Caring Headlines - May 23, 2002 - Nurse Week

Part travelogue (Mt. Kilimanjaro), part Entertainment Tonight (video clips of The West Wing), and part game-show nostalgia (re-enactment of The Family Feud), senior vice president for Patient Care and chief nurse, Jeanette Ives Erickson’s Nurse Week presentation was part tribute to the excellence of MGH nurses and part unabashed fun!

Teamwork was the order of the day, in word and deed. Following Ives Erickson’s presentation, nurses from the PACU and ED participated in a revival of the old TV game show, The Family Feud, the likes of which you’re not likely to see again within the walls of MGH. Questions were designed to test participants’ knowledge of recognition, professional practice, communication and retention within the department of Nursing. The game spotlighted the need to work together as a team in order to succeed. And if laughter and applause were any indication, the demonstration was a roaring success!

Punctuated by photographs, slides, video clips and television newscasts, what follows is the text of Ives Erickson’s presentation, entitled, "MGH Nursing: the Journey of a Lifetime" (edited for space).

While this week is a formal celebration of the contributions nurses make, I would be remiss if I failed to mention that a lot has changed since our last Nurse Week celebration. The world has changed. The contributions we make have changed. Our practice has changed. And our patients have changed.

Since September 11th, MGH nurses on our DMAT and IMSURT teams have applied their skills in a country they once hoped would never need them. These nurses were able to focus on their work at Ground Zero and at the Cornell Burn Unit in New York because of the support they got from you, their colleagues.

You did whatever it took to fill in the shifts left vacant by your peers. Our Emergency Department nurses have teamed up with colleagues in the community creating systems to keep us safe. All MGH nurses are aware that we have fewer patients from around the world. And we have all learned that the lives of those we work with are precious. So today, I want to talk about teamwork.

It is the people of MGH that make this a world-class institution. It is because of you, individually and collectively, that being a nurse at MGH is the journey of a lifetime.

"Journey of a lifetime" is a phrase we borrowed from the Omni Theatre film, Kilimanjaro: to the Roof of Africa. We selected this film because of the comparisons that can be made between the climbers of Kilimanjaro and the nurses of MGH.

Like MGH, Kilimanjaro is a landmark of beauty and mystery, revered like no other. Kilimanjaro and MGH are extraordinary, spectacular, and quite unique. Kilimanjaro means, ‘mountain of greatness’ (note the M and the G).

Like climbing Kilimanjaro, the knowledge and skills required to be a nurse at MGH are varied and complex. Individuals may come to the mountain and to MGH, but it is a team that ensures the success and safety of the team members.

A team is a group of people with complementary skills, committed to a common purpose, goals, and approach for which they hold themselves accountable. You cannot build a great team without great team players.

John Maxwell, in his book, The 17 Essential Qualities of a Team Player, cites what it takes to become the kind of person every team wants.

Every day we see the phenomenal outcomes of high-functioning teams at MGH. In our collaborative governance structure the essential characteristic is a team approach. Collaborative governance has become an important force at the MGH.

Our Clinical Recognition Program is the result of several teams (the Professional Development Committee; the Implementation Steering Committee; and the newly-formed review board) working together to pave the way for this new culture.

The Staff Nurse Advisory Committee provided invaluable input into the creation of the MGH Nursing Image Campaign. Their candor, creativity, and ability to articulate what it’s like to be a nurse at MGH contributed to a campaign that will differentiate MGH nursing from the competition. Each ad in the campaign has the tagline: ‘Simply the Best.’

I’d like to talk about the 7 essential skills of teamwork. These are the skills you would see if you observed a high-functioning team in action:

And there is another important ingredient in any successful team. It is impeccable leadership.

There is a quote from The West Wing that I particularly like. It was said by Martin Sheen in his role as President while addressing his White House team. He said, "What will be the next thing that challenges us, that makes us go farther and work harder?"

As we continue on our "Journey of a Lifetime" as MGH nurses, I ask the same question of you.

What will be the next thing that challenges us? Together, there’s nothing we cannot accomplish.

I’d like to end with this quote from Bill Clinton. And I want you all to substitute the words, ‘chief nurse’ where he says ‘President,’ because this is how I feel about all of you.

