centre, 2006).  The Centre provides both inpatient and outpatient services to approximately 2.8 million people residing within the region.  It opened as a mental health facility in 1919, and management of the Centre was transferred from the Ontario Government to a stand-alone public psychiatric hospital on March 27, 2006.  A culmination of recent developments has necessitated a significant transformation of clinical care.  The Centre’s divestment from government governance to a public hospital, the international emphasis on incorporating the recovery philosophy into best practices for mental health (Allott, Loganathan, & Fulford, 2002; Davidson, 2007; Farkas, Gagne, Anthony, & Chamberlin, 2005), the movement toward interprofessional practice for clinical excellence (Akhavain, Amaral, Murphy, & Cardone Uehlinger, 1999; Evetts, 1999; Infante, 2006), and Ontario’s initiative to strengthen the mental health system (Local Health Integration Networks [LHINs], 2008; Newman, 1998; Ontario Ministry of Health, 1999) have set the stage to enable the enhancement of clinical front-line care delivery at WMHC.   These factors have provided an opportunity to implement “The Shared Journey”, a large-scale organizational change initiative that will improve the quality of care provided by the centre.  The purpose of this paper is to explore the key factors that will impact the adoption of the recovery philosophy and interprofessional care (IPC) within the current healthcare climate in Ontario.

Healthcare: Reform & Transformation
Internationally, there is a movement to improve the quality of healthcare.  The United Kingdom has published a White Paper on healthcare reform and launched a series of quality improvement initiatives (Thomas, 1998).  The United States has identified the need for safer, more effective healthcare services and has made recommendations for system redesign (Kohn, Corrigan, & Donaldson, 2000; Institute of Medicine Committee on Health Care in America, 2001).  In Canada, a review of the healthcare system has resulted in recommendations for reform in order to enhance the efficiency and sustainability of healthcare delivery (Standing Senate Committee on Social Affairs, Science and Technology, 2002).  Efforts to address local healthcare challenges have begun, and in 2006 the province of Ontario developed the Local Health System Integration Act and created fourteen Local Health Integration Networks (LHINs) in order to plan, integrate, and fund healthcare services (Local Health System Integration Act, 2006; LHINs, 2008).  Mental health and addiction services were raised as a priority issue across all LHINs in Ontario.   This is indicative of the importance and priority that the province is placing on improving the present state of mental healthcare delivery.  The identification of mental health services as a priority issue can be traced back to the first wave of deinstitutionalization in the 1970’s, where neither the healthcare system, nor the community was adequately prepared to meet the needs of individuals living with severe and persistent mental illness (Hartford, Schreker, Wiktorowicz, Hoch, & Sharp, 2003).  The provincial government has since committed to the reorganization and restructuring of services through mental health reform.  Hartford et al. (2003) provide a historical context for mental health care in Ontario and illustrate that until the recent development of the LHINs, mental healthcare system improvement has been slow and changes have been nominal. The Central East (CE) LHIN is addressing system improvement through their Integrated Health Service Plan (Central East [CE] LHIN, 2008).  This action plan has identified key areas for healthcare improvement, and has included specific objectives for mental health and addictions.  The following areas in mental health have been identified as a priority in the mandate, and will have a significant impact on the type of care that is provided within the region: service delivery, knowledge exchange, interprofessional practice, and staff recruitment and retention (CE LHIN, 2006).  WMHC’s organizational change initiative to embrace the recovery philosophy and IPC aligns seamlessly with provincial objectives.  The LHINs’ mandate for mental health system improvement will be supported by the clinical transformation and care provision changes at the Centre.

