We define learners as all participants that co-construct the learning environment. Thus, learners include health professions students, health care professionals, faculty and staff of learning institutions, health care systems staff and administrators, and patients. For the purpose of clarity, in this article we use the word “students” to indicate learners enrolled in formal health professions education programs, including residents. Learners also include organizations such as health professions schools and health care organizations. These learning organizations, as described in the business literature,9 facilitate their members’ learning and continuously transform themselves. In health care, this idea is conceptualized as the “learning health care system,” in which research influences practice and practice influences research.9
These definitions illuminate the complexity of learning environments in health professions education, with multiple agents interacting to co-construct learning and the learning environment itself. Examining learning environments through the lens of complex adaptive systems helps us understand these interactions. Recent literature contains several in-depth reports describing complexity science as applied to health care.8,10,11 An important characteristic of complex adaptive systems is that order, innovation, and progress can emerge naturally from the interactions within a complex system, with each agent following a set of simple shared rules. “Simple rules” are defined as minimum specifications that allow each agent in a complex adaptive system to behave adaptively in the system.10 The word “rule” in this context does not imply a directive that is imposed on agents within the system; rather, a simple rule is intrinsic to a complex adaptive system, analogous to a “law of nature.” For example, Plsek and Wilson10 propose that 21st-century health care systems have simple rules such as “Care is customized according to patient needs” and “Decision making is evidence-based.”
Here, we elucidate our vision for exemplary learning environments and articulate the four simple rules we believe such learning environments will follow, once they exist. We based these simple rules on principles that are observed in all complex adaptive systems.8 Additionally, we describe the vision, explore the gap between the current state of learning environments and our vision, and propose strategies to close this gap.
A Vision for Exemplary Learning Environments
In the vision we propose, exemplary learning environments prepare, support, and inspire everyone involved in health professions education and health care to work toward optimal health of individuals, populations, and communities (Figure 1). The learning environment includes health professions students, health care professionals, faculty, staff, patients, and their families. Collectively, these agents and the organizations within which they learn, work, and seek care collaborate to advance their capabilities and create an inviting learning environment that fosters well-being and health for all. Such exemplary learning environments are complex adaptive systems that follow four simple rules (Table 2).
Simple rule 1
In exemplary learning environments, health care and health professions education share a goal of improving health for individuals, populations, and communities. Health care and health professions education both work to improve health. Health care focuses on those currently in need; health professions education prepares to meet future needs. Working together as a system requires a shared goal, reflecting Deming’s12 concept of “constancy of purpose” as a component of sustainably high quality. The value of clear goals is borne out in studies of high-performing health systems.13–16 In a commentary for the National Academy of Medicine, Kirch and colleagues17 argue that achieving the health outcomes that patients value and deserve requires a shared commitment across practice, education, and research.
Simple rule 2
In exemplary learning environments, learning is work and work is learning. Learning and work are co-constructed by those who learn and work in a particular environment. Such environments are described as “learning-centered,” moving away from the concept of “learner-centered” environments. Learner-centered approaches can conflict with the need to be patient-centered, efficiency-centered, and health-outcome-centered. Learning-centered environments emphasize the quality of learning. They foster an intentional approach to learning that supports the development of reflective practitioners who engage with joy in lifelong learning, regardless of seniority, expertise, or role.18
Simple rule 3
Exemplary learning environments recognize that collaboration with integration of diverse perspectives is essential for success. They therefore are inclusive and welcoming; integrate diverse perspectives to promote collaborative learning and practice; and prepare learners to care for diverse patients, populations, and communities. The positive effects of teamwork, collaborative practice, and shared decision-making are well documented.19–22 Diverse composition of health care teams improves teamwork,23 diversity in learning environments promotes learning,24,25 and adequate representation of minorities in the health professions may assist in overcoming health care disparities.26,27
Simple rule 4
The organizations and agents in exemplary learning environments learn about themselves and the greater system they are part of to achieve continuous improvement and innovation. Health professions education institutions and health care organizations are “learning organizations” that facilitate learning by all involved and continuously transform themselves in ways that are both adaptive and creative.28 Adaptivity and creativity are essential for learning environments in health professions education because of rapid changes in health care and the ongoing need to advance knowledge. To guide continuous process improvement, these learning organizations measure key elements of the learning environment along with learning and health outcomes.
