Dr Shabir Moosa, MMed, MBA, PhD

AMA HSS themes

This is a summary of the Health Systems Science book developed by the American Medical Association. Purchase here

Health Systems Science in Medical Education

Medical education has relied on two pillars: basic science and clinical science. Health system science – the understanding of how doctors deliver care to patients, how patients receive care and how health systems function – has been marginal. The health environment is changing rapidly: with new policies for universal health coverage, payment systems (beyond a fee for service), health care delivery system changes (with patient-, person- and people-centredness) and health information transformations.  Heath care is an iceberg with usual service the tip and many issues now under water e.g. teamwork, policy, value, population etc. Providers need to become health care “change agents”.  The idea is to make HSS the third pillar. HSS is intertwined with the other two but needed in its own right.  Roles of physicians are changing significantly and rapidly, and they need to understand HSS to fulfill their changing roles, moving away from a physician-centric role to a patient-centered, systems role identity. This is applicable to all health professions students. There are core curricular domains: health care structure and processes; health care policy, economics and management; clinical informations/health information technology; population health; value-based care; health system improvement; with cross-cutting domains: leadership and change agency; teamwork and interprofessional education; evidence-based medicine and practice;  professionalism and ethics; and scholarship; and the linking domain of systems thinking. The task is to develop comprehensive, standardised and integrated curricula; develop, standardise and align assessments; partner with accrediting bodies; improve graduate entry transition; enhance faculty; demonstrate value; address hidden curriculum.

The Health Care Delivery System

Health care delivery is evolving rapidly. All health care professionals must understand the systems and challenges posed by change. Systems are changing from fee-for-service based on patient perspectives towards more population-accountable care with payment for value (based on high quality-outcomes and low cost). The Institute for Health Improvement published the Triple Aim: health for all (population health); ideal patient experience; and lowest cost. This requires improved operational management of services. It involves collaborative team-based care with planned payment reforms realigning the system, where teams must leverage health care improvement strategies, data analytics, and population management to close deficiencies in care delivery and ensure patients receive care, education and support to maximise their health. Health systems have to be built around the patient to reduce fragmentation and improve integration. It is highly dependent on sharing of clinical information. It is even more crucial when managing risk within the full population. All health care professionals need to navigate in this terrain.

Value in Health Care

Value in health care is a strategic priority, as costs are rising unsustainably. Payment is being tied to value (cost vs. outcome). Health professionals need to be well-versed in thinking ‘value’ – current thinking and training are poor. We all want care that is effective, safe, patient-centred and affordable. There are many competencies required of clinicians to achieve this. We need to define value, explore what value means and discuss barriers to high-value care. The Institute of Medicine defined health system goals as: Safe, Timely, Effective, Efficient, Equitable and Patient-centred (STEEP). Value is defined as Quality (Outcome, Safety, Service) divided by Total Cost. There are five domains of the health care system: care delivery; knowledge; payer;  medico-legal; and regulatory. Generally, while the health care system falls short of value, there are many championing high-value initiatives. Key components for a high-value health care system are a clear shared patient-centered vision; leadership and professionalism with teamwork; robust IT/EBM; insurance for all; payment that removes incentive for volume-based care and instead promoting integration coordination, prevention and health promotion. Barriers to this are conflicting stakeholder initiatives; lack of shared reality; poor integration and coordination; and inadequate education of health care professionals. Health professionals need to actively address cost and quality (outcomes, safety, and service to patients) in the way they provide service not only at patient level but at different levels of the service, including leadership of the organisation.

Patient Safety

Patient safety is attracting increasing attention. Despite significant technological and clinical advances safe care in this complex environment is a challenge. Too often the mistakes are attributed to individuals instead of focusing on how the heathcare system contributes. Key principles and foundational learning are required for health professionals to effectively change the culture and systems in which they provide care. Understanding the epidemiology and types of errors is essential to investigating solutions. A systems approach to errors, like the Swiss Cheese Model can pick up latent and active failures, as well as patient, task, work and organisational factors.Other common errors are medication; surgical; diagnostic; transition of care; and teamwork errors (usually communication).  It is important to disclose errors and take care of ‘second victims’, promoting a just culture. Reporting systems and event analysis of error and near misses (e.g. using fishbone analysis) are an opportunity to prevent and correct system failures in a non-punitive manner using the old method of morbidity and mortality meetings, with patient safety improvement strategies e.g. as clinical pathways or protocols a clear element of this. Improvement in health technology may improve and confound future patient safety.