In order to improve the quality of care provided at WMHC, the Centre has decided to model a change initiative after the “Reconnecting to Care” project conducted at the Baycrest Centre in Toronto, Ontario (Glouberman, Richards, El Bestawi, Seidman-Carlson, & Teperman, 2007).  The Baycrest strategy was a deep change initiative for nursing services and emphasized the importance of clinical competencies and the value of direct care workers.  It was initiated in response to the challenge of maintaining a caring and positive work environment when clinicians experience decreased morale.  The work culture at Baycrest was reflective of the attitude represented across many non-acute healthcare settings, including the WMHC.  Staff felt that they were unrewarded and were trapped in a disconnected, task-driven routine. In order to improve services, Baycrest underwent a “renewal” process where patient care units at the facility were systematically shut down for a period of four weeks.  During this time the staff was immersed in an educational program that resulted in a more responsive, more alert, and more dedicated workforce.  After the intervention, staff also had a better understanding of their roles, as well as an enhanced awareness of system and process issues.  A number of quality indicators revealed that the nursing staff had improved their ability to relate to one another, their patients, and patient families.  As WMHC is looking to address similar workforce and organizational culture issues, a similar process will be adopted.  However, the “Rediscover & Recovery: The Shared Journey Project” will merge the concepts of recovery based competencies and IPC with specific clinical skills and proficiencies related to the field of mental health.  To ensure the successful implementation of this initiative, it is imperative that the organization be prepared to create and sustain a change to clinical expectations prior to anticipating transformation in frontline care delivery.  In order to set the stage for change and begin to transform the organizational culture to improve the quality of care delivery, WMHC must address the deeply entrenched values and beliefs that underpin clinical practice at the Centre (Davies, Nutley, & Mannion, 2000).

Transforming Systems: The Recovery Philosophy & Interprofessional Care
Instituting a new organizational strategic directive through the implementation of The Shared Journey Project will require the adoption of two approaches to care at the WMHC: the recovery philosophy and IPC.  This new philosophical mandate will require personnel values and behaviour that are significantly different from traditional healthcare delivery and current practices at the Centre.  Historically, mental health care has employed a top-down approach dominated by an expert-driven model, and interventions were based on deficiencies and incapacity (Swarbrick & Brice, 2006).  The “medical model” approach to care is based on the absence of disease, pathology, compliance, and in essence establishes a power differential between doctors and patients (Roberts & Wolfson, 2004).  In stark contrast, Anthony (1993) and Deegan (1988) describe the meaning of recovery as a shift in thinking from clinical pathology to a strengths-based approach; therefore, instead of focusing on relief from symptoms, emphasis is placed on building self-esteem and finding a meaningful role in society.  Deegan (1996) further describes recovery as providing opportunity for choice; empowering people by allowing them to have a voice and taking the time to listen to their story; allowing individuals to provide input regarding service engagement; and by providing opportunity for peer support, peer mentorship, self-help, and mutual support.  These concepts have attracted much attention and there has been a movement internationally for system-restructuring in order to embrace the recovery philosophy.  Scotland (Scottish Executive, 2006) and New Zealand (New Zealand Mental Health Commission, 2001) have identified core clinical competencies and system indicators for recovery.  The United States have developed core concepts of recovery and identified fundamental values and principles (Substance Abuse & Mental Health Services Administration, n.d.).  The Canadian government has identified the need for a recovery-oriented system reform, and has outlined a federal strategic implementation plan and a national mental health strategy (The Standing Senate Committee on Social Affairs, Science and Technology 2006).  In 2002, the Provincial Forum of Mental Health Implementation Task Forces published a report calling for the recovery philosophy to be the foundation for change in Ontario’s mental health system.  Locally, the CE LHIN will help deliver the mandate by improving access to mental health services, reducing stigma and discrimination, enhancing safety, and improving the effectiveness of services (CE LHIN, 2006).  It is evident that the recovery philosophy has gained international acceptance and has become the prevailing philosophy for mental health care delivery.  The values and principles of recovery will create a foundation for change, and will underpin clinical transformation at WMHC.  The Shared Journey Project will improve clinical care and create partnerships between clinicians and patients that inspire a sense of hope and empowerment, and ensure clinicians are providing meaningful involvement and choice for patients.