The Gap Between the Proposed Vision and the Current State
Simple rule 1
Realizing the vision of a shared goal between health care and health professions education is challenged by the fact that despite stated missions that are similar and synergistic, the responsible organizations are frequently structurally independent, with separate governance, leadership, and funding. For instance, efforts to bring learners together for interprofessional education invariably face dissimilarities in education routines, academic calendars, curricular mandates, and accreditation requirements.29 In our own experiences at different institutions, innovative activities at health systems aiming to achieve effective and efficient care often exclude students. Collaborative efforts to create learning environments that contribute to improving health care are often hampered by assumptions rooted in tradition. Examples include the dogma that education innovation must deal with the “zero sum” challenge of an already-packed curriculum, that students introduce inefficiencies into clinical encounters with little added value, and that patients cannot judge quality in health care. Another important obstacle comes from differences in funding streams and financial incentives for education and for health care systems. Funding mechanisms often fail to support what’s needed in both health care and health professions education for the shared goal of improved health. An example is the current Medicare payment system for graduate medical education (GME) that overemphasizes training in inpatient settings and only accounts for training physicians, not other health professionals.30
Simple rule 2
Workplace learning is an essential component of health professions education, yet we are still far from a situation in which work is learning, and learning is work. Many health professions curricula continue to distinguish between “preclinical years” to learn foundational sciences and “clinical years” for workplace learning. Learners in the workplace often get overwhelmed with work that doesn’t contribute to learning, undermining the educational value of the experience. This situation is exacerbated by stressors such as documentation requirements and production pressures, often resulting in clinician burnout.31,32 Many teachers in health professions education emulate their own teachers rather than using evidence-based approaches, and preparation for teachers is often absent.33 Structured mentoring, feedback processes, and quality standards for teachers are generally lacking.
Simple rule 3
Despite increasing awareness that diversity matters, meaningful inclusiveness and effective collaboration remain largely elusive. For example, there continues to be underrepresentation of ethnic minorities in the health care workforce,25,34 of men in nursing,34 and of women in academic leadership roles.35 Conflicts and turf wars between and within professions hamper effective collaboration.36,37 Examining the root cause starts with recognizing three distinct constructs underlying diversity: variety, separation, and disparity.38 Diversity as variety indicates differences in information, knowledge, or experience among members of an organization or group and positively affects creativity, learning, and decision making.39 This explains the positive impact of interprofessional teamwork on patient care23,40 and underlies the effects of diversity on learning.24,25 These positive effects may, however, be countered by the impact of diversity as separation: differences in position or opinion among members. This diversity construct explains how people categorize themselves and others, often following stereotypical patterns, to belong to either an in-group or out-group. This can lead to conflict, discrimination, and poor teamwork.39 In health care, social categorization may perpetuate silos between professions and impede interprofessional collaboration,41–43 and stereotyping may limit diversity in certain professions.44 The diversity as disparity construct describes how diversity frequently is associated with status differences.45 Status disparity is prominent in health care, leading to hierarchy and power differentials between professions. This creates additional barriers to interprofessional collaboration and education37,46 and perpetuates hierarchical leadership models in which leaders are selected because of academic or clinical success rather than leadership skills.
Simple rule 4
Existing and ideal states also differ for organizations and agents in the learning environments engaging in ongoing assessment and learning to promote continuous improvement and innovation. The growing practice of outcomes-based assessment in health professions education47,48 has advanced measurement of individual attainment of clinical expertise. However, it overlooks skills that individuals and teams need in order to collaborate adaptively in complex and changing health care systems.49 Health professions education institutions and health care systems tend to assess outcomes independently from each other. As a result, education leaders make decisions about education programs while overlooking potential effects on health system outcomes; health system leaders make decisions about clinical care without attention to impact on education. Recent efforts by the Accreditation Council for Graduate Medical Education, the American Association of Critical Care Nurses, the American Medical Association, and other organizations to promote education reform are laudable,50,51 but educational reform tends to represent reactive rather than proactive responses to changes in health care. Only recently did continuous quality improvement of medical education become an accreditation requirement for medical schools,52 prompting the GME community to think about outcome metrics that can guide program improvements.53,54
Closing the Gap
Despite these clear challenges, there are many initiatives offering promise that the vision of exemplary learning environments can be realized. We illustrate the proposed strategies below and present actionable ideas with examples from the literature in Table 2, organized by simple rule and the principles of complex adaptive systems with which the rules align. We also propose assessment targets for each of the four simple rules (Table 3).
