Health care transformation in U.S. academic health centers (AHCs) involves new models of care delivery aimed at achieving the Quadruple Aim: enhancing patients’ experiences of care, improving population health, lowering cost, and improving the work–life balance of clinicians.1–3 AHCs include health professions schools, graduate medical education (GME) programs, and affiliated teaching hospitals. A critical need for successful transformation within such settings is to engage faculty who are prepared to practice, educate, and lead in each of the four aims.4–6 Medical educators and health system leaders have identified this need as a key area of focus across the medical education continuum, including undergraduate medical education (UME), GME, and continuing medical education (CME).4,6,7
Despite this growing mandate and the potential benefits to the mission of AHCs, professional development efforts have been slow to emerge within AHCs for several reasons.8,9 First, many AHCs lack local faculty to teach and mentor others in the areas of patient experience, population health, value-based care, and physician work–life balance.10,11 To gain competency in new models of care, faculty are usually limited to attending short immersive programs at national meetings and conferences, which require a significant investment of time and resources and are usually devoid of contextual factors specific to the local AHC and the community it serves.12 Second, professional development programs tend to more narrowly focus on quality improvement and patient safety.13–16 More recently, an expanded framework of knowledge and skills required for providers to contribute to the achievement of the Quadruple Aim has been identified, and termed “health systems science” (HSS).17 HSS includes a broad-based framework of concepts, including population and public health, clinical informatics, value-based care, and systems thinking.17 Fellowships or master’s degrees (e.g., in health care delivery science18) are beginning to emerge to address the need for training in care delivery, public health, cost-conscious care, and physician work–life balance, but these programs usually require years of additional training and are available to only a subset of faculty in select university-based settings, which leaves a large cohort of faculty with little to no opportunity to develop their knowledge and skills in these areas. For widespread success of health care transformation, local HSS professional development should align with specific health system needs; however, an inclusive, empirically derived, faculty-level curricular framework of competencies that aligns with health care needs and outcomes in AHC settings has not been identified.
In the design phase of an innovative professional development program to educate faculty in our AHC, we explored health system leaders’ perceptions of faculty members’ educational needs related to HSS. Specifically, we approached this study with one overarching question: What are the critical knowledge and skills faculty need to improve care delivery and educate trainees? We designed this study to inform local, national, and international faculty development efforts to further enhance UME, GME, and CME programs in HSS.
Study setting and approach
In 2014, Penn State College of Medicine (PSCOM) initiated curricular innovations related to HSS. Although the innovations initially focused on medical students,17 curricular changes were envisioned to be implemented for all levels of learners, including resident physicians and faculty members. We performed this study, as part of the curricular innovation, to determine the HSS knowledge, skills, and attitudes needed by faculty to inform professional development efforts. Because little work has explored professional development in HSS concepts, we designed a qualitative research study using a data-driven, inductive approach to explore our question, “What are the critical knowledge and skills faculty need to improve care delivery and educate trainees?” We chose one-on-one interviews to explore participant perspectives in detail.
Our team’s perspective in approaching this work was that HSS is an evolving and broad-based framework for medical education, that HSS competencies are important for health care transformation, and that formally educating medical and other health professions students and resident physicians about HSS is important for 21st-century practice. While our previous work in this area17 informed this particular project, we were interested in a de novo exploration of the data, and we employed several strategies to help ensure this approach. To address our reflexivity, we used several methods in the participant sampling, data collection, and analysis to limit any potential biases in themes or categories.19
The Institutional Review Board of PSCOM determined this project to be minimal-risk research.
Because HSS encompasses a wide range of concepts, topics, and challenges, we intentionally recruited participants who were leaders. Collectively, they have a broad range of health care expertise across six competency domains of HSS (health care delivery, policy, informatics, population health, improvement, and high-value care), and we felt they could provide insight into faculty needs. We purposefully sampled individuals who were both (1) actively involved in health care delivery, at the clinical and/or administrative levels; and (2) in leadership positions within the health system. Because we estimated that approximately 40 individuals within our immediate community could meet these inclusion criteria, we first interviewed health system leaders and then employed a snowball sampling technique whereby we asked these initial participants to identify health system leaders they would recommend be interviewed.20 The investigator intending to perform the interview sent individual requests via e-mail describing the study and inviting each leader to participate in a digitally recorded, one-hour interview. We offered no incentives for participating.
