The Native Healthcare Engineering Internship: Interprofessional Approaches to Improving Rural Healthcare

Industry and engineering accreditors alike recognize the need for engineers who function well on interdisciplinary teams. To meet this need, undergraduate engineering programs often include project-based course work that brings a variety of engineering disciplines together for work on an engineering design problem. Studies show these courses increase the diversity of ideas and styles that engineering students are exposed to during their education. However, educators must also recognize that merely bringing different engineers together is a poor representation of the groups with which engineers must work collaboratively while in industry. Montana State University has a lengthy track record of developing graduate interprofessional education between the colleges of engineering and nursing. A new program, the Native Healthcare Engineering Internship, was recently piloted to expand this experience to undergraduate students. The program partners undergraduate engineering and nursing students to work with industry in order to improve the operations of rural healthcare centers in Montana. Through this program, students not only gain experience working on an interprofessional team, they also work to address key challenges facing our nation and Montana. The costs of the health care system in the United States have rapidly become a critical national issue. Health care spending currently absorbs over 17% of GDP, nearly twice the average of the 34 OECD member nations and nearly 1.5 times the next highest country. While prior research has generated meaningful improvements in health care delivery, the vast majority of this activity focuses on improvements in large urban centers, which has placed “rural communities . . . at the margins of the health care quality movement [with] most quality initiatives . . . not directly applicable to rural health care settings.” This work explores the design of the internship program, the challenges of interprofessional education and approaching improvement projects in rural healthcare settings, and the benefits the partner organizations and students received from the experience. Introduction While rural health care systems serve over 50 million Americans (Morris & Committee on Homeland Security and Governmental Affairs, Subcommittee on the Efficiency and Effectiveness of Federal Programs and the Federal Workforce, U.S. Senate, 2013), these areas of health care delivery are generally underserved by the research community and present meaningful opportunities for improvements (Paez, Schur, Zhao, & Lucado, 2013). This issue is especially true in the healthcare systems in Native communities. In order to help address these needs, while providing a vehicle to improve recruitment and retention of American Indian / Alaska Native (AI/AN) students at Montana State University (MSU), a pilot program that partnered undergraduate engineering and nursing students was created, the Native Healthcare Engineering Internship (NHEI). The NHEI is a pilot program to improve operations in rural healthcare facilities, with a focus on those serving AI/AN populations. The program funded the summer employment of two AI/AN undergraduate students, one from Nursing and one from Industrial and Management Systems Engineering, to perform process improvement projects at rural healthcare facilities in Montana. The program sought to achieve several objectives: 1. Provide an opportunity to improve the retention and success of AI/AN students by employing one engineer and one nursing student in mentored research projects serving the AI/AN healthcare system within Montana. 2. Develop new research partnerships with AI/AN serving healthcare systems that build on the success of ongoing work with rural healthcare systems throughout the state. 3. Improve the ability of both nursing and engineering students to successfully work in an interprofessional setting. 4. Improve the operations of AI/AN serving healthcare systems by performing engineering process improvement projects. This paper focuses on the work completed in support of Objectives 3 and 4, including student and client feedback that indicate the relative effectiveness of the program in these areas. Background The costs of the health care system in the United States are rapidly becoming a critical national issue. Recent studies show health care spending currently absorbs over 17% of GDP, nearly twice the average of the 34 OECD member nations and nearly 1.5 times the next highest country ("OECD Health Data: Health care resources," 2013). This increasing burden on the U.S. economy is a key driver for a great deal of the research activity trying to improve the effectiveness and efficiency of the nation’s health care delivery. As evident by increasing numbers of publications, a key activity area is the application of engineering management approaches to the work of health care delivery (e.g. Moody & Burtner, 2016; Schell & Kuntz, 2013; Sobek, Claudio, & Bischoff, 2012; Sobek & Lang, 2010; Waliullah & Schell, 2013). Engineering approaches, including Lean, Six Sigma, and others, are finding widespread adoption in health care because the approaches can be highly successful in improving operations and transforming care delivery (Grossmann, Goolsby, Olsen, & McGinnis, 2011). While prior research has generated meaningful improvements in health care delivery, the vast majority of this activity focuses on improvements in large urban centers, which has placed “rural communities . . . at the margins of the health care quality movement [with] most quality initiatives . . . not directly applicable to rural health care settings” (Quality Through Collaboration: The Future of Rural Health Care, 2005, p. ix). This relative lack of attention is further complicated by the fact that the challenges associated with rising costs and delivery of quality care are different, and often even more acute, in rural locations. Rural Americans face a unique combination of factors that create disparities in their care delivery such as: fewer physicians per capita, generally poorer residents with greater reliance on federal support programs, lower rates of employer-provided health care coverage, and lower Medicare payments forcing closure of many small locations (Organisation for Economic Cooperation and Development (OECD), 2013). Due to their remote nature, even greater percentage of at-risk population and substantial financial challenges, the systems serving AI/AN are often in even greater need of quality improvement support (Cunningham, 1993; Gryczynski & Johnson, 2011). Addressing the challenges and opportunities of the changing and increasingly complex healthcare environment will require new approaches by inter-professional teams working together to solve multi-faceted system and population-based problems that reach beyond the scope of a single discipline (Institute of Medicine, 2005). Engineers skilled in process improvement initiatives are invaluable members of the healthcare team. Together with point-ofcare partners, this type of team is well positioned to assess the need for change, design and implement improvements, and then evaluate their effectiveness. In 2005 the National Academy of Engineering (NAE) and the Institute of Medicine launched a study intended “to bridge the knowledge/awareness divide separating health care professionals from their potential partners in systems engineering and related disciplines” [i.e. engineering management]. The study recommended “a strategy for building a vigorous partnership between engineering and health care through cross-disciplinary research, education, and outreach” (Building a Better Delivery System: A New Engineering/Health Care Partnership, 2005, p. 2). The NAHI program incorporated this strategy by expanding the expertise represented in the student team beyond engineers. By involving students and faculty from both engineering and nursing, assigning them to an interdisciplinary team and having the teams work together with health care professionals at the partner sites, the NAHI sought to further promote the interdisciplinary partnerships critical for successful research efforts in health care delivery. Program Overview This project funded a one-year pilot to explore the impact of mentored research, interdisciplinary collaboration, and project work that gives back to the AI/AN community on retention of at risk AI/AN students currently enrolled at MSU. Student activities were broken into four distinct phases during the ten week internship. As outlined in Figure 1, these phases are designed to start students in a highly supported research environment and gradually move participants toward greater independence in their research efforts. The NHEI builds on the success of the ongoing Rapid Improvement Internship led by members of the MSU Industrial Engineering Faculty. Over the past six years Rapid Improvement Internship has successfully delivered projects focused on process improvement to over 25 Critical Access Hospital sites and provided twelve engineering students with the opportunity for hands on learning about how to improve healthcare. Phase I – Preparing for Interdisciplinary and Cross Cultural Research in Healthcare In this phase students participated in a variety of seminars and began exploratory work on their training project. Training seminars gave students a solid foundation in core areas of process improvement in healthcare, topics included a general introduction to healthcare process improvement, working with other professions, understanding healthcare processes, designing and testing process improvements, and data collection methodologies. Seminars were led by engineering faculty. This phase concluded with the cohort participating in seminars on process improvement tools and leading Kaizen events. Students from the NHEI project will complete both Phase I and Phase II of the program together with students from the Rapid Improvement Internship program. F