"Nothing the President does is possible without the talent, devotion, and hard work of the staff and the cabinet. I think it’s very important that every President acknowledge, and the American people understand, that it takes teamwork; it’s a group enterprise. The President needs to be responsible for the mistakes made on the big calls, but a lot of the really good things that happen day in and day out are because of the people who work here."

In the kick-off presentation of Nurse Recognition Week, Joan Fitzmaurice, RN, PhD, director of the Office of Quality & Safety, moderated a multi-disciplinary panel discussion designed to simulate the kind of investigative discourse that occurs when an incident report is filed following an adverse event.

Panelists representing Nursing, Respiratory Care, Medicine, Risk Management, Biotechnology, and the Office of Patient Advocacy, were given a brief summary of a hypothetical adverse event that could occur in ‘any hospital USA.’ The session was unscripted; audience members were given a ‘fly-on-the-wall’ view of the investigative process as it unfolded among panelists.

Patient X went for a diagnostic test as part of his work-up. He left the unit at approximately 8:30am. He had a trach tube to a mask; the cuff was inflated. Tube feeding had been turned off at 7:30am.

Patient X was in the waiting area when his wife witnessed him vomiting. He was suctioned, experienced extreme respiratory distress, and a code was called.

Following the reading of the incident, Fitzmaurice asked questions of panelists in an attempt to establish a more detailed understanding of the events that led to the code. Each question triggered more questions, and a much broader description of the incident was soon revealed. Discussion focused on precautions taken, documentation, communication, plan of care, medical history, nursing assessment, level of experience of staff involved, technological concerns, policies and procedures, interventions, and much more.

The framework for analyzing and identifying contributing factors centered around:

Throughout the discussion, Fitzmaurice stressed that the purpose of the investigative process is not to assign blame, but to learn from the events, identify opportunities to improve systems, and implement strategies to reduce risk in the future. More often than not, said Fitzmaurice, adverse events are the result of multiple factors not the mistake of any one person. Frequently, incidents result from a breakdown in systems, indicating that a change in policy is called for.

Switching from ‘any hospital USA’ to MGH, Fitzmaurice said, "Staff need to know that this is a safe environment in which to explore these issues. Close examination of adverse events is essential to minimizing the risk of future events. And that can only be done effectively in a blame-free environment."

Collaborating to improve pain assessment:
a multi-disciplinary thoracic oncology team
implements JCAHO pain standards in ambulatory setting

Unit nurse leader, Barbara Cashavelly, RN, MSN, and nurse practitioner, Jennifer Tenhover, RN, MS, present- ed the results of their (and co-investigators: Karen Sommer, RN, MSN; and Joan Agretelis, RN, PhD) research study, entitled, "Collaborating to improve pain assessment: a multi-disciplinary thoracic oncology team implements JCAHO pain standards in ambulatory setting."

The purpose of the study was to determine if implementation of JCAHO pain standards would impact the average pain rating of patients in the ambulatory thoracic oncology setting.

They began by defining pain as, "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." Since methods of assessing pain were not standardized across the practice setting, the research team saw this an opportunity to implement JCAHO pain standards and measure the results against a baseline pain-scale rating.

The study consisted of two phases, each 11 weeks in duration. A key aspect of the study was the education and participation of medical assistants in obtaining pain-scale ratings from patients.

The first 11-week period was spent collecting baseline data. Medical assistants obtained pain ratings from all thoracic oncology patients using a Visual Analogue Scale (VAS). This information was not entered into the patient’s chart (but for patients with a pain rating of 5 or greater, it was recommended that they tell their physician or nurse practitioner).

The second 11-week period was exactly the same except the JCAHO pain-standards were implemented as "the fifth vital sign," entered into the patient’s chart, and recorded in a database.

Average pain scores from both phases were calculated and compared. The study showed that pain-management awareness was increased with identification of practice variations.

The use of respite care services by parents of children with chronic illness and disability

Nurse researcher, Nancy Terres, RN, PhD, of the Graduate Program in Nursing at the MGH Institute of Health Professions, presented the results of her research study, entitled, "The use of respite care services by parents of children with chronic illness and disability."

The study examined the use of respite-care services by parents of children with chronic illness and disability:

Terres defined respite care as, "a formal support service designed to give family members temporary, short-term relief from the care of a child with chronic illness or disability."