Prior to the interviews, we developed an interview guide specifically for the purpose of this work (Appendix 1). Four investigators and two research associates all with prior interviewing experience performed digitally recorded, one-on-one, semistructured interviews with each participant. Two investigators (M.H., H.W.) who had no prior experience in the previous work related to HSS performed the majority of the interviews. We were particularly careful to ensure that questions were worded to allow participants to provide rich detail. Because we were acutely aware of any potential biases we might have had, we also piloted the guide with one faculty member. Additionally, after the third interview, we reviewed the data to assess the quality of the interview guide as well as the interview data. The primary modification resulting from this process was to change the probes to ensure that discussions did not relate only to the participant’s area of HSS-related expertise. We designed questions to probe responses about broader HSS needs rather than specific local issues. Discussions focused on knowledge, skills, and attitudes that participants believed were most important for academic faculty. Participants also discussed challenges in health care, specifically to explore and identify potential areas for education. Lastly, we asked participants to identify experts, internal and external mentors, and reference material for faculty education. We obtained the educational and clinical experience of each participant by reviewing publicly available online profiles. A professional transcriptionist prepared a verbatim transcript of each audio-recorded interview.
During data analysis, we again identified our biases21 related to our prior work related to HSS competency domains for students. To address this potential bias, we used three analysts (J.D.G., B.M.T., A.A.), two of whom had not been involved with the prior work. We triangulated our analysis by member checking with the individuals who conducted the interviews.
We approached our data using thematic analysis, using Atlas.ti 6.0 (Scientific Software, Berlin, Germany) and NVivo 11 QSR International (Burlington, Massachusetts) software to manage the text data.22,23 Two investigators (J.D.G., A.A.) coded interview transcripts using constant comparative analysis to identify initial competency domains and themes and to generate a preliminary codebook.24,25 Because we were unsure when data saturation would be reached, we made a decision, a priori, to code all interviews regardless of whether we reached saturation at an earlier point. Two of the data analysts (J.D.G., B.M.T.) had prior experience with the qualitative techniques used in this work.23,26 Through regular adjudication sessions, these three investigators compared codes for inconsistency and agreement, then updated the codebook. To ensure triangulation, a third member of the research team (B.M.T.) individually reviewed transcripts and cross-checked text with the developed codebook, which informed subsequent adjudication sessions. Through these sessions, the three investigators (J.D.G., B.M.T., A.A.) agreed that data saturation occurred after 18 transcripts (but, as mentioned, still analyzed the remaining transcripts). The team discussed disagreements and collapsed and modified codes as necessary. As suggested by interpretive qualitative research, we sought to be flexible to emerging results in order to meaningfully organize the results.27 In this process, we identified competency domains and themes—as well as subthemes—all of which we iteratively discussed. The research team discussed emerging results and exemplar quotations.
Between November 2015 and August 2016, we conducted a total of 23 one-on-one interviews, averaging 38 minutes in length (range 16–89 minutes), which resulted in 231 pages of double-spaced transcripts. All 23 individuals who received an invitation to be interviewed agreed to participate. Of these 23 participants, 15 (65%) were male and 8 were female. On average, the participants had worked for 26 years after graduation in health care. Of these 23 participants, 22 (96%) were currently employed within an AHC; 17 (74%) had previously practiced in at least one health system other than their current system of employment, and 23 (100%) had either trained or were employed by at least one health system other than their current employer. Participants’ roles within the health system were broad (List 1); they included the following: chief executive officer, chief operating officer, vice chair, and clinical department chair. Two participants held leadership positions in two different health systems.