The second component of the Shared Journey Project will necessitate the adoption of IPC practices.  In their review of the literature, Rice (2000) and Klein (2008) provide varying levels of evidence to support the implementation of interprofessional care.  Despite the lack of strong empirical evidence demonstrating the effectiveness of IPC, there is an abundance of publications that support its implementation to enhance services.  Evidently, the collaboration developed within IPC teams is correlated with enhanced clinical outcomes, continuity of care, decreased costs of providing care, improved job satisfaction, and the promotion of professional identity.  Interprofessional care happens when teams comprised of various health care professionals engage in equal participation to aid health care decision making (Yeager, 2005).  IPC occurs among and between healthcare providers, and the ultimate aim is to create empowering partnerships, teams, and organizations that are jointly responsible for services (McWilliam et al., 2003).  HealthForceOntario, a provincial strategy to ensure high quality healthcare delivery, has recognized that IPC may compensate for some of the challenges faced by Ontario’s healthcare system, as well as result in overall system improvement.  On behalf of HealthForceOntario (2007), the Interprofessional Care Strategic Implementation Committee has endorsed IPC to increase access to care, improve outcomes for people with chronic diseases, reduce tension and conflict among caregivers, enhance use of clinical resources, aid the recruitment of caregivers, and decrease rates of staff turnover.  The LHINs have been identified as enablers for IPC, and the CE LHIN is in the process of developing a strategic plan to implement an interdisciplinary team approach to care across agencies and across sectors in order to improve quality of care and to provide more efficient, effective healthcare delivery (CE LHIN, 2006).

Fundamentally, the recovery philosophy and IPC share many of the same basic concepts, which may facilitate their overall adoption into the workforce. Each require strong partnerships between the clinical team, the patient, family/caregivers, and the community; each require collaboration, participation, and effective communication; and each can provide enhanced quality of care and flexible services to meet the needs/goals of the patient.  Recovery and IPC necessitate a patient-centred approach (Blickem & Priyadharshini, 2007; Schauer, Everett, & del Vecchio, 2007) which not only encourages patient participation and responsibility, but may help to reduce tension and conflict among clinicians as they engage in more meaningful, focused interactions. This will also impact patient safety as active engagement of all team members will help to reduce errors and protect the health and welfare of patients and staff at the Centre (Infante, 2006).  At a system level, recovery principles have demonstrated improved clinical outcomes that will offer benefits to the patient, clinician, organization, and ultimately the healthcare system as a whole (Solomon & Stanhope, 2004).  Although many articles pertaining to IPC discuss similar enhanced clinical outcomes, there is a lack of strong evidence to support these claims (Rice, 2000).  The implementation of the recovery philosophy has resulted in better use of clinical resources and transitioning services, which will reduce costs and improve flow of patient care within and between organizations (Farkas et al., 2005).  The literature indicates that IPC has a similar impact on patient flow and reduced clinical costs; however, these claims are not grounded in empirical research and offer limited or mixed support (Reid Ponte et al., 2007; Rice, 2000).  Despite the lack of strong empirical support for IPC, there are many underlying similarities between the two philosophies that offer insight into the importance of collaboration and competence for organizational and system improvement.  As a result, WMHC’s strategic directive to embrace the recovery philosophy and IPC necessitates behaviour and value changes in frontline clinicians to support the practice of partnership on all levels: patient empowerment, teamwork and shared decision making (Schauer et al., 2007; McWilliam et al., 2003).  This will translate into significant role changes and expectations as the workforce deviates from the traditional medical model hierarchy and adopts a more egalitarian philosophy.  This change in practice is important for optimizing patient care; however, the significant shift in practice expectations also represents a barrier to successful implementation.

Addressing Challenges to Implementation
It is anticipated that recovery and IPC components, values, and principles will help to guide WMHC’s organizational transformation toward recovery-oriented services.  As with any large scale change initiative, significant barriers exist.  Challenges of implementing IPC are identified by Powell et al. (1999) and can also be applied to the adoption of the recovery philosophy as they share many of the same values and principles.  Barriers are identified as (1) personal factors, (2) professional factors, and (3) organizational factors.  The type of relationships formed with colleagues, the distribution of power between disciplines, and bureaucratic issues at an organizational level will impact the acceptance of recovery and IPC.