Simple rule 1
Convergence of goals between health care and health professions education is accomplished through aligning structures of care and education.55,56 Deans of health professions schools and hospital executives collaborate to support the teaching mission through provision of financial resources, faculty development, mentoring, and recognition.57 Nurse educators join health care leadership to create a work environment that supports both nurses and nursing education.58 In accordance with Lewin’s “unfreeze-change-refreeze” theory of change,59 such efforts involve letting go of assumptions rooted in traditions about what we need to learn and what learners, including patients, can contribute. Collaborative design, with unified goals and attention to roles and preparation, makes it possible even for novice learners to add value to care.60–63 Such an approach follows the recommendations of the National Collaborative for Improving the Clinical Learning Environment to implement strategies that ensure that new clinicians, including students, are prepared to fully participate in patient safety activities.64 Partnerships with patients and families are essential to align care and education and contribute to improvements in direct care, organizational design, health policy, and health professions education.57 Likewise, these partnerships are in line with the Josiah Macy Jr. Foundation’s vision that “individuals, families, and communities are understood to be the very reason our health care system exists, and that those who are caring, teaching, learning, or otherwise working within the system must partner fully and effectively with them to foster optimal health and wellness for all.”65 Attention to financing and incentives that drive decisions in health care versus health professions education is essential to successful alignment. Outcomes-based payments as suggested for GME30 are established across the educational continuum and for all health professions. Following recommendations by the Association of American Medical Colleges, incentives are routinely proffered for teaching, quality improvement, and continuing education.66 To fully accomplish the shared goal of improved health, health care and health professions education organizations develop a comprehensive approach toward allocation of funds, collaboratively advocating for needed changes in policies at the state and federal level.57
Simple rule 2
Through integration of work and education, exemplary learning environments ensure that learning is work and work is learning. Integrated approaches in classrooms and clinical settings can introduce new content more quickly and effectively than older education models.67–69 Technological and other solutions reduce work without educational value. Learning is an explicit part of the day-to-day activities of clinical care for all, and everyone in the learning environment is expected to learn. This intentional approach to learning promotes well-being by supporting personal development and creating space for mindfulness and reflection. Research using the “wicked questions” framework, which promotes thinking about paradoxical opposing-yet-complementary strategies,70 guides the development of innovative approaches. Recognizing the importance of effective teachers for the success of integration of work and learning, all who teach receive training, feedback, and mentoring in the application of evidence-based education practices. To support these efforts, exemplary learning environments embrace learning as a core value of leadership.
