Interprofessional education-relevant accreditation standards in Canada: a comparative document analysis

Increasing evidence suggests that interprofessional collaborative practice (IPCP) ultimately leads to enhanced recruitment and retention of healthcare professionals, improved patient-centered care health outcomes, and reduced healthcare costs, thereby resulting in improved efficiency and quality of healthcare services [1‐4]. The Centre for the Advancement of Interprofessional Education (CAIPE) defines interprofessional education (IPE) as “occasions when members or students of two or more professions learn with, from and about each other to improve collaboration and the quality of care and services” ([5], p. 1). It is postulated that successful and sustainable delivery (development, implementation, and evaluation) of interprofessional education (IPE) has the potential to lead to meaningful IPCP involving collaboration-ready health professional¹ graduates [7‐9]. As such, the World Health Organization (WHO, [10‐15]), among others, has been promoting IPE as an important and innovative pedagogical approach to ultimately improving healthcare services and outcomes by addressing the global workforce crisis [4].

The sustainable delivery of both IPE and IPCP, however, is complex, requiring interactions and influences among various micro-, meso-, and macro-level factors (Fig. 1) within and between both academic and healthcare systems [16]. Simultaneous, purposeful and deliberate consideration of these factors is important for sustainable delivery of IPE and IPCP and involves the adoption of common IPE language across health professions; the use of theoretical underpinnings to guide the delivery of IPE; scholarship that informs decision-making and continuous quality improvement of IPE; and the adoption of a collaborative approach to incorporating IPE language in the accreditation and regulation² of the health professions [17].

The presence of IPE language in the accreditation mechanisms (macro-level) can only be significant if it ensures academic programs are accountable and responsive to sustainable delivery of IPE [19, 20]. Furthermore, the WHO’s National Health Workforce Accounts (NHWA) system, specifically Indicator 3-06 [13], is a significant global driver of IPE accreditation. Through enabling IPCP, IPE accreditation is a small, albeit significant, step towards achieving several education and health-related Sustainable Development Goals [21] aimed at ensuring inclusive learning opportunities and promoting well-being for all. IPCP also addresses two of the WHO’s triple billion targets: “1 billion more people better protected from health emergencies” and “1 billion more people enjoying better health and well-being” ([14], p. 1). Despite these efforts and initiatives to influence IPE accreditation and, in turn, the sustainable delivery of IPE and IPCP, integration of IPE in the accreditation mechanisms of the health professions remains fragmented globally [22]—even in countries, where IPE accreditation is relatively sophisticated (e.g., Australia, Canada, the United States).

Within the Canadian context, analyses of the accreditation standards documents for six Canadian health professions revealed that, in 2005, only pharmacy explicitly addressed IPE in their accreditation standards [23, 24]. At the time, Curran et al. [23, 24] concluded that accreditation mechanisms in Canada neither promoted nor fostered IPE. A similar comparative analysis of ten health professions in the United States found that, with the exception of pharmacy, there was an inadequate emphasis on IPE culture as well as an overall lack of collaborative efforts by accrediting organizations in the United States to adopt common IPE language [25]. Similarly, a recent review in Australia demonstrated inconsistencies and inadequacies in standards that held academic programs accountable to providing evidence of IPE [26]. The findings from these studies [23‐26] raise concerns that even when IPE language exists within the accreditation standards, not holding academic programs accountable to those standards may lead to minimal sustainable delivery of IPE and ultimately lead to graduating a health workforce that is inadequately prepared for IPCP.

A significant turning point for Canada in terms of IPCP was the Interprofessional Education for Collaborative Patient-centered Practice (IECPCP) initiative (2004–2011) funded ($21 million) by the Government of Canada. A portion of these funds were used to support the establishment of the Canadian Interprofessional Health Collaborative (CIHC), which among its many deliverables included the now globally recognized National Interprofessional Competency Framework [27]. This framework, which aligned with the WHO’s Framework for Action [11], identified six interprofessional competency domains: (1) Interprofessional communication; (2) Patient-centred care; (3) Role clarification; (4) Team functioning; (5) Interprofessional conflict resolution; and (6) Collaborative leadership, to inform the interprofessional knowledge, skills, and dispositions that are required by all health professionals to work collaboratively. The IECPCP initiative further funded the two-phase Accreditation of Interprofessional Health Education (AIPHE) project (2007–2011) [28, 29], making Canada the first country in the world to use a collaborative approach to developing and embedding IPE language spanning the five accreditation standards domains [29] into the accreditation standards of six health professions: medicine, nursing, occupational therapy, pharmacy, physiotherapy, and social work (Table 1).

A more recent case study [30] of the Canadian accreditation standards documents for the same six health professions involved in the AIPHE project [28, 29] found IPE language within the documents for all six professions. This case study, however, neither systematically evaluated the “accountability” of such IPE language nor examined the extent to which such language addressed the accreditation standards domains identified in the AIPHE project [29]. Building on this case study, the intention of the present study was to understand the quality and accountability of IPE-relevant accreditation standards across the health professions. It is expected that this research would be a significant step towards understanding the impacts of IPE on IPCP and ultimately patient health outcomes.