List 1Roles of Participantsa Interviewed About Core Health Science System Competencies for Faculty, 2015–2016
Associate Dean for Administration
Co-Founder for Specialty Clinic for Children
Director of Quality Management Services for Department
Dean/Chief Executive Officer of Health System
Vice Dean for Clinical Affairs
Vice Dean for Regional Campus
Chair of Clinical Department
Chief Financial Officer
Chief Informatics Officer
Chief Medical Officer for Primary Care
Chief Network Development Officer
Chief Operating Officer for Health System
Chief Operating Officer for Medical Group
Chief Operational Excellence Officer
Chief Medical Information Officer
Chief of Medical Informatics
Chief Nursing Officer
Chief Quality Officer
Chief, Division of General Internal Medicine
Chief, Division of Population Health Research and Development
Vice Chair, Clinical Operations
Vice Chair, Patient Care
Vice Chair, Quality and Safety
aOf the 23 participants, 21 were from the same academic health center, 1 was from another regional health system, and 1 was from a regional academic health center; that is, the 23 participants were from 3 different institutions.
After coding all data, we identified four major themes: (1) functional competencies and curricular domains for conceptual learning, (2) foundational competency domains, (3) paradigm shifts in how faculty should approach health care, and (4) the need for faculty to be aware of challenges in the culture of AHCs as an influential context for change. We have provided quotations with a code for each deidentified study participant (e.g., participant 15, or P15).
In addition, participants provided a total of 80 references they deemed important reading material for faculty (Supplemental Digital Appendix 1, http://links.lww.com/ACADMED/A481).
Functional competencies and curricular domains for curricular learning
Our data were rich in information regarding specific knowledge, concepts, and skills that participants felt were vital for developing faculty members to serve as HSS educators, leaders, and change agents. We categorized these as “functional” competencies, defined as the HSS knowledge and skills required for everyday faculty practice activities.28 Not unexpectedly, given that our sampling method included participants with expertise in HSS competency domains, we recognized early that our subcategories were naturally fitting into these previously identified seven competency domains: (1) patient-centered care; (2) health care processes, collaboration, and teamwork; (3) clinical informatics, data, and tools; (4) population and public health; (5) policy and payment; (6) value-based care; and (7) health systems improvement.17 The subcategories within each domain uniquely related to specific concepts and competencies expected of faculty. Table 1 depicts the functional competency domains, subcategories, and representative curricular concepts for each subcategory.17 Below is a representative comment regarding value-based care:
[Faculty need to know] the concept of value-based care, and quality. What does that really mean? Who defines that? How do you monitor that? Are we going to just listen to what Medicare says and that’s what we’re going to track because we have to report it? [P15]
Foundational competency domains
Our participants also described what we refer to as foundational competency domains: the need for providers to possess systems thinking skills, to be empowered as change agents with management abilities, to exhibit teaming abilities in various clinical settings, and to develop and maintain leadership skills needed to catalyze lasting change. We have described these competencies as “foundational” because participants considered them prerequisites; that is, participants felt faculty must learn and apply these competencies before they can enact the functional competencies (described above) in either care delivery or education settings. Our data indicated that these foundational competencies were core concepts that cross-cut the skill sets identified within the functional competencies. For example, for faculty to participate in and lead change in population health, they need to demonstrate systems thinking skills that integrate knowledge of informatics, patient-centered care, and care delivery.
Although acknowledging that some faculty possess these foundational competencies, participants were clear that for most faculty, this area represents a critical gap. Table 2 lists the four foundational competencies, representative concepts, and illustrative quotations from participants, and we have provided one illustrative quotation about change agency and management here:
It’s the technical and adaptive side of leading change. [One must] understand the technical work that must get done, being able to take evidence-based practices and distill them. And understanding there’s an adaptive part of change that’s about engaging and winning the hearts and minds of clinicians and having them follow you through change. That’s a very hard thing to teach and learn and do. [P18]
Paradigm shifts in how academic faculty should approach health care
Interestingly, taken as a synthetic whole, the functional and foundational HSS competencies emerged as a different way of thinking and approaching patient care for AHC providers. Participants identified paradigm shifts in how faculty should approach and view health care transformation and education. Data indicated that these shifts could be categorized into four groups: health care delivery, change and transformation, provider characteristics and skills, and medical education. Table 3 depicts these general and specific shifts in faculty perspective, the categories of the shifts, the new understandings, and the traditional perspectives. Below is one representative quotation related to a paradigm shift—specifically health care delivery:
The modes of delivering care are changing right in front of us and it will continue. Do you need to see an MD to receive the care you need? You’ll start seeing other allied health professionals emerge. We’re going down an evolutionary path where health care will look and feel different, and we all have to acknowledge that. It’s exciting to be involved at the beginning of a large innovation. Those institutions that are forward-looking enough to make plans to do the care that way will be the ones that survive. [P23]
Culture of AHCs as an influential context for change
Participants frequently highlighted challenges to educating current and future generations of faculty in HSS. They recognized that AHCs have potential to lead in health care transformation and train future providers in HSS-related competencies. At the same time, they identified and described some significant barriers to realizing that potential. Participants identified AHCs as inefficient, “slow to change,” inadequately nimble, and siloed.