Simple rule 3
Integration of diverse perspectives occurs through promotion of collaboration and open-mindedness. An inclusive climate results from promoting diversity as variety, while countering diversity as separation and disparity. Opportunities for collaborative practice and learning foster diversity as variety, further promoted by deliberately establishing diverse representation in all committees, teams, and other groups. Emphasis on common goals and explicit efforts to reduce bias and stereotypes mitigate diversity as separation and disparity. Collaborative approaches to leadership that emphasize inclusiveness and relationships further counter disparity.71–73 This follows emerging social trends toward what has been called “new power,” which values collaboration, sharing, and transparency, as opposed to the exclusivity, authority, and confidentiality of “old power.”74 Formal training and competence in collaborative leadership are requirements for all leadership teams. An inclusive climate can reinforce itself through creation of “psychological safety,” defined as community members’ confidence that they can express their ideas without negative consequences.75 Psychological safety promotes learning,72,76 creates positive experiences, and can change perceptions of fit for those considering to join the learning environment.75 This can result in a reinforcing cycle wherein a culture of inclusivity invites and engages diverse learners while also promoting learning itself.77
Simple rule 4
The organizations and agents in the learning environments learn from and about themselves to achieve continuous improvement and innovation. They have what Dweck78 has called a “growth mindset,” focused on ongoing learning and development. Exemplary learning environments are shaped by data-driven cyclical analysis, reflection, and process improvement, analogous to plan–do–study–act cycles, at the individual, team, and organizational level. This approach expands the concept of “learning health care systems,” in which research influences practice and practice influences research,79 to “learning learning environments,” in which research, practice, and education all influence each other. At the individual level, the cyclical process leads to “master adaptive learning,” a recently coined term describing lifelong learning in the health professions.80 Master adaptive learning integrates the construct of the reflective practitioner with self-regulated learning and adaptive expertise. It describes a metacognitive process involving purposeful planning of learning based on assessment, feedback, and reflection. This supports the development of the routine expertise needed to function efficiently on everyday tasks, as well as the adaptive expertise required to respond to new problems.80 At the institutional level, organizations in exemplary learning environments collaborate in regular review of shared outcome data to guide adaptations and ensure ongoing alignment of goals. They include external data such as measures of population health and data on workforce needs in this review.81
In this article, we have articulated our vision for exemplary learning environments that prepare, support, and inspire people to work toward optimal health of individuals, populations, and communities. We believe that this vision can be achieved with health professions education, health care systems, and the people they serve coming together. The ideal learning environment will work toward shared goals; integrate learning into work and work into learning; incorporate diverse perspectives and create an inviting, inclusive climate; and learn from and about itself and its constituents in support of continuous improvement and innovation. We hope that if we embrace these ideas, observations of learning environments in the future will confirm that our proposed simple rules are no longer ideals but, rather, the minimum specifications that determine the direction, boundaries, resources, and permissions of a complex system that serves both current and future individuals, populations, and communities.
Acknowledgments: The authors wish to thank Dr. David Irby for his review of this manuscript, and Drs. George Thibault and Stephen Schoenbaum for their thoughtful contributions to an earlier description of the ideas outlined in the manuscript.
1. Colbert-Getz JM, Kim S, Goode VH, Shochet RB, Wright SM. Assessing medical students’ and residents’ perceptions of the learning environment: Exploring validity evidence for the interpretation of scores from existing tools. Acad Med. 2014;89:1687–1693.
2. Weiss KB, Wagner R, Nasca TJ. Development, testing, and implementation of the ACGME Clinical Learning Environment Review (CLER) program. J Grad Med Educ. 2012;4:396–398.
4. Roff S, McAleer S. What is educational climate? Med Teach. 2001;23:333–334.
6. Lave J. Resnick L, Levine J, Teasley S. Situating learning in communities of practice. In: Perspectives on Socially Shared Cognition. 1991:Washington, DC: American Psychological Association; 63–82.
7. Billett S. Situated learning: Bridging sociocultural and cognitive theorising. Learn Instr. 1996;6:263–280.
8. Plsek PE, Greenhalgh T. Complexity science: The challenge of complexity in health care. BMJ. 2001;323:625–628.
9. McGinnis JM, Aisner D, Olsen L. The Learning Healthcare System: Workshop Summary. 2007.Washington, DC: National Academies Press.
10. Plsek PE, Wilson T. Complexity science: Complexity, leadership, and management in healthcare organisations. BMJ. 2001;323:746.
12. Deming WE. Out of the Crisis. 2000.Cambridge, MA: MIT Press.
13. Donaldson MS. Exploring Innovation and Quality Improvement in Health Care Micro-systems: A Cross-Case Analysis. 2000.Washington, DC: National Academies Press.
14. Baker GR. High Performing Healthcare Systems: Delivering Quality by Design. 2008.Toronto, Ontario, Canada: Longwoods Publishing.
15. Øvretveit J, Staines A. Sustained improvement? Findings from an independent case study of the Jönköping quality program. Qual Manag Health Care. 2007;16:68–83.