Quality Improvement

Quality is related to value and patient safety is the first element (especially managing the benefits, harms and relatives costs of interventions). Quality improvement is part of the daily work of any professional. Quality goes beyond quality improvement (QI), as several things cannot be easily measured. There are types of quality measures (structure, process, and outcome) and data sources (administrative, clinical, registries, surveillance, survey, EHR etc) as well as commonly used QI methods (Model for Improvement, Plan-Do-Study-Act, Lean (team redesigning workflow to reduce waste) and Six Sigma (team reviewing root causes to reduce defects). Importance of outcome and ease of measure often drive QI projects.  The most common issues in clinical quality are clinical decision support; standardisation using protocols; equipment redesign and forcing functions; front-line engagement of clinical microsystem teams; leadership and change management (including identifying champions for change). The relationship between QI and scholarship is important, with value in the SQUIRE 2.0 Guidelines as a tool for reporting health care improvement.

Principles of Teamwork

Health care is undergoing a revolution, moving from a lone provider model to one that embraces a system of care. Improving quality, outcomes, and costs of health care delivery for patients and populations requires teamwork and an understanding of team science. Teams working towards a common goal can improve health outcomes for individuals and communities. An understanding of teams, their structures, and critical elements will enable health professions students to fully engage in this critical component of the future of health care. Students need a basic framework in how teams are formed, educated and trained, especially with interprofessional collaboration as a cornerstone of health care and education. Education on teamwork will equip students to be effective members and leaders of teams. This includes how to define teamwork; leading teams;  constructing teams (with tasks,s size, skills, operational rules etc.) and stages of team development.

Leadership in Health Care

Population health is a major issue in health care system changes. Successful health care leadership requires creative thinking, an ability to work across disciplines, operational skills and an understanding of organisational culture. The CanMEDs includes leader as a key competency for a physician. Health care leaders are not just at senior authority-based level but across the clinical service, especially informally and situationally. There are many leadership theories, leadership competencies and leadership pathways that can be used. Questions arise about how to best develop effective health care leaders: how is leadership best taught and learned? What leadership models or theories are most applicable to health care? How does health care leadership differ from management and how do leadership and management intersect? Is health care leadership distinct from leadership in other industries? are there distinguishing leadership competencies in a healthcare environment? What are the opportunities and pathways for healthcare leadership?

Clinical Informatics

Health information technology and clinical informatics are important and relevant to safe and effective patient care. Clinical informatics, especially the electronic health record (EHRs) with clinical decision support are important applications. EHRs with interoperability and telemedicine are valuable in supporting high-quality patient care. Data (and metadata) analytics need to support health providers and health system needs, with challenges in mining the use of EHRs and informatics. Recently developed competencies in clinical informatics need to be learned by health professionals in order to be relevant to future directions in health care. They need to ask the right data inquiries, structure EHRs,, Clinical Decision Supports, Population Health, Health Information Exchanges, improve patient safety, engage in quality measurement, maintain privacy and professionalism, engage with patients, function with telehealth etc.

Population Health

Population health is receiving increasing attention in the USA over the past decade, fueled by the expansion in focus of clinicians from individual care to population health management, as it adopts a broader perspective than traditional care. There is growing emphasis now with new payment systems. Population health’s role in health care delivery includes new models of care, alternative payment models, new technology and new evolving roles for health care workers. Population health is mostly defined by geographic communities but can be determined by disease, or type of community. Population health is strongly focused on clinical outcomes at a population level, and addressing social determinants of health of clinical relevance to the practice. Public health and population medicine are related concepts. Public health is long-standing discipline focused on populations but traditionally has not been focused on individual medical care and private sector health care delivery. There are examples of population health initiatives bridging medical care, public health, and the community. This area has implications for new directions in health professions education. There are limitations in the way health engages in population health: overly focused on sick care over prevention, fragmented care, poor use of data, poor patient engagement, inequity and payment systems.