The present study used comparative content analysis [31] to evaluate the accountability of the IPE language currently embedded in 11 Canadian health professions’ accreditation standards documents and examine whether such language spanned the five accreditation standards domains identified in the AIPHE project [29].

For the 11 health professions included in this study, 13 accreditation standards documents [32‐44] and three supporting documents [45‐47] were retrieved. A total of 208 statements within these documents were deemed potentially IPE-relevant. Inter-rater reliability was substantial; concordance between the two raters was 90.38% (188/208). Fleiss’ κ illustrated that there was very good agreement between the two raters, κ = 0.854 (95% CI, 0.757–0.951), p < 0.005. Discrepancies in the remaining 20 statements were resolved through discussion until consensus was reached.

Final categorization of the 208 statements resulted in 77 (37.02%) non-applicable statements, 54 (25.96%) non-accountable statements, and 77 (37.02%) accountable statements. The non-accountable statements were found in the Introduction/Preface (n = 6), Table of Contents (n = 7), headings/subheadings (n = 1), within non-mandatory (e.g., examples, exemplary, and desirable) standards (n = 32), glossaries (n = 4), and appendices (n = 3). A perfunctory examination of the 13 accreditation standards documents revealed that chiropractic, pharmacy, and physiotherapy documents represented nearly 50% (38/77) of all accountable statements, whereas the optometry document contained no accountable statements. Table 6 illustrates the number of categorized statements for each health profession.

Figure 3 illustrates which of the five accreditation standards domains identified in the AIPHE project [29] were addressed in the accountable statements for each health profession. The most common domains across health professions (n = 13) were “Educational program” (n = 10; 76.92%) and “Students” (n = 9; 69.23%). The accountable statements for pharmacy alone spanned four of the five accreditation standards domains, whereas the accountable statements for dentistry, dietetics, and nursing (registered) spanned three of these domains. The domains covered by the other health professions spanned from zero to two domains. Furthermore, it was noted that for eight of the health professions (dentistry, dietetics, medicine (family and specialty subdivisions), nursing [registered], occupational therapy, pharmacy, physiotherapy, and psychology [CNP program]), the accountable statements that addressed “Educational program” made reference to practice-based learning.

Table 7 illustrates a sampling of exemplary accountable statements extracted from the accreditation standards documents spanning the five accreditation standards domains identified in the AIPHE project [29]. See Additional file 1 for all 77 accountable statements.

Finally, only four of the 13 accreditation standards documents (for family medicine, occupational therapy, physiotherapy, and specialty medicine) included a definition of IPE. Family and specialty medicine cited their definitions from the CanMEDS framework [45, 47], which in turn cited the Royal College of Physicians and Surgeons of Canada (RCPSC) [50]. Furthermore, the documents for both occupational therapy and physiotherapy cited adapted versions of the globally accepted definition from CAIPE [5]. Of significance, the definitions from family and specialty medicine excluded a key component for IPE—learning “with, from and about” each other.

In this study, we undertook an assessment of IPE language embedded within the 13 current accreditation standards documents for 11 regulated health professions in Canada. Our analysis revealed that the number of accountable IPE-relevant accreditation standards contained in these documents ranged from zero (for optometry, psychology [CCSP program; CCSP internship; and CNP internship]) to over ten (for chiropractic, pharmacy, and physiotherapy). Nonetheless, we caution against judging the quality of IPE-relevant accreditation standards strictly by the number of accountable statements in each document. The AIPHE project [28, 29] was careful to not mandate a particular structure or content to the standards. Rather, guiding principles involved the adoption of a common lexicon, focusing on the common mandate of IPE as opposed to professional differences, and allowing for flexibility in how each accrediting organization developed their standards and collected their evidence.

That being said, the presence of IPE language contained within “accountable” statements in accreditation standards documents is critical as it provides the accrediting organizations the authority to look for evidence of IPE in the academic programs they accredit and hold those programs accountable and responsive to meeting these standards. The absence of IPE language in the accreditation standards documents for optometry and psychology (CCSP program; CCSP internship; CNP internship) implies a lack of incentive for these programs to deliver sustainable, evidence-based IPE.

Of greater significance than the absolute number of accountable statements, however, was our finding that the accountable standards for most professions spanned only two (“Students” and “Educational program”) of the five accreditation standards domains identified in the AIPHE project [29]. Only the accountable statements for pharmacy spanned four domains (“Organizational commitment,” “Faculty,” “Students,” and “Educational program”). It was reassuring, however, to see that in addressing the “Educational program” domain, eight of the 13 accreditation standards documents reviewed in this study referenced practice-based IPE in one or more accountable statements. To date, there has been limited global emphasis on advancing practice-based interprofessional learning compared to didactic learning. The hypothesis is that practice-based accreditation standards would incentivize innovative practice-based IPE [30].