Communication, trust, competence, and confidence will have an impact on the way that clinicians interact with their patients and with each other.  These personal factors and the concept of risk have important implications for recovery and IPC as it may be a significant barrier to embracing both philosophies.  The recovery philosophy encourages risk and risk taking in order to promote a patient’s personal growth and development.  Patricia Deegan, an individual treated for schizophrenia, is an internationally renowned recovery advocate and calls all professionals to “…embrace the concept of the dignity of risk and the right to failure if they are to be supportive of us” (1996, p.97).  This is contrary to the traditional treatment of individuals living with mental illness; historically the clinician was viewed as the “expert” and made decisions on behalf of the patient who was deemed incompetent as a result of their mental illness.  Roberts & Wolfson (2004) discuss the concept of risk from the perspective of shifting from risk avoidance to risk-sharing in regard to medication practices, a contentious issue between the medical model and recovery approach.  The medical model promotes compliance with medication as a life-long necessity to prevent symptoms and/or relapse.  The recovery philosophy considers medication within the context of the patient experience, and advocates for shared decision making, choice and self-determination in regard to medication practices (Deegan & Drake, 2006).  Allowing patients to make their own decisions and accepting the prospect of failure requires clinicians to provide unconditional support to individuals, and acknowledges that patients are entitled to make independent, informed choices.  Roberts & Wolfson (2004) state “…risks can be taken within safe parameters and lessons learned from experience” (p.42).  This approach will facilitate a partnership that unites the expertise of the clinician with the patient’s experience of their illness, and negates issues of power and control.  In a different context, the concept of risk threatens the successful adoption of IPC practices.  Accountability issues have been raised as a concern in implementing IPC (Evettes, 1999).  Bronstein (2003) offers further insight into regulation challenges of IPC as professionals share limited understanding of roles, expertise, and scope of practice which can result in tension, anxiety and conflict among care providers.  IPC team members may also experience role confusion and harbor feelings of resentment when tasks or duties are shared among team members (McWilliam et al., 2003).  This contributes to the reluctance to adopt IPC practices. Presently, Ontario does not allow for the flexibility required to foster interprofessional collaborative care as legislation is too rigid and focused on individual responsibility (Health Canada, 2007; Thornhill, Dault, & Clements, 2008).  Consequently, clinicians who fear the potential liability and/or risks related to the negligence of colleagues will be reluctant to adopt a collaborative approach to care.  As a result, individual values, skills, and perspectives will have a significant impact on the willingness to engage in change. 

To illustrate challenges on a professional level, the adoption of the philosophy has in part been hampered by the tension between recovery and the medical model.  Despite evidence from longitudinal research demonstrating that people can and do recover from long-term persistent mental illness (Harding, Brooks, Ashikaga, Strauss, & Breier, 1987; Harrison et al., 2001), the differences between the values and concepts of the medical model and recovery stand in significant opposition to one another.  Numerous publications have debunked concerns and perceived limitations to the adoption of the recovery model, but reluctance to abandon the expert-driven model still exists (Davidson, O’Connell, Tondora, Styron, & Kangas, 2006; Mountain & Shah, 2008; Samele, Lawton-Smith, Warner & Mariathasan, 2007). Similarly, the medical model remains a barrier to the implementation of interprofessional care.  Locally, a recent Ontario Medical Association (OMA) Policy Paper on Interprofessional Care (Hanna, 2007) states that “physicians, having greater breadth of training and larger scope of practice, should be the clinical lead in interprofessional teams” (p. 3), and further recommends that  “Physicians should be compensated for their leadership and the indirect services they provide in interprofessional team settings” (p. 7).  This type of professional elitism is apparent between all professional groups, as inflexibility, rigid role separation, tradition, and vested professional interest act as barriers to collaborative practice (Roberts & Priest, 1997).  As a result of the tension created from entrenched power differentials, there is significant resistance to adopt a practice that calls for an inclusive approach.  