16. Wartman SA, Zhou Y, Knettel AJ. Health reform and academic health centers: Commentary on an evolving paradigm. Acad Med. 2015;90:1587–1590.
18. Schon DA. The Reflective Practitioner: How Professionals Think in Action. 1984.London, UK: Basic Books.
19. Reeves S, Lewin S, Espin S, Zwarenstein M. Interprofessional Teamwork for Health and Social Care. 2011.Hoboken, NJ: John Wiley & Sons.
20. Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: Effects of practice–based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2009;3:CD000072.
21. Shay LA, Lafata JE. Where is the evidence? A systematic review of shared decision making and patient outcomes. Med Decis Making. 2015;35:114–131.
22. Rathert C, Wyrwich MD, Boren SA. Patient-centered care and outcomes: A systematic review of the literature. Med Care Res Rev. 2013;70:351–379.
23. Lemieux-Charles L, McGuire WL. What do we know about health care team effectiveness? A review of the literature. Med Care Res Rev. 2006;63:263–300.
24. Gurin P, Dey E, Hurtado S, Gurin G. Diversity and higher education: Theory and impact on educational outcomes. Harv Educ Rev. 2002;72:330–367.
25. Smedley BD, Butler AS, Bristow LR. In the Nation’s Compelling Interest: Ensuring Diversity in the Health Care Workforce. 2004.Washington, DC: National Academies Press.
26. Komaromy M, Grumbach K, Drake M, et al. The role of black and Hispanic physicians in providing health care for underserved populations. N Engl J Med. 1996;334:1305–1310.
27. Hassouneh D. Faculty of Color in the Health Professions: Stories of Survival and Success. 2017.Dartmouth, NH: Dartmouth College Press.
28. Senge PM. The Fifth Discipline: The Art and Practice of the Learning Organization. 2006.New York, NY: Doubleday.
30. Eden J, Berwick DM, Wilensky GR. Graduate Medical Education That Meets the Nation’s Health Needs. 2014.Washington, DC: National Academies Press.
31. Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89:443–451.
32. Cañadas-De la Fuente GA, Vargas C, San Luis C, García I, Cañadas GR, Emilia I. Risk factors and prevalence of burnout syndrome in the nursing profession. Int J Nurs Stud. 2015;52:240–249.
33. Cox SE. Perceptions and Influences Behind Teaching Practices: Do Teachers Teach as They Were Taught? 2014.Provo, UT: Brigham Young University.
34. U.S. Department of Health Human Services. The U.S. Nursing Workforce: Trends in Supply and Education. 2013.Washington, DC: Health Resources and Services Administration.
35. Bickel J, Wara D, Atkinson BF, et al; Association of American Medical Colleges Project Implementation Committee. Increasing women’s leadership in academic medicine: Report of the AAMC Project Implementation Committee. Acad Med. 2002;77:1043–1061.
36. Axelsson SB, Axelsson R. From territoriality to altruism in interprofessional collaboration and leadership. J Interprof Care. 2009;23:320–330.
37. Hall P. Interprofessional teamwork: Professional cultures as barriers. J Interprof Care. 2005;19(suppl 1):188–196.
38. Harrison DA, Klein KJ. What’s the difference? Diversity constructs as separation, variety, or disparity in organizations. Acad Manage Rev. 2007;32:1199–1228.
39. Guillaume YR, Dawson JF, Woods SA, Sacramento CA, West MA. Getting diversity at work to work: What we know and what we still don’t know. J Occup Organ Psychol. 2013;86:123–141.
40. Mitchell R, Parker V, Giles M, White N. Review: Toward realizing the potential of diversity in composition of interprofessional health care teams: An examination of the cognitive and psychosocial dynamics of interprofessional collaboration. Med Care Res Rev. 2010;67:3–26.
41. Burford B. Group processes in medical education: Learning from social identity theory. Med Educ. 2012;46:143–152.
42. Hudson B. Interprofessionality in health and social care: The Achilles’ heel of partnership? J Interprof Care. 2002;16:7–17.
43. Weller J, Boyd M, Cumin D. Teams, tribes and patient safety: Overcoming barriers to effective teamwork in healthcare. Postgrad Med J. 2014;90:149–154.