The study was exploratory, using a cross-section of eligible parents. Criteria were established to determine which families were eligible:

Interviews were conducted by mail (questionnaires), by telephone, and in person. A booklet entitled, Parent Survey on Respite Care was sent to participating parents along with a cover letter (stamped return envelope, and pencil). A small stipend of $25 was paid upon return of completed questionnaires.

Of the 70 parents who completed and returned questionnaires, 38 reported using respite care; 32 said they did not use respite care. Parents of children with medically complex care needs reported the highest degree of difficulty obtaining and maintaining respite care.

Children in families that used respite care were significantly older than non-users, and more likely to have speech disabilities, visual impairments, and developmental delays.

There were no significant differences between user and non-user families in terms of family functioning, social support, or parent coping styles.

The study revealed no substantive differences/improvements in the availability of respite care since a previous survey conducted in Massachusetts nearly two decades ago.

Despite numerous surveys and research studies aimed at empowering families to use respite care, the overwhelming attitude of parents still seems to be, "We could use a lot more help and a lot less empowerment."

Delivering the Research Day presentation, Barbara Wolfe, RN, PhD, director of the Research Collaborative at The Institute for Nursing Healthcare Leadership, spoke about using nursing research to expand our base of knowledge and improve our ability to provide quality patient care.

"Why research?" asked Wolfe as she showed a picture taken around the turn of the century. The picture showed a patient, wrapped in a bed sheet from head to toe, being doused with cold water by a healthcare provider.

"To look for more humane and effective ways to care for our patients," she said.

Research is happening at the national level in a variety of venues, including The National Institute of Nursing Research, the Institute of Aging, The Genome Project, biomedical imaging, complementary and alternative medicines, and in many other forums.

Wolfe noted that federal involvement in nursing research has come a long way since 1946. A brief summary of some of the national studies that have been conducted over the past few years include:

When we look at how research funding is allocated and which research institutes receive the most money, The National Institute of Nursing Research is close to the bottom; so there is much lobbying to be done in order to get the funding necessary to conduct valuable nursing research.

Wolfe noted that Boston is one of the ‘richest’ cities in terms of dollars allocated for medical research. MGH is the #1 recipient of medical research funding; and the top 5 recipients are all in the greater Boston area.

Visibility continues to be an issue for nurse researchers. Conducting research is essential, but sharing the results of research studies with the healthcare community at large must also be a priority. Wolfe suggested that awards, clinical scholarships, speaking engagements and mentoring programs are all opportunities to share nursing research.

Looking to the future, Wolfe foresees nursing research playing an important role in:

The Power of Nurses:
as observed by the Massachusetts Commissioner of Public Health

The Commissioner of Public Health for the Commonwealth of Massachusetts and former MGH Hematology-Oncology fellow, Howard Koh, MD, MPH, gave an informative and entertaining presentation on, "The Power of Nurses," Tuesday, May 7, 2002.

Koh began by explaining that the department of Public Health is like a "merger" of medicine and politics. The goal is to bring the leaders from medicine and politics together to try to craft public policy in a way that helps all people in the Commonwealth fulfill their health potential.

In a presentation rich with personal anecdotes and professional revelations, Koh spoke on a myriad of topics:

Koh ended with an a cappella serenade to all the nurses in the audience. In exceptionally good voice, he sang, "Did you know that you’re my hero...

Private practice nurse practitioner, Hollie Noveletsky, RNC, PhD, opened her presentation, "The role of reflective practice in advanced practice nursing," with a broad definition of reflection. Said Noveletsky, "Reflection allows clinicians to examine what they bring to an interaction and what others bring to an interaction that either enhances or hinders their ability to connect. Reflection allows us to identify ideal practice so that we can work toward achieving it."

Noveletsky noted that there is a difference in the way novice and more experienced clinicians reflect. Where novice reflection tends to be more of a retroactive process, looking back on past interactions, expert nurses have the ability to reflect almost as events are occurring. It is the difference, she said, of reflecting on practice, versus reflecting in practice.

Using Johns’ Model of Reflective Practice, a framework for reflection crafted by British nurse, Christopher Johns, Noveletsky shared what Johns calls the eight framing lenses of reflective practice:

The framework is based on the belief that knowing yourself is a prerequisite to caring for others. Within each of the perspectives, or framing lenses, there is a series of cues to help clinicians foster self-discovery and personal growth. The cues have to do with:

Noveletsky spoke of a study conducted with two groups, one of which used a traditional method of sharing clinical information, discussing encounters and concerns, and keeping a journal of clinically-related issues. The other group engaged in a reflective sharing of clinical interactions and kept a journal using Johns’ Model of Reflective Practice.