At an organizational level, operational structure does not typically provide an optimal environment for collaboration or recovery-oriented care.   Financial and budgetary decisions are often dependent on outcomes such as length of stay and readmission rates.  Recovery-oriented services and measures require a shift in financial resources that support the enhancement of quality of life, self-empowerment, and hopefulness of patients (Sowers, 2005).  These variables are much more difficult to define and measure as a result of their subjective nature.  In order to embrace collaboration that supports both recovery and IPC, organizational structure must adopt a clear policy direction, performance criteria, and incentives that outline key determinants of collaboration yet allow for flexibility (Ginsburg & Tregunno, 2005).  The importance of structure is reflected in effective leadership and commitment across all levels of the organization (Reide Ponte et al., 2007). At the heart of IPC, Ginsburg & Tregunno (2005) describe a type of shared leadership between frontline clinicians and management.  This type of shared leadership can also be applied in the recovery context and extended to the patient, allowing individuals to take more of a leadership role when making decisions about their care.  Evidently, creating a clinical infrastructure that fosters collaboration requires system changes and amendments to current policies and procedures to promote collaboration across all care providers. 

Despite the many challenges on personal, professional, and organizational levels, recent attempts to bridge the gap between the recovery approach, IPC, and the medical model have begun.  As a result of efforts to strengthen the recovery evidence base and establish the philosophy as a viable approach to care, new measures and outcomes are being generated and there is a movement to engage in quantitative research inquiries that formalize and operationalize recovery dimensions (Anthony, Rogers & Farkas, 2003).  Attempts to find common ground between the two philosophical approaches have encouraged clinicians to connect symptoms with the specific meaning they have for the patient; to listen to individual patient stories and experiences instead of just taking a diagnostic history; and to reduce stigma and challenge clinicians’ assumptions about mental illness (Mountain & Shah, 2008). These developments are particularly relevant for WMHC.  A significant challenge faced by the Centre is to abandon medical dominance and embrace a collaborative practice that addresses both the physical and mental health needs of individuals living with long-term, persistent mental illness.  IPC models offer insight into the type of collaboration required to utilize effectively the clinical expertise of various disciplines to meet the client’s needs during their journey of recovery. Clearly, the redistribution of power and control, and the inclusive nature of recovery and IPC will result in a significant shift in values for all healthcare professionals as it will necessitate a change in the way they view their role, their patients, and their practice.  

Facilitating Change: Creating a Shift in Culture
Today’s healthcare system thinking has shifted from classic reductionism or top-down design, toward nonlinear dynamics or a complex systems theory (Burns, 2001; Suchman, 2001).  This theory views the organization as a complex and adaptive system that continually interacts with several micro-systems thus evolving in response to multiple feedback loops (Plsek & Wilson, 2001). The complexity of implementing organizational change involves multiple variables that interact and impact each other (Sturmberg, 2007; Suchman, 2001). It is relatively easy to introduce new processes and procedures on a superficial level, but creating change that will impact ingrained values and beliefs is much more challenging and complex (Davies et al., 2000).  Resistance to change in organizations is well documented, and many of the barriers to change have been identified in the literature.  Senge et al. (1999) describe change as a disturbance in balance, and states that individuals resist change to maintain status quo or comfort; others describe how change is frequently perceived as a loss (Folger & Skarlicki,1999).  Considering there are many theories that offer insight into behaviour change, WMHC’s transformational change initiative must consider multiple factors that effect behaviour change.

In order to explain how behaviour change occurs among healthcare professionals, various theoretical perspectives have evolved.  Grol & Grimshaw (2003) provide examples of how theoretical constructs translate to practice.  For example, the cognitive theory offers an explanation of behaviour change in the context of receiving knowledge and information; adult learning theories attribute change to experience, reflection, and discussion with colleagues; behavioural theories contend that performance is shaped by feedback, incentives, modeling, and reinforcement; and organizational theories explain change within a system, process, and cultural context.  Despite investigations that attempt to identify standardized strategies that change or modify clinician behaviour, specific knowledge translation tactics remain elusive (Perkins et al., 2007).  Deane, Crowe, King, Kavanagh & Oades (2006) have investigated the failure of transfer of training related to recovery oriented practice, and found that despite policy implementation, support from management, and staff training, there were minimal behaviour changes in clinicians.  In their 2006 publication, Crowe, Deane, Oades, Caputi & Morland discuss the friction between the recovery philosophy and the value system that differentiates recovery-oriented care from traditional care models; they conclude that staff attitude can  be a barrier (or in some cases a facilitator) to adopting implementation.  Staff attitude and perspectives are important considerations in developing strategic change initiatives as both represent the culture of the organization.  They can also be applied when attempting to understand barriers to change at an individual, group, or systems level.  To establish a change management process, it is apparent that a baseline measure of values, attitudes, and beliefs must be conducted.