Our challenge is to acknowledge that we’re truly an academic medical center. We have the obligation, expectation, and opportunity to be different than [community-based] clinical enterprises. It’s hard because we live in silos. [P2]
Participants discussed their views regarding the slow pace of change often exhibited by AHCs, and also the challenge of faculty and leaders pursuing the “shiny object” without necessarily first discerning value, as reflected in the following comment:
How do we get the right projects with the right people so that enough people adopt this, so that we make it part of our fabric? There’s so many distractions. Today we’re going to focus on this. It’s that shiny object challenge that is typical of an academic health system. How do you get people to share and understand and come up with standards that work together for the whole organization? [P12]
Discussion and Conclusions
AHCs bring a distinct combination of education, research, scholarship, and advanced clinical care to the health care landscape, and they are uniquely positioned to play a leading role in health care transformation. Regrettably, this potential has by and large not been realized. The change process has been hampered by structural and cultural issues, including policy and payment reform, which significantly impact the pace of implementation. Another influential contributor includes the gap in the professional development of faculty who have been educated in traditional programs deficient in emerging competencies in HSS.29 Closing these gaps requires a significant investment by health systems to educate faculty in these competencies. Although several programs exist nationally, they tend to be limited to patient safety or quality improvement tools and methodologies (e.g., plan–do–study–act, Lean, Six Sigma).12–14,30–34 Although these areas are logical and beneficial starting points, health system leaders are calling for a broader, more comprehensive scope of “new” faculty competencies that extend well beyond patient safety and quality improvement.4–6,11,35 The findings from our 23 interviews with leaders fill an important void in the literature by identifying the competencies required for ongoing health care transformation in AHCs from the perspective of those overseeing and managing that change.
The functional competency domains and subcategories identified in this study are similar in some ways to previously identified areas in UME and GME, but we also noted differences that help illuminate a developmental continuum of HSS competencies.17 At the UME level, Core Entrustable Professional Activities for Entering Residency36 have been described, and a broad curricular framework related to HSS has been identified.17 The GME literature, as exemplified in the Clinical Learning Environment Report, is also expanding the systems-based practice and practice-based learning and improvement areas to include competencies in clinic-based skills, systems thinking, and interprofessional collaboration.4,16,37 Our work focuses on the HSS-related competencies required for faculty, many of whom have not been educated in these areas. Ultimately, we believe that a clear trajectory of competencies along the UME-GME-CME continuum is required to develop the most effective educational strategies.