The study revealed that those who participated in the traditional group tended to focus on role-development, attainment of goals, and their journals were broad and general in nature. The reflective practice group focused on issues of context, values, relationships with patients, and their journals were more personal and introspective.

The reflective practice group was able to expand their insight into their own values and build on their experiences. They reported a better sense of ‘being known,’ and a greater ability to connect with others.

Noveletsky stressed that reflective practice is an ongoing process of striving to achieve your ‘ideal practice.’ She cautioned clinicians not to use reflection as a means of finding fault with your current practice, but as a tool to become more aware of your strengths and weaknesses, to help you continually work toward the ideal.

Reflection on practice will start to become reflection in practice as you become more comfortable in self-reflection. Noveletsky suggested that reflection in practice is not a clinical tool that you pick up and put down as needed; it is a way of life that you carry with you wherever you go.

You may never reach your perception of ‘ideal practice,’ but you can continue to strive for it through reflective practice.

"When we study, we learn what is ideal, what is optimal. In life, we sometimes fall short of the ideal. This semester reminded me that it is part of my contract with society and my profession to always strive for ideal practice. And if my practice is not ideal, then to figure out to the best of my ability, why not, and make an honest attempt to correct it."

My name is Ann East- man. I have been a nurse for 27 years. I’ve had many different experiences with patients. When I look back, some of my experiences make me laugh, some make me cry, and some just make me shake my head and wonder. Each is unique and different. I had cared for patients who had lost loved ones while hospitalized before, but with Ms. Q, I was directly involved in conveying the news of the unexpected death of a loved one.

When I got report on Ms. Q on Sunday morning, I learned the basics about her hospitalization and our interventions so far. She was a middle-aged woman from the South who had needed a tracheal repair secondary to tracheal stenosis. This meant she would have a variety of needs. She would require close observation of her respiratory status, monitoring for tracheal edema, and encouragement to rest her voice and participate in pulmonary hygiene activities. I knew she would need encouragement to ambulate and ‘get moving.’ Pain could also be an issue since her chin (as is typical in this type of surgery) had been loosely sutured to her neck to keep her head in a forward position to prevent strain on her tracheal anastomosis. This position can put a lot of tension on the muscles at the back of the neck and can be uncomfortable. She was also likely to have some pain at the incision line across her neck. I would need to assess her nutritional status and her swallowing capabilities. She would be advanced to a clear-liquid diet and would need supervision to be sure she could swallow with her head in this position. Further, we needed to discuss her history of diabetes and her medications (which included medications for neuropathic pain, diabetes, irritable bowel syndrome and depression). With all these issues in mind, I began to plan her care.

Then, to complicate matters even more, I was informed by the night staff that they’d just gotten word that Ms. Q’s mother had passed away.

Beth, a friend of Ms. Q, had accompanied her to Boston and was staying at a hotel nearby. I felt it was too early in the morning to call Beth; I decided to wait until about 9:30. I also decided I wouldn’t discuss the matter with Ms. Q until her friend could be with her. I was prepared to revise this plan if too much time went by, or if I was unable to reach Beth.

Next, I spoke with the resident who would be speaking with Ms. Q’s surgeon to be sure there were no medical reasons not to inform Ms. Q of her mother’s death. The surgeon had no reservations about going ahead.

I went in to see each of my patients to check vital signs and give meds. When I met Ms. Q, she was very formal with me calling me, "Ma’am," despite introducing myself by my first name. She seemed a little stiff and distant. I wasn’t feeling a comfortable relationship here, and I knew this could complicate things when it came time to give her the news of her mother’s death.

I watched for visitors arriving on the unit, hoping to head off any company Ms. Q might have. But I became involved in an emergent situation elsewhere on the unit and didn’t see Beth arrive. I knew asking her to step outside would be awkward, but I did so with apologies to Ms. Q.