A critical factor in any change management process is to determine the organizational culture and readiness for change (Jones & Redman, 2000). In describing the term organizational culture, Scott, Mannion, Davies, & Marshall (2003) offer the following description:
It denotes a wide range of social phenomena, including an organization’s customary dress, language, behavior, beliefs, values, assumptions, symbols of status and authority, myths, ceremonies and rituals, and modes of deference and subversion; all of which help to define an organization’s character and norms (p. 925)

A post divestment cultural assessment survey has indicated that the majority of employees at the WMHC exhibit significant concern about pay; lack of respectful treatment; need to improve patient focus; tension between union/management relations; lack of adequate staffing; decreased morale; and inadequate leadership (HayGroup, 2007).  In order to devise a change management strategy additional workforce assessments were completed.  These assessments confirm that the current environmental culture at WMHC resists change initiatives, that frontline staff engage in bullying tactics, that there is a lack of communication throughout the organization, and that employees take minimal ownership for initiatives and have a “why bother” attitude.  (Deloitte, 2008).  Many of the factors identified by HayGroup and Deloitte are not unique to the WMHC organizational culture and are well documented in the literature.  Sovie (1993) describes dysfunctional hospital cultures as organizations that engage in turf battles, do not recognize staff accomplishments, have limited concern about employee satisfaction, and do not regularly measure quality of service.  Perceived power imbalances, dissatisfaction, frustration, internal competition, organizational change, and changes in the composition of the work group are other variables that contribute to dysfunction in organizations (Liefooghe & Mackenzie Davey, 2001; Salin, 2003). 

Many of the predominant themes that emerged from the cultural assessments completed at WMHC can be related to theoretical constructs of bullying.  Bullying in healthcare is a significant issue resulting from organizational structure and power imbalances among/ between clinicians and/or management and has been identified as a key factor in shaping organizational culture (Bate, 2000).  Absenteeism, high staff turnover, decreased morale, loss in productivity, and a depersonalized organization, are behaviours that have been identified as indicators of workplace bullying specifically in healthcare (Hutchinson, Vickers, Jackson & Wilkes, 2006).  Turney (2003) provides evidence to support both vertical and horizontal workplace bullying in the medical profession.  She describes workplace bullying that occurs between professionals on the same level, and bullying caused by power imbalances created by status attributed to certain professions. Potentially, the shifting power among and between clinicians working within an IPC team could initially heighten tensions and increase animosity among the staff at WMHC, an important factor to consider when developing a strategic implementation plan.  Hutchinson et al. (2006) argue that bullying can become normalized within an organization and is strategically used to maintain order.  This concept needs to be considered when implementing change initiatives as the “push back” from staff may result in rejection of the recovery and IPC philosophies as it represents such a drastic change from current practice.  Many of the behaviours and values currently held by staff are not reflective of those required for the successful adoption of the values inherent in the recovery philosophy and IPC. Clearly, the cultural context at WMHC will have a significant impact on the successful implementation of The Shared Journey project.  As a result of organizational culture similarities, it is anticipated that the Baycrest strategy will provide insight into successful techniques that bring about significant organizational culture change at WMHC. 