Socio-Ecologic Determinants of Health

There is an old and established evidence base for the significance of social determinants of health.  The focus in the modern world is on access to health care services but social determinants may prevent or reduce people accessing services e.g social class, education, early childhood development, housing, racism, and discrimination. It is important to move upstream to reduce their impact on health. Soci-ecologic determinants of health are crucial to overall population health and to equitable distribution of health within a population. Understanding why social and economic conditions relate so strongly to health outcomes helps explains the wide health inequalities that exist around the world. Social determinants need to be integrated into clinical practice and health systems in general, using screening tools e.g. poverty intervention tool. health leads (equivalent to CHWs) and intervention tools e.g. referrals, information, Health Leads. Innovative collection/use of practice data, equitable practice design and community-policy support for health advocacy can address these.

Health Care Policy and Economic Payments

Health policies reflect and shape historical and contemporary political philosophies and also drive government actions. All policies can have unintended consequences. Also with the intention for the greatest good for the greatest number, some feel that for others to get they have to give, making them disgruntled. One needs to understand the interplay between multiple stakeholders, why these individuals and organisations behave the way they, and how their decisions interact to become the form and function of the health care system. Health care economics (including micro-economics, government contributions and understanding health insurance) is important as it concerns the affordability and high costs motivating policymakers. Students need to understand major health care reforms to make sense of the different impacts of health policies on multiple different stakeholders. Politics underly health care reform with varying interests  (with different strengths of lobbying) driving change. The Accountable Care Act tries to expand access to health insurance mainly by forcing young people to enter the market, improve consumer protections by mainly reducing discriminatory enrolment, saving costs and improving quality (with links to payment).

Health Systems Science in Medical Education

Learning content without applying it may lead to limited comprehension and practice. Skills in evidence-based medicine, communication, cultural competence, teamwork, and professionalism are required but how do we operationalise adherence to the best evidence in care? What are the pros and cons of using patient portals to communicate with patients? Practically, how can we provide culturally competent care that accommodates less common belief systems or gender identities? How do health providers and leaders balance competing interests such as finance and ethics? There is a need for more than foundational skills with skills that cut across. Evidence-based medicine is the practice of applying the best available evidence for the best care and at least cost. Clinical Guidelines incorporate the best evidence and are increasingly involved in payment systems, quality monitoring, and electronic health records. Formularies are also part of this equation. Communication skills via new technologies are also emerging, whether electronic patient portals or social media. Organisational culture and teamwork are a big part of health care delivery by a complex network of professionals. Teamwork requires shared perceptions of collaboration, understanding factors that influence this, and knowledge of other health professions. Professionalism is required to balance finance and ethics, and resistance to change.

Assessment in Health Systems

Assessment is required in driving and measuring learning and improvement in health system science (HSS). The workplace is less structured than the traditional classroom with poor role-modeling in HSS. There is a need for students to take the initiative in defining their assessment, learning and improvement needs and provide a list of key steps that will help students in developing knowledge, skills, and attitudes intrinsic to HSS. The concept of self-regulated learning is important, where students can adjust their behaviours to achieve their learning goals.  Students can set goals, build self-efficacy and find reasons for their results, including team performance. They can direct their thoughts, feelings, and actions towards controlling their academic and clinical performance. Key elements of self-regulated learning include goal setting, self-efficacy, attributions of learning outcomes, self-assessment, feedback seeking, and reflection. To be effective self-assessment needs to be informed by external data or feedback; without this information, learners and physicians typically self-assess inaccurately. With external data or feedback assessment then becomes a driver and a measure of learning. Core principles of assessment help learners understand how best to measure their knowledge, skills and ultimately their performance in practice. Although learners may not control which assessments are used within their educational programmes, understanding how they are used and the results generated by them will help learners get the most out of assessment in supporting their self-regulated learning.

The Future of Health Systems Science

Competence in HSS, is necessary like basic and clinical sciences, to proficiently serve patients in both current and future health care environments. HSS domains range from information technology to health policy, all rooted in systems theory, represented by the bio-psycho-social model. HSS is driving educational change in the USA, much like the Flexner Report did about 100 years ago. HSS is a dynamic, developmental, contextually-based paradigm that will evolve over time. The gap between changes in the health care system and changes in health professional education needs to be as narrow as possible. There is growing use of 1st-year students as patient navigators in longitudinal preceptorships starting on entry to medical schools, exposing them to clinical and HSS skills earlier and engaging them in quality improvement processes. This includes working in non-traditional healthcare settings, interprofessional teamwork, population health, risk contracts with capitation and understanding costs.

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