While emphasis on “Educational program” and “Students” is of obvious importance, a lack of emphasis on the other three domains potentially hinders sustainable delivery of IPE within academic institutions [17]. The D’Amour framework [16] illustrated the micro-, meso-, and macro-level factors that must be addressed when delivering IPE within the educational system. In addition to emphasis on educational programs and student learning, the framework identifies “organizational commitment” and the allocation of adequate “resources” as essential meso-level factors that influence the sustainable delivery of IPE. Furthermore, the framework emphasizes the key roles of “faculty” and faculty development as critical to offering theoretically grounded and evidence-based IPE. At the micro-level, faculty are essential to fostering a culture that enables positive interprofessional learning interactions as opposed to a “hidden curriculum” that fuels stereotypes, miscommunication, and mutual distrust among students of different health professions [51, 52], which, in turn, generates healthcare professionals who are unable to effectively collaborate within an interprofessional team. Hence, incorporating IPE language across the five pillars of accreditation standards domains is imperative. That being said, data supporting the impact of accreditation on the quality of educational programs and further the impact on graduates’ performance in clinical environments, and ultimately on the quality of patient care is complex and our current understanding is limited [53]. Blouin [53] has recently proposed a framework of outcome markers to guide future research in this emerging area.

Furthermore, it was noteworthy that inductive analyses of the accountable statements within ten health professions’ accreditation standards documents in the United States [25] found that the IPE language also spanned five major domains (“IPE inclusion in mission and goals,” “IPE responsibilities of the Dean,” “allocation of budgetary and fiscal resources to IPE,” “IPE inclusion in curricular programs and defined learning outcomes,” and “student competencies”). These categories generally paralleled four of the five accreditation standards domains identified in the AIPHE project [29], with only “Faculty” not addressed in the United States’ analysis. Hence, it seems that the scope of IPE-relevant standards determined by both Canadian and the United States’ collaborative efforts were closely aligned, in essence serving as a validation of the domain categories, and further underscoring the recommendation that implementation of sustainable, evidence-based IPE innovations requires accreditation standards that span all five domains.

It was also noteworthy that in this study, with the exception of family medicine, occupational therapy, physiotherapy, and specialty medicine, most accreditation standards documents failed to provide definitions for IPE—a finding similar to Bogossian and Craven’s findings in Australian accreditation standards documents [26]. The globally accepted definition of IPE is that from CAIPE [5]. To ensure delivery of evidence-based and theoretically informed IPE, it is imperative to have a common understanding across all relevant stakeholders of what IPE is and what it is not [28]. For example, an interprofessional panel presentation to a group of students from various health professions, is not IPE, as this activity comprises one-way exchange of knowledge with no interaction among learners from different professions and, therefore, no opportunities for them to learn “with, from and about” each other. Therefore, the lack of a definition of IPE in most accreditation standards documents and the missing text “with, from and about” from the definitions from family and specialty medicine are concerning and need to be addressed.

The greatest limitation to this study was exclusion of the 31 health professions that did not meet our eligibility criteria. Our findings are limited to the 11 health professions reviewed and can neither be representative nor generalizable to other professions without further investigation. Furthermore, most accreditation standards documents failed to provide definitions for IPE; thus, we could only assume that when they referenced IPE language, they were all referring to IPE as defined by CAIPE [5]. Finally, this study examined the accreditation standards documents for IPE-relevant statements to which accrediting organizations can hold their respective academic programs accountable, but did not examine types of evidence provided by the academic programs in meeting these standards across all five accreditation standards domains [29]. A team of CIHC researchers is currently conducting a national survey to address this research objective.

This research provides an informative update on the incorporation of IPE into the accreditation standards of a large number of health professions in Canada. Though evidence of the real-world impact of such standards is scant, and measurement and attribution of team performance is quite challenging, this study can be seen as providing early evidence of the relative value of IPE as judged by national leadership in a large number of health professions.

The AIPHE project’s [28, 29] approach that aimed to embed IPE language into the accreditation standards for six Canadian health professions academic programs appears to have directly or indirectly influenced several other Canadian health professions not involved in AIPHE. The standards for chiropractic and psychology are cited as having a publication year of 2011―the same year as the AIPHE guidelines, thereby suggesting that such professions may not have had the opportunity to review their guidelines and incorporate adequate IPE language before they last published an update to their standards. More interestingly is that the professions (e.g., optometry and undergraduate medicine) with the least thematic coverage are among those that have more recently updated their standards.

Furthermore, this study found that IPE language in the accountable statements within a majority of health professions’ accreditation standards documents were mostly relevant to “Students” and “Educational program.” The emphasis within the “Educational program” on practice-based IPE was especially noteworthy. The authors suggest these standards could be even more comprehensive and explicit. The lack of emphasis on “Resources” and “Organizational commitment” raises concerns regarding sustainable delivery of IPE within any given institution. Furthermore, the lack of emphasis on “Faculty” raises concerns about the quality of IPE being offered. To enable evidence-based IPE and IPCP, it is our recommendation that all relevant stakeholders including accrediting organizations and educational and healthcare systems in Canada and elsewhere, adopt a common definition of IPE—the most widely accepted definition provided by CAIPE [5]. We assert that the adoption of the findings and exemplary IPE-relevant accountable statements highlighted in this paper will be of global relevance, especially for those countries where accreditation and more specifically, accreditation of IPE, are still emerging.