Organizational Readiness and Implementation Strategies
As discussed earlier, adoption of the recovery philosophy extends well beyond written policy statements.  Similar to any large scale change initiative, preparation and process are critical success factors for implementing the recovery philosophy and IPC initiatives.  Organizational change literature has established that workplace culture, leadership and motivation are critical elements for any change process. However recent evidence has also correlated the following variables with successful change initiatives: the duration of the project and benchmarking for success, the integrity of team members, staff and leadership commitment, and the amount of effort the change demands from staff (Sirkin, Keenan, & Jackson, 2006).  This emphasizes the importance of planning in order to embark on a successful organizational change initiative. Grol & Grimshaw (2003) recommend proper preparation to engage in a change process involving patient care.  Key steps include involving the relevant people; developing a proposal for change that is evidence based, and feasible; studying the main difficulties in achieving the change; and selecting a set of strategies and measures at different levels (individual, team, and organization) that are linked to identified problems. The importance of defining indicators for measurement of success and monitor progress continuously or at regular intervals is emphasized.

Organizational change management strategies are critical considerations; however, approaches specifically related to the recovery and IPC systems issues must also be considered.  Farkas, Ashcroft, & Anthony (2008) offer specific strategies to facilitate the introduction of the recovery philosophy within organizations.  They recommend enabling a culture of recovery through the implementation of values based practice, obtaining commitment from staff and administrators, and building capacity through staff skills training and knowledge development.  Anthony & Ashcroft (2008) offer strategies for overcoming resistance to the adoption of recovery, including encouraging all clinicians to participate in planning for recovery, and integrating trained peer support workers to work alongside staff to represent examples of hope and recovery. New developments are emerging to address the challenges related to transfer of training and include an emphasis on values-based interventions for clinicians (Crowe, Couley, Diaz, & Humphries, 2007; Oades, Crowe, & Deane, 2007).  Outcomes from their preliminary research should be interpreted with caution as the evaluative tools used by Crowe et al. (2006) are subject to sources of error, including bias in responding and measurement bias as clinicians are likely to provide socially desirable answers and may not have an accurate perception of the recovery-oriented services they provide.  The psychometrics of each proposed measure, the Collaborative Recovery Knowledge Scale and the Staff Attitudes to Recovery Scale, are compared with the Recovery Attitudes Questionnaire (RAQ-7).  However, the RAQ-7 does not establish strong reliability as Chronbach’s alpha coefficients ranged from .64 to .70, the low end of acceptable limits for research (Streiner & Norman, 2003).  Each measure establishes face and content validity but fails to report on longitudinal validity, a key indicator that changes in behaviour have been adapted over time.  This emerging research is encouraging; however, it reinforces the need for stronger evaluative measurement tools to demonstrate transfer of training.  Clearly, disseminating the best methods to implement change, monitor, and evaluate effectiveness is important for the success of the Shared Journey Project.

Systems structures must be adapted to support a new approach to collaboration and reinforce change efforts.  The new processes may include implementing new policies, procedures, and strategies that recognize and reward partnership efforts, and performance appraisals that recognize partnership-building efforts (McWilliam et al, 2003).  Strategies for implementing IPC and expanding collaboration within WMHC include: creating opportunity for interprofessional education, partnerships, and relationship building (Bronstein, 2003); developing routine processes for feedback, negotiation, and conflict management; and providing opportunities for informal relationship building, encouraging a spirit of fun, and inviting participation (Gerardi & Fontaine, 2007).  Creating and sustaining a change in practice will require strong leadership and a highly structured, organized approach to implementation (Barrier, Anson, Ording, & Rogers, 2002).  Clearly, implementation strategies must also be sensitive to the tensions between recovery and traditional pathological models if change efforts are to be successful.  The shared values and underlying philosophical approach to recovery and IPC will act as enablers in their implementation; each approach reinforces the values and beliefs of the other. 