I didn’t know what Beth’s relationship with Ms. Q was, or whether Beth had known Ms. Q’s mother. So I had some trepidation about breaking the news to Beth. When I did tell her, she was shocked and saddened. She became teary-eyed. She said she had just talked to Ms. Q’s mother the previous evening. Beth and Ms. Q had grown up together and Beth had known Ms. Q’s mother nearly all her life. This was a personal loss for Beth, too. I now needed to comfort Beth and make some plan with her, despite her own sorrow, to tell Ms. Q.

First, I helped Beth call her hometown and get the details of what had occurred. I let her use our staff lounge so she could have some privacy and speak without distraction.

I returned to Ms. Q’s room and began reviewing medications with her as we had planned. I felt uncomfortable doing this, wondering if it was appropriate at a time like this. But I felt that leaving her alone with her friend absent on a very thin explanation would feel like desertion. My plan was to let Beth get some information and then have Ms. Q learn about her mother’s death with her close friend and a caring nurse there to support her.

When we were done reviewing meds, I found Beth and we prepared to talk With Ms. Q. We spoke some words of comfort and encouragement to each other and joined Ms. Q in her room. With Beth sitting on her bed and me close by, Beth told her the news as gently as she could. Ms. Q looked totally unbelieving and then began to sob. My heart went out to her, even as the clinician in me worried about her making any sudden head or neck movements that might damage the repair.

Beth and I had also decided that a chaplain might be helpful. I had made arrangements for the Catholic chaplain to come. When he arrived, I briefed him quietly and he came in, prayed, and spent some time with both Beth and Ms. Q. I left to catch up on my other patients, whom my colleagues had been monitoring, to give me time to be with Ms. Q and Beth.

When I returned to the room, Ms. Q thanked me for my help. She said she had felt some awkwardness when her friend left so abruptly, even some irritation. But she said she understood now and was very grateful for what we had done. She told me about the plans and arrangements they were making. She told me a little about her mom, about how she and Beth grew up together, about their being sisters in their hearts.

Beth called her husband and made arrangements to stay in Boston a few more days. By this time, Ms. Q and I were on a first-name basis. I called her Abby. As it turned out, Abby’s brother was on his way to Boston to see her. He was driving an RV and was bringing his dogs. He couldn’t be reached on the road and so didn’t know about his mother’s death. I needed to find some information about parking an RV and boarding dogs. Why not? I contacted Social Services. They were very helpful; they referred me to a good resource for boarding dogs, and they suggested that Security could help with the parking question.

I, of course, had the usual physical care to provide for Abby as well. We followed up on my outlined plan of care, limiting some activities in deference to her mourning.

Later in the afternoon, Abby and I were alone. She said Beth had called her mother Saturday to let her know she had done well in surgery. She felt that had brought her mother some peace. She showed me a set of rosary beads. Her mother had suggested they exchange rosaries before she came in for her operation. It gave her a special connection to her mother, and I felt privileged to be included in that bit of intimacy.

While nursing may be made up of many little acts, for me it is utterly complex. Each thing that I did for Abby could be considered "simple." But taken all together, they made it possible for me to provide good basic care, and with the help of the team, care that addressed many facets of the human condition.

Comments by Jeanette Ives Erickson, RN, MS, senior vice president for Patient Care and chief nurse

One of the great joys of nursing is having that opportunity to impact another person’s life. Ann’s sensitivity in supporting Ms. Q through the ordeal of learning about her mother’s death while ensuring optimal post-operative care is truly exemplary. Ann’s plan of care even extended to finding shelter for her patient’s brother’s dogs and a place to park an RV. Ann knows that nursing doesn’t stop at the bedside.

Reading this narrative, I think we all felt that Ms. Q was in caring, capable hands.

This session will be presented by the Concord Hospital Cardiac Surgery Team, which includes a registered nurse, a pharmacist, a physical therapist, a nurse practitioner, a surgeon, and a family member.

The presentation will be facilitated by Paul N. Uhlig, MD, MPA, associate professor, Dartmouth Medical School and medical director of the Cardiac Program at Concord Hospital in Corcord, New Hampshire.

The Oncology Nursing Career Development Award recognizes professional staff nurses for meritorious practice.

Nominees must be MGH registered nurses functioning at the staff level in the inpatient or outpatient setting.

The Yvonne L. Munn Nursing Research Program supports research initiated by MGH nurses for the purpose of improving the care of patients and families.