The need for advancing faculty education in HSS is increasing and has ramifications for patient outcomes as well as education in both UME and GME. Supervising and role modeling care delivery that reflects such areas as the social determinants of health, population health, value-based cost-conscious care, and health system improvement can have a significant impact on learners’ professional role identity.38–40 In UME, a major limiting factor in advancing HSS education has been the lack of knowledgeable and skilled faculty.9 The same problem plays out in GME where research suggests that academic faculty insufficiently integrate learning about quality improvement and value into clinical training.16,29,41 The paucity of faculty educators skilled in HSS competencies is a rate-limiting step for education and system change in AHCs. We believe the results of this work will help inform improvement strategies, such as the implementation of professional development programs or fellowships in HSS more broadly across AHCs, to close this gap.16
Another key finding in this study is the need for faculty to know and be skilled in the foundational HSS competencies, including health system processes, systems thinking, change management, leadership, and teaming. These foundational competencies have been previously and independently identified in other areas of health professions education, including UME and public health, as critical targets for faculty development.4–6,16,17,42–45 Our results have significant implications for education occurring in both local and national settings, and they support the idea that knowledge acquisition alone is insufficient. Our results indicate that clinical knowledge must be leveraged with foundational competencies by faculty-level clinicians and educators. Successful educational programs will need to move beyond simple knowledge transmission to exploring innovative educational models that integrate skill development and workplace-based learning.9 Education must also help academic faculty shift their professional identity to one that includes their role as providers of not only high-quality care for patients but also high-quality education for trainees and advocacy/leadership for the communities they serve.46 Faculty in AHCs are in the unique position of not only being active contributors to health care transformation but also the role models and supervisors of the next cohort of providers who will also need to employ these skills.
The results of our work can help those creating professional development programs to identity the content and competencies for HSS; however, our study does not provide information regarding how to teach these competencies. Additional study is required to determine the best methods to use in educational settings. We also recognize that faculty development in HSS will require considerable financial investment, alignment with the goals and values of the health system, new educational processes, a group of educators familiar with principles of adult learning, and buy-in from numerous stakeholders (including supervisors such as department chairs responsible for overseeing faculty time). In the end, the success of even the best-designed and executed program will depend on facilitators and barriers within the health system, many of which our study identified (e.g., culture). These are likely even more important for each individual AHC to identify and address. We submit that health systems will need to go beyond simply espousing the goals of HSS professional development to actualizing them by, for example, providing protected time and investing financial resources.
We acknowledge that our study has several limitations. The health system leaders interviewed were from three AHCs, which may limit the transferability of these findings to different settings.47 All participants, however, had experience in other AHCs, and many had a national presence in health care delivery. Second, we purposefully explored our research question broadly and did not differentiate the level of proficiency expected for a targeted faculty member. Additional studies are needed to determine the competencies expected for each level of faculty (e.g., AHC executives, faculty specialized in HSS, junior faculty, or perhaps all faculty providing care and educating in AHCs). We believe, however, that our study is a starting point to develop educational initiatives with the goal of transforming provider skills and redesigning care delivery and education in clinical learning environments.
In conclusion, we identified key competencies for professional development programs that can potentially improve health care transformation and education, as well as paradigm shifts in how faculty educators should view health care and education. We believe this framework can help inform the national conversation of emerging educational priorities for faculty in AHCs. The identification of core competencies by faculty specialty and role, and of the best methods for education and assessment in the areas of HSS, will require additional research.
The authors would like to thank all participants for volunteering their time to be interviewed, and Dr. McGillen and Ms. Barbara Blatt for their assistance with data collection.
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Appendix 1 Representative Questions From Health System Leader Interview Guidea
We are designing a faculty development program at the Penn State College of Medicine. The purpose of this study is to explore health system leaders’ perceptions of challenges in health care and educational needs for faculty members. This assessment is designed to inform local, national, and international efforts to incorporate Health Systems Science (HSS), specifically at the graduate and faculty levels. Questions will relate to your views of the health system, what faculty need to know to be better able to provide care and education in our health system. The data will be analyzed to identify themes of the views of numerous “health system leaders.”
- Please describe your path to acquiring your expertise and interest in (their specific domain).
- What do you think are the 10 most important concepts to understand in (their specific domain)?
What do you think are the seminal works to read in (their specific domain)?
- And/or—What do you think are the 10 most important concepts in Health Systems Science in general?
Relate a story about a real challenge that you are either currently facing or have faced in (their specific domain).
- And/or—What do you think are the sentinel works to read in Health Systems Science in general?
Who else, either internally or external to the institution, do you identify as a leader or expert in (their specific domain)?
- How does this challenge relate to a “gap” in education for our faculty?
- Who would you consider a mentor in this area?
aThis interview guide has been formatted and titled, but not otherwise edited, by Academic Medicine.