44. Coleman CL. Perceived and real barriers for men entering nursing: Implications for gender diversity. J Cult Divers. 2008;15:148.
45. van Dijk H, van Engen ML. A status perspective on the consequences of work group diversity. J Occup Organ Psychol. 2013;86:223–241.
46. Baker L, Egan-Lee E, Martimianakis MA, Reeves S. Relationships of power: Implications for interprofessional education. J Interprof Care. 2011;25:98–104.
47. Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287:226–235.
48. Watson R, Stimpson A, Topping A, Porock D. Clinical competence assessment in nursing: A systematic review of the literature. J Adv Nurs. 2002;39:421–431.
49. Lucey CR. Medical education: Part of the problem and part of the solution. JAMA Intern Med. 2013;173:1639–1643.
50. Skochelak SE, Stack SJ. Creating the medical schools of the future. Acad Med. 2017;92:16–19.
51. Wagner R, Weiss KB, Passiment ML, Nasca TJ. Pursuing excellence in clinical learning environments. J Grad Med Educ. 2016;8:124–127.
52. Liaison Committee on Medical Education. Functions and structure of a medical school. Standards for accreditation of medical education programs leading to the MD degree. http://lcme.org/publications
. Published 2018. Accessed February 13, 2019.
53. Weinstein DF. Optimizing GME by measuring its outcomes. N Engl J Med. 2017;377:2007–2009.
54. Weinstein DF, Thibault GE. Illuminating graduate medical education outcomes in order to improve them. Acad Med. 2018;93:975–978.
55. Weiss KB, Bagian JP, Nasca TJ. The clinical learning environment: The foundation of graduate medical education. JAMA. 2013;309:1687–1688.
56. Weiss KB, Bagian JP; CLER Evaluation Committee. Challenges and opportunities in the six focus areas: CLER national report of findings 2016. J Grad Med Educ. 2016;8(2 suppl 1):25–34.
57. Cooke M, Irby DM, O’Brien BC. Educating Physicians: A Call for Reform of Medical School and Residency. 2010.Hoboken, NJ: John Wiley & Sons.
58. Benner P, Sutphen M, Leonard V, Day L. Educating Nurses: A Call for Radical Transformation. 2009.Hoboken, NJ: John Wiley & Sons.
59. Schein EH. Kurt Lewin’s change theory in the field and in the classroom: Notes toward a model of managed learning. Syst Pract Action Res. 1996;9:27–47.
60. Gonzalo JD, Lucey C, Wolpaw T, Chang A. Value-added clinical systems learning roles for medical students that transform education and health: A guide for building partnerships between medical schools and health systems. Acad Med. 2017;92:602–607.
61. Regan-Smith M, Young WW, Keller AM. An efficient and effective teaching model for ambulatory education. Acad Med. 2002;77:593–599.
62. Headrick LA, Barton AJ, Ogrinc G, et al. Results of an effort to integrate quality and safety into medical and nursing school curricula and foster joint learning. Health Aff (Millwood). 2012;31:2669–2680.
63. Chessman AW, Bellack JP, Lahoz MR, et al. Students add value to learning organizations: The Medical University of South Carolina experience. Qual Manag Health Care. 1998;6:38–43.
65. Fulmer T, Gaines M. Partnering With Patients, Families, and Communities to Link Interprofessional Practice and Education. 2014.New York, NY: Josiah Macy, Jr. Foundation.
67. Headrick LA, Hoffman KG, Brown RM, Webb WD, Higbee DK. University of Missouri School of Medicine in Columbia. Acad Med. 2010;85(9 suppl):S310–S315.
68. Holmboe ES, Batalden P. Achieving the desired transformation: Thoughts on next steps for outcomes-based medical education. Acad Med. 2015;90:1215–1223.
69. Bell SK, Krupat E, Fazio SB, Roberts DH, Schwartzstein RM. Longitudinal pedagogy: A successful response to the fragmentation of the third-year medical student clerkship experience. Acad Med. 2008;83:467–475.
70. Lipmanowicz H, McCandless K, Wang H. Wang H. Liberating structures: Engaging everyone to build a good life together. In: Communication and “The Good Life.” 2015:New York, NY: Peter Lang; 233–246.