Research proposals are now being accepted by The Center for Clinical & Professional Development, Founders House 636.

Incorporating meditation into our daily lives can help reduce the level of stress we feel.

This seminar will outline the basics of meditation and provide an explanation of the cumulative and short-term benefits associated with meditation.

When/Where

Description

Contact Hours

May 28

1:00–3:00pm

Basic Cardiac Pacing

VBK601

---

May 30

8:00am–4:30pm

Advanced Arrhythmia Interpretation Program

Haber Conference Room

7.8

May 30

TBA

Wound and Skin Care:Common Problems, Common Products

Training Department, Charles River Plaza

---

June 4

8:00am–4:30pm

Chemotherapy Consortium Core Program

Wolff Auditorium, NEMC

TBA

June 6

7:30–11:30am,

12:00–4:00pm

CPR—American Heart Association BLS Re-Certification

for Healthcare Providers

VBK 401

- - -

June 6

1:30-2:30pm

Nursing Grand Rounds

O’Keeffe Auditorium

1.2

June 12

1:30–2:30pm

OA/PCA/USA Connections

"Working Together with Chaplaincy to Assist our Patients."

Bigelow 4 Amphitheater

- - -

June 12

8:00am–2:30pm

Mentor/New Graduate RN Development Seminar I

Training Department, Charles River Plaza

6.0

(mentors only)

June 12

5:30–7:00pm

Advanced Practice Nurse Millennium Series

O’Keeffe Auditorium

1.2

June 13 and 14

7:30am–4:30pm

Pediatric Advanced Life Support (PALS) Provider Course

Shriners Hospital Auditorium

TBA

June 13

1:00–2:30pm

The Joint Commission Satellite Network presents:

"Pain Management: Preemptive Strikes and Needs of Special

Populations"

Haber Conference Room

---

June 14

8:00–4:30pm

Advanced Concepts in Cardiac Nursing

O’Keeffe Auditorium

---

June 17

8:00–4:00pm

Keeping Our Patients Safe

Wellman Conference Room

---

June 19

7:30–11:30am,

12:00–4:00pm

CPR—American Heart Association BLS Re-Certification

for Healthcare Providers

VBK 401

- - -

June 19

8:00am–4:00pm

CVVH Core Program

VBK601

6.3

June 20

10:00–11:30am

Social Services Grand Rounds

"Helping Children Make Meaning of Illness and Hospitalization." For more information, call 724-9115.

CEUs

for social workers only

June 20 and 21

8:00am–5:00pm

Adult CCRN Course Review

Shriners Burns Hospital

18 AACN contact hours

(for both days)

June 20

8:00am–4:30pm

Preceptor Development Program: Level II

Training Department, Charles River Plaza

7.8

June 20

1:30–2:30pm

Nursing Grand Rounds

O’Keeffe Auditorium

1.2

Published by:

Caring Headlines is published twice each month by the department of Patient Care Services at Massachusetts General Hospital.

Publisher

Jeanette Ives Erickson RN, MS,

senior vice president for Patient Care and chief nurse

Managing Editor/Writer

Susan Sabia

Editorial Advisory Board

Chaplaincy

Mary Martha Thiel

Development & Public Affairs Liaison

Georgia Peirce

Editorial Support

Marianne Ditomassi, RN, MSN, MBA,

executive director to the office of senior vice president for Patient Care

Mary Ellin Smith, RN, MS

Materials Management

Edward Raeke

Nutrition & Food Services

Patrick Baldassaro

Martha Lynch, MS, RD, CNSD

Orthotics & Prosthetics

Eileen Mullen

Patient Care Services, Diversity

Deborah Washington, RN, MSN

Physical Therapy

Occupational Therapy

Michael G. Sullivan, PT, MBA

Reading Language Disorders

Carolyn Horn, MEd

Respiratory Care

Ed Burns, RRT

Speech-Language Pathology

Carmen Vega-Barachowitz, MS, SLP

Distribution

Please contact Ursula Hoehl at 726-9057 for all issues related to distribution

Submission of Articles

Written contributions should be submitted directly to Susan Sabia as far in advance as possible.

Caring Headlines cannot guarantee the inclusion of any article.

Articles/ideas may be submitted

by telephone: 617.724.1746

by fax: 617.726.4133

or by e-mail: ssabia @partners.org