Implications for Rehabilitation Practitioners
The evolutionary nature of healthcare will continue to have a significant impact on the rehabilitation practitioner.  In Ontario, healthcare system changes coupled with mental health reform will drastically change the demands and expectations placed on clinicians.  With the implementation of recovery and IPC the rehabilitation practitioner will engage in a collaborative process with team members and patients within a system that promotes and encourages all health disciplines to share their expertise.  Interactions with patients will transform from an “expert” clinician approach to a partnership that includes the patient as an equal participant in information sharing and decision making.  The rehabilitation practitioner will adapt to new organizational structures, changes to professional autonomy, and new approaches to teamwork (Ginsburg & Tregunno, 2005).  In order to engage effectively in IPC, the rehabilitation practitioner must understand their full scope of practice and be competent in their skill set (McCallin, 2006).  The emphasis on teamwork and team collaboration will require interpersonal skills, effective communication, and ongoing reflective practice (Barry, 2007).  The rehabilitation practitioner will engage in shared leadership practices with their colleagues, and extend shared leadership with their patients.  Assessments and interventions will be conducted from a strengths-based perspective ensuring client centredness and effective use of clients’ personal resources. Interventions will need to be conveyed in a manner that is easily understandable for patients and colleagues to ensure continuity of care and follow-through.  Documentation will encompass client’s strengths and resources instead of focusing on symptoms and pathology. Clinical records will also become a forum for all healthcare providers to “contribute their personal and professional knowledge of the client on a regular basis” and become “…an evolving collection of information about the client’s holistic health status” (McWilliam et al., 2003, p.370). Patient care will be provided by all disciplines working from, and contributing to, the same plan of care.  To support this type of collaboration from a theoretical perspective, new models of IPC are being developed (Bronstein, 2003; McWilliam et al., 2003).  The rehabilitation practitioner must show “respect for other disciplines, a willingness to share information and listen to others’ opinions, and tolerate disagreement” (Reid Ponte et al., 2007).  As a result recovery and IPC will support the LHINs mandate and mental health reform in Ontario, while enhancing the role of the rehabilitation practitioner by encouraging true collaboration.  

Not only will clinical practice be transformed, but the way that clinicians study and train will also change.  New approaches to interprofessional education have been incorporated into academic training, and initiatives for continuing IPC education have increased in recent years (Barr, 1998; Roberts & Priest, 1997).   A review conducted by the Cochrane Collaboration has found a lack of strong evidence supporting the effectiveness of current methods of inter-professional education; therefore, new methods of teaching and instruction coupled with more rigorous studies will also have an impact on the rehabilitation practitioner (Zwarenstein et al., 2007). Collaboration among professionals will be reflected in research initiatives as the integration of different disciplinary perspectives will add richness and depth to our inquiries (McCallin, 2006).  Recovery research will bring professionals together in an approach that expands traditional notions of services, outcome measures, and standards of evidence (Solomon & Stanhope, 2004).  Best practice guidelines will be enhanced as contributions across disciplines will promote mutual understanding and better partnering (McWilliam et al., 2003).

In order to promote IPC, Health Canada (2007) has called for legislative reform to address the current practice of assessing negligence on the level of the individual, and to develop a framework to better support IPC and collaboration.  This will provide opportunity for rehabilitation practitioners to participate in a process that will restructure regulatory policies and legislation, thus shaping the future of their practice.  As a result of recovery and IPC, the rehabilitation practitioner will have to engage in reflective practice and maintain ongoing assessment of values, both personal and professional, in order to provide optimal care.  The rehabilitation practitioner will experience large-scale system changes and will have opportunity to engage in a more efficient and effective process when delivering healthcare to Ontarians.

Conclusion
Undoubtedly, we live in an age of continuous quality improvement and healthcare system advancement.  Ontario’s initiative to strengthen the delivery of mental health services can employ the shared values and philosophies of recovery and IPC to provide effective, efficient services in the future.  In order to improve frontline clinical care, WMHC will need to address organizational culture issues and engage in its own recovery process prior to facilitating the recovery of individual patients. A successful change initiative must assess workforce readiness to embrace the recovery philosophy, a comprehensive change management strategy, and a long-term sustainability plan that will act as a catalyst for system improvement. Future research is needed to better understand barriers when translating knowledge from policies and procedures to behavioural changes in the frontline staff.  Strategic initiatives that help to ensure healthcare organizations are ready and able to sustain changes must also be developed.  The shared values and beliefs introduced by recovery and IPC will facilitate the development of newer ways of thinking, and may contribute to yet another paradigm shift in our ongoing efforts for system improvement in Ontario.


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