71. Edmonstone J. Developing leaders and leadership in health care: A case for rebalancing? Leadersh Health Serv. 2011;24:8–18.
72. Nembhard IM, Edmondson AC. Making it safe: The effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. J Organ Behav. 2006;27:941–966.
73. Singer SJ, Falwell A, Gaba DM, et al. Identifying organizational cultures that promote patient safety. Health Care Manage Rev. 2009;34:300–311.
74. Heimans J, Timms H. Understanding “new power.” Harv Bus Rev. 2014;92:48–56.
75. Roberts BW. Personality development and organizational behavior. Res Organ Behav. 2006;27:1–40.
76. Torralba KD, Loo LK, Byrne JM, et al. Does psychological safety impact the clinical learning environment for resident physicians? Results from the VA’s learners’ perceptions survey. J Grad Med Educ. 2016;8:699–707.
77. Billett S. Integrating learning experiences across tertiary education and practice settings: A socio-personal account. Educ Res Rev. 2014;12:1–13.
79. Grumbach K, Lucey CR, Johnston SC. Transforming from centers of learning to learning health systems: The challenge for academic health centers. JAMA. 2014;311:1109–1110.
80. Cutrer WB, Miller B, Pusic MV, et al. Fostering the development of master adaptive learners: A conceptual model to guide skill acquisition in medical education. Acad Med. 2017;92:70–75.
81. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376:1923–1958.
References cited in the tables only
82. Gupta R, Arora VM. Merging the health system and education silos to better educate future physicians. JAMA. 2015;314:2349–2350.
83. Myers JS, Tess AV, McKinney K, et al. Bridging leadership roles in quality and patient safety: Experience of 6 US academic medical centers. J Grad Med Educ. 2017;9:9–13.
84. Gale SA, Beal JA. Building academic–practice partnerships: Sharing best practices. Nurse Leader. 2013;11:21–28.
85. Harmon LM. Rural model dedicated education unit: Partnership between college and hospital. J Contin Educ Nurs. 2013;44:89–96.
86. Margolis PA, Peterson LE, Seid M. Collaborative chronic care networks (C3Ns) to transform chronic illness care. Pediatrics. 2013;131(suppl 4):S219–S223.
87. Sabadosa KA, Batalden PB. The interdependent roles of patients, families and professionals in cystic fibrosis: A system for the coproduction of healthcare and its improvement. BMJ Qual Saf. 2014;23(suppl 1):i90–i94.
88. Headrick LA, Shalaby M, Baum KD, et al. Exemplary care and learning sites: Linking the continual improvement of learning and the continual improvement of care. Acad Med. 2011;86:e6–e7.
89. Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T. In search of joy in practice: A report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11:272–278.
90. Bonner D. Enter the chief knowledge officer. Train Dev. 2000;54:36–40.
91. Bainbridge L, Regehr G. Orchard C, Bainbridge L. Should there be an “I” in team? A new perspective on developing and maintaining collaborative networks in health professional care. In: Interprofessional Client-Centred Collaborative Practice: What Does It Look Like? How Can It Be Achieved? 2015:New York, NY: Nova Science Publishers; 51–66.
92. Murray-García JL, Harrell S, García JA, Gizzi E, Simms-Mackey P. Dialogue as skill: Training a health professions workforce that can talk about race and racism. Am J Orthopsychiatry. 2014;84:590–596.
94. Turbes S, Krebs E, Axtell S. The hidden curriculum in multicultural medical education: The role of case examples. Acad Med. 2002;77:209–216.
95. Xiong K, Boehrer RH. Improving physician behavior with an obstetric dashboard. Obstet Gynecol. 2017;129:140S.
96. Boscardin C, Fergus KB, Hellevig B, Hauer KE. Twelve tips to promote successful development of a learner performance dashboard within a medical education program. Med Teach. 2018;40:855–861.
© 2019 by the Association of American Medical Colleges
98. Lucey CR. Is medical education a public or a private good? Insights from the numbers. JAMA. 2017;318:2303–2305.